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156 Cards in this Set

  • Front
  • Back
What is the function of the Upper Airway and what are its components ?
• Function warm, humidifies and filters inspired air
• Components
– Nose
– Pharynx
– Larynx
– Epiglottis
What is the function of the Lower Airway and what are its components ?
• Functions—conduction of air mucociliary clearance, production of pulmonary surfactant
• Components
– Trachea
– Right and left mainstem bronchi
– Segmental bronchi
– Terminal bronchioles
What is cilia ?
Microscopic hair0lie projections propel trapped material and mucus toward upper airway
What is a Surfactant ?
Detergent-like phospholipid, reduces surface tension between membranes of the aveoli, preventing colapse
Define pulmonary ventilation :
Movement of air into and out of the lungs
Define respiration :
Gas exchange between the atmospheric air in the aveoli and blood capillaries
Define perfusion :
The process that oxygenated blood passes through body tissues.
Define Inspiration :
Active phase, involving muscle movement to bring air into the lungs
Define expiration :
Passive phase, movement of air out of the lungs
One respiratory cycle includes
One inspiration and one expiration
Four Factors Influencing Diffusion of Gases in the Lungs
• Change in surface area available
• Thickening of alveolar-capillary membrane
• Partial pressure
• Solubility and molecular weight of the gas
Movement of the gas from areas of higher pressure to areas of lower pressure
inadequate amount of oxygen is available to cells
Difficulty breathing
Decreased rate or depth of air movements to the lung
Where is the respiratory center located in the brain ?
Internal respiration
Exchange of oxygen and carbodioxide between the circulating blood and the tissue cells
What are the normal respiratory rates for Infants, early children, late children, adults and elderly ?
Infants = 30-60 breaths/min
Early Childhood = 20-40 breaths/min
Late Childhood = 15-25 breaths/min
Adults = 12 - 20 breaths/min
Aged adult = 16-20 breaths/min
Can anemia affect respiration ?
Anemia can affect perfusion. The primary route of oxygen transportation(97%) is via hemoglobin. When RBC count is low, less oxygen may be available to body tissues.
Respiratory Activity in the Infant
• Lungs are transformed from fluid-filled structures to air-filled organs.
• The infant’s chest is small, airways are short, and aspiration is a potential problem.
• Respiratory rate is rapid and respiratory activity is primarily abdominal.
• Synthetic surfactant can be given to the infant to help reopen alveoli.
• Crackles heard at the end of deep respiration are normal
When is surfactant formed in the utero ?
Between 34 and 36 weeks. Infants born prematurely need synthetic surfactant to allow full aveoli expansion
What are elderly in increased risk of ?
Pneumonia due to the loss of elasticity in the respiratory system and easier collapse of its structures
Whats Kyphosis ?
Curvature of the spine, contributes to an appearance of leaning forward.
Adult chest wall should be slightly convex, no sternal depression
Infants have rounded chest wall, and is very thin
Tachypnea and Bradypnea
Tachypnea rapid breathing and Bradypnea is slow breathing
Tactile fremitus
Ability to feel sound with the palm of your hand. Ask patient to say 99
What are the three normal breath sounds and where are they heard ?
Vesicular - low pitched, soft sound - over the lungs
Bronchial - high pitched sounds - over the trachea
Bronchovesicular - mediumpitched blowing sound heard over the major bronchi
Sounds Heard Upon Percussion of the Chest Wall
• Resonance—___________, hollow low-pitched sound heard over normal lungs
• Hyperresonance—loud, low pitched sound heard over emphysematous lungs
• Flatness—detected over bone or heavy muscle
• Dullness—with medium pitch and intensity heard over the liver
• Tympany—high-pitched, loud, produced over the stomach
Abnormal (Adventitious ) Lung Sounds
• Crackles—intermittent sounds occurring when air moves through airways that contain fluid
– Classified as fine, medium, or coarse
• Wheezes—continuous sounds heard on expiration and sometimes on inspiration as air passes through airways constricted by swelling, secretions, or tumors
– Classified as sibilant or sonorous
What is important to do prior the ABG test ?
The Allen test to ensure arterial refill
Instrument that measures lung volumes and airflow
Peak expiratory flow rate


• Vital Capacity (VC)
• Forced Expiratory Vital Capacity (FEVC)
• Forced Inspiratory Vital Capacity (FIVC)
• Forced Expiratory Volume (FEV)
• Total Lung Capacity (TLC) – total amount after maximum inspiration
• Residual Volume (RV) – total residual volume left after maximum expiration
• Peak Expiratory Flow Rate (PEFR)
• Tidal Volume - Volume of gas inhaled & exhaled during one respiratory cycle
Pulse oximetry - measures arterial oxyhemoglobin saturation. Helpful when monitoring hypoxic patients and patients during oxygen therapy
RN assist the MD, puncture of thoracic wall to draw fluid by syringe of catheter for diagnostic purpose or to palliative reasons
• Performing chest physiotherapy
– Percussion – tapinha nas costas pra ajudar a perder o mucus
– Vibration
– Postural Drainage
What teachings can you do to help promoting Proper Breathing ?
• Deep breathing (DB) – help with hypoventilation, breath through now to help
• Using incentive spirometry (IS) - used to help patients improve the functioning of their lungs
• Pursed-lip breathing – design to help prolong expiration
• Abdominal or diaphragmatic breathing –
What are the main four Types of Cough Medications
Expectorants - GUAIFENESIN
• Cough suppressants (codin – very effective, controlled med)
• dextromathorfane (OTC) non habit forming – used with caution for DM pt’s
– Suppress the cough reflex
• Expectorants – fluids also help liquefy
– Help reduce the viscosity of secretions
• Lozenges –held in mouth until they dissolve
– Provide mild, local anesthetic effect which helps control the cough
Chest tubes purpose
Help decompress lung from :

– Pneumothorax – (air in the pleural space)
– Hemothorax - (blood in the pleural space)
– Pleural Effusion (fluid in the pleural space)
Respiratory secretion expelled by coughing
Oxygen therapy : • Administered by low-flow or high-flow system
– Low-flow: nasal cannula, simple face mask, partial rebreathing mask, nonrebreathing mask
– High- flow: Venturi Mask
Types of oxygen delivery masks
Oxygen Delivery Systems
• Nasal cannula (can eat/dring take meds with it on) up to 6 L
• Simple mask – 6 – 10 L per minute
• Partial rebreather mask 6 – 15 L
• Nonrebreather mask (up to 100% O2 delivery) 6 – 15 L
• Venturi mask (precisely regulated) 4 – 10 L
• Tent
• Oxygen concentrator
What are the three types of artificial airways and what is its use ?
Used for patient with risk of or unable to maintain a patent airway

Type of Artificial Airways
• Oropharyngeal and nasopharyngeal airway
• Endotracheal tube
• Tracheostomy tube
CPR-Cardiopulmonary Resuscitation
• American Heart Association (AHA ):
• CAB (not ABC)
– Circulation, Airway, Breathing
• Compressions First !
• Fast & Hard-100/min.
• Priority is ACTION, not Assessment
• Determine if unresponsive
• Call 911 and someone to get the AED
• Check carotid pulse; NO PULSE?
• Begin Chest Compressions
– 30:2
– Depth two inches (2”) for adults
• Open airway
• Give 2 rescue breaths
• Repeat cycle of compressions and breaths for a total of 5 cycles
artificial opening made into the trachea, usually at the level of the second or third cartilaginous ring. Can be cuffless or cuffed. A cuff is an inflatable balloon that can cause nicrosis of the airways if is too inflated but its purpose is to help air go into the tube and not escape on the outsides
What oxygen mask provide the highest concentration (not highest flow) of oxygen
Nonrebreather mask
What is the total body weight (%) for Infants, Adults and Elderly ?
Infant - 77% | 29% ECF, 48% ICF
Adult - 50-60% | 15% ECF, 45% ICF
Elderly - 45% | 20 % ECF, 25% ICF
What is the fluid intake recommended and how long should output balance take at the most to remain in normal levels ?
2-3 L per day
Within 2 to 3 days
What part of the brain controls thirst ?
Whats is the difference between sensible and insensible fluid losses ?
Sensible - Can be measured (Urination, defecation, wound)
Insensible losses - loss through skin and respiration
What are the two compartments of fluid in the body and what are there percentages ?
Two Compartments of Fluid in the Body
• Intracellular fluid (ICF)—fluid within cells (70%)
• Extracellular fluid (ECF)—fluid outside cells (30%)
What are electrolytes ?
• Electrolytes are substances that are capable of breaking into particles called ions
Name the major electrolytes and its functions
• Sodium—controls and regulates volume of body fluids
• Potassium—chief regulator of cellular enzymes activity and water content (major cation)
• Calcium—nerve impulses, blood clotting, muscle contraction, B12 absorption(major cation ion)
• Magnesium—metabolism of carbohydrates & proteins, vital actions involving enzymes
Major Anion Electrolytes & Chief Function
• Chloride—maintains osmotic pressure in blood, produces hydrochloric acid
• Bicarbonate—body’s primary buffer system
• Phosphate—involved in important chemical reactions in body, cell division, and hereditary traits
• Sulfate
• Osmosis
Water passes from area of lesser solute concentration to greater concentration until equilibrium is established
• Diffusion
Tendency of solutes to move freely throughout a solvent; moves from an area of higher concentration to an area of lower concentration (“downhill”) until equilibrium is achieved
• Active transport
Requires energy for movement of substances through cell membrane from lesser solute concentration to higher solute concentration
• Filtration
Passage of fluid through permeable membrane from area of higher to lower hydrostatic pressure
• Hydrostatic pressure
Pressure exerted on the walls of blood vessel (‘pushing force”)
• Colloid osmotic pressure or oncotic pressure
Pressure exerted by the protein in the plasma (“pulling force”)
• Osmolarity
is the amount of osmotic pressure exerted by the particles in a solution
• IV solutions are classified as:
– Isotonic
– Hypertonic
– Hypotonic
Isotonic Solutions
• Have same concentration of particles as plasma
• Causes the expansion of the ECF
• Cell neither swells nor shrinks
• Osmolarity is 270-340 mOsm/L
– 0.9% NaCl (NS)
– Lactated Ringer’s (LR)
– 5% Dextrose in Water (D5W)
Hypertonic Solutions
• Have greater concentration of particles than plasma
• Used to replace electrolyte and shift fluid from the interstitial space to the ECF
• Causes cells to shrink
• Osmolarity greater than 340 mOsm/L
– D5½NS, D5NS, D5LR, D10W, D50W
– 3% NaCl
– 5%NaCl-highly hypertonic solution - used to treat symptomatic hyponatremia
Hypotonic Solutions
• Have lesser concentration of particles than plasma
• Causes fluid to shift from the ECF into the ICF and interstitial spaces
• Causes cells to swell
• Osmolarity less than 270 mOsm/L
• Examples:
– 0.45%NaCl (½NS)
– 0.33%NaCl
– Dextrose 2.5% in Water
IV Fluids
• Purpose of IV Therapy
– To maintain daily fluid/electrolyte requirements or;
– Replenish deficits if pt. unable to consume orally
• Standard IV solutions do not meet daily caloric protein or fat requirements
• Only solutions with dextrose contain calories
– Solutions with 5% dextrose contain 170 calories/L
– Solutions with 10% dextrose contain 340 calories/L
What is Acidosis ?
Excess of H ions or loss of base ions(HCO3 -bicarbonate)
What is Alkalosis ?
Lack of H ions or gain of base (HCO3 -bicarbonate)
What are the normal ranges for blood pH, PaCO2 and HCO3 ?
pH 7.35-7.45
PaCO2 35-45 mm Hg
HCO3 22-26 mEq/L
What is a buffer ?
Substance that prevents body fluids from becoming overly acidic or alkaline
What organ is the primary controller of carbonic acid supply (H2CO3) ?
The lungs.
What organ is primarily responsible for Bicarbonate (HCO3) regulation ?
This hormone works with the hypithalamus to regulate the thirst/water conservation
• Hypovolemia
Deficiency in amount of water and electrolytes in ECF with near normal water/electrolyte proportions
• Third-space fluid shift
Distributional shift of body fluids into trans cellular body spaces (other places like joints where fluid can move to)
• Hypervolemia
Excessive retention of water and sodium in ECF
• Interstitial-to-plasma shift
Movement of fluid from space surrounding cells to blood
Common causes of hypovolemia and hypervolemia ?
Hypovolemia - blood loss, vomiting, diarrhea.
hypervolemia - Kidney malfunction, excess IV fluid, heart failure
Increase fluid in the interstitial space
What is the best way to measure fluid depletion/retention ?
By Weighting the patient
The most abundant electrolyte.
Level - 135-145 mEq/L
Lower than 135 - hyponatremia
Highee than 145 - hypernatremia
Major intracellular electrolyte
Normal range 3.5 - 5 mEq/L
hypokalemia < 3.5
hyperkalemia > 5
S/E : Muscle weakness, leg cramps
Sodium imbalances can cause what S/E ?
Hypotension, Edema, weakness, muscle cramp
ECF electrolyte
Normal range 8.9 mg/DL - 10.1 mg/DL
Hypocalcemia < 8.9 mg/DL
Hypercalcemia > 10.1 mg/DL
Major causes of hypercalcemia is cancer ahd parathyroidism.
S/E : Excessive urination, thirst, constipation, vomiting, slirred speech
Intracellular cation
Normal ranges 1.5 - 2.5 mEq/L
S/E : muscle weakness, tremors, tetany, deep tendon replexes
Phosphorus electrolyte levels
2.5 mg/dl - 4.5 mg/dl
• Hypochloremia – Serum Chloride < 96 mEq/L
• Hyperchloremia - Serum Chloride > 106 mEq/L
Acid–Base Imbalances
• Occur when carbonic acid or bicarbonate levels become disproportionate
Respiratory acidosis—primary excess of carbonic acid in ECF
– Respiratory alkalosis—primary deficit of carbonic acid in ECF
– Metabolic acidosis—proportionate deficit of bicarbonate in ECF
– Metabolic alkalosis—primary excess of bicarbonate in ECF
Whats urine normal pH ?
4.6 - 8.2
When hematocrit values increase or when it decreases ...
Increases - meaning less plasma, plama moved into interstitial fluid, meaning dehydration - Hypovolemia
Decreases - Massive blood loss or fluid overload.
Arterial blood gases - a lab test to determine proper oxygenation and acid-base balance
Interpret the ABG values below :
pH | PaCO2 | HCO3
7.52 | 40 | 35
Metabolic alkalosis
Interpret the ABG values below :
pH | PaCO2 | HCO3
7.32 | 30 | 18
Metabolic acidosis w/ compensation
Interpret the ABG values below :
pH | PaCO2 | HCO3
7.49 | 34 | 26
Respiratory alkalosis
Interpret the ABG values below :
pH | PaCO2 | HCO3
7.52 | 44 | 38
Metabolic alkalosis
Interpret the ABG values below :
pH | PaCO2 | HCO3
7.16 | 82 | 30
Respiratory acidosis w/ compensation
Respiratory acidosis/alkalosis VS Metabolic acidosis/alkalosis
Respiratory - Arrows point to opposite directions
Metabolic - Arrow point to the same direction
Interpret the ABG values below :
pH | PaCO2 | HCO3
7.37 | 50 | 22
Complete compensation
Complication of Iv Therapy
• Infiltration
• Phlebitis - inflammation of vein
• Thrombophlebitis - swelling (inflammation) of a vein caused by a blood clot.
• Fluid overload
• Embolus – blood clot (air, foreign body, moving through system)
• Sepsis – systematic infection
• Septicemia – bacteria in blood
What are the three types of vascular access devices ?
Peripheral venous catheters, midline peripheral catheters and Central Venous Access Devices.
Types of CVAD ...
Peripherally inserted central catheters PICC's - usually used for TPN, narcotic infusion, chemotherapy
Nontunneled CVADs
Tunneled CVADs
Implanted ports
Name blood types for universal donors and universal recipient
Universal donor => O
Universal receiver => AB
Direction for administering blood
• Correct labeling must be followed. Follow policy and procedure. Must check for compatibility of blood type. Checking Rh, blood type …
• Doctor’s order, sign consent.
• ID band – BLOOD band – different from Id band
• Ask patients if they have ever had a reaction with blood products.
• Prophylactic PRN orders such as Tylenol and Benadryl for symptoms may be order by Dr.
• Proper gage (smaller gage #)
• 0.9 % NaCl ONLY, proper tubing (w/ an inline filter), NS KVO
• Blood bank – use pt label
• Blood product must be administered 30 minutes from the pick-up time from the blood bank.
• Two RN’s must check everything
• Observe the patient for reactions.
• Check vital signs (include baseline VS)
• Start infusion slowly (25-50ml / hr)
• Stop immediately if a reaction occur, you don’t need an MD order for that. Start NS IV with new tubing
• After administrating blood, clamp off blood and take vital signs.
• Never add anything to their blood(meds)
Define culture
Shared system of beliefs, values and behavioral expectations
Large group of people who are members of an even larger cultural group . • Have certain ethnic, occupational, or physical characteristics not common to the larger culture
• Cultural Assimilation (acculturation)
– Minorities living within a dominant group lose the characteristics that made them different
– Values replaced by those of dominant culture
• Culture shock
– The feelings a person experiences when placed in a different culture
– May result in psychological discomfort or disturbances
• Cultural imposition
– Belief that everyone should conform to the majority belief system
• Cultural conflict
– Occurs when people become aware of cultural differences, feel threatened, and act negatively
– Response—ridiculing beliefs and traditions of others to make themselves feel more secure
• Sense of identification with a collective cultural group
– Attained through birth or adoption of characteristics of the group
• Largely based on group’s common heritage
• Usually share common beliefs, behavior patterns, music/folklore, languages/dialects, food, and religious practices
• Typically based on specific physical characteristics
– Skin pigmentation, body stature, facial features, hair texture
• One assumes that all members of a culture or ethnic group act alike
• May be positive or negative
– Negative stereotyping includes racism, ageism, and sexism
– Even “positive” stereotyping can have negative effects
• Belief that one’s ideas, beliefs, and practice are the best or superior or are most preferred to those of others
• Nursing culture
the largest subculture of the healthcare system
Personal space
Important for Asian descendants
Define all types of loss
• Actual loss—can be recognized by others (limb, child, or valued object)
• Perceived loss—is felt by person but intangible to others (like loss of financial instability)
• Physical loss vs. psychological loss (may be both)
– Psychological loss may be caused by an altered self-image.
• Maturational loss—experienced as a result of natural developmental process (kids go to college)
• Situational loss—experienced as a result of an unpredictable event (unpredictable even)
• Anticipatory loss—loss has not yet taken place
Define Grief, Bereavement, Mourning, Dysfunctional grief
• Grief—internal emotional reaction to loss
• Bereavement—state of grieving from loss of a loved one
• Mourning—actions and expressions of grief that make up outward expression of grief
– May include symbols or ceremonies
• Dysfunctional grief—an abnormal or distorted grief that may be unresolved or inhibited
Name Engel’s Six Stages of Grief – ( psychiatrist who lived in New York, did research and came up with six stage grief)
• Shock and disbelief - refusal to accept loss (No, not me !"
• Developing awareness – manifest a physical or emotional response "Why me?"
• Restitution – rituals involving loss - expressions of mourning
• Resolving the loss - dealing with the void
• Idealization - exaggeration of good qualities that the person had
• Outcome - Final dealing with loss as a life cycle
Definition of Death
• Uniform Definition of Death Act: An individual who has sustained either
(1) irreversible cessation of all functions of circulatory and respiratory functions or
(2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead.
• Medical criteria used to certify a death: cessation of breathing, no response to deep painful stimuli, and lack of reflexes (such as the gag or corneal reflex) and spontaneous movement
Clinical Signs of Impending Death
• Difficulty talking or swallowing
• Nausea, flatus, abdominal distention
• Urinary and/or bowel incontinence or constipation
• Loss of movement, sensation, and reflexes
• Decreasing body temperature with cold or clammy skin
• Weak, slow, or irregular pulse
• Decreasing blood pressure
• Noisy, irregular, or Cheyne-Stokes respirations
• Restlessness and/or agitation
• Cooling, mottling, and cyanosis of the extremities and dependent areas
Kubler-Ross’s Five Stages of Dying - stages can overlap and revert back to stages.
• Denial and isolation - Pt denies the reality "They made a mistake ! It cant be true)
• Anger - rage and hostility - "why me ?"
• Bargaining - pt tries to barter for more time - "If I can only see my granddaughter be born I would be happy"
• Depression - Period of grief before death - "I waited all these years to see my granddaughter be born and I'm dying before it happens"
• Acceptance - "I made plans for after death and I'm in peace"
Advance Directives
• Two kinds of written Advance Directives
– Living will
– Durable Power of Attorney for Healthcare
• Patient Self-Determination Act of 1990
– Requires all hospitals to inform patients about a
Combined Directive – “Five Wishes”
• Specifies who will make decisions for the patient in case he or she is unable
• Specifies the kind of medical treatment the patient wants or doesn’t want
• Specifies how comfortable the patient wants to be
• Specifies how the patient wants to be treated by others
• Specifies what the patient wants their loved ones to know
Advance Directives Special Orders
• Do-not-resuscitate (DNR) or no-code - must have a physician's order. Until its proven that DNR order exist, resuscitation can be done
• Comfort measures only - goal of treatment is comfortable, dignified death and life-sustaining measures are no longer indicated
• Do-not-hospitalize
Needs of Dying Patients
• Physiologic needs—physical needs, such as hygiene, pain control, nutritional needs
• Psychological needs—patient needs control over fear of the unknown, pain, separation, leaving loved ones, loss of dignity, loss of control, unfinished business, isolation
• Sexual needs—patient needs ways to be physically intimate that meets needs of both partners
• Spiritual needs—patient needs meaning and purpose, love and relatedness, forgiveness and hope
Postmortem Care of the Body
• Prepare the body for discharge
• Place the body in anatomical position, replace dressings, and remove tubes (unless there is an autopsy scheduled)
• Place identification tags on the body
• Follow local law if patient died of communicable disease
Postmortem Care of the Family
• Listen to family’s expressions of grief, loss, and helplessness
• Offer solace and support by being an attentive listener
• Arrange for family members to view the body
• In the case of sudden death, provide a private place for family to begin grieving
• It is appropriate for the nurse to attend the funeral and make a follow-up visit to the family
Define : Spirituality, Faith, Religion, and Hope:
• Spirituality—anything that pertains to the person’s relationship with nonmaterial life force or higher power
• Faith—a confident belief in something for which there is no proof or evidence
• Religion—term used to describe cultural or institutional religion
• Hope—ingredient in life responsible for a positive outlook
Atheist vs Agnostic
Atheist - Deny existence of higher power
Agnostic - holds that nothing can be known about existence of higher power
Hope acronym
H - Source of hope, meaning, comfort , strength, peace, love.
O - organized religion
P - Personal spirituality
E - Effects on medical care and end of life
Spiritual distress
Impaired ability to experience and integrate meaning and purpose in life through one's connectedness.
A Child’s Perceptions of God
• God works through intimacy and the interconnectedness of lives
• God is involved in self-change and growth and transformation that make the world fresh, alive, and meaningful
• God has tremendous power, and children show considerable anxiety in face of it
• God is an image of light
Nursing Diagnoses for Spiritual Problems
• Readiness for enhanced spiritual well-being
– Ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature and/or a power greater than oneself that can be strengthened
• Spiritual distress
Aphasia –
Can’t express themselves verbally
Falls can occur at any age but...
among adults older than 65 they are the leading cause of injury fatality
Where does 80 % of fire deaths occur ?
in the home, 50 % of those home have no smoke detector.
What substances children usually ingest during accidental poisoning ?
Cosmetics, cleaning fluids and analgesics
Suffocation or asphyxiation
High risk for children
Emergency fire acronym RACE
R - Rescue everyone
A - Activate the fire code
C - Close doors/windows
E - Evacuate patients
Safety car seat for infants
• Use car seats properly - – rear -facing safety seat placed in the backseat, preferably in the middle, is recommended for infants younger than 1 year and weighing less than 20 lbs.
Drowning victims age group
• Nearly ½ of all drowning victims are younger than 5 years old
Fact about firegun accident
• 82% of homicide victims between the ages of 10 and 24 are killed with a firearm
Joint Commission Safety Goals
• Improve patient identification
• Improve communication among caregivers
• Improve safety of high-alert medications
• Eliminate wrong site, wrong patient, wrong procedure, and wrong surgery
• Improve safety using infusion pumps
• Improve effectiveness of clinical alarm systems
• Reduce risk of healthcare acquired infections
P.A.S.S. Use of Fire Extinguisher
• P ull pin
• A im stream at base of fire
• S queeze handle
• S weep across base of the fire
Use and Legal Implications of Restraints
• Restraints restrict the individual’s freedom
• Nurse must know their agency policy and state laws regarding restraint use.
• Orders renewed daily
• Order must state the type of restraint, justification for use, criteria for removal
• PRN order prohibited
• The nurse must document the need for the restraint was made clear both to client & family
• Always use the least restrictive device
• Never use a restraint for punishment or for the nurse’s convenience
• Ensure the client’s circulation is checked frequently
• Check Q 15 minutes and release Q 2hours to toilet/exercise/check skin integrity.
• Do not tie restraints in a restraints ina full know and to side rails (tie to bed frame)
• What about side rails? Are they a restraint? Yes
Three Phases of Perioperative Period
• Preoperative—
– Begins with decision to have surgery,
– Lasts until patient is transferred to operating room or procedural bed
• Intraoperative—
– Extends from admission to surgical department
– Ends with transfer to recovery room (PACU)
• Postoperative—
– Lasts from admission to recovery room (PACU)
– Ends with complete recovery from surgery and last follow-up physician visit
• Degree of urgency
– Emergency – to preserve life & function
– Elective – non life-threatening (knee replacement, carpal )
– Urgent – Cancerous tumor
– Optional – Face lift
• Degree of risk
– Major – poor health, advanced age, major blood loss, other health problems
– Minor - usually done in outpatient surgical centers
Purposes of Surgical Procedures
• Diagnostic – biopsy
• Ablative – removed of a disease organ or body part like a splenectomy
• Palliative – non curative, relief symptoms (decompressed surgery )
• Reconstructive – severely burned person
• Constructive
• Transplantation – replacement of an organ
Preoperative Assessment
• Current health status
• Allergies – latex, tape, medication, anesthesia
• Medications – what meds will be held or given prior operation
• Previous surgeries – any reaction to anesthesia
• Mental status – anxiety can me detrimental to surgery
• Understanding of the surgical procedure and anesthesia
• Smoking, alcohol and other mind-altering substances
• Coping
• Social resources
• Cultural and spiritual considerations
Types of Regional Anesthesia
• Nerve blocks - peripheral limbs
• Spinal anesthesia - for visceral surgery
• Caudal and epidural anesthesia - lower limb surgery
• Internal Sensory Stimuli
– Stereognosis (perceives solidity of objects)
– Graphesthesia (tactual ability to recognize writing on the skin)
– Kinesthetic and visceral (basic internal orienting systems)
Part of the brain that responds to sensory system
Reticular Activating System (RAS)
Regulates arousal
Term used to describe the sense, usually at subconcious level
agent/act influence capable of initiating a response by the nervious system.
Factors Contributing to Sensory Alteration
• Sensory overload - see this problems often
• Sensory deprivation - see this problems often
• Sleep deprivation
• Cultural care deprivation
Clinical Manifestations of Sensory Deprivation
• Excessive yawning, drowsiness, and sleeping
• Decreased attention span, difficulty concentrating, and decreased problem solving
• Impaired memory; periodic disorientation, general confusion, or nocturnal confusion
• Preoccupation with somatic complaints, such as palpitations, HAs
• Hallucinations or delusions
• Crying, annoyance over small matters and depression
• Apathy and emotional lability
Clinical Manifestations of Sensory Overload
• Complaints of fatigue, sleeplessness
• Irritability, anxiety, and restlessness
• Periodic or general disorientation
• Reduced problem-solving ability and task performance
• Increased muscle tension
• Scattered attention and racing thoughts