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94 Cards in this Set
- Front
- Back
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Elective
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Not necessary to preserve life it is scheduled at the patients convenience
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Urgent
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Required to keep additional health problems from reoccurring
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Emergency
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Necessary to sustain life
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Classification of surgery
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Minor or major
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Preoperative
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Before surgery
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Intraoperative
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During surgery
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Post operative
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After surgery
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Factors influencing the ability to tolerate surgery
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Surgery is stressful for patients as nurses we can address her feelings and concerns and the nurse and offer support reassurance and information that address is fear of the unknown
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Factor that influencing ability to tolerate surgery: age
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The very young and the elderly do not tolerate surgery as well as other age groups
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Preoperative assessment
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You assess their health history and whether it's acute or chronic illness
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Document
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Document all teaching so others can continue where you left off
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Informed consent
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Physician must explain the procedure the RN will reinforce the procedure evaluate the patients understanding before the permit is signed
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Latex allergy
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The powder absorbs protein allergens from the latex and deposit them on the skin and into surgical wounds
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After surgery vital sign
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Explain to the patient the vital signs will be taking frequently
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Cardiovascular
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Leg exercises are important to prevent venous stasis
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Preop medicine
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Any patient receiving preop meds must be given the meds at the time ordered by the physician
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Nerve blocks
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Agent injected into a nerve plexus blocking the nerve supply to the area
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Spinal's local anesthetic
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Injected into the cerebrospinal fluid lower part of the body
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Epidural local anesthetic
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Injected into the epidural space
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Iv the regionals bier block
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Blood removed from the arm via tourniquets agent given IV at the site
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Local anesthetic
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Loss of sensation at the site
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Conscious sedation
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Causes a depressed level of consciousness creates analgesia and amnesia it relieves anxiety
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Post op assessment
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Need immediate assessment and all pre-op orders need rewritten including meds
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Initial dressing
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In most cases the initial dressing will be changed by the surgeon
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Preventing abdominal complications
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Ambulation and proper NG tube care and assessment of drainage
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Reduce a complication
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Getting a patient out of bed early and ambulating earlier has many benefits and can reduce a lot of complications
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Discharge information
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Remember what would you want to know if you were the patient
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Prior to discharge
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Patient needs instructions vitals you need to check the incision home supplies follow-up care consult and transportation
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Appetite is affected by
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Our physical and mental state
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Laboratory data
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Nutritional assessment should include CBCs Hgb HCT lymphocytes albumin transferrin levels cholesterol triglycerides and lipoprotein levels
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Mechanical soft diet
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Use for chewing difficulty and the speech therapist assesses it
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Visual impaired client
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Describe what the food looks like and use the analogy of the clock
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Dysphagia
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Place a client in the sitting position request for a full liquid or mechanical soft diet you may need to add the thickener and encourage repeated swallowing attempts remind them to chew their food thoroughly
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Enteral feeding
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Nourishment provided through the stomach or the small intestine rather than orally
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Oragastric intubation
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Tube through the mouth into the stomach
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Nasogastric intubation
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A tube through the nose into his stomach
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Nasal intestinal intubation
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Through the nose and into the intestines
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Ostomy
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Surgically created opening
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Gastrostomy
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Artificial opening into the stomach
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Orogastric tube
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Tube inserted at the mouth into the stomach it is used in emergency to remove toxic substances that have been ingested the diameter of the tube is large to remove pill fragments this is short term less than 30 days it's very irritating to the mucus and you have an increased risk for aspiration
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Nasogastric tube
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Tube placed through the nose and advanced into the stomach in a smaller in diameter you at greatest risk for gastric reflex and aspiration
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Keofeed tube
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Specific nasointestinal tube
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Gavage
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Means to feed
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Lavage
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Means to remove something
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NEX measurement
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Nose earlobe xiphoid process you mark the tube
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Tube placement
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Ship insert the tube high fowlers position you can confirm the tube placement by two ways secure the tube by taping to avoid upward downward migration primary concerns are causes little discomfort as possible preserve the integrity of the nasal tissue locate the tube within the stomach not the respiratory tract and assess for correct placement each time
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Checking tube placement
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Aspirating fluid auscultating the abdomen and testing the pH of the aspirated fluid
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Monitor patency observe any signs and symptoms of obstruction
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Nausea vomiting around the two and abdominal distention and occluded tube may need irrigated normal saline water 30 mL and pump it into the tube
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Tube Feeding system
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Needs changed every 24 hours
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Bolus feeding
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insulation of liquid nourishment 4 to 6 times per day in less than 30 minutes it mimics the stomach
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Intermittent feeding
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Gravity feeding drips in anywhere from 30 to 60 minutes it varies in amounts
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Cyclic feeding
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Liquid nourishment for 8 to 12 hours followed by a rest period 16 to 12 hours
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Continuous feeding
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Liquid nourishment without interruption it's at a constant rate usually for an unconscious patient
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Checking gastric residual
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Do not feed patient if the residual exceed 150 mL keep pulling residual out until you meet resistance recheck in an hour if the residual exceed 150 mL
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Transabdominal tube
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Long term feedings they include your G tube and your j tubes
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To maintain patency
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Flush with 30 mL of water before and after administering with feedings medication and every four hours of patient is receiving a continuous feeding tapwater is effective
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Common tube feeding problems
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Aspiration it means the tube is in the wrong place or vomited you're at the greatest risk with tube feeding for aspirations
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Characteristics of urine normal
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Volume 500 to 3000 mL a day
Color light yellow Clarity it should be transparent Odor should be faintly aromatic |
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Anuria
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Absence of urine
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Oliguria
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Urine output of less than 400 mL in a 24 hour period
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Polyuria
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Greater than normal volume maybe with diabetes and endocrine disorders
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A condom catheter Texas catheter
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Helpful with homecare it's a flexible sheet that is on rolled over the penis the narrow and is attached to the larger collection device
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Three problems with the Texas catheter
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The sheath may be applied to tight restricting bloodflow moisture tends to accumulate leading to skin breakdown and frequently leak and fall off
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Retention catheter Foley catheter
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Indwelling catheter is left in place for a period of Time it's secured with a ballon and is inflated once it is inside the bladder they are available in various diameters usually a 14 F 16 and 18 F are the most common
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Supra pubic catheter
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Inserted by the physician do they have Domino wall above the symphysis pubis it diverts urine flow from the urethra
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technique for inserting a catheter
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Straight or indwelling are similar other than the step for inflating the balloon want to see your and insert one to 1 1/2 inches then inflate the balloon the catheter should be inserted 6 to 7 inches for males and 2 to 4 inches for females
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Closed drainage system
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Device used to collect urine from a catheter you need to hang to suspend the bag from the bed of always keep drainage system lower than the water to avoid the back flow of urine
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Cath care
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Hygiene measures used to keep them meatus and adjacent area of the catheter clean to deter the growth and spread of pathogens
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Catheter irrigation using an open system
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Separate the cath from the drainage system to insert the tip of then irrigation syringe least desirable method because it creates a potential for infection to enter the expose connection
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Catheter irrigation using a close system
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With a self sealing Port cleanse the port with alcohol pierce the port with an 18 or 19 gauge needle attached to a 30 to 60 mL syringe instill the solution clamp the tube beneath the port so it enters the bladder then unclamp and allow it to return to the bag this is the preferred method it's the least risk for infection
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catheter irrigation with a continuous irrigation
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Solution instills into a catheter by gravity over a period of days it is used after prostate surgery or urology surgery to keep the cath patent from blood and tissue debris you need a three-way catheter it has 3 ports one port connects to the drain system another provides means for inflating the balloon third port instills the irrigation solution
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Kegel exercises
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Need to teach an older adult Keagle exercises tighten on the internal muscles used to prevent urination or interrupt urination once it has begun keep the muscle contracted for at least 10 seconds relax the muscle for the same period And repeat the pattern of contraction and relaxation 10 to 25 times perform the exercise regimen 3 to 4 times a day for two weeks to one month
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Assessing oxygenation
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Collect data of the physical assessment there blood gases in their pulse ox
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Physical assessment monitor
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Clients respiratory status observer breathing pattern and effort check for Chest symmetry asculation of the lung sounds recording your heart rate and blood pressure determine your LOC observing color skin mucous membranes lips and nailbeds
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Pulse oximetry
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Noninvasive transcutaneous technique for monitor oxygen saturation of the blood
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Promotion of oxygenation
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Positioning should either be in the high Fowlers or the orthopneic and teach them breathing techniques
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Deep breathing technique
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Take in large volumes of air
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Incentive spirometer
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Help Deep breathing
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Pursed lips breathing
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Former breathing technique to promote oxygenation control ventilation
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Diaphragmatic breathing
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Use a diaphragm increases the volume of air
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Flow meter
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Measured in liters per minute a gauge used to regulate the amount of oxygen delivered to the patient the nurse can adjust the flow rate
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Common delivery devices simple facemask
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5 to 8 L
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Partial rebreather mask
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6 to 10 L
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Non-rebreather mask
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6 to 10 L
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Venturi mask
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4 to 8 L
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Nasal cannula
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2 to 6 L
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Oxygen toxicity
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Lung damage occurs due to oxygen causing traces of more than 50% for longer than 48 to 72 hours it decreases surfactant
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Oxygen toxicity signs and symptoms
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Nonproductive cough chest pain nasal stuffiness fatigue headache nausea and vomiting and hyperventilation
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Suctioning
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Used to clear airways it irritate mucosa it's painless can cause coughing sneezing and gagging you sterile technique determine proper length insert give oxygen before suctioning do not suction while inserting the tube restrict suctioning time to 5 to 15 seconds encourage coughing and deep breathing before suctioning allow rest periods protect yourself from exposure and document amount consistency color and odor of the sputum
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Key points for all suctioning
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Use sterile technique hyperventilate or give extra breath do you not apply suction while inserting suck rotate and withdraw catheter restrict suctioning time for 5 to 15 seconds encourage patient to cough and deep breathe between suctioning and measure length of tube to insert
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Obturator (trachea)
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Guides for initial placement
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Outer cannula
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Mainshaft
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Inner cannula
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Fits into the outer cannula
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Procedures for care and cleaning of a trach
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Place client in Fowler's position provides for communication a signal to you for distress establish a sterile field Don sterile gloves suction first remove the inner cannula and place in a sterile hydrogen peroxide to remove the old dressing clean incision site and the tube with sterile gauze and applicators cleanse the inner cannula with a brush or a pipe cleaners rinse with sterile saline dry it replace the inner cannula and applying a new 4 x 4 gauze
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