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197 Cards in this Set
- Front
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- 3rd side (hint)
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Parenteral Medication
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absorption route for administering medications other than the GI tract
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types we will be adminstering |
Subcutaneous
Intramuscular Intradermal |
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what are the 6 rights for administering medication |
Right Medication
Right Dose Right Patient Right Route Right Time Right Documentation |
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what are the 3 paper checks |
Check the medication when it is pulled from drawer
Check it against the MAR Check it once more prior to discarding the wrapper/or returning med to cart |
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what are the 3 checks for pyxis/medselect |
Select medication and compare to MAR and Pyxis screen
Remove medication from Pyxis. As you remove medication, compare medication to Pyxis screen/MAR screen Check medication against MAR |
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what is the criteria for choosing equipment for injections (5) |
Route of administration
Viscosity of the solution Quantity to be administered Body size Type of medication |
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when preparing injections first do an assesment |
Check the appropriate method for administration of drug was ordered (IM, SC) -Assess condition of administration site ---Bruising, Breakdown Assess clients understanding of medication actionSoreness afterward Check written history/ask patient about historyReactions to previous injections Review client’s chart noting previous injections sites -Alternate sites |
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Second step in preparing injections is planning |
Ensure the proper route -Protection from harm -Use six rights/ 3 checks -Reduce pain at site -Alternate injection sites for consistent absorptionReport side effects/adverse reactions |
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Third step in preparing injections is implentation |
Preparing injections Administering ID, SC, IM injections Use of insulin [one and two insulins] Administering anticoagulant Administering IM injections using Z-Track Method |
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Fourth and final step in preparing injections is Evaluation |
Injection should be administered:Without complications Painless Therapeutic effect is achieved |
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Selecting the appropriate syringe |
Is part of the planning and im\mplementation stage |
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Parts of needle and syrynge |
plunger barrel tip: threads for luer lock needle hub needle safety guard needle: shaft, bevel,lumen |
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Maintaining sterility of syringe is important: parts to keep sterile include |
out/inside of tip inside of barrel inside of plunger |
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three kinds of syringes |
hypodermic syringe marked in tenths (0.1) of milliliters and in minims;
insulin syringe marked in 100 units; tuberculin syringe marked in tenths and hundredths (0.01) of cubic millimeters and in minims. |
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Selecting appropriate needle |
look at the type of fluid that is being administered choose the correct needle gauge that would accommodate it. thicker the fluid = larger the bore of the needle=smaller the gauge. |
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Parts of a needle |
Bevel (lumen is hole in bevel) shaft hub (gauge # is on hub) |
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bevel of a needle |
Longer bevel = sharpest needles and less pain; SC and IM
Shorter bevel = ID and IV injections |
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Shaft of needle |
Can be 3/8 – 1 ½” Length chosen according to clients muscle development, weight, type of injection
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Gauge of needle |
Can be #18 - #30The > gauge the < diameter of the shaft
the lager the guage # to smaller the diameter |
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needle and syringe size for SC |
Syringe size: 0.5-3ml needle length: 3/8-5/8 in needle gauge:24-26 |
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needle and syringe size for IM |
Syringe size: 1-5ml needle length: 1-1 1/2 in needle gauge: 20-22 (usually larger) 23-25 |
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needle and syringe size for ID |
syringe size: 1 ml TB syringe needle length: 3/8-1/2 in needle gauge: 25-27 |
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Safety Syringes |
Intended to protect provider from needle stickFamiliarize yourself with the equipment prior to utilizingNever recap a needleLocate receptor (sharps container) for disposal prior to injectionUsually located on room wall or in bathroom
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example of safety syringes |
Some needle eject back Sheath Safety cap |
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mixing medications in 1 syringe |
If compatible, 2 drugs can be mixed together in 1 syringe ex insulin and pre-op meds (morphine w/ atropine or scopolamine) * Always check with pharmacist or compatibility chart before mixing meds!!! * the 2 meds , total dose has to be within accept limits |
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Insulin preparation (for diabetes tx) |
Administered by injection bc GI tracts breaks down and destroys oral form of insulin. *use correct syringe: -100-unit insulin syringe or an insulin pen to prepare u-100 insulin** Insulin is classified by route of action: rapid. short, intermediate, and long acting *know onset, peak and duration for each oreder insulin doses. |
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mixing insulins |
Patients whose blood glucose levels are well controlled on a mixed-insulin dose need to maintain their individual routine when preparing and administering their insulin.Do not mix insulin with any other medications or diluents unless approved by the prescriber.Never mix insulin glargine (Lantus) or insulin detemir (Levemir) with other types of insulin. Inject rapid-acting insulins mixed with NPH insulin within 15 minutes before a meal.Verify insulin doses with another nurse while preparing them if required by agency policy.
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Mixing medication from vial and ampule |
Mixing medications from a vial and an ampulePrepare medication from the vial first.Use the same syringe and filter needle to withdraw medication from the ampule.
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Mixing medicaiton for two vials |
look in book |
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Parenteral sites: Sucutaneous |
Areas that have good blood circulationTypically given at 45 degrees½ to 5/8 inch needleThe most important consideration is the depth of the subcutaneous tissue in the area to be injected2 inch of tissue, safe to administer the injection at 90 degrees with the skin spread1 inch of tissue, safe to administer with skin pinched and at 45 degreesDetermination: pinch skin – choose needle ½” width of skin foldAnchor, inject (no aspiration)
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Sites of administration for SC |
Administered into the adipose tissue layer just below the epidermis and dermis. Various sites used:Outer aspect of the upper armAbdomen (from below the costal margin to the iliac crests)The anterior aspects of the thighThe upper backThe upper ventral or dorsogluteal area
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preparing to administer SC injection |
Absorption is slower than with IM injections. Administering low-molecular-weight heparin requires special considerations.A patient’s body weight indicates the depth of the subcutaneous layer.Choose the needle length and angle of insertion based on the patient’s weight and estimated amount of subcutaneous tissue.
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SC injection: Insulin and heparin |
Insulin:use an insulin syringe with a short needleADA 2004 - Routine aspiration is no longer recommended w/ insulin administrationHeparin: use a TB syringedo not massage, or aspirate with heparinAbdomen site most common, must be 2” away from umbilicus and above iliac crests
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Tips for administering SC inj |
Pinch or spread skin according to tissue amountRotate sites to 1. minimize tissue damage 2. aid in absorption 3. avoid discomfort
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Intradermal injections |
within the dermal layer of the skinTesting allergiesPPDLocal anesthesia
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Administering intradermal injection for TB and allergies (card 1) |
Skin testing requires the nurse to be able to clearly see the injection site for changes.Use a tuberculin or small hypodermic syringe for skin testing.Angle of insertion is 5 to 15 degrees with bevel up.A small bleb will form as you inject; if it does not form, it is likely the medication is in subcutaneous tissue, and the results will be invalid.
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administering intradermal injections (card 2) |
Administered into the dermis, just below the epidermis.Has the longest absorption time of all parenteral routes.Body’s reaction to the substances is easily visible.Sites commonly used are the inner surface of the forearm and the upper back, under the scapula.A 1/4″ to 1/2″, 25- or 27-gauge needle is used and the angle of administration is 5 to 15 degrees. The dosage given intradermally is small, usually less than 0.5 mL.
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intradermal injection sites |
chest scapula and area above scapula forearms |
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tips for administering intradermal sites |
-Explain to patient that medication will produce a small wheel/bleb
-Wheel slowly disappears -Expel any air bubbles -Bevel up with the insertion of the needle and parallel to skin -Skin is taught during this injection -Insert through the epidermis into the dermis -Do not massage site |
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Intramuscular injection |
– within the muscle; rapid absorption due to rich vascular blood supply; typically given at 90 degrees
Several factors determine size/ length of needle 1.The muscle 2.Type of solution 3.Amount of adipose tissue covering muscle 4.The age of the client Location are away from large blood vessels, nerves, bonesAnchor,and inject We no longer aspirate |
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Intra muscular injection |
Adult with well developed muscles can safely tolerate 3ml of fluidSize of syringe depends on the amount of medication being administeredLocation that is: safe and away from large blood vessels, nerves, bones.Avoid using same site twice in a row.Quick piercing of skin:spreading of skin90degree angle Anchor Aspirate Inject
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Angles of insertion for injections |
Intra muscular: 72- 90 degress SC: 45-90degrees ID 5-15 degrees |
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3 gluteal muscles used for intra muscular injections |
gluteus medius gluteus minimus gluteus maximus |
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Vetrogluteal site |
Preferred site for IM injectionsContains no large nerves or blood vesselsGreatest muscle thicknessSealed off by boneContains less fat Side lying position is best, with knee bent and raised slightly toward the chest |
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Landmarks for ventral gluteal site (hip) |
First landmark is palm on the greater trochanter of the femur. middle finger pointing to iliac crest index finger pointing to anterior superior iliac spine (form the v) |
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Vastus Lateralis |
Most common site for IM injections in newbornsLocated on the anterior lateral aspect of the infant’s thighThe middle third of the muscle is suggested as the site
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Land marks for vastus lateralis (side of thigh) |
palm on greater trochanter of femur palm of lateral femoral condyle create a box and point index finger toward each other, this is the area to inject. |
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advantages/disadvantages of Rectus femoris (top of thigh) |
Administer Anterior aspect of thigh
Clients who administer their own injections can reach this site easily More uncomfortable Rarely used on ambulatory clients |
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Landmarks of rectus femoris |
anterior superior iliac spine lateral femoral condyle |
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Deltoid injection |
No more than 1-2 ml of fluid can be administered
Identify the acromion process( where clavicle is) 3-4 fingers below Create triangle with axilla |
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z-track method |
Pull skin back then inject
Skin returns to its normal position after needle is withdrawn Seal is formed Prevents seepage of medication into subcutaneous tissue Keeps skin from discoloring (look in book for clearer explanation) |
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telangiectasias |
: red marks on the skin caused by distention of the superficial blood vessels
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vitiligo
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a localized or widespread condition characterized by destruction of the melanocytes in circumscribed areas of the skin, resulting in white patches
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wood's light |
ultra violet light used for diagnosing skin conditions |
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dernatosis |
any abnormal skin condition |
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erythemia |
redness of the skin cased by congestion of the capillaries |
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hirsutism |
the condition of having exceswsive hair growth |
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keratin |
an insoluble, fibrous protien that forms the outer most layer of the skin |
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Langerhans cells |
dendritic clear cells in the epidermis that carry surface receptors for immunoglobulin and complement and that are active participants in delayed hypersensitivity of the skin |
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Epidermis |
stratisfied epithelial cells keratincytes (0.1 mm (eyes) -1mm (feet)) 4 layers: 1. stratum corneum 2. lucidium 3. granulosum 4. germinsativum EXTERNAL LAYER IS COMPLETELY REPLACED EVERY 3-4 WKS |
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Dermis (true skin) |
2 layers 1. Papillary: fibroblast cells produce collagen, a component of connctive tissue 2. reticular: collegen elastic bundles contains blood and lymph vessels, nerves, sweat and sebeceous glands, and hair roots |
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Subcutaneous tissues |
need info from book |
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Factors affecting skin integrity |
Age:
Very young & very old have fragile skin More susceptible to injury Medications: Corticosteroids Many medications increase sensitivity to sunlight: -Certain antibiotics -Chemotherapy drugs for cancer -Psychotherapeutic drugs |
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Factors affecting Wound HEALING (Card 1) |
AgeWounds heal more rapidly in infants and children; more slowly in elderly
Obesity Diabetes Compromised circulation Poor Nutrition Incontinence |
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Nutitional care Evaluate appropriate lab data |
Albumin: 3.2-5.0 mg/dl
Pre-albumin: 15-36 mg/dl HCT: Female: 37-47 % Male: 42-52 % Hgb: Female: 12-16 mg/dl Male: 14-18 mg/dl |
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3 phases of wound healing |
inflammatory phase proliferatuve phase maturation phase |
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Inflammatory phase: first response of wound healing |
When: immediately after injury How long: 4-6 days Processes: Macrophages ingest debris; release growth factors |
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Proliferative phase: 2nd response of wound healing |
When: Between 2-3 days of injury How long: Several wks Processes: New tissue built w/ fibroblast action |
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The nurse is reviewing the medical record of a client scheduled to be seen at the clinic. The nurse determined which of the following individuals is at greatest risk for development of an integumentary disorder? |
An older female An adolescent An outdoor construction worker A physical education teacher |
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Complications of wound healing |
Hemorrhage Infection Dehiscence Evisceration |
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Factors affecting Wound HEALING (Card 1) |
Age Wounds heal more rapidly in infants and children; more slowly in elderly Obesity Diabetes Compromised circulation Poor Nutrition Incontinence |
Picoda = factors affecting wound healing |
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INFECTION
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the multiplication of colonizing organisms and invasion of tissues
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DEHISCENCE
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the partial or total rupturing of a wound
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EVISCERATION
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the protrusion of internal viscera through an incision
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Which of the following clients would least likely be at risk of developing skin breakdown?
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A client who is unable to move about & is confined to bed.
A client incontinent of urine & feces. A client with chronic nutritional deficiencies. A client with a lowered mental awareness status. |
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risk factors for pressure injury development |
Impaired sensory perception Alterations in level of consciousness Impaired mobility Shear Friction Mositure |
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More risk factors for Pressure injuries |
•Dehydration
•Incontinence •Skin hygiene •Diabetes mellitus •Diminished pain awareness •Fractures •History of corticosteroid therapy •Immunosuppression •Multisystem trauma •Poor circulation •Previous pressure ulcers •Significant obesity or thinness |
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Braden scale: risk assesment tool |
Used for predicting pressure sore risk -sensory perception -moisture -Activity -Mobility -Nutrition -Friction and shear A total score fo 23 is possible An adult who scores below 18 is at risk |
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Pressure injury |
localized damage to skin and underlying tissue usually over a bony prominence or related to a medical condition or other device. |
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Stages of pressure injuries |
Stage 1-4 and unstagable pressure injury and deep tissue pressure injury |
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Stage 1 of pressure injuries (ulcers) |
nonbanchable erythema of intact skin usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to surrounding tissue.
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Stage 2 of pressure injuries (ulcers) |
partial thickness loss of dermis and presents as a shallow, open ulcer
*Abrasion *Blister *Shallow crater |
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Stage 3 of pressure injuries (ulcers) |
Full-thickness tissue loss.
Involves damage or necrosis of subcutaneous tissue May extend down to but not through fascia Deep crater with or w/o undermining of adjacent tissue Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Ulcers at this stage may include undermining and tunneling |
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Stage 4 of pressure injuries (ulcers) |
Full-thickness skin loss Adipose is visible; granulation tissue & epibole often present Tissue necrosis or damage to: -muscleBoneSupporting structures (tendons, joint capsules) |
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Unstageable Pressure Injury |
Obscured full-thick- ness skin & tissue loss -Actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed. -Cannot confirm extent of tissue damage |
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Deep tissue pressure injury |
Persistentnon-blanchable deep red, maroon or purplediscoloration
Resultsfrom intense or prolonged pressure & shear forces at the bone-muscleinterfaceE} |
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Wound measurements
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Wound measurements are made in centimeters.
1st measurement is from head to toe 2nd is from side to side 3rd is the depth (if any). -Tunneling (this is charted in respect to a clock with 12 o’clock being toward the patient’s head. ex. This wound would be charted as a full-thickness, red wound, 7 cm times 5 cm times 3 cm, with a 3-cm tunnel at 7 o’clock and 2-cm undermining from 3 o’clock to 5 o’clock. |
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Medical device related pressure injury |
results form use of devices designed & applied for diagnostic or therapeutic purposes. PI conforms to the pattern or shape of the device. (Use staging system)
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Mucosal Membrane Pressure Injury |
On mucous membranes with a history of a medical device in use at the location of the injury. (Cannot be staged)
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What is the best choice for pressure ulcer |
wait until lecture for answer |
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3 stages to wound healing |
primary, secondary and tertiary |
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Primary Intention healing |
Tissue surfaces approximatedMinimal or no tissue lossFormulation of minimal granulation & scarring
Incision w/blood clot Edges approximated w/ suture Then fine scar |
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Secondary intention healing |
Extensive tissue loss
Edges cannot be closed Repair time longer Scarring greater Susceptibility to infection greater
*Ireggular large wound with blood clot Granulation tissue fills in wound Large Scar |
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Tertiary Intention Healing (delayed primary closure) |
Initially left open
Edema, infection or exudate resolves Then closed * Contaminated wound left open until granulation tissue develops and then delayed closure wih suture |
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Words used to describe Drainage on dressing |
Serous Purulent serosanguineous sanguineous |
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Serous |
need definition |
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Purulent |
need definition |
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serosanguineous |
need definition |
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sanguineous |
need definition |
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Mr. G. underwent an emergency appendectomy 3 days ago. His abdominal wound was left open because of intra-abdominal contamination at the time of surgery. His wound is healing by what method?
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Tertiary intention Wound was contaminated with ruptured appendixSurgeon left wound open to heal |
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The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges
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#1 Are approximated. Would healing by primary intention is due to the edges pulled together and approximated with sutures or staples. Healing occurs by connective tissue deposition.
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Wound Assessment
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Location
Type Size in (cm.): LengthWidthDepthApproximation Tunneling Undermining Wound appearance: RedYellowBlack Drainage type/Amount Surrounding tissue: Intact Excoriated Macerated Purple Erythema |
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ex of nursing diagnosis |
Risk for infection
Imbalanced nutrition: less than body requirements Acute or chronic pain Impaired physical mobility Impaired skin integrity Risk for impaired skin integrity Ineffective peripheral tissue perfusionImpaired tissue integrity |
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Nursing strageties to prevent pressure injuries: |
Providing nutrition
Maintaining skin hygiene Avoiding skin trauma Providing supportive devices |
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Providing Nutrition
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Fluid intake (2500 ml/day)
Protein Vitamins (C, A, B1, B5 & zinc) Dietary consult & nutritional supplementsWeight monitoring Lab data monitoring (albumin & Hgb) |
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Maintaining Skin Hygiene
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Mild cleansing agents (do not disrupt skin’s “natural barriers)
Avoid hot water, exposure to cold & low humidity Moisturizing lotions/skin protection Reduce irritants (urine, feces, sweat) Skin protectants (dimethicone-based creams or alcohol free barrier film) Do not massage over bony prominences |
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Avoiding Skin Trauma
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Smooth, firm & wrinkle free surfaces
Semi-Fowler’s position (no more than 30 degrees) Frequent weight shifts (every 15-30 mins)Exercise and ambulation Lifting devices Reposition every 2 hours (correctly) Turning schedule |
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Providing Supportive Devices
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Mattresses (overlay or foam and gel combination)
Beds, specialty Heels off mattress using wedges, pillowsPressure-reducing devices to distribute wt during sitting |
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Treatment-Nursing Strategies
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Treating pressure ulcers
RYB Color Guide for Wound Care Promote wound healing Prevention of complications of wound healing |
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dressing selection: necrotic tissue |
requirements: debridement Ex: hydrogel, impregnated gauze, hydrocolloid, enzyme preparation forchemical debridement |
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dressing selection for granulation tissue |
requirements: protection ex: hydrocolloid, hydrogel or foam dsg |
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dressing selection for Dry wound base |
Requirements: hydration ex: hydrogel or gauze with saline |
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dressing selection for moderate to heavy exudate |
requirements: Absorption ex: hydrocolloid, foam, alginate |
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Dressing selection for significant depth |
Requirements: packing ex. gauze, alginate or wound filler |
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Dressing selection for Erythema, warmth, edema, tenderness |
Requirements: Infection management Ex: antimicrobial dressings or solutions |
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Dressing selections for Periwound skin maceration |
Requirements: Protection ex: skin sealant or barrier ointment |
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A surgical wound requires a hydrogel dressing. The primary advantage of this type of dressing is that it provides
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Moisture needed for wound healingHydrates wounds and absorbs some smaller amounts of exudate. Good for partial-thickness and full-thickness wounds
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Dressings
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Dry or moist guaze
Film dressing Hydrocolloid-protects from surface contamination Hydrogel-maintains a moist surface to support healing Wound vacuum assisted closure (V.A.C.)-negative pressure to support healing |
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Purpose of healing |
Protect wound from microorganism contamination
Aid in hemostasis Promote healing by absorbing drainage & debriding a wound Support or splint the wound site Promote thermal insulation of the wound surface |
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Treating pressure injuries |
Minimizedirect pressure
Schedule& record position changes Providedevices to reduce pressure areasClean& dress the ulcer using surgical asepsisNeveruse alcohol or hydrogen peroxideObtainculture & sensitivity if infected Teachclient importance of moving ProvideROM exercise |
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RYB Color Guide for Wound Care
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Red (Protect)-avoid disturbing the regenerating tissue
Yellow (Cleanse)-remove nonviable tissueBlack (Debride)-remove so wound can heal |
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Red (protect) |
Gentle cleansing
Covering periwound skin w/ alcohol free barrier film Filling dead space w/ hydrogel or alginateCovering wound w/ appropriate dsg -Transparent film -Hydrocolloid dressing -Clear absorbent acrylic dsg -Infrequent dsg changes |
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Yellow-(Cleanse) liquid “slough” w/ purulent drainage
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Cleansing to remove nonviable tissue
Moist-to-moist NS dsg Irrigating wound Absorbent dsg material -Impregnated hydrogel or alginate dsg -Topical antimicrobial |
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Black-(Debride) thick necrotic tissue or eschar
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Require debridement (removal of dead tissue)
-Sharp -Mechanical -Chemical -Autolytic -Fly larvae |
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Debridement methods |
Sharp Autolytic enzymatic mechanical chemical |
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Sharp |
Necrotic tissue is removed w/ scalpel, nippers or sissors |
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Autolytic |
Occlusive dressing (transparent film or hydrocolloids) cause melting of necrotic tissue by phagocytes |
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Ezymatic |
Urea active ingredient causing disintegration of slough and eschar |
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Mechanical |
Wet-to-dry dressing (pulls away tissue) and pulse lavage as high pressure water steams dislode necrotic tissue |
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chemical |
topical use of enzymatic gels and solutions that can dissolve necrotic tissue from the wound. Enzymes: proteolytics, fibrinolytics, collagenases |
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promoting wound healing |
Fluid intake (2500ml/day)
Protein, vitamins, & zinc Dietary consult Nutritional supplements Monitor weight/lab values |
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Possible interventions |
Keep skin clean and dryUse moisturizer on dry skinDo not massage bony prominencesProtect skin from moistureUse skin-protecting ointments to protect skin exposed to urine, stool, or wound drainageDecrease friction and shearAssess skin daily
Wound care coordinator evaluationUse lift pads /trapeze to minimize friction and shearConsider pressure reduction device on beds and chairUtilize turn scheduleEncourage proper dietary intake/dietician consultReposition every 1-2 hours if bed or chair boundIncrease mobility and activity if bed or chair boundElevate HOB PRN for meals and treatmentsPressure reduction/relief mattress or specialty bed |
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examples of evaluation |
The patient’s response to interventions/teaching, actions performedAttainment/progress toward healingModifications to plan of care
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The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure injuries. The nurse recognizes that the risk factors that predispose a patient to pressure injury development include:
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1. A diet low in calories and fat. 2. Alteration in level of consciousness. 3. Shortness of breath. 4. Muscular pain.
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The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage 3 pressure injury. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this pressure injury?
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Healing Stage 3 pressure injury
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Thenurse is caring for a patient who has experienced a laparoscopic appendectomy.The nurse recalls that this type of wound heals by
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Primary intention.
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The nurse is collaborating with the dietitian about a patient with a Stage 3 pressure injury. After the collaboration, the nurse orders a meal plan that includes increased
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1. Fat. 2. Carbohydrates. 3. Protein. 4. Vitamin E.
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The nurse is caring for a patient with a pressure injury on the left hip. The pressure injury is black. The nurse recognizes that the next step in caring for this patient includes
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1. Monitoring of the wound. 2. Irrigation of the wound. 3. Débridement of the wound. 4. Management of drainage.
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Medical asepsis |
Includes all practices intended to confine a specific microorganism to a specific area Limits the #, growth, & transmission of microorganisms Objects referred to as clean or dirty (soiled, contaminated) |
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Surgical asepsis
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Sterile techniquePractices that keep an area or object free of all microorganisms
Practices that destroy all microorganisms & spores Used for all procedures involving sterile areas of the body |
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***Interventions to ReduceRisk for Infection
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Proper hand hygiene techniques
Environmental controls Sterile technique when warranted Identification & management of clients at risk |
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Chain of infection |
1.Etiologic agent (microorganism 2.resivior 3. portal of exit 4. method of transmission 5. portal to the susceptible host 6. susceptible host |
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Control portal of exit (from reservoir)
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Avoid talking, coughing, or sneezing over open wounds or sterile fields
Covering mouth & nose when coughing/sneezing |
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Control transmission
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Cleansing hands properly
Instructing clients/families to cleanse hands before handling food or eating, after elimination & after touching infectious materials Wearing gloves when handling secretions & excretions Wearing gowns if in danger of soiling clothing |
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Control transmission slide 2
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Placing discarded soiled materials in moisture-proof bags
Holding used bedpans steady to avoid spillageDispose of urine & feces in appropriate receptacles Use aseptic technique with all clients Wearing masks & eye protection (droplet/body fluid) |
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Stop entry through portal of entry
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Sterile technique for invasive proceduresSterile/clean technique for open wounds & handling dressings
Place used needles & syringes in puncture-resistant containers All clients have their own personal care items |
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Protect susceptible host
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Maintain integrity of skin & mucous membranesBalanced diet
Educating client/family importance of immunizations |
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Maintaining Surgical Asepsis
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An object is sterile only when it is free of all microorganisms.
Examples: surgery, changing wound dsg on unit, administering IV therapy |
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Principles of Surgical Asepsis
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All objects used in sterile field must be sterileSterile objects become unsterile when touched by unsterile objects
Out of vision or below waist or table level = unsterile Prolonged exposure to airborne microorganisms = unsterile Moisture that passes through a sterile object draws microorganisms from unsterile to the sterile surface through capillary action |
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Principles & Practices of Surgical Asepsis
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Sterile objects can become unsterile by prolonged exposure to airborne microorganismsFluids flow in the direction of gravity
Skin cannot be sterilized; it is unsterile |
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Assessment of incisions/wounds
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Described according to how they are acquired
Incision Contusion Abrasion Puncture Laceration Penetrating wound |
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REEDA
(Acronym for remembering how to assess surgical wounds) |
R=redness
E=ecchymosis E=edema D=drainage A=approximation |
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Simple Dressings |
Protect the wound
Provide humidity Absorb drainage Prevent bleeding Immobilize Hide wound from view |
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Dry Sterile Dressing Change
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Remove outer dressing with clean glovesDispose of soiled dressing
Remove gloves, wash hands Remove inner dressing with forceps or sterile gloves Assess location, type, odor of drainage and diameter of drainage Remove and discard sterile gloves Assess overall appearance of wound and measure Clean wound if indicated using new sterile gloves or instruments Apply sterile dressingSecure dsg with tape, tie tape or binder |
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Wet to MOIST
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Rationale-moist gauze keeps wound bed from drying outS
ame principles of asepsis Wound has wet dressing applied Changed when the dressing becomes moistWET TO DRY SUBSTANDARD CARE --no longer used |
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Wound Vac
Vacuum-Assisted Closure
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Use of suction equipment to apply negative pressure to a variety of wound types
Speeds tissue generation Reduce swelling around wound Enhance wound healing by providing moist and protected environment |
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WOUND IRRIGATION
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Rationale: Promotes wound healing throughRemoving debris from a wound surfaceDecreasing bacterial counts
Loosening & removing necrotic tissue SOLUTIONS USED: Normal saline Warm water Commercial wound cleansers |
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WOUND IRRIGATION
PROCEDURE |
1.Waterproof drape under wound 2.Clean gloves to remove dsg 3.Measure and asses wound and draingage 4.New gloves 5.Irrigate with steady stream of irrigating solution 6.Irrigate until solution becomes clear 7.Dry area around the wound 8.Reassess appearance of wound 9.Apply sterile dressing 10.Document |
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PACKING A WOUND
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1.Clean wound if indicated
2. Pour ordered solution into bowl 3.Packing into bowl (unless contraindicated by manufacturer) 4.Wring out packing until slightly moist 5.Pack would with damp packing 6.DO NOT too pack tightly 7.Pack only to edge of wound 8.Dress the wound 9.Document |
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WOUND CULTURE-Obtaining
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1.Clean gloves
2.Remove outer dressing 3.Observe drainage 4.Determine amount, color, consistency & odor 5.Remove and discard gloves, wash hands 6.Assess wound 7.Cleanse 8.Remove residual ointment/cream 9.Obtain culture 10.Rotate swab back & forth over clean areas of granulation tissue from sides or base of wound 11.DO NOT collect pus or pooled exudates 12.Return culture swab to tube, do not touch outside |
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dressing closed/open wounds |
closed= dry dressing (surgical_ open= moist to allow for healing |
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RYB Color Code of Wounds
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R=Red (protect/cover)
Y=Yellow (cleanse) B=Black (debride) |
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Red
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Late regeneration phase of tissue repairDeveloping granulation tissue
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Red-Nursing Interventions
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Gentle cleansing
Protecting periwound skin w/ barrier film Filling dead space w/ hydrogel or alginateCovering w/ appropriate dressing (transparent film, hydrocolloid dsg or clear absorbent acrylic dressing) Infrequent dressing changes |
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Yellow-Nursing Interventions
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Cleanses to remove nonviable tissue
Damp-to-damp normal saline dsgs Irrigating wound Absorbent dsg material(impregnated hydrogel or alginate dsg) |
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Black-Nursing InterventionsPatient centered care
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Debridement of nonviable tissueSharp-scalpel, scissorsMechanical-wet-to-dry dsgChemical-topical enzyme preparation (Dakin’s solution)Autolytic-synthetic dsg (transparent, hydrocolloid)
Must be done to be able to stage wound & allow for healing |
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PATIENT CENTERED CARE Goa ls of IV therapy are to: |
Administer continuous or intermittent meds Replenish blood volume Assist in pain management -Use communication and diversion techniques to lessen abt infusion therapy - Provide culturally competent care |
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IV Safety
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Maintain sterility of all components of IV therapy including needles, injection caps and tubing - During insertion changing of fluids or tubing, and flushing Follow agency guidelines fro scheduled IV site, tubing, and fluid changes |
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IV therapy `Nursing Role Critical thinking |
-Determine if ordered IV is appropriate for pts hydration and electrolyte levels -Choose appropriate IV catheters and infusion devices -Administer IV fluids and meds as ordered -Evaluatete appropriate change |
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Body fluid compartments and movement
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extracellular (ecf)-side cell (2 compartments intravascular-inblood vessels, interstitial- in tissue spaces * fluids move continuously between intracellular and extracellular compartments * cell membranes and capillary walls separate the 2 compartments |
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Tonicity |
-These molecules act osmotically to cause the movement of water |
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types of IV fluids
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cystalloids |
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colloids
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-Pulls fluid into the bloodstream (plasma expander) -Treatment of shock, when rapid expansion of the intravascular is needed ex. 5% Albumin 25% Almumin Commerical plasmas (plasmate, hetastarch) |
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Caution for colloids
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Check for: Increased BP Dyspnea Crackles in the lungs Jugular vein distention (JVD) Edema Bounding pulse |
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CRYSTALLOIDS
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-Solutes may be electrolytes or non-electrolytes such as dextrose -Flow easy across semi permeable membranes |
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Types of crystalloid solutions
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Hypotonic Hypertonic NOTE: The osmolality os used as the standard for comparing the tonicity of IV infusions |
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Isotonic solution
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-Tonicity is equal to plasma -Osmotic pressureis the same inside and outside the cell -The fluid in each compartment remains the same (no shift occurs) -solution remains within the bloodessels -Used to increase the intravascular volum and replace elular fluid losses ***Most IV solution prescribed isotonic**** |
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Examples of isotonic solutions
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Lactated Ringers (LR) 5% Dextrose in water (D5W) |
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Isotonic solution: Normal saline
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`Same toniity as plasma, but NS and Cl concentration is greater than plasma `Tx for hypovolemic shock, hemorrhage, burn victims - |
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What excessive administration of normal saline may cause
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-hypernatremia-excess Na in plasma Critically think ask MD to d/c IVF No IV if kidneys are not working |
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Lactated Ringers |
-Tx for burns, lower GL trat fluid loss, acute blood loss - Electrolyte content is similar to serum but doesn't contain magnesium * Contains k- use cautiously in pts w/ renal failure (high k) *Don't use in pt failure bc it contains lactate (these pt cant metabolize lactate) |
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Isotonic solutions: D5W |
-fluid loss and dehydration -hypernatremia -Not an appropriate maintenance solution (does not replace Na or other elec lost in normal body fluids) **** D5W administered continuously becomes HYPOTONIC solution -Dextrose is metabolized rhe remaining free water decreases serum osmolality |
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D5W caution |
*****Test question: Do not administer to pts with increased intracranial pressure- will increase cerebral edema**** |
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Hypotonic solutions
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-lower osmolality than plasma uid to shift out of blood vessels into the cells and interstitial spaces -Hydrates the intercellular and interstitial spaces |
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Examples of Hypotonic solutions |
0.33% NaCl (1/3 normal saline) 5% Dextrose in water (D5W) when given continuously |
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Hypotonic solution: 1/2 NORMAL SALINE
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-Used to replace body fluids -Used as a maintenance |
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cautions for hypotonic solutions
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Do not give to hypotensive pts Never give to pts at risk for increased ICp Do not use for pts sease, trauma, or burns |
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Hypertonic Solution:
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-used ofr tx of hypovolemia and hyponatremia (sometimes) |
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Examples of hypertonic soultions
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5% Dextrose in 0.9% NaCl 10% Dextrose in Water- use in a central line |
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Cautions for hypertonic solution
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Do not use in pts w/ heart or reRisk for intravascular fluid volume excess Solutions can be irritating to the vein |
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Iv equipment and supplies
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-Pt preparation -Selection of appropriate IV site -Selection of IV catheter for prescribed therapy Iv solutionbottles come in different sizes: 1000 ml 500 ml 250 ml 100 ml 50ml |
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Iv equipment and supplies
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microdrip- alwy 60 drops/gttss per ml |
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Iv equipment and supplies: Piggyback I |
Secondary administration set -used to deliver intermittent doses of medication or fluids |
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IV pumps
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Smart pump: Iv pump with computer software that can alert users to potential errors Intermittent infusion pumps: also called a saline or heparin lock |
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Maintenance or IV site
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-Prevent contamination of sterile surfaces -Follow agency for site, tubing, and dressing changes -Change insertion site dressing regularly or when loose, wet or soiled -Change solutions, medication containers and tu, depending on agency policy -Never disconnect infusion tubing to change a pt gown or other clothing |
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Documntation of IV therapy
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Venous acces device including guage and length Location of IV site Type of IV solution and flow rate Assesment of dressing IV fluid I and O sheet |
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Never administer an Iv solution unless you know
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The intended effect on the pt Ask: what is the rational IV fluids? |
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