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138 Cards in this Set

  • Front
  • Back
Three reasons baths are important
Decrease the likelihood of infections

Promote effective circulation through moving patient around in bed and rubbing skin with washcloth

gives you an opportunity to assess the patient in depth
Order of baths
Cleanest to dirtiest (usually head to toe)

Perineal care always last
Disuse
A state of decreased or absent use of an organ or bady part
Immobility
The innability to move the whole body or body part
How quickly can the effects of immobility/disuse on body systems occur?
Can begin within 48 hours of innactivy
Atrophy
Decrease in size of a tissue or organ due to inactivity
Contractures
Abnormal shortening of a muscle that causes resistance to stretching and eventually, if not managed, a state of permanent flexion
Calcium Resorption/Disuse Osteoporosis
Demineralization of bones that makes them brittle and easily fractured.

Occurs with age, but is accelerated by prolonged immobility.
Shear
The pressure exerted against the skin in a direct parallel to the body surface. Commonly occurs when the patient slides down while in a semi-Fowler position.
Friction
Mechanical irritation to the skin that occurs when it is "dragged" across a course or rough surface. The epidermal layer of the skin is rubbed off.
Excoriation
A general term for damage to the epidermis (scratch, abrasion)
Maceration
Softening of the skin due to prolonged contact with water.
Does the cardiovascular load increase or decrease when a patient is on bedrest?
Increase.

-related to the effects of the heart having to push blood against gravity
Valsalva's Maneuver
Pushing/straining with mouth closed and breath held stimulates the vagus nerve causing reflex bradycardia which can result in fainting or worse.
(Straining against closed glottis)
Orthostatic Hypotension
(also called Orthostatic Intolerance)
a drop in systolic 15 mmHg or more
or
a drop in diastolic 10 mmHg or more

AND
an increase in heart rate of 15%

when the patient goes from supine to standing.
- tendency is exacerbated by immobility.
Venous stasis
Slow stagnant blood flow in the veins of the lower extremities. Increases liklihood for DVT.
What percent of hospital patients are at risk for Deep Vein Thrombosis?
50%
Stationary Clot
Thrombus
Clot travelling through the circulatory system
embolus
Important positioning aids for the nurse
Frequency of turning (every 1-2 hours)
Decreasing friction and shear
Draw sheet for lifting
Trapeze
Keep head of bed low to prevent sliding down
Footboard: maintain dorsiflexion
Trochanter roll: prevents external rotation of hip
High Fowler's
60-90 degree elevation
Semi Fowler's
45 degree elevation
Low Fowler's
30 degree elevation
Trendelenberg
entire fram of bed tilted with feet higher than bed.
Used for shock or to facilitate lung drainage.
Reverse Trendelenberg
Entire bed frame on slant with head higher than feet.

Promotes gastric emptying and prevention of acid reflu into the esophagus
Supine
Flat on back

-Also called dorsal recumbant
Prone
flat on stomach, face down
Sims
one side but further toward prone. One leg over the other. Can be Sims left lateral or Sims right lateral. Sims left lateral used for enema administration
Single best way to prevent the transmission of MOs between individuals
Proper hand hygiene
Rub with alcohol based waterless hand rub for how long?
15-30 seconds
When do you wear gloves?
To avoid direct contact with infectious material and as a second line of defense.
Standard Precautions
-Used with every patient.
Include: hand hygiene before and after patient contact, barrier precautions (gloves, gowns, eye protection) proper disposal of sharps and biohazard waste.
Restraints
Devices used for medical reasons that limit movement ONLY to the extent needed for proper treatment.
Do restraints require a physician's order?
Yes, and they can not be PRN for more than 24 hours without a new order being written.
Graded Compression Stockings
TED hose- used to help prevent venous stasis and thrombi in the lower extremities
Sequential Pneumatic Compression Devices
plastic sleeves containing air bladders and connected to an electric air pump.
Also used to prevent venous stasis
Body Mechanics for Nurses

(Nurses have the 2nd highest occupational incidence of back injuries.)
-Get help (or hydraulic lift, gait belt, etc)
-Keep straight, and back, neck, pelvis and feet aligned
-Flex knees and kep feet wide
-Use arms and legs, not back
-Tighten your abs and glutes
-Count to 3 to coordinate the lift
-Lower bed to comfortable position for you
Three basic reasons for hospital patient to exercise:
1. Maintain Stregth

2. Preserve ROM

3. Prevent Venous Stasus
Flexion
Bending a joint in the natural position of movement
Extension
Moving from a flexed to a straight or neutral position
Rotation
Pivoting on axis
Abduction
Movement of limb away from midline of body
Adduction
Toward midline of body
Supination
Rotation of palm anterior (upward)
Pronation
Rotation of palm posterior (downward)
Plantar Flexion
Flexion of ankle toward floor
Dorsi Flexion
Flexion of ankle toward knee
eversion
Movement of ankle away from midline
inversion
movement of ankle toward midline
circumduction
to move in a circle
Factors affecting mobility
Quadriplegia
Quadriparesis
Paraplegia
Paraparesis
Hemiplegia
Hemiparesis
Safety when moving a patient
-Put bed in lowest position.
-Lock wheels on wheelchair
-Allow to "dangle" when helping to sit. (helps prvnt Orthostatic Hypotension)
-Apply gait belt if needed
-Have pt push down on bed
-Place pivot foot closes to chair
-Have pt reach for chair arms
Six Rights
Right medication
Right Dose
Right Patient
Right Route
Right Time
Right Documentatin
Nine Routes
Oral (po)
Sublingual (s.l.)
Buccal
Topical
Otic (AD - right ear, AS- left ear, AU- both ears)
Ophthamalic (OD - right eye, OS left eye, OU both eyes)
Rectal (p.r.)
Inhalation
Parenteral
Parenteral Routes
Intradermal (ID) - given within the dermis. Usually used for immunologic testing rather than medication delivery.
Subcutaneous (SC or SQ) - shallow injection.
Intramuscular - IM
Intravenous (IV) - bolus or push
What gauge syringe for Subcutaneous injections?
25 gauge or less, 3/8 - 5/8 inches long
What's the most you can give in a single injection in the SubQ route?
1.5 mL

(only 1/2 to 1 mL in the deltoid)
What type of insulin can be delivered Subcutaneously or intravenously?
Only Regular Insulin

- All other insulin can only be given subcutaneously. (or rarely in some types, by inhalation)
What guage syringe for intradermal injections?
25-27 gauge
What guage for IM injections?
21-23 gauge, 1 - 1.5 inches long
Injection Sites
Ventrogluteal (preferred for IM) ok for children >7 mos

Deltoid

Vastus Lateralis (Recommended for children <7 mos)

Dorsogluteal (NEVER for children <3)
Z-track Technique
Always used for IM injections which are irritating or stain the skin (ie iron). Seals the medication in the intramuscular tissues. Use a deep muscle site such as ventrogluteal. Then change needle after drawing up med, pull the overlying skin and subQ tissue 1-1 1/2" to the side, hold it there, aspirate, then inject slowly (10 sec/mL) Count to 10 before removing needle. Release skin you pulled to the side AFTER w/drawing needle. Don't massage the site.
How many mg are in one grain?
60
Weight gain does not always mean obesity; it can also indicate
fluid retention
Some physical signs of malnutrition:
Skin scaling, poor wound healing, brittle nails

Pale oral mucosa/conjunctiva may indicate anemia

Weight for height/ Rapid weight changes

I&O
NPO
"Nothing by Mouth"

Small sips of water and small amounts of crushed ice are sometimes permitted.

Standard IV solutions cantaining 5% glucose contain 170kcal/L, so 1L/8hrs = 510 kcal/day. If NPO is prolonged, special measures need to be taken.
Clear liquid
Liquids that are clear and have no solid particles AT BODY TEMP. Apple juice, ginger ale, coffee, tea, plain jello, bouillon, popsicles. Usually patients are on this diet just long enough to be sure they can tolerate food. Provides few calories and nutrients.
Full liquid Diet
It is possible to provide a nutritionally adequate intake over time with this diet. Clear liquid diet + custard, pudding, ice cream, plain soups and all juices.
Soft/mechanical soft-foods easily chewed and swallowed Diet
Even if the patient has no teeth. Low in fiber, no nuts, raw fruits/ vegetables, etc.
Meats are often ground or pureed. Yum.
Low Sodium Diet
Necessary for some heart, kidney or liver patients because high sodium intake promotes fluid retention. Sodium can be restricted to about 2 G per day just by not using salt shaker in cooking or at table along with food with obvious salt (like pretzels)
Renal Diet
Protein, sodium and potassium are restricted. Kidney loses ability to regulate products of protein breakdown.
Diabetic Diet
Calories need to be strictly limited to prescribed level based on patient's weight and activity level to minimize dependence on insulin injections.
What must the patient be able to do in order for enteral feedings?
Digest and absorb nutrients
NG tubes
Nosogastric. Used for suctioning out stomach contents. CAN be used for feeding, but aren't ideal, bc their diameter is so large that they are uncomfortable. "Large-bore"
Types of feeding tubes:
Small bore feeding tubes inserted through nose into either:

a. stomach (small-bore nasogastric feeding tube)
b. small intestine (small-bore nasointestinal feeding tube)

Feeding tube inserted via surgical incision directly into either

c. stomach (gastrostomy or "G-tube")
d. jejunum (jejunostomy or "J-tube"

Feeding tube inserted percutaneously (through the skin) directly int the stomach
e. Percutaneous Endoscopic Gastrostomy or PEG tube
Is locating the feeding tube in the stomach or small intestine preferred?
stomach - larger resevoir, and a more normal digestive process.
How are feedings adminstered?
1. Continuously (constant slow drip via special electric pump)
2. Intermittantly (formula is dripped in over a short period of time, several times per day. Mimics normal eating patterns.
3. By bolus (formula is poured directly into the tube, several times per day using a 60 mL syringe with the plunger removed as a funnel.
It infuses as rapidly as gravity will permit.

J-tube feedings are limited to the continuous route. (too small)
The "Gold Standard" definitive way to be certain the feeding tube is in proper placement:
X-ray

Method commonly used: pH testing. If pH is 6 or higher, it usually indicates the tube is in the lung or the intestine. Visual examination of what is aspirated with a syringe is also a good method.
Residuals- It is important to check the amount of stomach contents before giving feedings or a medication. Excess contents may indcate:
digestion problems or blockages.
How often should residual volume be checked for a patient on continuous feeding?
Every 4-6 hours
How do you check for residual?
Hook up a 50 or 60 mL syringe to the tube and pull back (injecting 30 mL of air prior to aspiration may help.
If there are 2 successive measurements of 200 mL (so 400 mL) feeding should be distended.
If GRV is 200-400, bedside eval should be performed for gastrintestinal complaints.
If GRV is less than 400, rtn asperiated residual to patient, follow with 50 cc water and continue with feeding.
If oral medication is to be given via the tube, what do you do first?
Flush the tube with 15 mL of sterile water before med administration.
CHECK DRUG GUIDE TO MAKE CERTAIN MEDICATION CAN BE CRUSHED.
Can crushed medications be administered together via a tube?
No. Crushed medications should be administered seperately with a 15 mL flush between each med to decrease drug interactions
What if the tube clogs?
Try very warm water first. Carbonated soda, cranberry juice.

Enzyme-based dissolvers require an order.
Hematamesis
Partially digested blood in Ng aspirate or vomitus. Will have an apearance like coffe grounds..
N/g tube insertion
Points to emphasize
(very abbreviated-review your notes for more details)
1. Assemble equipment. Tear some tape, check suction unit.
2. Put patient in high Fowler's.
3. Have pt blow nose and determine which nostril is clearer.
4. Measure tube - nose to earlobe to xiphoid. Mark.
5. Lubricate bottom 3-4" w/ ky.
6. Have pt. sip water & swallow while tube is passed.
7. Tape tube to nose & secure to gown with pin and rubber band.
8. Never clamp off or connect tubing from the suction apparatus to the air vent.
Merconium
The first few stools produced by newborns. They are sticky and black due to digested amniotic fluid swallowed by the neonate. Does not indicate blood in the stool.
Constipation
abnormally hard and dry feces that beome difficult to expel. The longer stool remains in the intestine the more hard and dry it becomes.
Impaction
A large constipated mass of stool that becomes so hard that it can't be passed. Sometimes manual disimpaction becomes necessary. Frequent passage of small amounts of liquid stool can signal a presence of an impaction
Diarrhea
rapid movement of feces through GI tract resulting in poor absorption of water and nutrients and producing frequent watery stools. It isn't alwyas good to try to stop diarrha. Sometimes it is nature's way of getting rid of infectious agents and toxins.
Steatorrhea
Grayish stool with visible fat. Results from poor fat digestion, or for some people, from eating Lay's Fat Free potato chips. (There's an endorsement.)
Stools with very hight fat content "float."
Melena
Large amounts of digested blood in the lower GI tract that makes blood look black and tarry.
hematochezia
Large amounts of undigested bright red blood in the stool
Occult blood (hidden blood)
blood mixed in throughout stool in quantities too small to be seen by the naked eye. Could be a sign of cancer of the colon or rectum.
Name of the Diagnostic Test used to screen for blood in the stool
Fecal Occult Blood Testing (FOBT)
See Mosby videos for instructions)
Administering Large Volume Enimas - Key Points
1. Place pt. in Sims Left lateral position.
2. Administer solution at lukewarm temp
3. Lube tip and insert 3-4" for adult
4. the higher the bag is raised the faster the fluid will flow. Start about 18 inches above rectum. Take about 10-15 min to administer 500-750 mL.
5. If soapsuds are to be added, use only what comes with kit.
6. If the order states "enimas until clear" be sure to clarify MD's expectations.
3 reasons patients are at high risk for infection:
1. lowered resistance due to disease.

2. invasive procedures which breach normal skin defenses/barriers

3. large numbers of disease-causing bacteria in hospital environment
The major mode of transmission of disease causing organisms in healthcare settings:
the hands of healthcare workers
Healthcare-associated Infection
an infection acquired in a helthcare setting in a previously uninfected patient.
5-10% of hospitalized patients experience.
90,000 deaths annually.
Up to 70% are preventable.
Pathogen
a MO capable of causing a disease
Colonization
Proliferation of MOs on or within body sites without detectable immunie response, cellular damage or producion of clinical infection
Aespsis
the absense of disease-causing organisms.
Hand Hygiene
Hands should be washed:
1. when visibly soiled (use soap & water, not waterless cleansers)
2. before and after pt contact
3. after any contact with possible source of MOs (blood, body fluid, mucous, membrnes, non-intact skin)
4. when moving from a contaminated to clean site (on same pt)
5. after significant contact with the pt's environment
6. after eating
7. after removing gloves
Wear (clean, not sterile) gloves:
1. when nurses have scratches or breaks in skin
2. when inserting needles in patients
3 whenever there is a high risk of contacting the body fluids of a patient.

Gloves are to be worn only once and then discarded.
Gloves don't substitue for hand washing.
Change gloves during patient care if the hands will move from a contaminated body site to a clean body site
Serous
Clear and watery
serosanginous
a pale red and water type of drainage (has some red blood cells in it)
sanguinous
frank blood - a thick type of drainage. If the amount of blood is large, it is termed hemorrhage. Occasionally a hermatoma can form in closed wounds
purulent
pus - liquified necrotic tissue. usually indicative of infection
Signs of infection in a wound
edema
redness
excessively warm peri-wound skin
increased pain
development of tunnels (sinus tracts)
dehiscence
partial separation of wound layers at the surface of the wound. Usually with abdominal wounds. Obese patients are especially at risk due to constant strain on wound.
evisceration
total separation of all layers of a wound with protrusion of abdominal organs. Medical emergency. Requires surgical repair. If it occurs, cover with sterile cloths or dressings soaked in sterile saline.
fistula
an abnormal passageway connecting one epithelial surface with another epithelial surface
Enterocutaneous fistula
an abnormal passageway connecting an epithelial surface with an organ
Micturnation
process of emptying the blader
dysuria
diffucult or painful urination
oliguria
diminished flow of urine. may be due to dehydration or to kidney disease. normal urine output is 1200-1500 mL/day or 50-60mL/hr. 30mL/hr is considered oliguria.
Anuria
absence of urine. usually defined as 100 cc/day or less
Polyuria
production of a larger than normal amount of urine, assuming intake is not excessive. It is often seen in the early stages of diabetes or pituitary trauma secondary to head injury (underproduction of ADH)
Hematuria
RBC in the urine. Can be gross (blood in urine visible to the naked eye) or microscopic
Enuresis
involuntary urnination. incontinence
also, nocturnal neuresis - bedwetting
70% of 4 yo and
91% of 8 yo have attained nighttime continence
Urine specimines - General Info
-Should be placed in a labled "Biohazard" bag and taken directly to lab
-Don't let urine sit around in unit. It can become colonized with bacteria very quickly.
-Urine that cannot be taken to a lab w/in 15 minutes should be refrigerated.
Routine and Microscopic Urinalysis
-screening for certain chemicals, physical properties and under microscope.
-does not need to be collected in sterile fashion
-may be placed in clear container
Urine color
usually yellow or straw color and clear. (cloudy indicates infection)
Urine pH
4-6
Dark urine
Amber=very concentrated

very dark = presence of bilirubin
Specific Gravity of Urine
a measure of the concentration of dissolved solids in the urine.
Normal specific gravity = 1.005 (very dilute) - 1.030 (very concentrated.)
Most people with good hydration fall between 1.010 and 1.020.
Measured with a urinometer
Should protein , glucose ketones, bilirubin, bacteria, crystals or casts be in urine?
no
Should RBC and WBC be in urine?
no more than 2 RBC and 4 WBC.
Urine Culture
Testing for the presence of infection. Needs to be collected in a sterile fashion.
Clean catch / Midstream technique
Patient washes hands

Cleans external genitals with three antiseptic wipes

Obtain mid stream void - 1-2 oz
24 hour Urine Collection
Some substances are not excreted at a constant rate. In order to know whether their concentration is truly elevated or depressed, it is necessary to do a 24 hr collection so that an avererage value can be obtained. (Substances include: Creatinine, total protein, sodium, potassium and Vanylmandelic Acid)
24 hr Urine Collection method
Patient voids and discards urine. This marks start time.
Patient saves all urine for exactly 24 hrs in container (may need to be iced or have preservative added.) After exactly 24 hours, patient voids again.
If pt is menstruating, just mark on lab slip.
External catheter
device attached to the skin to catch urine. mostly useful for men. (Tend to leak and cause skin problems for women.) Men's variety is a condom-like sheath with attached drainage tubing and a collection bag. risk of infection is lower than with bladder catheter but higher than with no cath. should be removed daily - meticulous hygeine.
How are condom catheters secured in place?
1. with a stretchy adhesive band around the sheath at the base of the penis
2. an inflatable ring inside the sheath
3. a tacky substance on the inside that sticks to the penis
Interventions for Urinary Retention
1. Fluid management - 1500-2000 mL/per day

2. Enhancing stimulus to void
-provide privacy, don't rush
-position in normal voiding position
-sound of running water
-spray water over perineum, place hand in warm water
-Crede maneuver - press inward and downward on lower abdomen
Reasons for urethral catheters
for urninary retention
to relieve urinary obstruction
to keep bladder empty prior to, during or after surgical procedures
to prevent incontinence
to collect sterile urine specimens
to keep bladder decompressed after urinary tract surgery
to aid in obtaining precise I & O
to empty bladder of person unable to void due to neurogenic problems
Catheter Placement:
Things to Remember
1. Choose the right size. 6-24. Ave female 14-16. Ave male 16-18.
2. For indwelling caths, don't forget to test the balloon prior to insertion
3. Insert until urine begins to flow and then 1 more inch.
(2-3" for females, 5-7" for males.)
Indwelling Catheter Removal
1. Sterile Gloves are not necessary
2. Put pads down
3. Attaach a syringe and empty the balloon.
4. Pull the catheter out steadily

Patients should void on their own within 6-8 hours of removal. Usually sooner. If not, check for distention and notify MD