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132 Cards in this Set
- Front
- Back
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What is the purpose of a Braden scale
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Assess patient risk for developing pressure ulcers
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What are the 6 dimensions of the Braden Scale?
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Sensory Perception
Moisture Activity Mobility Nutrition Friction/Shear |
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What is the max score for the Braden scale?
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23 (little risk)
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How do the risk scores work for the Braden scale?
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Maximum= 23 (little risk)
≤ 16= At Risk ≤ 9= High Risk |
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What is fecal impaction? What are the S&S?
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Collection of hardened feces in the rectum or sigmoid colon.
Constipation n/v Diarrhea (around impaction) Urinary frequency |
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What does fecal impaction prevent?
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Prevents the passage of a normal stool
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What is digital removal of fecal impaction?
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a technique of removing feces with fingers (scissor technique)
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Digital removal of fecal impaction steps
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Proved privacy
Position pt left side-lying Place bedpan next to patient Lubricate gloved index and middle fingers Ask pt to take a deep breath while inserting index finger Insert middle finger Work feces down using scissors maneuver |
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What side should pt lay on when performing a digital removal of fecal impaction?
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left side
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Be cautious of _________ when performing fecal impaction
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Bradycardia
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What is an enema?
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a type of a solution put into the rectum and sigmoid colon
Volume and type of fluid breaks up the fecal mass, stretches the rectal wall and initiates the defecation reflex. |
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Tap water (hypotonic) enema
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Be cautious of water toxicity or circulatory overload
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Kayexalate enemas
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High K+
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Neomycin enema
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reduces bacteria prior to colon surgery
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Cleansing enema (Fleets)
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stimulates peristalsis
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Oil-retention enema
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colon absorbs a small volume-allows the stool to soften
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NS enema (isotonic)
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used often for children or for fluid intolerance
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Hypertonic (fleets)
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Small volume if unable to tolerate large volume-draws fluid into bowel to soften stool
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Pt position for administering enemas
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Sim's position
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Depth of enema for adults, children, infants
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Adults: 3-4in
Children: 2-3in Infants: 1 -1½in |
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Where to aim enema tip?
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Towards the umbilicus
� |
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How long should pt stay on the side after enema administration?
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5 min
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Pt position for enema bag?
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Sim's
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amount solution added to enema bag?
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750-1000ml
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Steps for Enema Bag
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Position pt in Sims’
Add 750-1000ml of warm solution to enema bag Prime the tubing with fluid then reclamp bag Lubricate tip and insert toward umbilicus Raise enema bag above rectum to appropriate height Unclamp enema bag and allow fluid to flow Clamp bag and withdraw tip from anus |
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Caution for administering enemas
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Inspect for bleeding
Rigid abdomen Abdominal cramping |
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If pt is experiencing abdominal cramping during enema administration, what should you do?
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Lower height of enema bag
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enema bag heights
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High: 12-18in
Regular: 12in Low: 3in |
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Stoma
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opening made from small intestine or colon
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Effluent
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Output from stoma
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Colostomy
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stoma made from colon
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Ileostomy
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stoma made from the ileum
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Colors of a stoma
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Pink- good
Blue-bad |
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Intestine order
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Ascending- liquid
Transverse-semi solid Descending-mostly formed Sigmoid-formed |
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What is an urostomy?
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It removes urine in cases where drainage of urine through the bladder and urethra is not possible, e.g. after extensive surgery or in case of obstruction
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Urstomies are permanent
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True
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How does the effluent of a urostomy look?
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Effluent will be urine with mucus
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How is a Urostomy made?
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Formed from resected portion of intestine and attached to ureters
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Reasons for NG tubes
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Enteral Feedings
Lavage (Overdose) Compression (Prevent hemorrhage) Gastric Decompression (Post-op abdominal surgery Bowel rest) |
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Types of would healing?
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primary, secondary, tertiary
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Primary Intention for would healing
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Edges close together
Minimal tissue loss Heals quickly Minimal risk for infection Staples, sutures |
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Secondary intention
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Open wound with tissue loss
Heals by scar formation Prolonged phase of inflammation Longer phases of proliferation and maturation |
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Tertiary intention
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Wound is closed after 3-5 days
Allows edema and infection to resolve Heals by primary intention |
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What are the types of pressure ulcers?
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Stages I-IV and unstagable
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Stage I pressure ulcer
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Skin intact
Non-blanching erythema May be painful May be warm |
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Treatment for stage I pressure ucler
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Keep pressure off area
Maintain hygiene Maintain adequate diet Protective dressing |
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Stage II pressure ucler (partial thickness)
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Loss of epidermis and dermis
Shallow opening No slough Ex. Blisters, abrasion |
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Treatment for stage II pressure ucler
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Remove pressure source
Clean wound with sterile saline Hydrocolloid dressing (Ex. Duoderm) Cleanse with sterile saline |
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Stage III pressure ucler
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Full thickness tissue loss extending to SQ tissue and fascia
Drainage common |
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Treatment for stage III pressure ucler
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Debridement
Packing agents Consult wound care nurse Pressure- relieving mattress |
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Stage IV pressure ucler
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Full-thickness tissue loss extending to bone, muscle, or tendons
Slough and eschar may be present |
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Treatment for stage IV pressure ucler
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MD consult
Wound care nurse consult Surgery |
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Unstageable pressure ulcer
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Full-thickness tissue loss
Base of ulcer: Slough: Yellow, Tan, Green, Brown Eschar: Tan, Brown, Black |
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Treatment for unstageable pressure ulcer
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Surgery
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How do you prepare a sterile field?
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1. Sterile package on a dry surface above waist level.
2. Open outermost flap away from body. 3. Pull side flaps open using the outside of the flaps. 4. All flaps should be open and lying flat. |
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Ways to contaminate a steril field?
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Sterile field below waist level
Reaching across sterile field Leaving sterile field Turing your back to the sterile field. Placing no steril items in sterile field. |
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When to use soap and water?
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C Diff
Soiled hands Blood Bodily Fluid |
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When to use alcohol rub?
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Not visibly soiled hands
B&A direct pt contact B&A donning gloves B&A removing gloves After contact with inanimate object |
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Pts with airborne diseases like Measles, Varicella/ Shingles and TB require what?
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Isolation, Negative air pressure room, Special mask “N-99”
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Pts with droplet transmitted organisms like Haemophilus Influenzae type b, Meningitis, Pertussis and Pneumonia require what?
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Mask and isolation
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Examples of illnesses that can be easily transmitted through direct pt contact or contact with pt environment
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MRSA, Respiratory infections (RSV), Skin infections (Impetigo, Scabies) C. Diff, GI infections
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Illnesses that can be easily transmitted through direct pt contact or contact with pt environment require what?
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Gown and gloves
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What is a medical asepsis? What does it prevent?
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A clean technique. It prevents the spread of microorgsnisms (not kill)
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What are some examples of medical asepsis?
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Hand hygiene
Barrier Techniques Change soiled dressings Discard items that touch the floor. |
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What is surgical asepsis?
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Sterile Technique
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When is an object sterile?
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When all microorganisms and their spores are destroyed.
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Some places where surgical asepsis is used?
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operating room
Labor and delivery Procedural areas Pt's bedside Invasive procedures |
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What to do when handling a sterile package?
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Peel open package and let contents fall onto sterile field
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What to do when handling a sterile solution?
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Hold bottom of bottle on angle away from sterile field
Pour contents 1-2 inches above sterile container |
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When should you consider restraints?
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Fall risk, pulling out tubes, removing dressing, wandering
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What are the different types of restraints?
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Belt (prevents falling or rolling out of bed), extremity, mitten (prevents removing dressing) chemical (sedating for behavioral control
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Restraints must be removed every ____ hours
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2
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The Physical or APN must physically evaluate pt within ____ hours of restraint initiation.
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4
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How often must a restraint order be renewed?
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Every 24 hours
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Document assessment of pt for injuries every ___ min
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15
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Do not attach restraints to ______________.
Use a ______ _______ tie. |
side rails
quick release tie |
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Time limits on restraints
Adults 9-17 <9 |
4 hours
2 hours 1 hour |
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Required documentation for a fall.
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SPLATT
Symptoms at time of fall Previous fall Location of fall Activity at time of fall Time of Fall Trauma post fall |
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What to do when there is a medication error?
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Fill out an Incident Report with:
Patient identification information Time and location of incident Description of event with follow-up care This should NOT be referred to in the patient’s chart |
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6 rights
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Right Dose, Patient, Route, Documentation, Medicine, Time
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Preventing Medical errors
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6 Rights of medication
Double check calculations with another nurse Question exceptionally large or small doses Document medications immediately after administration |
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Medications can be given 30min before or after scheduled time.
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True
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Can only crush scored tablets
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True
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What is aspiration?
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Food or medication moves into trachea
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What are some aspiration precautions?
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Thicken medication
Sit patient up to 90° Administer small amounts at a given time |
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Always insert needle with bevel up
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True
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Parts of a needle
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Hub, shaft, bevel (pointy part)
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Gauge Vs. Needle Diameter
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Smaller the gauge, larger the needle diameter
Larger the gauge, smaller the needle diameter |
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Insulin Injection "How To"
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L to S, S to L
Alcohol wipe both. Aspirate air equal to amount of long-acting insulin Inject air into long-acting insulin vial Remove syringe and aspirate air equal to short-acting insulin Inject air into short-acting vial and withdraw medication Remove air bubbles Insert syringe back into long acting insulin and aspirate correct volume Cap needle |
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Most common site for BP
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Arm at brachial artery
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Other sites for BP and where to auscultate
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Leg (dorsalis pedis or posterior tibial arteries), thigh (popliteal artery) , forearm (radial)
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When taking BP in the thigh...
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SBP 20-30mmHg higher than upper extremity
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BP equals what
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CO X PVR
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Peripheral Vascular Resistance (PVR) is
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PVR is the semi-contracted state of arteries that maintain a relatively constant resistance to blood flow. Controlled by the autonomic nervous system.
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Volume (BP)
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the greater the volume, the greater the pressure
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Elasticity
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as elasticity decreases, pressure increases
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dialation constriction
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dilation lowers BP, constriction raises BP
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Define Blood pressure
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force exerted by blood against the vessel walls.
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Systolic
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force or pressure in walls of arteries when (L) ventricle contracts
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Diastolic
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force or pressure on walls of arteries when heart is filling
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At what age do start BP for children?
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a 3 y/o
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Normal
High Normal HTN For Children |
Normal 90th percentile
High normal 90th-94.0 HTN >95th percentile |
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For Children Any reading of 120/80 or higher is pre-hypertensive (unless it is 95th percentile or higher) and then it is HTN.
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True
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After age ___, high ____ BP (>140 mmHg) is much more important than high diastolic pressure as a cardiovascular risk factor.
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50, systolic
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____% chance of developing HTN after age ____
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90%, 60
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40 to 70 yo risk for cardiovascular disease doubles with each increment of 20/10 mmHg above 115/75
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True
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Lifestyle modifications for HTN
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lose weight
fruits& vegetables low-fat dairy products reduce Na intake (1 tsp./day) exercise alcohol in moderation Smoking cessation |
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Caffeine and Nicotine's effect on BP
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Caffeine false high up to 15 minutes
Nicotine false high up to 3 hours |
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How to avoid Auscultory Gap?
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By doing 2 step BP
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Auscultory Gap usually heard in ______. Results in....
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Underestimation of SBP
Overestimation of DBP |
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What is Orthostatic BP?
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Decrease in SBP > 20mmHg and/or a decrease in DBP >10mmHg with an increased pulse 10-20bpm when pt moves from lying to standing position
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Causes of Orthostatic BP
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hypovolemia, prolonged bedrest, medications
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Assessment technique for Orthostatic BP
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Measure BP in lying, sitting, standing position; wait 2-3 minutes between each position.
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If arm lower than level of heart false high
If arm higher than level of heart false low Unsupported arm false high Bladder cuff too wide false low Bladder cuff too narrow false high |
True
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Width of bladder should cover 2/3 of upper arm
Length of bladder should reach 80% around arm Bladder should be centered 1inch above Anticubital fossa |
True
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Temperature usually ______ in the morning. Peaks between....
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lower, 5-7
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Women have _______ temperature fluctuations.
Older adults have a more ________ range. |
wider
narrow |
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Are core or surface temps more reliable?
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Core
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Examples of core sites?
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Rectum
Tympanic membrane Temporal artery Urinary bladder |
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Examples of surface sites?
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Oral
Axilla Skin |
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Tympanic membrance 0.5 ______ than oral.
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lower
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Rectal 0.5 ______ than oral.
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high
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Axilla 0.5 ______ than oral
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lower
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Technique for rectal temp
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Place temperature probe in lubricant
Insert probe 1.5 inches toward the umbilicus Remove if you feel resistance |
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Advantage of axilla temp?
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Used in newborns and unconscious patients
� |
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Axilla technique
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Place probe in center of axilla and place arm across pt chest
� |
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What is Pulse Oximetry?
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Noninvasive measurement of arterial blood oxygen saturation
LED emits light that is absorbed differently from oxygenated and deoxygenated Hgb |
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Limitation of Pulse Oximetry?
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Can’t tell whether or not CO or Oxygen is bound to Hgb
� |
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Locations for Pulse Oximetry
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Finger
Earlobe Bridge of nose Forehead |
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Things to remember when doing pulse oximetry
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Requires pulsating vascular bed
Site must be free of moisture Nail polish should be removed Use forehead in low perfusion states |
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What is a pulse?
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Reflects the volume of blood ejected against the arterial wall with each beat
� |
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Low volume=______pulse
HIgh volume= _______ pulse |
weak
bounding |
