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94 Cards in this Set
- Front
- Back
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Types of Infusions
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peripheral, central, continious, intermittent
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How to Maintain IV
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Be sure it is correct solution
Check flow rate every hour Inspect patency of IV tubing & check for kinks in tubing Maintain solution 3 feet above IV site Splint the joint if IV is positional Make sure all connections are tight to prevent leakage If IV is infiltrated -stop the infusion and reinsert in another site change every 72 hours |
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Types of IV fluids
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Hydrating solutions-D/W, D/S, Normal Saline(0.9%),Lactate Ringers
Blood Tranfusions-all types;plasma, RBC's,whole blood,platelets, Albumin Total Prerenteral Nutrition(TPN)-solution that provides all needed calories and contain high dextrose concentrations, water, fat, proteins,electrolytes,vitamins |
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TPN IV Indications
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Must be careful with infection control-high percent of glucose invites bacteria
Must monitor glucose levels to prevent hypoglycemia or hyperglycemia Never stop TPN abuptly-the sudden absence would cause hypoglycemia-check levels if this happens IV never left up after 24 hours because of sugar |
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Infiltration
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when IV fluids enter the subcataneous space around the venupuncture site-into tissues
pallor , swelling, IV fuid rate slows or stops, coolness, discomfort discontinue, reinsert IV in another vein, elevate affected extremity and wrap in warm towel for 20 minutes |
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Heparin Lock
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Use injection cap, IV loop or extension tubing
Use 1-3 mls of normal saline or heparin flush-to make sure tubing is clear Use syringe with 25 gauge needle or needleless system |
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Phlebitis
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Inflammation of the vein
Risk factors include type of catheter material, chemical irritation form additives, and anatomical position of catheter Client is at risk for developing thrombophlebitis (bloodclot) which can result in emboli Prevention involves removal and rotation of IV sites every 48-72 hrs depending of hospital protocol |
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Phlebitis signs and symptoms
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pain, edema, erythema(redness), increased skin temp. over vein, can have redness traveling path of vein
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Phlebitis treatment IV
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discontinue line
reinsert IV into another vein apply warm moist heat for relief |
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What is JCAHO role in clients education
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sets standards for providing education in health care institutions
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Purpose of client education
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Health maintenance and promotion
Restoration of health Coping with impaired function Helping clients develop positive health practice |
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learning motives
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task mastery-based on needs such as achievements and competencies
physical motives-client who desires to return to normal level of physical function social motives-need for connection, social approval, or self esteem |
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Teaching principles
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Set priorities
Appropriate timing Organize materials Maintain learners attention and participation Build on existing knowledge |
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Teaching methods
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discussion, Q&A, role play, computer assisted instruction,teaching aids and demonstration
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Barriers to learning
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emotions, physiological events and cultural
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Levels of communication
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intra personal
inter personal public communication |
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Elements of communication process
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referent-stimulus motivates person to communicate with another
sender-(encoder)person who intiates interpersonal communication receiver-(decoder) person who receives and interprets the message message-content of info that is sent and the way the message is sent channel- means of conveying and receiving messages through any of the senses feedback or response-message returned by the reciever interpersonal variables-factors within both the sender and receiver that influence communication environment-the setting for sender-receiver interaction |
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therapeutic communication
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purposeful communication between nurse and client
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intimate space
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18 inches is considered intimate space nurse works within that
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personal distance
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18 inches to 4 feet
(sitting for interview) |
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social distance
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4 feet to 12 feet
(making rounds with physician) |
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public distance
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greater than 4 feet
(formal speaking) |
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asking related questions(Therapeutic)
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open ended questions
validating sequencing directing |
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paraphrasing
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restating clients message in the nurse own words
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Peri-operative
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time before, during and after surgery
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surgery settings
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ambulatory surgical centers
acute care hospitals |
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classification of surgical procedures
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ectomy-removal of an organ or gland
rrhaphy-suturing or stitching(repair) ostomy-providing an opening plasty-plastic repair scopy-looking into |
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degree of surgery
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major- CABG,colon resection,mastectomy
minor-cataract removal, cyst removal |
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Urgency of surgery
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elective-necessary but not life threatening it is client choice
urgent-prompt attention within 24 hrs. fix blockage, fracture repair emergency- to save life |
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purpose of surgery
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diagnostic- laparascopy, breast biopsy
ablative-removal of diseased part palliative- does not cure, will reduce or relieve symptoms (resection of nerve roots) reconstrutive or repairative- restores function or appearance procurement (harvesting) cosmetic-performed to improve personal appearance curative- removes pathological cause |
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pre admission testing
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blood type & cross match rh factor
CBC-wbc(infection)RBC(low blood volume)Hgb&Hct(potential for oxygenation problems serum electrolytes PTT&PT-coagulation studies serum creatinine/BUN-renal function glucose-blood sugar reading Chest xray/EKG-clients over 40 |
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pre-op teaching
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diaphragmatic breathing, incentive spirometer(minimal inpsiration&reduces collapse of alveoli)controlling cough(cascade cough) sequential compression device or AE hose
leg exercises turning |
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physical prep pre surgery
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NPO
skin preparation bowel and bladder preparation rest and comfort |
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informed consent
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written consent obtained before invasive procedure
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3 elements of informed consent
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consent is giving voluntarily
client is competent to understand what procedure involves sufficient information is provided about procedure |
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pre anesthetic agents
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benzodiazepines,barbituates,H2 blockers(reglan)antacids, antinausea agents,antochlolinergics,opiods(morphine)antibiotics
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reasons for pre-op meds
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client anxiety
amount of general anesthesia required risk of nausea/vomiting risk of respiratory secretions |
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prep of post op bed
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BP machine,stethoscope, thermometer, pulse ox
emesis basin clean gown extra pillows towels, bed pads IV poles, suction set-up,oxygen(if indicated) bed raised to height of stretcher |
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intraoperative phase
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transport to OR
positioning identify patient |
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nurse role intraoperative phase
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scrub nurse/circulating nurse
correctly identifies patient(asking patient name,verifying doctor and procedure,checking ID band and chart assesses patient |
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JCAHO protocol
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universal protocol for preventing wrong site, patient and procedure
involves- verification process marking op site "time-out" before op |
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anesthesia classifications
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conscious-
general regional |
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regional anesthesia
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local-specific area for minor surgery
nerve block-into and around nerve or nerve group epidural-into epidural space numb large area spinal-lumbar puncture in subarachnoid space |
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stages of general anesthesia
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induction
maintenance emergence |
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scrub nurse
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maintains surgical asepsis while draping and handling instruments & supplies
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circulating nurse
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assesses client on admission to OR, helps position patient, assist with monitoring during surgery, maintains environmental safety,verifies the count
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PACU assessment
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Activity,respiration,circulation, consciousness,O2 saturation
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Aldrete score
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must be 8-10 before patient leaves PACU
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Airway assessment
post op |
presence of artificial airway devices(pharangeal airway,endotrachial tube
tracheostomy tube) oxygen ussually given to decrease pulmonary expansion due to anesthesia oxygen given via nasal cannula or face mask 3 liters patient shivering increases oxygen consumption, should be given oxygen oro-pharangeal airway- do not remove until gag reflex returns hypopharyngeal obstruction-assisted airway management(tilt head back,open mouth,push lower jaw forward) if client becomes restless and O2 is 88% or lower may be hypoxic-common cause atelectasis O2 sat goes down but everything is in normal limits have patient take deep breaths |
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Circulation assessment
post op |
at least every Q5-15 mins
BP, pulse, respirations,pulse ox temperature-core temp hypothermia can occur apply warming devices EKG |
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post op assessments
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color of skin, nail beds& lips
appearance of skin LOC reflexes check IV check dressings, drains & tubes presence or absence of urge to void |
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PARSAP
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post anesthesia recovery score for ambulatory patients
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General anesthesia risks
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malignant hyperthermia-early sign tachycardia,tachypnea,jaw muscle rigidity
cardiovascular irratibility and depression respiratory depression liver and kidney failure |
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assessment upon admission of surgical patient to unit
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record time
take vitals receive verbal report from PACU nurse establish baseline assesment of all systems note wound dressing connect tubing to gravity or suction as indicated check IV infusion rate pain assessment position for comfort, bed rails up, bed low,call light in reach,etc reorient client to surroundings check for family members or significant others review order with PACU nurse check physicians order and carry out monitor vital every hour for 4 hours then every 4 hours |
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classification of hemorrage
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capillary-slow general ooze
venous-bubbles outs quickly, dark arterial-spurts and bright red evident- can be seen concealed-cannot be seen |
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post operative complications
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shock-hypovolemic(hemorrage)
thrombophlebitis urinary retention infection dehiscense evisceration |
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wound dehiscense & evisceration
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serious in abdominal wounds
obsese patients susceptible dehiscence-partial or complete separation at suture line everceration-total seperation of wound layers |
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wound seperation post surgery
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3-14 days post op- technical complications
after 14 days- metabolic factors |
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Post operative care-lungs
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clear airway-suction
promote lung expansion-exercise,IS, auscutate lungs before and after exercises |
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post operative care-fluids & electrolytes
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IV first 12-24 hrs
water-room temp quicker client eats quicker GI function returns clear liquid-full liquid to soft diet to regular diet must check bowel sounds-watch for paralytic ileus |
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urination after surgery
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urinate 8-10 hours after surgery
UTI-6-8 hours after foley removal strict I&O take in 2000-3000 void 1500cc |
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client record
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describes nursing and medical care given to patient
provides timeline of remarkable care establishes baseline assessment legal document of clients health status..includes problems treaments and responses |
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documentation and reporting
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must be factual,accurate,correct time frame, sign entries,countersign entries(student nurse)
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types of reporting
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change of shift
telephone reports(must be taped) transfer reports incidents reports(not in nurses notes) |
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methods of recording
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narrative-source oriented
problem oriented medical record charting by exception focus charting critical pathways computerized |
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soap note
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subjective obejective assessment plan
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PIE
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problem intervention evaluation
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legal guidelines for charting
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do not erase
do not write critical comments-don't chart opinions correcct all errors promptly record only facts do not leave blank spaces record all entries legibly and in ink if order is questioned record that clarification was sought chart only for yourself avoid using generalized phrases begin each entry with time and signature and title do not allow relatives to access chart |
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classification of wounds
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incised-clean cut sharp with instrument
lacerated-jagged, irregular edges puncture-small opening in the skin(bullet stab) debridement-wounds do not heal because of infection operate to cut out infected tissue |
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wound drainage
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serous drainage-clear watery
sanguineous drainage-bright red-active bleeding serosanoguineous drainage-pale, red, watery mix of serous and sanguinous purulent drainage-thick yellow green tan or brown sign of infection |
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purpose for dressing wounds
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prevent contamination
absorb drainage will support or splint wound site protect from injury promote homeostasis if pressure dressing |
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purpose for maintaining wound undressed
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eliminate conditions that favor growth of organisms
allows for better observation & assessment avoid tape reaction avoid friction and irratation |
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exudate
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fluid and cells that escape from blood tissues and are deposited in or on tissue surface
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granulation tissue
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new tissue found in wound that is highly vascular
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eshcar
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necrotic tissue
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primary intention- wound
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wounds with little tissue loss skin edges are approximate or close (surgical wound)
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3 phases primary intention
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inflammatory phase 1-4 days
epithelial proliferation and migration phase- 4-7 days reetablishment of the epidermal layers phase |
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secondary intention-wound
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wounds with extensive tissue loss, edges cannot appoximate, injury is greater, takes longer to heal, chance of infection is greater
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3 phases secondary intention
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inflammatory phase 1-3 days
proliferation phase-regeneration 3-24th day maturation phase-remodeling 21 days to months to year |
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third intention-wound
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delayed wound closure process is deliberate by surgeon in order to allow drainage and cleaning of contaminated wound
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surgical wound infection
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develops 4-5th day
fever,increased WBC's,tenderness and pain at the wound site, wound edges appear inflamed- purulent drainage present |
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fistula
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abnormal passage from an internal organ to the skin or from one internal organ to another
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Kardex
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clinical worksheet that includes allergies, IV fluids,current treatments and procedures, scheduled diagnostics or lab tests,diet,care needs etc
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Purpose of Nasogastric Intubation
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decompression, feeding(gavage),
compression,lavage |
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decompression
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removal of secretions and gaseous substances from GI tract or relief of abdomninal distention
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feeding (gavage)
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instillation of liquid nutritional of liquid nutritional supplements or feeding into stomach
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compression
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internal application of inflatable balloon to prevent esophageal or GI hemorrage
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lavage NG
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irrigation of stomach in cases of active bleeding, poisoning or gastric dilation
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measuring tubing for NG
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distance from tip of nose to earlobe to xiphoid process of sternum
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PEG (percutaneous endoscopic gastromy)
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surgically inserted tube to allow for liquid feeding must be assesed by Xray for placement
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focusing
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guiding conversation toward info that is important
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cognitive- domains of learning
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understanding includes all intellectual behaviors and requires thinking
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affective-domains of learning
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deals with expressions of feelings, values, and attitudes
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psychomotor-domains of nursing
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involves acquiring skills that require mental and muscular activity-does the skill
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