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132 Cards in this Set

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  • Back
What is the purpose of a Braden scale
Assess patient risk for developing pressure ulcers
What are the 6 dimensions of the Braden Scale?
Sensory Perception
What is the max score for the Braden scale?
23 (little risk)
How do the risk scores work for the Braden scale?
Maximum= 23 (little risk)
≤ 16= At Risk
≤ 9= High Risk
What is fecal impaction? What are the S&S?
Collection of hardened feces in the rectum or sigmoid colon.
Diarrhea (around impaction)
Urinary frequency
What does fecal impaction prevent?
Prevents the passage of a normal stool
What is digital removal of fecal impaction?
a technique of removing feces with fingers (scissor technique)
Digital removal of fecal impaction steps
Proved privacy
Position pt left side-lying
Place bedpan next to patient
Lubricate gloved index and middle fingers
Ask pt to take a deep breath while inserting index finger
Insert middle finger
Work feces down using scissors maneuver
What side should pt lay on when performing a digital removal of fecal impaction?
left side
Be cautious of _________ when performing fecal impaction
What is an enema?
a type of a solution put into the rectum and sigmoid colon
Volume and type of fluid breaks up the fecal mass, stretches the rectal wall and initiates the defecation reflex.
Tap water (hypotonic) enema
Be cautious of water toxicity or circulatory overload
Kayexalate enemas
High K+
Neomycin enema
reduces bacteria prior to colon surgery
Cleansing enema (Fleets)
stimulates peristalsis
Oil-retention enema
colon absorbs a small volume-allows the stool to soften
NS enema (isotonic)
used often for children or for fluid intolerance
Hypertonic (fleets)
Small volume if unable to tolerate large volume-draws fluid into bowel to soften stool
Pt position for administering enemas
Sim's position
Depth of enema for adults, children, infants
Adults: 3-4in
Children: 2-3in
Infants: 1 -1½in
Where to aim enema tip?
Towards the umbilicus
How long should pt stay on the side after enema administration?
5 min
Pt position for enema bag?
amount solution added to enema bag?
Steps for Enema Bag
Position pt in Sims’
Add 750-1000ml of warm solution to enema bag
Prime the tubing with fluid then reclamp bag
Lubricate tip and insert toward umbilicus
Raise enema bag above rectum to appropriate height
Unclamp enema bag and allow fluid to flow
Clamp bag and withdraw tip from anus
Caution for administering enemas
Inspect for bleeding
Rigid abdomen
Abdominal cramping
If pt is experiencing abdominal cramping during enema administration, what should you do?
Lower height of enema bag
enema bag heights
High: 12-18in
Regular: 12in
Low: 3in
opening made from small intestine or colon
Output from stoma
stoma made from colon
stoma made from the ileum
Colors of a stoma
Pink- good
Intestine order
Ascending- liquid
Transverse-semi solid
Descending-mostly formed
What is an urostomy?
It removes urine in cases where drainage of urine through the bladder and urethra is not possible, e.g. after extensive surgery or in case of obstruction
Urstomies are permanent
How does the effluent of a urostomy look?
Effluent will be urine with mucus
How is a Urostomy made?
Formed from resected portion of intestine and attached to ureters
Reasons for NG tubes
Enteral Feedings
Lavage (Overdose)
Compression (Prevent hemorrhage)
Gastric Decompression (Post-op abdominal surgery
Bowel rest)
Types of would healing?
primary, secondary, tertiary
Primary Intention for would healing
Edges close together
Minimal tissue loss
Heals quickly
Minimal risk for infection
Staples, sutures
Secondary intention
Open wound with tissue loss
Heals by scar formation
Prolonged phase of inflammation
Longer phases of proliferation and maturation
Tertiary intention
Wound is closed after 3-5 days
Allows edema and infection to resolve
Heals by primary intention
What are the types of pressure ulcers?
Stages I-IV and unstagable
Stage I pressure ulcer
Skin intact
Non-blanching erythema
May be painful
May be warm
Treatment for stage I pressure ucler
Keep pressure off area
Maintain hygiene
Maintain adequate diet
Protective dressing
Stage II pressure ucler (partial thickness)
Loss of epidermis and dermis
Shallow opening
No slough
Ex. Blisters, abrasion
Treatment for stage II pressure ucler
Remove pressure source
Clean wound with sterile saline
Hydrocolloid dressing (Ex. Duoderm)
Cleanse with sterile saline
Stage III pressure ucler
Full thickness tissue loss extending to SQ tissue and fascia
Drainage common
Treatment for stage III pressure ucler
Packing agents
Consult wound care nurse
Pressure- relieving mattress
Stage IV pressure ucler
Full-thickness tissue loss extending to bone, muscle, or tendons
Slough and eschar may be present
Treatment for stage IV pressure ucler
MD consult
Wound care nurse consult
Unstageable pressure ulcer
Full-thickness tissue loss
Base of ulcer:
Slough: Yellow, Tan, Green, Brown
Eschar: Tan, Brown, Black
Treatment for unstageable pressure ulcer
How do you prepare a sterile field?
1. Sterile package on a dry surface above waist level.
2. Open outermost flap away from body.
3. Pull side flaps open using the outside of the flaps.
4. All flaps should be open and lying flat.
Ways to contaminate a steril field?
Sterile field below waist level
Reaching across sterile field
Leaving sterile field
Turing your back to the sterile field.
Placing no steril items in sterile field.
When to use soap and water?
C Diff
Soiled hands
Bodily Fluid
When to use alcohol rub?
Not visibly soiled hands
B&A direct pt contact
B&A donning gloves
B&A removing gloves
After contact with inanimate object
Pts with airborne diseases like Measles, Varicella/ Shingles and TB require what?
Isolation, Negative air pressure room, Special mask “N-99”
Pts with droplet transmitted organisms like Haemophilus Influenzae type b, Meningitis, Pertussis and Pneumonia require what?
Mask and isolation
Examples of illnesses that can be easily transmitted through direct pt contact or contact with pt environment
MRSA, Respiratory infections (RSV), Skin infections (Impetigo, Scabies) C. Diff, GI infections
Illnesses that can be easily transmitted through direct pt contact or contact with pt environment require what?
Gown and gloves
What is a medical asepsis? What does it prevent?
A clean technique. It prevents the spread of microorgsnisms (not kill)
What are some examples of medical asepsis?
Hand hygiene
Barrier Techniques
Change soiled dressings
Discard items that touch the floor.
What is surgical asepsis?
Sterile Technique
When is an object sterile?
When all microorganisms and their spores are destroyed.
Some places where surgical asepsis is used?
operating room
Labor and delivery
Procedural areas
Pt's bedside
Invasive procedures
What to do when handling a sterile package?
Peel open package and let contents fall onto sterile field
What to do when handling a sterile solution?
Hold bottom of bottle on angle away from sterile field
Pour contents 1-2 inches above sterile container
When should you consider restraints?
Fall risk, pulling out tubes, removing dressing, wandering
What are the different types of restraints?
Belt (prevents falling or rolling out of bed), extremity, mitten (prevents removing dressing) chemical (sedating for behavioral control
Restraints must be removed every ____ hours
The Physical or APN must physically evaluate pt within ____ hours of restraint initiation.
How often must a restraint order be renewed?
Every 24 hours
Document assessment of pt for injuries every ___ min
Do not attach restraints to ______________.
Use a ______ _______ tie.
side rails
quick release tie
Time limits on restraints
4 hours
2 hours
1 hour
Required documentation for a fall.
Symptoms at time of fall
Previous fall
Location of fall
Activity at time of fall
Time of Fall
Trauma post fall
What to do when there is a medication error?
Fill out an Incident Report with:
Patient identification information
Time and location of incident
Description of event with follow-up care
This should NOT be referred to in the patient’s chart
6 rights
Right Dose, Patient, Route, Documentation, Medicine, Time
Preventing Medical errors
6 Rights of medication
Double check calculations with another nurse
Question exceptionally large or small doses
Document medications immediately after administration
Medications can be given 30min before or after scheduled time.
Can only crush scored tablets
What is aspiration?
Food or medication moves into trachea
What are some aspiration precautions?
Thicken medication
Sit patient up to 90°
Administer small amounts at a given time
Always insert needle with bevel up
Parts of a needle
Hub, shaft, bevel (pointy part)
Gauge Vs. Needle Diameter
Smaller the gauge, larger the needle diameter
Larger the gauge, smaller the needle diameter
Insulin Injection "How To"
L to S, S to L
Alcohol wipe both.
Aspirate air equal to amount of long-acting insulin
Inject air into long-acting insulin vial
Remove syringe and aspirate air equal to short-acting insulin
Inject air into short-acting vial and withdraw medication
Remove air bubbles
Insert syringe back into long acting insulin and aspirate correct volume
Cap needle
Most common site for BP
Arm at brachial artery
Other sites for BP and where to auscultate
Leg (dorsalis pedis or posterior tibial arteries), thigh (popliteal artery) , forearm (radial)
When taking BP in the thigh...
SBP 20-30mmHg higher than upper extremity
BP equals what
Peripheral Vascular Resistance (PVR) is
PVR is the semi-contracted state of arteries that maintain a relatively constant resistance to blood flow. Controlled by the autonomic nervous system.
Volume (BP)
the greater the volume, the greater the pressure
as elasticity decreases, pressure increases
dialation constriction
dilation lowers BP, constriction raises BP
Define Blood pressure
force exerted by blood against the vessel walls.
force or pressure in walls of arteries when (L) ventricle contracts
force or pressure on walls of arteries when heart is filling
At what age do start BP for children?
a 3 y/o
High Normal
For Children
Normal 90th percentile
High normal 90th-94.0
HTN >95th percentile
For Children Any reading of 120/80 or higher is pre-hypertensive (unless it is 95th percentile or higher) and then it is HTN.
After age ___, high ____ BP (>140 mmHg) is much more important than high diastolic pressure as a cardiovascular risk factor.
50, systolic
____% chance of developing HTN after age ____
90%, 60
40 to 70 yo risk for cardiovascular disease doubles with each increment of 20/10 mmHg above 115/75
Lifestyle modifications for HTN
lose weight
fruits& vegetables
low-fat dairy products
reduce Na intake (1 tsp./day)
alcohol in moderation
Smoking cessation
Caffeine and Nicotine's effect on BP
Caffeine false high up to 15 minutes
Nicotine false high up to 3 hours
How to avoid Auscultory Gap?
By doing 2 step BP
Auscultory Gap usually heard in ______. Results in....
Underestimation of SBP
Overestimation of DBP
What is Orthostatic BP?
Decrease in SBP > 20mmHg and/or a decrease in DBP >10mmHg with an increased pulse 10-20bpm when pt moves from lying to standing position
Causes of Orthostatic BP
hypovolemia, prolonged bedrest, medications
Assessment technique for Orthostatic BP
Measure BP in lying, sitting, standing position; wait 2-3 minutes between each position.
If arm lower than level of heart  false high
If arm higher than level of heart  false low
Unsupported arm  false high
Bladder cuff too wide  false low
Bladder cuff too narrow  false high
Width of bladder should cover 2/3 of upper arm
Length of bladder should reach 80% around arm
Bladder should be centered 1inch above Anticubital fossa
Temperature usually ______ in the morning. Peaks between....
lower, 5-7
Women have _______ temperature fluctuations.
Older adults have a more ________ range.
Are core or surface temps more reliable?
Examples of core sites?
Tympanic membrane
Temporal artery
Urinary bladder
Examples of surface sites?
Tympanic membrance 0.5 ______ than oral.
Rectal 0.5 ______ than oral.
Axilla 0.5 ______ than oral
Technique for rectal temp
Place temperature probe in lubricant
Insert probe 1.5 inches toward the umbilicus
Remove if you feel resistance
Advantage of axilla temp?
Used in newborns and unconscious patients
Axilla technique
Place probe in center of axilla and place arm across pt chest
What is Pulse Oximetry?
Noninvasive measurement of arterial blood oxygen saturation
LED emits light that is absorbed differently from oxygenated and deoxygenated Hgb
Limitation of Pulse Oximetry?
Can’t tell whether or not CO or Oxygen is bound to Hgb
Locations for Pulse Oximetry
Bridge of nose
Things to remember when doing pulse oximetry
Requires pulsating vascular bed
Site must be free of moisture
Nail polish should be removed
Use forehead in low perfusion states
What is a pulse?
Reflects the volume of blood ejected against the arterial wall with each beat
Low volume=______pulse
HIgh volume= _______ pulse