exam 1 Flashcards by Callie Wanek

Patient positions in health assessment

standing
sitting
supine
dorsal recumbent/lithotomy (face down) (stirrups)
sims (left lateral, butt access)
prone (face down)
Trendelenburg/reverse Trendelenburg (head down, feet up)

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heart sounds

Aortic
pulmonic
Erb's point
tricuspid
mitrial (PMI)
APE To Man

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examination is used when hands are used to assess skin temp

palpation

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stages of a helping relationship

pre orientation
orientation
working
termination

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focused interview to complete an admission hisotry

use direct questions

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techniques for physical assessment

inspection: smells, situation, reactions
palpation: touch, mass/lumps
percussion: listen for diagnostic info
auscultation: listen with stethoscope
- diaphragm
- bell: vascular (fluids, swishing in carotid fistulas)

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lung sounds

wheeze: constriction in lung
sibilant: classic asthma on inspiration and exspiration
stridor: super loud all above neck
Sonorous / Rhonchi: constriction, chronic bronchitis/inflammation, musical/coarse/dull
friction rub: plura of lungs is inflamed; grating on chest walls on inhale/exhale

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. . . inserted to drain fluid or air from any of these three compartments of the thorax

chest tubes

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Placed in the pleural space to restore the normal negative intrathoracic pressure needed for lung re-expansion after surgery or trauma
Surgery
Tension pneumothorax (most common: lung can’t inflate due to pressure)
Pneumothorax (air in lung)
Hemothorax (blood in lung)
Cardiac tamponade (pericardial sac fills with blood, mediastinal space put pressure on heart)
Penetrating wounds

indications for chest tube

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two types of catheters

small bore: 7-12 Fr

large bore: up to 40 Fr

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All chest drainage systems have…

suction source
collection chamber for pleural drainage
mechanism to prevent air from reentering the chest with inhalation

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amount of suction is determined by the amount of water instilled in the suction chamber
Has a water seal to prevent air from moving back into the chest on inspiration
Drain to gravity
Sucks air out, sends through H2O, can’t get back in

The water level in the water seal chamber reflects the negative pressure present in the intrathoracic cavity
Excessive negative pressure can cause trauma to the tissue

wet water seal

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Use a one-way valve and may have a suction control dial in place of the water
at -20

dry suction

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Increase in water levels during inspiration and a return to baseline with exhalation

tidaling

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A wet suction control chamber
A water seal chamber
Air leak zone
A collection chamber

4 chambers of water seal system

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Dry suction regulator
Water seal chamber
Collection chamber
Suction monitor/bellow

4 chambers in dry suction water seal system

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collection chamber
one way mechanical valve
dry suction control chamber

3 chambers in dry suction systems with one way valve

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The valve allows air and fluid to leave the chest but prevents their movement back into the pleural space
No water seal so it can be set up very quickly in emergencies
=

dry suction systems with one way valve

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150,000 to 450,000/mm3

Total platelets found in the blood

Platelets

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11 to 12.5 sec

Detects deficiencies in the extrinsic coag system. Depends on adequate Vit K

Prothrombin time (PT)

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0-1.1
(therapeutic levels are higher)
Same at PT test, but used internationally in all laboratories. Both monitor Coumadin and can detect liver failure

International ratio (INR)

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170-340 mg/dL

Protein that converts to fibrin- needed for clots. Screen for DIC

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Fibrinogen

0-250 ng/mL

Degradation product of fibrin clots. It’s presence confirms thrombin and plasmin activation. Diagnoses DIC.

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D-dimer

O: universal donor
A: can receive A or O
AB: universal recipient: can receive AB, A, B, O
B: can receive B or O

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cross matching

``` Fever Chills Itching Hives respiratory distress low back pain Nausea pain at the IV site anything “unusual” ```

signs of reaction to blood

1 degree C increase in temp- caused by donor antibodies and leukocytes- most common, especially with increased number of transfusions signs and symptoms are chills followed by fever, typically sets in 2 hours after transfusion. Not life threatening. Can give Tylenol preop.

febrile nonhemolytic reactions

Most dangerous and life threatening!- incompatibility. Antibodies destroy cells. Can happen with very little blood. fever, chills, low back pain, nausea, chest tightness, dyspnea, hypotension, hematuria, oliguria, bleeding, anxiety- hypotension, bronchospasm, vascular collapse, DIC

acute hemolytic reactions

Onset 14 days after transfusion- typically not dangerous, difficult to detect fever, anemia, possibly jaundice

delayed hemolytic reactions

1-3% of transfusions- mild, responds to antihistamines (Benedryl) uticaria or itching

allergic reactions

Hypervolemia- titrate infusion to their tolerance, diuretics, place them upright dyspnea, orthopnea, tachycardia, anxiety, JVD, crackles, pulmonary edema (pink, frothy sputum)

circulatory overload

Why for trach

Obstructed airway Mobilize secretions Deliver oxygen Measure from chin to jaw

``` Respiratory failure (COPD, ARDS) Airway injuries (trauma) SEVERE allergic reactions Head and neck cancer Neuromuscular disease (ALS) (loss of muscle strength) Spinal cord injuries Stroke ```

conditions for trachs

One way valve Allows air in, not out Forces air around tracheostomy tube, through the vocal cords, out the mouth Patient can speak helps air move around trach tubes and vocal chordes

passy-muir valve

``` *Obturator at bedside Suction equipment Ambu bag Spare trach Dressing change PRN *Humidified air ```

nursing care for trachs

Types of IVs

``` Peripheral Venous (IV): up to 72096 hours -terminates in peripheral vein Central Venous: implanted and externa (95%)l: stay in longer ```

Enter of Venous System

peripheral: cephalic or basilica vein | Central (tunneled or non): subclavian, internal jugular, external jugular, femoral vein

gauge: 20-22: common IV fluids gauge: 14-18: blood or trauma

types of gauge

inflammation of vein see redness due to irritation of tissue, warm, painful fix with hot pack

phlebitic

vessel starting to harden | overtime vessel gets harder and stronger like calcified rock

sclerotic

Inserted just above or below the antecubital fossa into the basilica or cephalic veins Catheter longer than 3 inches Considered a Peripheral IV Left in from 2-6 weeks

midline peripheral catheters

``` With running IV’s done hourly With Saline Locked every shift Monitor site/running fluid/tubing changes (running IV tube/bag 24 hrs, secondary 96 hrs, IV site q 72 hrs, follow agent policy) Redness= phlebitis swelling=infiltration pain=phlebitis coolness = loss of circulation ```

assessment of IV site

swelling, firmness, coolness

indicates infiltration

blood clots in IV line

so discontinue infusion

Common of dialysis catheters Usually placed in surgery, may be done under local anesthetic Two incisions are made on the chest (entrance and exit sites). A tunnel is made under the skin between the two incisions, and the CVC Is threaded through the skin and into a vein under the clavicle. Sterile dressings are applied and the lumens are flushed with heparin. Caps changed with dressing changes. tunnel makes difficult for bacteria to track into bloodstream and helps hold catheter in place sterile due to close <3

tunneled CVCS

“Central line” or “Triple-lumen” Placed at bedside w/ sterile technique or in OR by MD, with or without guidewire Tip lies at superior vena cava of heart Placed at subclavian or jugular veins Change dressing 24 hours after placed and weekly Flush per protocol TRUE CENTRAL LINE: terminates AT superior vena cava

non tunneled CVC

Peripherally inserted in the arm, but the end of the catheter lies the sub-clavian vein. Used for long term therapy with limited IV access who need antibiotics, blood, vasopressors, or parenteral nutrition Inserted sterilely under local anesthetic, typically ultrasound guided, by specially trained nurse or doctor. Sutured or tightly secured. Dressing changes are sterile. =

peripherally inserted central catheter (PICC)

1. Pause IV to prevent drawing med that's lfowing 2. Largest lumen 3. Aspirate 10 mL and flush* 4. Discard 10 mL* 5. New syringe- Blood draw* 6. Flush* 7. Positive pressure technique

how to draw blood

Thrombus (clot) -> embolism(moving clot) Infection -> sepsis -> shock Arterial puncture Catheter malposition Pneumothorax/hemothorax: try to put in vein and puncture lung or nic something --> blood in lungs Air embolism Arrthymias Nerve/tendon damage Subcutaneous hematoma (under skin bleeding) Thrombophlebitis (inflammation of clot) Local: dermatitis, cellulitis, burns

complications

``` heparin or TPA substances - 5000 U to dissolve clot. Can't give to stroke pt. change position raise arm cough positive pressure technique ```

occlusions

osmolality equal to serum stays in intravascular space and expands in intravascular compartment -Expands blood volume only. Stays where "I" put it Treats hypernatremia, fluid loss and dehydration not given in head injuries

isotonic | DSW

osmolality lower than serum. Shifts fluid of intravascular compartment, hydrating cells and interstitial compartments Goes into cells and sticks there Go "O"ut of the vessel free water-rids waste in kidneys decrease BP, cellular edema, cell damage

hypotonic solution | 0.45% NACL

osmolality higher than serum. draws fluid into intravascular compartment from cells and interstitial compartments water follows salt. fluid goes into cells and back out pulling excess fluid "E"nter the vessel treat hypernatrema and swollen cells be careful: circulatory overload Pulmonary Edema

hypertonic solution | 3% or 5% NACL

Calculated very specifically, typically daily 5-6X the solutes as blood (lots of pressure to veins) **CVCs only Not compatible with anything else Lots of glucose=lots of bacteria! Glucose monitoring, fluid overload

Parental nutrition (PN) needs to be at least 1 wk of therapy when weight loss/protein calorie malnutrition show up use in extensive bowel surgeries or pancreatitis use if can't, unwilling, or NG/G tube wont work

exam 1 Flashcards

(53 cards)