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236 Cards in this Set
- Front
- Back
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What is an acid mantle?
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Term used to describe the acid pH of skin
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What is the largest external organ?
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The skin or integument
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What is the outermost layer of skin?
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Epidermis
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What is the area that separates the epidermis from the dermis?
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Dermoepidermal
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___ makes up about 70% of the dermis and is extremely important in wound healing
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Collagen
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What is a partial-thickness wound?
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Loss of tissue limited to epidermis and dermis, which heals by process of regeneration
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What is a full-thickness wound?
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Loss of tissue, including total loss of skin layers plus some deeper tissue, that heals by scar formation
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What are the phases of wound healing for a full-thickness wound?
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Hemostasis, inflammatory, proliferative, remodeling
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Describe the hemostasis phase of full-thickness wound healing
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Blood vessels constrict, clotting factors activate coagulation to stop bleeding, clot formation seals disrupted blood vesssles and acts as a temporary barrier against bacteria, growth factors are released, beginning repair process
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Describe the inflammatory phase of full-thickness wound healing
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Vasodilation occurs, allowing plasma and blood cells to leak into wound (noted as edema, erythema, and exudate), WBCs arrive in wound to clean up, macrophages arrive to regulate wound repair, all resulting in a clean wound bed
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Describe the proliferative phase of full-thickness wound healing
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Epitheliazation (construction of new epidermis) occurs, while new granulation tissue is formeed; new capillaries are formed (angiogenesis), restoring delivery of O2 and nutrients to wound bed; collagen is synthesized and begins to provide strength for wound; contraction, which occurs in open wounds, reduces its overall size
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Describe the remodeling phase of full-thickness wound healing
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Collagen is remodeled to become stronger and provide tensile strength to wound; outer appearance in an uncomplicated wound will be that of a well-healed scar
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What is a wound "healing ridge"?
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Newly formed collagen in a healing wound, along the edges of the wound
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What is healing by primary intention?
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When edges of a clean surgical incision remain close together, and the wound heals quickly with minimal tissue loss; sutures, staples, or adhesive tapes are used to keep the wound closed and healing occurs by connective tissue deposition
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What is healing by secondary intention?
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Wounds that are left open and allowed to heal by scar formation (granulation tissue) and contraction of tissue, with some tissue loss and open wound edges; a gap is left betweeen edges; slower than healing by primary intention
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What is healing by tertiary intention?
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When surgical wounds are not closed immediately but left open for 3 to 5 days to allow edema or infection to diminish; then, the wound is sutured or stapled closed; scarring is minimal; dressing is used
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What does viable wound tissue look like?
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Red to pink in color; moist in appearance -- granulation tissue -- indicative of wound that is healing
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What does eschar tissue look like?
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Black, brown, or tan tissue in the wound that should be removed before healing can begin
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Can a nurse remove an initial surgical dressing for direct wound inspection without a physician's orders?
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No
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What are the systemic factors that affect wound healing?
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Tissue perfusion and oxygenation
Nutritional Status Infection Diabetes Mellitus Corticosteroid therapy or hypercortisolemia Chemotherapy and radiation Age Stress, both psychological and physiological Immunosuppression Systemic conditions that affect health status Hemotopoietic disorders |
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What do black/brown wounds indicate?
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Eschar, which represents full-thickness tissue destruction; black = necrotic tissue or desiccated tissue like tendon; debridement is used to quickly remove this tissue (sharp or chemical)
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What do yellow wounds indicate?
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Slough -- nonviable tissue and sometimes infection; usually, it is accompanied by purulent drainage; moisture-retentive dressings enhance debridement; if infected, topical antimicrobials are used
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What do red wounds indicate?
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Presence of granulation tissue; red color indicates increasing amount of new blood vessels in wound -- this is desirable; select a dressing that maintains a clean, moist environment and minimizes damage to the healing tissue
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What is NPWT?
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Negative pressure wound therapy, a mechanical wound treatment that uses controlled negative pressure to assist and accelerate wound healing; often, a vacuum-assisted closure (VAC) is used; NPWT optimizes blood flow, removes wound fluid, and maintains a moist environment
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True or false - chronic wounds like pressure ulcers and diabetic ulcers are approved for NPWT therapy.
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True
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__ is the most common method of wound cleaning, using the mechanical force of a stream of solution to remove debris, bacteria, and necrotic tissue from a wound
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Irrigation
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What are some of the basic principles of wound irrigation?
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1. Clean in a direction from least contaminated to most contaminated
2. All the solution flows from least contaminated to most contaminated 3. Flow of irrigation moves from area being cleansed to an area that is both distal and lower 4. Area you are cleaning is considered "clean" while all other areas are considered "contaminated," even if the wound is not infected |
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In a sutured wound, what area is considered the least contaminated?
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The suture line
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In what direction should sterile swabs or gauzes be used when cleaning a suture line area?
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Move away from suture line with each stroke, starting at center and working towards the other end
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In what direction should cleansing of a drain site take place?
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Circular, starting with the area immediately next to the drain
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What is dehiscence? When does it occur?
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Failure of wound healing in which surgical wound breaks, separates, and opens to fascial level, occuring 4 to 14 days after surgery with a mean of 8 days; wound edges open and serosanguineous drainage is present
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What is evisceration?
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Failure of wound healing, with total separation of wound layers and protrusion of internal organs through the wound - this is a surgical emergency; wound must be covered with saline dressing and the patient must be prepped for surgery
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Effective wound irrigation occurs best through use of a __ mL syringe with a __ gauge needle
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35; 19
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If an angiocatheter is used to irrigate a wound, what should the PSI be? Why should it not exceed this pressure range?
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Between 4 and 15; any higher pressure may cause damage to the tissues and increase risk of infection because bacteria may be driven into the wound
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When irrigating a wound with a syringe, how far should the syringe be from the wound?
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Tip remains 2.5 cm or 1 inch from wound
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If ambulatory patients can have their wounds irrigated by shower spray, how far should the shower head be from the wound?
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Approx. 30 cm or 12 inches
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What is high pressure irrigation?
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Cleansing of a necrotic wound with irrigating fluid at 4 to 15 psi with a 35 mL syringe and a 19 gauge angiocatheter; this provides force to remove wound debris without damaging healthy tissue
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What is high pressure lavage?
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Alternative to high pressure irrigation, using a machine to deliver intermittent high pressure irrigation combined with suction to remove the irritant and wound debris
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Can sterile wound irrigation be delegated to NAP?
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No, but cleansing of a chronic wound using clean technique can be delegated with instruction
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True or false - drainage accumulation in a wound does not affect its ability to heal
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False - drainage accumulation delays healing
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A __ drain system removes drainage from a wound and deposits it onto the skin surface.
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Open
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A __ drain system uses a vacuum to remove drainage from a wound and collect it into a collection device
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Closed
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What are some examples of closed drainage devices?
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Hemovac; Jackson-Pratt
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What are some precautions one should take when using a drainage system for wound care of older adults?
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Older adults may become dehydrated faster, so hydration is important; take measures to prevent a confused patient from pulling out the drain collector
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How soon after surgery are sutures and staples generally removed?
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Within 7 to 10 days if healing is adequate
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True or false - sutures leave scar marks if left in longer than 3 weeks
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False - 2 weeks will leave scars
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True or false - dressings should be nontraumatic and reduce volume of exudate, keeping the wound dry
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False - dressings should be nontraumatic and reduce the volume of exudate, but the wound should not be allowed to dry
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What is a primary wound dressing?
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It comes in direct contact with the wound bed
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What is a secondary wound dressing?
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It covers and holds primary dressings in place
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What type of wounds are moist dressings used for?
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Full-thickness wounds that resemble craters
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What is a moist-to-dry dressing?
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It has a moist layer that touches the wound surface, increasing the absorptive abilities of the dressing to collect exudate and wound debris; it has an outer dry layer that protects the wound from invasive organisms
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Identify nursing interventions to promote urinary elimination.
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Encourage fluids if not contraindicated
Privacy Warm bedpan Normal voiding position ↓ pain level Running water Pelvic muscle exercises Respond quickly to call lights Voiding schedule Commode, urinal, bedpan at bedside |
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What are the common indications for intermittent urinary catheterization (Straight Cath)?
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Straight Cath:
One-time bladder emptying Post-void residual Sterile urine collection Bladder irrigation |
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What are the common indications for Short-Term Catheterization?
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During surgery/post surgery
Strict I+O Critical illness Stage III/IV pressure ulcers Bladder irrigation |
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What are the common indications for Long-Term Catheterization?
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Unable to void (spinal cord injury)
Post-op Urethral obstructions/bypass Comfort care at end of life |
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What are some cultural considerations the nurse will need to know for urinary catheterization?
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Gender congruent care (same gender)
Presence of family member Privacy with draping/screens Do not allow opposite sex in room during procedure Professional, non-judgmental manner Interpreter |
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List signs of fluid volume deficit.
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Patient is “dry” – eyes, oral cavity, etc
↑ HR, ↓BP Oliguria/anuria, ↑ specific urine gravity (N= 1.010 – 1.030) |
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List signs of fluid volume excess.
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Fluid volume excess
Patient is “wet” – edema, excessive salivation Bounding pulse rate, BP normal, JVD ↓ urine specific gravity |
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What is an average urine output for an adult? At what point would the nurse become concerned?
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Adult- 1,000-2400 ml output/day
Of concern: < 30ml/hr for 2 hours |
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What position is most frequently used for female catheterization
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Dorsal Recumbent
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Why would a patient need a coudè catheter?
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Male with an enlarged prostrate – catheter has a curve at the end to pick up the extra tissue
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How are catheters measured?
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In "French," as in 14 French
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Why does a nurse need to consider allergies when administering a urinary catheter?
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Many are made of latex
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The bigger the number (in French), the (smaller/bigger) the size of the catheter.
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Bigger
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What type of solution is used for catheter care?
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Soap and water
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Where does the nurse begin the cleansing process on the catheter?
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At the meatus
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Why would some females be considered “males” when using a bladder scan?
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Females who have had a hysterectomy
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Why would a patient need continuous bladder irrigation (CBI)?
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To prevent the occlusion of the catheter by small clots or mucous after genitourinary surgery
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What type of fluid is used for CBI?
(continuous bladder irrigation) |
Normal Saline
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What assessments would the nurse make for a patient with a suprapubic catheter?
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Urine output, dressing, exit site, temperature
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According to the research by Robinson et al. (2007), which clients do not benefit from an indwelling catheter
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Clients who can not communicate the need to void
Clients who are incontinent Clients who are hemodynamically stable Clients with urinary retention that can be controlled by other methods |
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Discuss the indications for peritoneal dialysis.
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Acute or chronic renal failure
Electrolyte imbalances Toxic waste build-up Little or no urine output Fluid volume build-up |
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Describe the three phases of peritoneal dialysis.
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Inflow – infuse into abdomen
Dwell – time in abdomen Drain – drain out of abdomen |
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List the words used to describe urine when documenting.
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Clear
Cloudy Yellow Amber Bloody Visible clots Sediment/mucous Odorous Amount |
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Which statement is true regarding catheterization of a male client with an indwelling catheter?
A. insert catheter 1-2 inches and inflate balloon. B. clean technique is used for this procedure C. insert catheter to bifurcation of the catheter ports D. use a 10Fr size catheter |
C. insert catheter to bifurcation of the catheter ports
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List common causes of constipation.
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Irregular bowel habits
Ignoring urge Chronic illness (MS, Parkinson’s, depression, eating disorders, etc) ↓ fiber diet / ↓ fluid intake Stress Bedrest Medications Heavy laxative use Age (slowed peristalsis) Neurological conditions (spine injury, tumors) Organic illnesses (hypothyroidism, hypocalcemia, hypokalemia) |
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List symptoms of fecal impaction.
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Symptoms
Constipation Rectal discomfort Anorexia N/V Abdominal pain Diarrhea (around impaction) Urinary frequency |
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What complications can occur during excessive rectal manipulation?
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Complications
Bleeding from rectum Changes in baseline VS from stimulation of Vagus nerve Irritation of the mucosa |
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How far into the anal canal should the nurse insert the tip of the enema bag tubing or a commercially available product?
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Adult/Adolescent: 3-4 inches
Children: 2-3 inches Infant: 1 – 1.5 inches |
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What should the nurse do when a patient reports cramping during enema administration?
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Decrease height of enema bag
Slow rate Have patient take deep breaths in through nose and out through mouth |
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Differentiate between the different types of ostomies.
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1. Ileostomy: small intestine
More liquid drainage Must always be pouched 2. Sigmoid Colostomy: large intestine Semi-formed stool 3. Ileal conduit (urostomy) Uses piece of ileum for stoma Single or double ureterostomy One or both ureters are used as stomas 4. Continent urinary diversion Pouch is formed to hold urine internally Client catheterizes self several times a day |
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What color should a healthy stoma be?
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“Beefy” Red and Moist
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The physician has ordered a clean-voided urine specimen to be collected. The patient is capable of self-collection. What instructions will the nurse give to the patient regarding how to collect the specimen?
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1. Clean voided specimen
2. Using surgical asepsis, open collection kit and container – do not touch inside 3. Use cleansing towelettes to clean perineum -- circular (male) or downward (Females) motion to cleanse meatus 4. Collect middle of urine stream 5. Replace cap/clean 6. Label and give to the nurse |
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What is the significance of finding protein and ketones in the urine when using the dipstick method?
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1. Protein in the urine –
DM or other renal diseases 2. Ketones – Uncontrolled DM Anorexia Dehydration Prolonged vomiting |
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The nurse is about to do a throat culture on a patient. What important education should the nurse do with the patient before the procedure?
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1.Swab will take only a few seconds
2.Patient will need to tilt head back 3.Explain there may be a tickling or gagging sensation as the swab is placed in the throat |
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List signs and symptoms of hypoxia.
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Apprehension/Behavioral changes; Anxiety; ↓ LOC/Confusion; ↑ HR; ↑rate and depth of respirations; ↓ lung sounds; ↑ BP, then ↓ BP; Dyspnea; Use of accessory muscles; Cardiac dysrhythmias; Pallor/Cyanosis; ↑ fatigue; Dizziness; Clubbing of nails (prolonged hypoxia); Pulse Ox < 90%
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What are the safety guidelines that must be implemented with O2 therapy?
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1. O2 is a medication – do not adjust w/o an order
2. An “Oxygen in Use” sign must be posted on door and room or on door to client’s home 3. O2 delivery systems must be at least 10 ft from any open flames 4 O2 supports combustion but will not explode 5. No smoking 6. O2 cylinders: Must be secured to prevent falling; Stored upright or in appropriate holders; Be sure all electric equipment is functioning properly in the room and grounded – an electrical spark can result in a fire; Check O2 level of tanks before transporting |
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Discuss low flow (1-6 liters) delivery systems and the nursing interventions associated with them.
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Low flow: p.632
Nasal cannula 1-6L/min Simple face mask (FiO2 depends on Liter flow) – room air through side vents. Interventions: Positioning of delivery device Assessing flow meter and source (wall, tank) Skin integrity/ Need for humidification O2 saturation and s/s of hypoxia Respiratory assessment Client education/Safety precautions |
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Discuss high flow O2 (>6 liters) delivery systems and the nursing interventions associated with them.
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High flow p.632
Simple face mask ( higher levels of FiO2) Venturi mask(adjustable entrainment ports to control O2 concentration) Partial nonrebreather (Room air and CO2 can mix with pure O2) – has a reservoir bag Nonrebreather (one-way valves allow for more pure O2 inhalation – less CO2 and room air can mix in the bag with pure O2) – has a reservoir bag Face tent (fits under chin and around face) |
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A (partial non-rebreather / non-rebreather) has one-way valves.
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Non-rebreather
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A (partial non-rebreather / non-rebreather) has no valves.
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Partial Non-rebreather
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True or false - The interventions for high flow O2 delivery systems are the same as nasal cannula and simple face mask.
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True
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True or false - O2 delivery systems that involve masks should be used with clients known to retain CO2.
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False
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What types of devices are used to deliver O2 with an artificial airway?
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T-piece and tracheostomy collar?
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What is a T-piece?
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connects to an O2 source such as an Endotracheal (ET) tube or a tracheostomy p.636
Flow rate is 10 Liters/min with a nebulizer set |
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What is a tracheostomy collar?
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Tracheostomy collar – fits over the trach and straps around neck p.637
2 ports Exhalation O2 port Flow rate is 10 Liters/min with nebulizer set |
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What types of clients are likely to receive noninvasive ventilation?
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Clients with:
Neuromuscular diseases CHF Sleep disorders (obstructive sleep apnea) Chronic pulmonary diseases |
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Differentiate between BiPAP and CPAP.
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1. BiPAP (bilevel positive airway pressure)– provides assistance during inspiration (↑tidal volume) and prevents airway closure during expiration by keeping more air in the alveoli (increases residual capacity)
2. CPAP (continuous positive airway pressure) – preset positive airway pressure during inspiration and expiration (prevents upper airway collapse) and more continuous gas exchange – increases patient’s O2 level |
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What are some common problems with CPAP?
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Discomfort from mask and dry mucous membranes
Skin integrity disruption from tight fitting mask Difficult relationships with sleep partner Claustrophobia noise Hypercapnia – CO2 levels may rise from air trapping in alveoli Gastric distention from air into stomach May also impair diaphragmatic motion |
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According to the article by McGloin (2008) what complications can occur with high concentrations of O2?
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Decreased lung compliance caused by changes to the lung tissue (O2 toxicity)
Decrease surfactant production leading to atelectesis Non-compliance of patients due to discomfort Dry upper airway and nasal mucosa Additional complications Skin irritation or breakdown Continued hypoxia CO2 narcosis – stimulation to breathe is extinguished by high levels of O2 due to patient’s problems with ongoing CO2 retention |
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Identify the components of chest physiotherapy (CPT).
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Postural drainage
Chest percussion Vibration Shaking |
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What is postural drainage? (CPT)
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Component of CPT:
Gravitational clearance of airway secretions from specific bronchial segments by using different body positions |
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What is chest compression? (CPT)
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Component of CPT:
Clapping the chest wall with cupped hands Sets up vibrations to dislodge secretions |
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What is vibration? (CPT)
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Component of CPT:
Sustained contraction of the upper extremities of the caregiver Downward pressure and vibrating with flat palm of hand placed over area to be drained during exhalation |
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What is shaking? (CPT)
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Vigorous downward rocking motion with the flat part of the hand during exhalation on the area to be drained
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What is CPT indicated?
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Bronchitis
Asthma Cystic fibrosis Pneumonia Bronchiectasis Post-op |
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___ and ___ are very important to move secretions.
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Hydration and humidification
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Which patients would not be candidates for chest physiotherapy (CPT)?
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Clients with:
Head, neck, and spinal injuries until stabilized Any active bleeding Empyema (accumulation of pus in the pleural space) Pulmonary edema/pulmonary embolism Surgical wounds Risk for aspiration Rib fractures |
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List seven indicators for suctioning.
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1. excess oral secretions / drooling
2. gastric secretions or vomitus in mouth 3. coughing without clearing secretions 4. ↓ O2 sat / cyanosis 5. absent or diminished breath sounds 6. gurgling on inspiration/expiration 7. crackles |
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Describe assessments performed during and after suctioning.
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During and after suctioning
Observe respiratory status Rate/Rhythm HR Muscles used Breath sounds Effective cough Sputum characteristics O2 sat Observe client tolerance |
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Discuss worsening respiratory status that may occur during suctioning, how to recognize them, prevent them, and nursing interventions needed.
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Complications
Worsening respiratory distress ↓ O2 sat<90% or 5% from baseline ↑ RR ↑ HR>40 beats or ↓HR>20 ↓ LOC ↓ depth of breathing Behavioral changes ↑BP Dysrhythmias Prevention: proper suction technique (no longer than 10 seconds) Interventions: stop suctioning; apply O2; position change; notify physician |
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Discuss the complication of being unable to pass a catheter through nares at first attempt, and how to prevent this (include interventions).
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Complication
Unable to pass catheter through nares at first attempt Prevention: check client history for deviated septum or past complications Interventions Try other nares or oral route Insert nasal airway (trumpet) Apply suction if obstruction is mucous – do not suction blood clots ↑ lubrication |
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Discuss coughing paroxysms as a result of suctioning and what a nurse can do about them.
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Complication
Coughing Paroxysms (bronchospasm may be the cause) Prevention Proper technique Rest between passes Hyperoxygenate Interventions Apply supplemental O2 Rest between passes Consult with care provider for need for inhalers or topical anesthetics |
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What should a nurse do if no secretions are suctioned?
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Complication
No secretions Prevention Hydration Humidification of O2 Keep infection free Interventions Check fluid levels Assess for infection Chest physiotherapy if appropriate Humidify O2 |
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What should a nurse do if bloody secretions are suctioned?
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Complication
Return of bloody secretions Prevention Correct technique Correct suction pressure Frequent oral care Interventions ↓ suction pressure Intermittent suction and rotation Frequent oral care |
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Why is suctioning dangerous for a client with a head injury?
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Suctioning can cause ↑ in intracranial pressure (ICP), mean arterial pressure (MAP), and cerebral perfusion pressure (CPP)
Cerebral HTN can occur Delays of 10 minutes have been reported for return to hemodynamic and neurological stability Each suction pass ↑ risk for ↑ ICP |
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What are the advantages of “in-line” suction catheters?
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Minimizes infection in critically ill and immunosuppressed clients
Quicker lower airway suctioning No gloves or mask Does not interfere with ventilation/oxygenation Nurse is protected from secretions |
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Define a tracheostomy and why it is performed.
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Tracheostomy: insertion of a tube directly into the trachea through a small incision in the neck
Reasons: Relieve airway obstruction Mechanical ventilation Easy access for secretion removal Protect airway from gross aspiration in impaired cough and gag reflexes |
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What are some indications for tracheostomy tube cuff inflation?
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Mechanical ventilation
Prevent aspiration of gastric secretions |
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What are some care requirements for patients with a trachesotomy tube?
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Site assessment
Equipment necessary / disposal Complications of suctioning and interventions Proper securing of tube Cuff inflation Dressing changes S/S to report Oral hygiene Communication methods |
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What solution is used when cleaning the site of a tracheostomy tube?
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Normal saline
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Describe what happens when negative pressure is disrupted within the pleural space and the rationale for chest tube insertion.
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Air, blood, or fluid leaks into the intrapleural space creating positive pressure which collapses the lung tissue
Chest tube is inserted to remove the air, blood, or fluid from the pleural space Pneumothorax Tension Pneumothorax Hemothorax Hemopneumothorax |
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Define tension pneumothorax and how this complication would be recognized and treated.
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Tension pneumothorax: air is drawn into the lung through a rupture or small hole in the chest wall – air accumulates more rapidly than it is removed
↑ tension causes lung to collapse and the heart, great vessels and the trachea to shift to the unaffected side s/s: air hunger, agitation, hypoxemia, central cyanosis, absence of breath sounds, chest pain, profuse diaphoresis, ↓BP, ↑HR Tx: Insertion of chest tube |
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What are the components of a closed chest drainage system?
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1. Water seal system/ water for suction
Purpose is to allow air to exit the pleural cavity on exhalation and prevent air from entering the pleural cavity on inhalation (add water prior to use) 2. Waterless Water seal is replaced by a valve 3. Dry suction No water added for suction Has a water seal incorporated into the system; no need to add water |
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How can you tell that there is an “air leak” in a closed chest drainage system?
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terless system
Constant left to right bubbling or violent rocking in air leak indicator Water seal system and dry suction system Continuous bubbling in water seal chamber Bubbling is normal for first few minutes after insertion due to air in system – should stop after a few minutes |
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Identify the location of chest tube placement for the removal of air/fluid.
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1. Air (high placement)
2nd or 3rd intercostal space and anterior chest because air rises – little or no drainage 2. Fluid (low placement) 5th or 6th intercostal space and posterior or lateral because gravity pulls fluid down |
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What are the nursing responsibilities associated with chest tube insertion?
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Insertion (chest tube drainage container, chest tube, anesthetic, gloves, clamps, Sterile H2O/NS, syringe)
Pre-medicate if ordered Psychological support Education Position patient Display anesthetic label to MD and hold bottle Help attach drainage tube to chest tube and check all connections Respiratory assessment |
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What are the nursing responsibilities associated with chest tube removal?
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Removal (suture set, sterile scissors/forceps, sterile gloves, clean gloves, mask, petroleum gauze, ABD pad, tape
Pre-medicate if needed Education Position client at edge of bed, supine, or on unaffected side **Tell client to take a deep breath and hold during removal Prepare occlusive dressing for airtight seal Firmly secure dressing Reposition client Post-procedure assessment |
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Describe the components of a complete assessment in a patient with a chest tube.
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VS
O2sat Pain level (chest or otherwise) Mental status Breath sounds Skin color Work of breathing (rate, depth, regularity, accessory muscles, symmetry) Check meds for anticoagulants and allergies (skin, latex) Check: Patient positioning Site/dressing: may have some subcutaneous emphysema/air pockets around site Tubing – may need to be “lifted” to drain Drainage system (must be below insertion site) Air leaks |
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Mnemonic for Assessing Chest Tubes.
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FOCA:
1. Fluctuations Spontaneously breathing: up on inhale and down on exhale 2. Output - amount 3. Characteristics of output 4. Air leak |
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Mnemonic for Chest Tube problems
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DOPE:
Dislodgement Obstruction Pneumothorax Equipment failure |
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Describe the components of a complete assessment in a patient with a chest tube.
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Immediately apply pressure over insertion site
Have assistant place petroleum gauze over site and tape 3 sides (prevents spontaneous closure) Assess patient (VS, Respiratory assessment) Notify MD |
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When reporting to the surgeon that a chest tube is malfunctioning, the nurse is ordered to reposition the tube and obtain a Chest x-ray. The nurse should:
A. Turn off the suction, remove the dressing, and reposition the chest tube B. Clamp the tubing, remove the dressing, and reposition the chest tube C. Inform the physician this is not within a nurse’s scope of practice D. Report the surgeon to the nursing supervisor |
C – not within the scope of nursing practice
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While assessing the exit site of a chest tube, the nurse feels a crackling sensation under the fingertips along the incision line. Which of the following should be the nurses’ first reaction?
a. Lower the HOB and call the MD b. Prepare an aspiration tray c. Mark the area with a skin pencil d. Turn off the suction of the drainage system |
C – mark with a pen - the crackling sensation is subcutaneous emphysema or air pockets which are normal around the edge of the insertion site
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A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water seal chest tube drainage system. The nurse notes that the fluid in the water seal chamber is fluctuating with each breath. What does this mean?
A. an obstruction is present B. the client is developing sir pockets C. The system is functioning properly D. There is a leak in the system |
C –
No fluctuations would indicate an obstruction Continuous bubbling would indicate an air leak |
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Immediately following the insertion of a chest tube, the nurse should do a complete patient assessment according to which of the following schedules:
A. every 4 hours B. every hour x 4 hours C. every 30 minutes x 2 hours D. every 15 minutes X 2 hours |
D – standard post-operative procedure
Every 15 minutes for 2 hours |
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The nurse is performing a skin assessment on a patient who is lying supine in bed. The nurse is aware that which of the following bony prominences are at a high risk for skin breakdown in this position:(Check all that Apply)
1. elbows 2. Knees 3. Spinous Processes 4. Occiput 5. Heels 6. Trochanter 7. Coccyx 8. Chin |
1. Elbows
3. Spinous Processes 4. Occiput 5. Heels 7. Coccyx |
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In which position can the trochanter and malleolus be at high risk for skin breakdown?
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Lateral
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Identify the risk factors for developing pressure ulcers. (Check all that apply)
1. Shearing 4. Confusion 2. Nutritional status 5. Friction 3. Incontinence 6. Immobility |
All of the above
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What does the Braden scale assess?
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Risk for pressure ulcers/sores
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How does one assess scores on the Braden scale?
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The higher the score the better
Lowest possible score is 6 Highest possible score is 23 Risk assessments based on score 23 – minimal or no risk ≤ 16 – at risk ≤ 9 – high risk |
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What are the components of the Braden scale?
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Sensory Mental – higher level of impairment
Moisture – incontinence and other sources of moisture Activity – bedrest Mobility – dimished ability to move Nutrition – poor nutrition Friction/Shearing - inability to reposition self in bed |
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What are the characteristics of a stage 1 pressure ulcer?
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Skin intact
Non-blanchable redness May be painful, firm, soft, warmer or cooler Difficult to observe on patients with dark skin tone |
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What are the characteristics of a stage 2 pressure ulcer?
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“partial-thickness” loss
Shallow open ulcer Bed red-pink May be open/ruptured serum-filled blister DO NOT use this classification for other wounds (skin tears, tape burn, etc) |
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What are the characteristics of a stage 3 pressure ulcer?
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“full-thickness” skin loss
sub-q fat may be visible May see sloughing (dead tissue separating from a wound) |
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What are the characteristics of a stage 4 pressure ulcer?
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Similar to Stage 3 BUT has exposed bone, tendon or muscle
Undermining and tunneling Risk for osteomyelitis (bone infection) |
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What are the characteristics of an unstagable pressure ulcer?
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Full thickness loss
Covered by slough and/or eschar Cannot assess true depth until slough/eschar removed |
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What are the characteristics of a deep tissue injury?
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Variant form of pressure ulcer
May be sign of developing Stage III or IV ulcer Purple or maroon color Skin intact Prior to color change may be painful, firm and “boggy” Difficult to detect on patients with dark skin tones |
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How often should a nurse assess pressure risk in acute care, long-term care, or home care?
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1. Acute care
Admission Daily basis Change in condition 2. Long-term care Admission Weekly x 4 weeks Quarterly basis Change in condition 3. Home care Admission Every visit by RN |
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How should pressure ulcers be assessed in patients with darker skin?
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Skin color changes
Color is darker than surrounding skin Assess for edema, firmness Assess sensation Assess for pain Skin temperature |
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How can pressure ulcers be prevented (nursing interventions)?
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Assess risk on a regular basis
Identify individual risk factors Inspect skin daily Treat incontinence Use skin barrier Use absorbent underpads Use turning sheets or devices HOB ↓ 30° T+P Q2hrs Pressure reduction mattress Raise heels Maintain adequate nutrition Patient education (causes/risk factors) |
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What is the difference between a pressure relieving device and a pressure reducing device?
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1. Pressure relieving
Removing pressure from area Ex: elevating heels with a pillow Ex: 30° lateral position 2. Pressure reduction Reducing the pressure to an area Ex: air mattress, pillows Ex: HOB↑ 30° or less |
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What are the treatment options for a stage 1 pressure ulcer?
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Stage I
Transparent dressing Nothing Hydrocolloid Turning schedule Nutrition Pressure-reduction mattress |
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What are the treatment options for a stage 2 pressure ulcer?
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Stage II
Hydrocolloid Hydrogel Manage incontinence Treatment options for stage 1 |
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What are the treatment options for a stage 3 pressure ulcer?
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Stage III
Hydrocolloid Hydrogel foam Ca+ alginate Gauze (W→D) Growth factors (use with gauze) |
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What are the treatment options for a stage 4 pressure ulcer?
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Stage IV
1. Hydrogel 2. Ca+ alginate 3. If eschar present: Gauze Growth factors Adherent film Hydrocolloid Gauze with ordered solution Enzymes No treatment – eschar used as covering Debridement |
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List the systemic factors that affect wound healing.
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Tissue perfusion and oxygenation
Nutritional status Infection DM Steroid therapy Chemotherapy or radiation Age Stress (psychological or physiological) Immunosuppression Blood disorders Systemic illnesses: renal or liver disease, sepsis, cancer |
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A client has a large pressure ulcer on his lower extremity. The nurse instructs the client about the nutrients necessary for healing, especially Vitamin C and protein. When evaluating the client’s intake, the nurse determines that instruction was successful when client is eating which of the following breakfasts?
A. coffee, buttered toast with jelly, and bacon B. milk, scrambled eggs, and cantaloupe C. pancakes with butter and syrup, hot tea D. oatmeal with milk, coffee, and bacon |
B. milk, scrambled eggs, and cantaloupe
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Describe how a full-thickness wound heals.
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1. Hemostasis phase: blood vessels constrict; clotting occurs
2. Inflammatory stage (3 days): vasodilation (allows blood cells to come in); leukocytes (clean-up); macrophages (start healing process) 3. Proliferative stage (2-3 weeks): epithelialization 4. Remodeling phase (up to 1 year): collagen; scar formation |
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What are the signs of infection in a surgical wound with sutures?
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Signs of infection
Redness Swelling Drainage |
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What are the advantage and disadvantages with using staples to close a surgical wound?
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Advantages:
Quicker to insert Less risk of infection Less tissue reaction than sutures Disadvantages: Difficult to align edges More expensive Can’t be used on some areas (hands, face, neck) |
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What are the main categories of surgical wound complications?
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Infection
Dehiscence Evisceration |
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What is dehiscence?
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Surgical wound separation (wound comes apart)
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When is a surgical wound at greatest risk for dehiscence?
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First 2 weeks after surgery/post-op
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If a surgical wound comes apart (dehiscence), what are the primary interventions a nurse should take?
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Dress the wound (sterile) & contact the physician
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How can wound dehiscence be avoided?
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Splinting incision
Abdominal binder Prevent constipation |
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What is evisceration?
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Wound opens and internal organs exit
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What are the possible causes of evisceration? What are the primary interventions?
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May be due to wound hematomas, excessive abdominal pressure (coughing, vomiting, etc)
More common in patients with diabetes, cancer and those taking steroids Notify physician Cover wound with sterile saline soaked gauze Treatment: surgical repair (most often) |
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What is a Jackson Pratt Drain?
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Inserted during surgery via a separate “stab wound” near the surgical incision
Allows drainage of blood, etc from a surgical site to promote healing |
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What is a Penrose Drain?
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Soft rubber tubing
Inserted via incision or separate stab wound Allows drainage from wound bed Drainage leaks along outside of drain LIP pulls back short distance daily until removed |
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What piece of equipment is recommended for high pressure irrigation of a wound?
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Irrigation pressure – 4-15 psi with a 35ml syringe and 19 gauge catheter
Cleanse from least contaminated to most contaminated |
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A nurse is assessing a wound and finds slough in the wound. Which of the following colors would the nurse most likely document as the color of the slough?
A. Black/brown B. Creamy/Yellow C. Red D. Purple |
B. Creamy/Yellow
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What are some cultural considerations for caring for patients with wounds?
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Meaning of words “blood” and “secretions”
Muslims and Hindus – blood is “dirty” Asians – blood is life force and losing blood could mean losing life Some Africans – negative reaction towards blood is disrespectful Recognize family members in education Arabic families – usually one family member at bedside at all times Remind patients to avoid home remedies and practices |
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What is the purpose of a Wet→Dry dressing?
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Mechanically debrides a wound
Moistened gauze ↑ability of dressing to collect exudate and wound debris Inner dressing covered with a dry outer dressing As the dry gauze is pulled from the wound, tissue that adhered to it is removed |
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What are the types of wound drainage?
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Serous – clear
Sanguineous or bright red – fresh bleeding Serosanguineous – pink Purulent – thick and yellow, pale green, or white |
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What problems are associated with wounds requiring debridement?
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Irritating solutions
Wound becomes dry Wound is deep and retention of packing can occur (Use a long strip of gauze in deep wounds) Wound drainage can damage normal tissue Tape irritation |
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When should a nurse use Montgomery ties?
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To support wound
Ensure stability and placement of dressing Frequent dressing changes |
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When should transparent dressings be used to dress a wound?
|
To manage superficial wounds
For autolytic debridement Protection from friction or sheer Stage 1 or II For use on clean, debrided, non-bleeding wounds |
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When should a nurse consider using a hydrocolloid dressing?
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Stages I –IV
Autolytic debriding Maintaining a moist environment Protecting high friction areas Infected wounds Wounds with dry eschar Providing absorption of minimal/moderate exudates – can be used with alginate or absorbent powders |
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What are the advantages of using a wound vacuum for acute and chronic wounds?
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Speeds healing
Promotes formulation of granulation tissue Uses negative pressure to remove fluid/increase perfusion Reduces bacterial counts Improved patient comfort Reduces number of dressing changes Highly effective with diabetic patients |
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What is “Wound Vac”?
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VAC (Vacuum Assisted Closure)
Also known as “NPWT” (Negative Pressure Wound Therapy) |
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What are the therapeutic benefits of continuous compression therapy?
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1. Increased return of venous blood to the central circulation
2. Venous insufficiency Decrease venous hypertension Stimulation of fibrinolysis Increased local O2 3. Support varicosities 4. Reduction of local edema |
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What are the key points in applying ACE wraps?
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Start distally and wrap toward body
Avoid wrinkles Overlap previous by ½ to 2/3 bandage width Use “figure 8” dressing around joints Secure with clip, tape or velcro Assess distal CSM (circulation, sensation and movement) after application and periodically while ace wrap in place |
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What is the purpose of an abdominal binder?
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Supports large abdominal incisions vulnerable to tension or stress
Underlying muscles Large incisions |
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What conditions increase the risk of injury from warm and cold application?
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Areas with little body fat
Open wounds/broken skin/stomas Areas of edema Areas with immature scar tissue Peripheral vascular disease (Diabetes, Arteriosclerosis) Confusion or unconsciousness Spinal cord injury Tooth abscess Inflamed appendix |
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What are systemic responses to heat and cold?
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Systemic responses
Heat-loss mechanisms: sweating & vasodilation Heat conservation: vasoconstriction & piloerection (“goosebumps”) Heat production: shivering |
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What are local responses to heat and cold?
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Local responses – stimulation of temperature sensitive nerve endings in skin
Pain & burning sensation (when temp >1130 F) Cold produces numbing sensation before pain |
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What are the effects of heat application?
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Improves blood flow to injured part
If applied >1 hour, body will reduce blood flow (reflex vasoconstriction to control heat loss) Continuous exposure to heat results in cell damage (redness, tenderness, blistering) |
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What are the effects of cold application?
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Initially diminishes swelling and pain
Prolonged exposure results in reflex vasodilation May lead to tissue ischemia |
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What is the most effective way to obtain a wound culture?
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1. Apply sterile gloves
2. Remove swab from culture and insert into wound drainage area and rotate gently – aerobic culture Anaerobic culture – insert swab deeply into drainage area and rotate 3. Return swab to culture medium – crack open medium if indicated 4. Label and send to lab |
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Where should a chest tube be placed for air removal?
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For air removal, the tube is placed in 2nd or 3rd intercostal space on the anterior chest because air rises.
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Where should a chest tube be placed for fluid removal?
|
For fluid removal, it is a low placement in the 5th or 6th intercostal space. Gravity pulls fluid down
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What does crackling along the incision of a chest tube mean?
|
This is sub-q emphysema or air pockets which are normal around the edge of the insertion site
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How much water should the water seal and the pressure chamber hold for a chest tube device?
|
The water seal should hold 2mL, and the pressure control chamber should hold 20mL
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How often should a patient be assessed after insertion of a chest tube?
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Assess PT every 15 minutes for 2 hours immediately after insertion of tube.
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How often should an 'ostomy' bag be emptied?
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Always empty the bag (urine and fecal) when it is 1/3-1/2 full to prevent overfilling and pouch rupture.
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When performing fecal disimpaction, why should the patient be checked for history of heart disease?
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Precautions: check PT for history of cardiac disease as digital disimpaction may cause arrhythmias. Monitor PT for signs of fatigue and pulse. Allow rest periods during procedure.
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How should fecal disimpaction be performed on an adult client?
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• Skill: put PT on L side-lying, double glove, lube fingers, PT takes slow deep breaths. Put one finger in and move around in a circle to loosen the stool off the wall. Press stomache tward you and break apart feces if possible. Remove feces an place in bedpan. Provide perineal care and ensure comfort. If PT still does not go, the impaction is too high up and we will need to use an irrigating enema solution
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How should an enema be performed on an adult client and a child?
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Place lubricated tube 3-4 inches into anus for adults toward the umbilicus, 2-3 inches for children. Hang the enema bag full of warm solution12-18 inches up above PT. Can use castile soap suds enema or may be medicated solution, or hypertonic solution to draw water into the colon, hypotonic or isotonic to soften stool, soapsuds irritate the mucosa, oils lubricate stool and membrane.
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What should the nurse do if a client reports cramping during an enema?
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If PT reports cramping during administration, decrease the height of the enema bag, slow the rate, and have PT take deep breaths in through the nose and out through the mouth
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True or false - when inserting a catheter in a male client, stop immediately upon hitting urine.
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False - once urine is reached, go a little further.
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What is the procedure for collecting specimens from a Foley/indwelling catheter?
|
Clamp the tubing 30 minutes prior to collection. There is a blue port on the drainage bag tubing near war cath is attached for urine specimen collection. Cleanse the port with alcohol, may need to remove specimen with a syringe needle or if the port is needleless, attach syringe and remove specimen
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Why are indwelling catheters irrigated after genitourinary surgery?
|
Continuous bladder irrigations with isotonic normal saline are used to prevent the occlusion of the catheter by small clots or mucous after genitourinary surgery.
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How should a Foley be irrigated if clogged?
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Pour NS into sterile graduate, draw up with a cath tipped syringe as ordered 30-60mL. Inject saline slowly and reattach cath to tubing. Document saline as intake via Foley. May drain solution after instillation into a sterile basin, inject more solution, drain, until obstruction is cleared (blood clot, mucous thread etc.)
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What is the purpose of Guaiac test? How is it performed?
|
• Occult blood in stools: Guaiac test: take a piece of non bloody stool with a wooden swab and wipe on hemoccult box. Put 2 drops of solution on the opposite side of the stool box. Heme negative will not turn blue. Also perform a QC control test and document results. If it turns blue, it is Guaiac positive.
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What is the significance of red/black/white stool?
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Colors: if feces if bright red, it is from blood in the rectum, low. If it is black, there is bleeding higher up. If it is white, there is a bile duct problem
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What are the procedural guidelines for measuring urine for glucose, ketones, blood, protein, and pH?
|
Procedural guidelines: If measuring the urine for glucose, ketones, protein, blood, and pH, do NOT use the first voided specimen of the day. Have PT void, give water, than collect specimen in 30-45 minutes. Dip a strip into the urine and remove quickly, place on a paper towel and read strip after waiting for it to season—not all tests are read at the same time. Most range from 60-120 second.
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How should throat cultures be performed around meals?
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Perform either ONE HOUR BEFORE of ONE HOUR AFTER meals
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Do you want to drain more or less than the amount of fluid you infuse when dialyzing a patient? Why?
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You should drain more than you infuse because urine is made and left in the peritoneal cavity, so we will be draining that as well, not just inflow.
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What is the purpose of incentive spirometry?
|
Incentive spirometry: to assist PT with deep breathing. Used after abdominal/thoracic surgery to reduce postop atelectasis or postop pneumonia.
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What is the technique for using an incentive spirometer?
|
Technique-PT exhales through mouth, applies spirometer, takes a slow deep breath, holds breath for at least three seconds at max inspiration, and then exhales normally. Coughing and deep breathing in betweehn. Repeat.
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How often should an incentive spirometer be used?
|
Perform 5-10 times followed with controlled coughing every waking hour or as directed.
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What are some considerations for COPD clients when performing incentive spirometry?
|
Some COPD PTs can only hold breath 2-3 seconds. Allow rest between incentive spirometry breaths to prevent hyperventilation and fatigue
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What are the considerations for type of O2 Delivery?
|
Type of O2 delivery based on severity of hypoxia and disease, age, health and orientation, artificial airway, environment, discharge care.
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What is a nasal cannula (O2 delivery)?
|
Nasal cannula: short term and long term, cheap and disposable, easy. Low flow--1-6 L/min. Higher flow rate dries mucosa and does not increase FIO2 (fraction of inspired O2)
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What is a face mask (for O2 delivery)?
|
Face mask: short term. 30-60% O2 concentrations. Contraindicated for PTs with CO2 retention.
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Describe a Venturi mask.
|
Venturi mask: delivers more precise concentration of O2, Cone shaped with entrainment ports. 24-60%
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What is a face tent and when is it used?
|
Face tent: shield like device under chin and around face. Used for humidification and O2 only when tight fitting mask not tolerated. Cannot estimate amount of O2 delivery, so used more for humidification only
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What are O2 hoods or tents?
|
O2 hoods or tents: for pedi PTs. Give high concentrations of humidified O2. (Epiglottitis/croup, URI)
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What is a non-rebreathing mask?
|
Nonrebreathing mask: does not allow exhaled air to be rebreathed—valves on side close during inhalation so only getting O2 from the bag, no room air. Bag is 100% full. If this does not get the PTs pulse ox to normal, put on ventilator or intubation.
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What is a partial rebreathing mask?
|
Partial rebreathing mask: has a bag that is partially full. Holes in the side of mask remain open so PT gets room air
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What is non-invasive ventilation? What types are there?
|
Noninvasive ventilation (NIV)—CPAP and BiPAP: for PTs with CHF, sleep disorders, neuromuscular diseases, and chronic pulmonary diseases.
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When can "medical air" be used with a patient?
|
Never hook a PT up to “medical air”—this may be anesthesia or nitrous oxide, which will kill the PT is inhaled for a period of time (NOT O2).
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How often should a O2 cannula or face mask be checked?
|
Check cannula/mask every 8 hours. Keep humidification container filled at all times (O2 is a dry gas so must be humidified)
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Why should a trach tube constantly be humidified?
|
PTs with artificial airway require constant airway humidification because air bypasses nose and mouth.
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What is the progression of O2 delivery devices from least invasive to most invasive?
|
PT flow between O2 devices if worsening: nasal cannula (low dose)=>simple face mask=>venti venturi=>partial non-rebreather=>100% non-rebreather=>mechanical ventilation
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|
This type of ventilation involves continuous positive airway pressure that maintains a set positive airway pressure during inspiration and expiration. Good for obstructive sleep apnea or acute COPD.
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CPAP
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This type of ventilation involves bilevel positive airway pressure. Face mask. Provides assistance during inspiration and prevents closure during expiration. The level of pressure is higher during inspiration to force air into the lungs and lower during expiration. Ie: Different pressure modes for inspiration and expiration.
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BIPAP
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What is the protocol for checking ABGs with a COPD patient receiving non-invasive ventilation (CPAP or BIPAP)?
|
Check ABG levels to monitor for CO2 retention—In COPD PTs, obtain ABG after 1st hour and every 2-6hrs the first day or use.
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|
How much NIV is generally recommended?
|
6-8 hours of continual NIV often recommended. During bedtime or TV is a good time.
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What is oropharyngeal suctioning?
|
Oropharyngeal suctioning removes secretions from the back of the throat
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When is oropharyngeal suctioning indicated?
|
For PTs who have had maxillofacial surgery, mouth trauma, neurovascular injury and cerebrovascular accident causing hemiparesis and drooling/impaired swallowing. And who are experiencing excess oral secretions, drooling, vomitus, coughing without clearing, decreased O2 sat or cyanosis, absent or diminished breath sounds, gurgling, crackles.
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What is the procedure for oropharyngeal suctioning?
|
Assess patient. Auscultate for adventitious lung sounds (gurgling, rhonchi/ wet sounds). Sit PT upright or in semi fowlers, drape neck, clean gloves, mask/face shield if splashing likely, fill cup with 100 mL of H20 or N2, connect tubing to suction machine and Yankauer cath, turn on, test by suctioning NS, remove O2 mask from PT, keep it near the face
*Be prepared to reapply O2 if SpO2 falls below 90% or respiratory distress develops. Insert cath into mouth along gum line to pharynx, move cath around the mouth, encourage coughing, replace O2. Rinse cath with NS to clear tubing of secretions, turn off. Wash PTs face if soiled. Observe respiratory status, repeat procedure if necessary. If status not improved, continue to tracheal airway suctioning. |
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What sort of device should be used for oropharyngeal suctioning?
|
Yankauer or tonsillar tip device with a bulbous tip.
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What is the proper technique for nasopharyngeal suctioning?
|
• Proper Technique: Cannot delegate to NAP unless PT is stable with a trach. May use a lubricated nasal trumpet/nasopharyngeal airway (NPA) to avoid trauma to nose or if the PT has a deviated septum. Insert cath 20cm/ 8 inches, and suction with 100-150mm Hg while removing the cath fro mthe trachea. 10 seconds maximum. STERILE!
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What is the proper method for performing tracheostomy care?
|
Sterile procedure. Clean gloves to remove old trach dressing. Clean stoma and trach cuff with NS from inside to out. Dry area.Remove old cannula and dispose, or clean in a sterile basin with hydrogen peroxide/NS mixture, scrub with brushes, rinse in NS, dry with pipe cleaners. Or insert new cannula. To change a cuff, have a partner hold the trach in place so it does not dislodge, remove old tie, clean and dry the neck, and replace with new tie. Replace the gauze dressing.
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