final Flashcards
(137 cards)
1
Q
support surfaces reduce
A
pressure by redistributing it over large surface areas
2
Q
preventative surfaces are for
A
patients at risk for skin breakdown
3
Q
therapeutic surfaces are for
A
patients at high risk for pressure ulcer development
4
Q
never place a pt at high risk for pressure ulcers in
A
ordinary chairs or regular hospital mattress, use specialized surfaces
5
Q
priority for those at risk of tissue injury
A
frequent repositioning
6
Q
pt centered care for support surfaces
A
- when selecting a pt’s support surface complete a thorough assessment
- match surface to pt needs
- explain interventions to pt/family members; allow time for questions
- consider the pt culture (no experience with technology, accommodate any rituals or practices in the care plan, gender-congruent care providers as needed)
- demonstrate device use as needed
7
Q
support surfaces include
A
- mattresses (powered and non powered, air, water, gel, foam, or combo)
- low pressure seat cushion
- always use bedsheet to cover mattress
- must deflate air mattresses for CPR
8
Q
reporting and documenting special services
A
- type of support surface applied
- pt toleration of procedure
- condition of pt’s skin
- record in nurses notes any teaching and validation of understanding
- report to charge nurse or HCP for pressure ulcer formation
9
Q
powered beds
A
- air-suspension beds are designed for pts who are immobile or confined to bed
- for pts w/ pressure ulcers or wounds
- maintains an air movement against the skin to decrease moisture
10
Q
air-fluidized bed
A
- powered device designed to distribute pt’s weight evenly over support surface
- use filter sheet which also warms the pt
- diaphoresis is difficult to see - pt can have fluid/electrolyte imbalance
11
Q
bariatric bed
A
- made for morbidly obese pt’s
- upright and sitting position
- pt transport
- in-bed scale
- pt can operate
- does not have pressure reduction/relief in the mattress must add additional device
12
Q
rotokinetic bed
A
- maintains skeletal alignment while constantly rotating
- used for spinal cord injuries or multiple traumas
- may lead to sensory deficits for older patients (eye and ear)
13
Q
delegation of specialized services and beds
A
UAP can only inform nurse of any skin or mental status changes
cannot do assessment
14
Q
nursing care
A
- skin assessment/risk for pressure ulcer development
- assess comfort level
- assess orientation/anxiety
- pt education
- positioning
- monitor functioning of device
- adequate fluid intake - pt may have insensible fluid loss
- ROM if appropriate
15
Q
unexpected outomes of special services and bed
A
- skin breakdown gets worse
- dehydration
- agitation/restlessness
- bed malfunctions
- hypotension or abnormal lung sounds - rotokinetic bed
16
Q
reporting for bed
A
- record transfer of pt to bed, amount of assistance needed for transfer, tolerance of procedure, and all assessmnet
- record pt teaching and validation of understanding
- report changes in condition of skin, level of orientation, respiratory function, and fluid and electrolyte levels
17
Q
fecal impaction
A
- occurs in all age groups
- digital removal performed when enemas and suppositories are not successful
- fecal removal cannot be delegated
- beware of vaginal stimulation, may cause decrease in HR and change in ryhtm
18
Q
s/s of fecal impaction
A
- constipation
- rectal discomfort
- abdominal pain/bloating
- leakage liquid stool
- anorexia
- urinary frequency
- nausea
- vomiting
19
Q
pediatric fecal impaction
A
- do not digitally remove stool in pediatric pt
- dietary changes (high fiber, increase fluids)
20
Q
older adult fecal impaction
A
- prone to dysrhythmias and other problems related to vaginal stimulation
- increase fiber
- laxative use with caution
21
Q
enemas
A
used to treat constipation or to empty bowel before diagnostic procedures or certain types of abdominal surgery
22
Q
types of enemas
A
- bag/bucket
- SSE
- hypertonic
- normal sline
- harris flush
- carminitive
- oil retention
23
Q
bag/bucket enema
A
tap water
24
Q
sse
A
soap suds enema
25
hypertonic enema
fleet's (small amount of solution)
26
normal saline enema
best for infants and children
27
harris flush enema
return flow enema with 100-200mL of enema solution for excess gas
28
carminitive enema
for excess gas
Mg+, glycerin, H2O
29
enema procedure
- left lying sim's position
- if child, dorsal recumbant
- well-lubricated tip for insertion
- insert in direction of umbilicus
30
insertion of enema length ADULT
3-4 inches
31
insertion of enema length ADOLESCENT
3-4 inches
32
insertion of enema length CHILD
2-3 inches
33
insertion of enema length INFANT
1-1.5 inches
34
bag/bucket enema procedure
- the higher the bag, the faster
- high enema = 12-18 inches above anus
- regular = 12 inches
- low = 3 inches
- at the hip = to start
35
side effects of enemas
- cramping and distension are normal
- if cramping occurs, stop solution momentarily and lower the height
- stay with pt at all times
- have bedpan/toilet tissue available nearby
36
most important info for bag enemas
- obeserve height
- warm solution not hot
- the higher the faster
37
prepackaged enemas
- always add lubricant to tip
- tip of bottle aimed at umbilicus
38
pediatric considerations
- do not give prepackaged hypertonic solutions as it may cause rapid fluid shift
- oral stool softners as first treatment
39
older adult considerations
- caution with enemas until clear (can cause fluid and electrolyte imbalances)
- poor sphincter control, may be not be able to hold enema
- changes in VS
40
documenting enemas
- type and volume of enema
- characteristics of result
- pt tolerance
- pt education provided
41
local application of heat or ice
- provides comfort
- reduces muscle spasm
- improves mobility
- promotes healing
42
principles for heat or ice application
- causes systemic and local responses
- sensory adaptation quickly to local temperature extreme can occur quickly
- orders for heat or cold application is ALWAYS necessary
- cold vasoconstricts to slow bleeding into damage tissue
- hypothermia and hyperthermia devices are used selectively for specific conditions
43
EBP of heat or ice
- cold therapy reduce the conduction of pain impulses which occurs when the ski temperature is lowered
- ice applied to soft tissue injuries is effective in initial pain control
- cold therapy decreases nerve conduction velocity, formation and accumulation of edema and VF to injured tissues
- application of heat is useful in maintaining or improving range of motion following acute soft tissue injury
- a combo of heat and cold therapy is effective in adults and child w/ MS injuries to reduce inflammation and edema and improve ROM
44
safety guidelines for heat and cold
- know pt risk for injury
- protect damaged skin when applying cold or heat therapy
- know temp of application being used
- burns and injuries from hot or cold therapies are preventable events
- modify intensity of heat and cold when treating sensitive skin areas
- check the pt frequently during a heat or cold application
- do not allow pt to adjust temperature settings
- position pts so they can move away from temperature source
- do not leave pt unattended if he or she is unable to assess temperature changes or move away from temp source
- if pts have diabetes mellitus or peripheral vascular diseases, use caution when applying hot or cold therapies
- be aware of impact heat has on vital signs
45
application of moist heat
- promotes healing and relaxation and relieves muscle spasms/joint stiffness
- consists of warm compresses
- also commercial heating packs
- provide warm baths, soaks, and sitz bath
- check water temp frequently to prevent burns
- removed pt before adhering heated solutions
46
if there are no risks or complications a UAP
CAN apply moist heat
47
reporting of apply heat or cold
- record and report procedure noting type, location, and duration of application; solution and temperature; condition of body part, wound and skin before and after treatment; pt's response to therapy
- precord pre and post VS
- record teaching and ability for pt to teach back
48
teaching for heat and cold
- explain wound packing if needed
- heat application
- temperature sensing
49
pediatric heat and cold
- have fragile skin
- incorporate play when child needs to soak
- remain w/ child during baths or heat applications for safety
50
older adults and heat and cold
age related skin changes, cardiac conditions, and alterations of thermoregulation
51
home care and heat and cold
assess caregiver's ability and physical environment; pt may need assistive devices
52
aquatherma and dry heat
- water flow pads
- electric heating pads
- commercial heat packs
- air-activated wearable heat wraps
53
application of cold
- cold therapy treats localized inflammatory responses that lead to edema, hemorrhage, muscle spasm, or pain
54
PRICE principle
P - protect from further injury
R- restrict/rest activity
I - apply ice
C - apply compression
E - elevate injured areas
55
cold examples
- ice packs
- moist cold compresses
- chemical cold packs
- cold soak immersion of a body part
- electrome chanical or compression devices
56
hypothermia or hyperthermia blankets
used manually or on automatic setting
57
recording heat and cold
- record baseline data: vitals, neuro and mental status of peripheral circulation, and skin integrity, when therapy was initiated
- include hyper or hypothermia unit used; control settings (manual, automatic and temperature settings), date, time, duration, and pt's tolerance of tx
- report unexpected outcomes
58
teaching
instruct pts and families to not move blankets or source of heat or cold unless bothersome
59
pediatric
infants have unstable thermoregulation; mottling of extremities is common and does not always indicate adverse reaction
60
mottling
common in infants, assess for any other issues first before raising concern
61
older adults and heat and cold
some older adults at greater risk for tissue damage because of loss of cold sensation, check pt frequently during all treatment
62
restraint
any method (chemical, physical, or seclusion) of restricting an individual's freedom of movement, including physical activity or normal acces to his or her body that
- is not usual part of medical or diagnostic treatment
- is not indicated to treat individual's medical condition
- does not promote the individual's independent functioning
63
serious and often fatal complications of restratints
- strangulation
- suffocation
- neurovascular injury
- skin breakdown
- confusion/agitation
- respiratory complications
- incontinence
- loss of appetite
- fracture/head trauma
- impaired muscle strength
64
restraints are used as
LAST RESORT
65
restraint CANNOT
be delegated to UAP but educated on safety in room, applying appropriate monitoring of alarm devices, and reporting pt behaviors and actions
66
alternatives to restraints
- frequent orientation
- same caregivers
- close to nurse's station
- apply assistive devices
- clock/calender
- music/tv
- pictures of family
- scheduled ambulation, toileting, and activites
- hourly rounds
- place tubes outside pt view or cover
- eliminate stressors
- back rubs
- motion or bed alarms
- diversional activities
67
restraint policy
1. a restraint must be justified by the patient being a danger to self, staff, or others
2. a restraint must be used safely
3. a restraint must have an order by a liscened practictioner
4. an order for a restraint can NOT be prn
5. a restraint order must be time limited (4 hrs >18 years old, 2hrs 9-17 years old, 1 hr for <9 year old)
6. must be renewed every 24 hrs
7. pt must be monitored if on restraints or in seclusion (vs, circulation, comfort)
8. must be written policies in place
9. pt must be evaluated and re-evaluated within 1 hr of restraint initiation (by HCP or RN ,assessed q2hrs)
10. if pt is on both restraints and seclusions, must be continuously monitored
11. documentation of pt behavior, alternative restraint attempts, pt response, assessment, orders, injuries, deaths (during or 24 hrs after restraints have been removed)
12. staff training
68
pre-restraint assessment
- skin
- sensation
- circulation
- ROM
- pad skin or bony prominences
69
during restraint assessment
- every 2 hrs as per policy
- check for 2 finger breaths under restraint
- remove one restraint at a time if violent, agitated or nonadherent
- skin integrity
- pulses
- temperature of skin
- skin color
- sensation/numbness/tingling
- offer food, fluids, toileting, with each assessment
70
physical restraints
- applying wrist, ankle, or waist restraint
- tuckin in a sheet too tight to limit movement
- 4 side rails up
71
chemical restraint
- admin of drug to restrict movement or behavior that is not normally perscribed for the pts condition
72
seclusion
in ED or psych units
73
side rails considered as a restraint
depends on intent, if intent is to restrict pt from getting out of bed it would be considered a restraint
if intent is to prevent from falling out of bed, not a restraint
74
enclosure bed
considered restraint unless for children or infants
75
hand mitts are considered restraints when
- mitts are pinned or otherwise attached to bed or wrist restraints are used in conjunction
- mitts are applied so tightly the pt's hands or fingers are immobilized
- mitts are so bulky pt ability to use hand is significantly reduced
- mitts cannot easily be removed intentionally by pt in same manner it was applied by staff considering the pt's physical condition and ability to accomplish objective
76
restraint types
- wrist extremity
- elbow
- belt
- enclosure bed
- chemical
- seclusion
77
all restraints must be
quick release
78
pressure bandages
temporary treatment to control excessive, unanticipated bleeding, stops blood flow and promotes clotting
79
hemostatic wound products
adherent when in contact w/ blood
80
aeseptic technique is
secondary during episode of acute bleeding
81
reporting of dressings
- report pt status of bleeding control, time bleeding was discovered, estimated blood loss, nursing interventions (effectiveness of applied bandage), apical and distal pulses, BP, mental status, restlessness, need for HCP to admin pt
- record assessment, application of pressure dressing, and pt response
- record appearance of wound, color, size, characteristics of drainage, responses to dressing change, condition of periwound skin, pts comfort level
- graph surface area or volume if chronic
- record pt understanding through teach-back for proper wound dressing
- report to HCP immediately signs of infection, necrosis, or deteriorating wound status
82
teaching for dressings
explain the need to monitor VS and for pt to remain quiet and stay in position to reduce bleeding
83
pediatric considerations for bleeding
child will calm down if care providers and family remain calm
84
older adults and dressings/bleeding
pts at increased risk for vascular and tissue changes distal to pressure dressing
85
home care for bleeding
- provide instruction: apply pressure to control bleeding and call 911, elevate extremity
- do not remove a penetrating object
- positioning to elevate body part
86
transparent film dressing
- clear, adherent polyurethane sheet
- prevents tissue dehydration and allows for rapid, effective healing by speeding epithelial growth
- preferred for IV insertion sites
- wounds with minimal or no exudate (does not have absorptive quality)
- commonly used as secondary dressing for alginates, foams, gauze
87
teaching for transparent film dressings
explain need to change dressing if edges loosen
explain that fluid under dressing isn't pus it is the result of normal interaction of body fluids with the dressing
88
pediatrics and transparent film dressings
- adhesive may tear premature infant skni
- tell children the longer the dressing is left on the easier it is to remove
89
older adults and transparent film
adhesive may tear older adult skin
90
home care and transparent film dressing
wound may be cleaned in shower with provider approval
explore dressing types with pt and recommended one that the pt can easily locate and finds easy to apply
91
hydrocolloid dressings
- adhesive and gelling agent
- absorptive and hydrating
- forms gel that promotes moist environment and facilitates autolytic debridement
- diminishes pain
- protects wound and periwound skin
- for wounds w/ minimal drainage
92
hydrogel dressings
- glycerin or water based
- rehydrates wounds by promoting moist wound healing and autolysis
- non-adherant with absorptive properties
- cooling/soothing properties
93
foam dressings
protect wound surface while maintaining moist, insulated environment
for wounds with light to heavy amounts of drainage
94
alginate dressings
- promote autolysis, granulation, and epithelialization
- calcium alginate material (seaweed)
- form a gel over the wound to contain exudate
- requires secondary dressing
- must irrigate gel before placing a new dressing
- for wounds with moderate to large amounts of drainage
95
application of...
hydrocolloid, hydrogel, foam, or alginate dressing cannot be delegated to UAP
96
pediatric considerations
- obtain pt cooperation or aid in holding child
- child will calm down if everyone else is calm
- adhesive may tear premature infant skin
- tell children, longer the dressing is left on, the easier to remove
97
older adult considerations
- prevent tape from contacting skin
- pts may have delayed wound healing
- pts are at increased risk for vascular and tissue changes distal to pressure dressing
- adhesive may tear older adult skin
98
applying gauze and elastic bandages
- gauze and elastic bandages secure or wrap hard to cover body areas
- banadages are a secondary dressing
- select type of bandage turn and width on the basis of size and shape of body part and wound
- place outer surface next to the skin and roll it around the surface to be covered
- apply even tension during application
- check circulation
99
the task of applying _____ for compression ____ be delegated to UAP
elastic bandage, CANNOT
100
the task of applying _____ to secure nonsterile dressings ___ be delegated to UAP
bandages, CAN
101
the nurse direct UAP by
explaining how to modify bandage application, as with special taping
reviewing what to observe and report
102
binders
- elastic or cotton
- breast
- abdominal
103
applying a binder CAN
be delegated
nurse direct UAP about modifying task such as special wrapping or securing, reporting complaints of pain, numbness, tingling, or difficulty breathing or any changes in skin color or temp
104
wrist wrap
begin by holding edge of bandage between thumb and forefinger and start wrapping around wrist beginning at base of palm and wrap multiple times, then wrap diagonally through hand and palm once or twice, continue wrapping upwrist overlapping by 1/2 of the previous layer ended halfway between wrist and elbow
105
Hemoccult testing (1)
106
sterile field
work surface on which sterile equipment and supplies are set up and handled during treatment
107
preparing sterile field
1. check expiration date on sterile packaging
2. look for punctures stains evidence of moisture
3. apply PPE as needed
4. perform hand hygeine
5. select clean, flat, dry work surface above waist level
108
sterile drape
1. place package on flat dry sruface
2. open outside cover and grasp folded top edge of drape with fingersr of one hand
3. lift drape from wrapper without touching anything, let drape unfold holding it above waist and work surface
4. with other hand discard wrapper
5. grasp adjacent corner of drape and positoin drape flat on work surface
6. allow top half of drape to cover bottom half of work surface
7. outer 1 inch of drape is not sterile
109
maintaining sterile field
- object remains sterile if other objects that touch it are also sterile
- contaminated when touched with any nonsterile object
- if hands or sterile object are below waist level = contaminated
- sterile field is contaminated if moisture happens within field
110
tips for maintaining sterile field
- never reach across sterile field
- never turn back on sterile field
- never leave room after sterile field is set up
111
sterile gloving
1. select correct size and type of gloves
2. examine package to ensure it is intact and dry and has no tears or water stains
3. select gloves
4. place packages near where youll be working
5. inspect condition of hands and fingers looking for cuts or lesions
6. perform hand hygiene
7. before applying, be aware of own and pt's reaction to latex
8. remove outer wrapper of glove package by seperating and peeling apart two side
9. grasp inner package and lay it on clean, dry, flat surface at waist level
10. open package keeping gloves on side surface of wrapper
11. ID R and L gloves
12. cuff on gloves 2 inches wide
13. glove dominant hand first
14. using thumb and first 2 fingers of nondominant hand, grasp glove for dominant hand touching only gloves inside surface
15. pull glove over dominant hand leaving a cuff
16. with gloved hand, slip fingers beneath cuff and pull it over other hand
17. interlock hands and hold above waist level
18. touch only sterile sides of gloves
112
what is tested in neuro assessment
1. LOC
2. mental status
3. cranial nerves
4. motor systems
5. sensory system
6. coordination
7. reflexes
8. gait and balance
113
LOC
use glasgow coma scale
114
mental status
use MMSE
115
assessing CN II
assess for PERRLA
116
assessing CN III, IV, VI
ask pt to follow finger with both eyes as you move finger laterally upward downward back to midline, medially, upward, and downward
observe for nystagmus
117
assesing CN V - trigeminal
motor: ask pt to clench teeth and plapate temple and jaw and feel contraction strength
sensory: using cotton wisp ask partner to close eyes and state where you touched them on the face
118
assessing CN VII (facial)
ask pt to raise eyebrows, close eyes tight, puff cheeks, smile, and show teeth
119
assessing CN XI (accessory)
ask partner to shug shoulders and turn head from side to side
120
assessing motor system
observe for abnormal or involuntary movements
incpect muscle tone and size
assess muscle strength using ROM with resistance
121
assessing sensory system
- sharp dull testing
- use tuning fork to initate vibration on distal phalangeal joint of thumb and great toe
- placing object in hand with eyes closed asked to ID it = stereognosis
- trace number in partner's palm= graphesthesia
122
coordination
- ask partner to touch thumb back and forth rapidly
- flip hand from pronating to supinating rapidly
- ask partner to tap foot rapidly
- ask to take heel on opposite shin and trace down to ankle
- ask to tocuh tip of your finger with tip of their forefinger
123
reflexes
- biceps
- triceps
- bracioradialis
- patellar
- achilles
- plantar
124
ears
- whispher test
- inspect and palpate outer ears
- assess tragus for tenderness
- use otoscope pulling pinna up and back to straighten canal, inspect external canal
- inspect tympanic membrane (pars flaccida, handle of malleus, umbo, cone of light
125
nose and sinus assessment
- palpate frontal and maxillary sinuses bilaterally for tenderness
126
assessment of mouth and throat
- inspect teeth, upper and lower palpate, tonsils and uvula, and tongue
- observe for symmetrical uvula rising
127
skin assessment
- inspect skin
- assess temperature
- assess skin turgor
128
head and neck inspection
- head sclap and hair
- inspect for facial symmetry
- inspect color sclera and conjunctive
- inspect skin color, moisture, lesions, rashes, and potential skin cancers
- inspect neck for deviations or masses
129
palpation of head and neck
- palpate for massess, depressions, or tenderness
- scalp discoloration or lesions
- palpate temporal artery
- palpate TMJ
- palpate lymph nodes
- assess midline of trachea
- palpate thyroid (swallow displace palpate)
130
inspect MSS
- inspecting for body posture (kyphosis, scoliosis, or lordosis)
- inspect gait, balance, and coordination
- inspect extremities (deformities, abnormal positioning, assymetry, swelling)
131
palpation MSS
palpate and assess ROM of
- TMJ
- cervical spine
- shoulder
- elbow
- wrists and hands
- hip
- knee
- ankle and foot
- thoracic and lumbar spine
- gait and balance
132
pulses
- assess for JVD with HOB at 30-45 degrees
- palpate carotid pulses ONE at a time
- auscultate for bruits with bell of stethescope
133
palpation of pulses
- radial
- brachial
- femoral
- posterior popliteral
- posterior tibial
- pedal
NORMAL IS 2+
DIMISHED IS 0-1+
BOUNDING IS 4+
134
heart assessment
- inspect for lesions, massess, and color, lesions, pulsations, lifts, and heaves
- palpate lifts and heaves if appropriate
- listen to heart from 2 right ICS, 2 left ICS, 3 left ICS, 4 left ICS, 5 left ICS
- repeat listening with bell
135
mini mental state exam
short measure of cognitive status for adults
136
mmse test
- ask about date
- where are you?
- name 3 objects slowly and clearly, ask pt to repeat
- ask pt to count backwards from 100 by 7
- recall objects stated ^^
- point to watch or pencil and ask what is this
- ask pt to say no ifs, ands, or buts
- give pt peice of paper and have them take it with right hand, fold it in half, and put it on the floor
- have them read paper that says close ur eyes
- ask pt to write a sentence
- ask pt to copy a pair of intersecting penatgons onto piece of paper
137
