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CP4 > final > Flashcards

final Flashcards

1
Q

primary intention

A

all tissues, including the skin, are closed with suture material after completion of the operation

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2
Q

secondary intention

A

wound will be left open (rather than being stitched together) and left to heal by itself, filling in and closing up naturally. It will mean you need regular dressings to the area for up to six weeks, but the time to full healing depends on the size, depth and site of the wound

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3
Q

risk factors for wounds

A
  • decreased LOC
  • impaired mobility
  • moisture/incontinence
  • age
  • medications
  • friction/shear
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4
Q

pressure injury stage 1

A
  • intact skin, local non-blanchable erythemia (redness) with change in temperature/firmness
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5
Q

stage 2 pressure injury

A
  • partial thickness tissue loss showing viable, pink/red, moist with distinct wound margin
  • intact or ruptured serum-filled blister
  • slough/eschar NOT PRESENT
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6
Q

pressure injury stage 3

A
  • full thickness tissue loss with just subcutaneous adipose layer exposed
  • slough/eschar initially present
  • healing wounds show granulation tisue
  • rolled edges (epibole) may be visible in chronic wounds
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7
Q

pressure injury stage 4

A
  • full thickness tissue loss, damage going through subcutaneous adipose layer; fascia, muscle, tendon, ligament
  • slough/eschar initially present
  • healing wounds = granulation tissue
  • rolled edges
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8
Q

unstageable wounds

A

dry, stable eschar firm cap

OR

moist, boggy eschar cap

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9
Q

deep tissue injury

A

dusky, boggy, or discoloured area of purple, maroon, ecchymosis, or blood-filled blister

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10
Q

medical devicde injury

A

injury can have appearance of any one of the stages or be instageable or DTI

usually conforms to the pattern or shape of device

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11
Q

mucosal injury

A

injury can have appearance of any one of the stages or unstageable but itself is not staged

usually conforms to pattern or shape of device

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12
Q

when wound bed is covered with slough/eschar….

A

unstageable, once visible, can be restaged either as stage 3 or 4

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13
Q

can you back stage/reverse stages of pressure injuries?

A

NO

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14
Q

venous ulcers

A

leg ulcers caused by problems with blood flow (circulation) in your leg veins. Normally, when you get a cut or scrape, your body’s healing process starts working to close the wound. In time, the wound heals. But ulcers may not heal without proper treatment

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15
Q

arterial ulcers

A

painful, deep sore or wound in the skin of the lower leg or foot. The ulcer doesn’t heal as you’d expect an ordinary sore to heal. That’s because there isn’t enough blood flowing to the area. Blood supplies oxygen and nutrients to the tissues.

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16
Q

venous vs arterial ulcers

A

They often form on the lower extremities, such as the legs and feet. Arterial ulcers develop as the result of damage to the arteries due to lack of blood flow to tissue. Venous ulcers develop from damage to the veins caused by an insufficient return of blood back to the heart.

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17
Q

phases of wound healing

A
  • inflammatory phase
  • proliferative phase
  • remodeling
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18
Q

inflammatory phase

A

hemostasis, clots form a fibrin, damaged tissue and mast cells secrete histamine = vasodilation, WBC

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19
Q

proliferative phase

A

new blood vessels appear, filling wound with granulation tissue, fibroblasts synthesize collagen

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20
Q

remodeling

A

maturation, can take up to 2 years

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21
Q

wound assessment

A

pain, size, bed, exudate, edge, odor, periwound skin

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22
Q

measuring wounds

A

length “head to toe” at longest point

width side to side at widest point

measure depth by sticking qtip in

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23
Q

tunneling/sinus tract

A

narrow channel or passage extending in nay direction from the base of the wound = dead space with potential risk for abscess formation

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24
Q

undermining

A

open area extending under intact skin along the edge of wound

CLOCK!! 12 = head, 6 = legs

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25
Q

wound irrigation syringe size

A

30 or 35 cc syringe w/ saline or water

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26
Q

how do you irrigate wound

A

start at wound edge, apply full force of syringe, slowly sweep along wound bed

flush all sinus tracts using catheter tip and solution runs clear

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27
Q

how much solution should you flush with total

A

100 cc to adequately flush wound bed

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28
Q

purpose of packing wound

A

loosely fill dead space

facilitate removal of exudate and debris

encourage growth of granulation tissue from base of wound to prevent premature closure and abscess formation

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29
Q

overfilling wound

A

cause pressure on wound tissue which can cause pain, impair blood flow and potentially cause further tisssue damage

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30
Q

underpacking wound

A

not provide enough packing material to be in contact with base and sides of cavity, undermining or sinus/tunnel and can lead to rolled wound edges and/or abscess formation

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31
Q

what should you do with the tails of packing

A

leave clearly visible or on the peri-wound skin (secured with steri-strips_

ensure 2 or more pieces are knotted together and palced in wound cavity

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32
Q

moisture wound healing

A

similar to whites of eyes

healable wounds with sufficient perfusion to tissues

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33
Q

autolytic debridement wound dressing selection

A

gels, hypertonic dressings, honey based/antimicrobial dressings, dressing that retain moisture

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34
Q

non-healable wounds dressing selection

A

due to inadequate blood supply, inability to treat cause or wound exacerbating factors that cannot be corrected

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35
Q

typical size of catheters for males and female

A

M = 14-16 fr

F = 12 - 14 fr

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36
Q

3 way lumen catheter parts

A
  • drainage
  • balloon
  • irrigation
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37
Q

aim to insert catheter …

A

5-7.5 cm for female

17-22cm for male

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38
Q

ADVANCE EXTRA 2.5-5CM ONCE URINE FLOWS BEFORE INFLATING

A

YES

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39
Q

documentation of catheter insertion

A

size, ballon size inflated, amount of urine drained & characteristics, specimens, pt tolerance

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40
Q

how would catheter-associated UTI prevented

A

sterile technique

cleansing perineum well

promoting one-way flow of urine

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41
Q

closed irrigation catheter

A

flushes the bladder with sterile liquid.

prevent or remove blood clots after surgery in the urinary system.

Sterile solution enters the bladder through a thin tube, then the fluid is removed and collected in a bag.

CONTINUOUS

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42
Q

open irrigation catheter

A

flushed with saline via saline connected to irrigation port

stop-go

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43
Q

instructions to pt after foley removal

A
  • increase fluid intake
  • tell nurse first time need to void (needs to assess first void within 6-8 hrs post removal)

measure first void

some irritation

try to empty bladder fully

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44
Q

what is nasogastric tube

A

tube inserted through one of nostrils, down nasopharynx, down esophagus into stomach

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45
Q

large tubes (NG) used for

A

salem sump tubing for gastric decompression and medications

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46
Q

small tubes (EN) used for

A

feeding and medications

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47
Q

how do you determine length of tube for insertion

A

nose to ear to xyphoid process

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48
Q

how can we determine correct tube placement

A

pH of gastric fluid should be 1.5-5

chest xray

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49
Q

if there is a pH greater than 6.. then

A

it is likely in the tracheal-bronchial tree

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50
Q

ongoing care and management of ng tubes

A
  • pH checks
  • external measurement check
  • inspection of nostrils (discharge, irritation, adhesive tape)
  • resp assessment
  • abdo assessment
  • mouth care
  • connection to suction
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51
Q

what position should pt be in for EN tubes

A

high fowlers

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52
Q

EN tube placement..

A

duodenum to reduce aspiration risk

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53
Q

how do you verify placement for EN

A

xray!

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54
Q

complications of EN

A

tube displacement

tube occlusion

abdo cramping, N & V

diarrhea

pulmonary aspiration

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55
Q

pulmonary aspiration can present like & how to prevent

A

SOB, crackles, gurgly, cyanosis, anxiety

high fowlers, check placement, tell dr

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56
Q

flushing meds through tubes

A

30 cc before meds

mix med with 15-30 cc

flush inbetween with 15-30 cc

flush with 30 cc after ALL meds

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57
Q

tips for flushing meds through tube

A

use warm water to mix

use liquid if possible

crush finely

flush well inbetween and after

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58
Q

open feeding solutions

A

pour solution into bag and prime tubing

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59
Q

closed feeding solutions

A

comes prepared so oyu spike bag with tubing

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60
Q

gastrojejunum (GJ) tubes

A

long term use

surgically inserted

no risk for aspiration d/t placement

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61
Q

goal of ostomy management

A

promote client’s independence and quality of life through client teaching

62
Q

ileostomy

A

surgically created opening in abdo that ileum is brought through

RIGHT SIDE

63
Q

indications for ileostomy

A

crohns, ulcerative colitits, cancer

64
Q

loop ileostomy

A
  • temp rod
  • proximal and distal opening
65
Q

normal ileostomy output

A
  • 500 to 750 mls
  • toothpaste to oatmeal consistency
66
Q

ileostomy considerations

A
  • require “drainable” system that will allow for frequent emptying
  • empty 1/3 full
  • empty 4-6 times daily
67
Q

if pouch is leaking, change it!

A

TRUE

essential to have peri-stomal skin protected with a properly fitted appliance

68
Q

for ileostomy, diet and fluid modifications

A
  • 6 to 8 weeks AVOID high fiber
  • chew food well and smaller
69
Q

ileostomy daily fluid loss

A

500 to 750 mls

70
Q

hydration considerations for ilestomy

A

drink extra 2-3 cups

71
Q

partial / complete obstruction of ileostomy

A

client education!!

  • symptoms: no output or high liquid output, cramping, bloating/nausea
72
Q

colostomy

A

surgically created opening in the abdo which part of large bowel is brought out

73
Q

indications for colostomy

A

trauma, IBD, obstruction

74
Q

types of colostomies

A

loop & end colostomies

  • LEFT SIDE!!!!
75
Q

colostomy dietary considerations

A
  • no changes required
  • healthy diet
  • adequate fluids, fruit, milk, meats
76
Q

bowel care for colostomies

A
  • may experience constipation, a bowel protocol
  • stomal enemas are more effective if used with an irrigation cone for fluid retention
77
Q

normal output for colostomies

A

1-3 movements daily

varying shades of brown

semi formed to formed

78
Q

types of urinary diversions

A

ileoconduit = urostomy

79
Q

what side urostomy located

A

right side

80
Q

normal output for urostomy

A

1000 - 2000ml

yellow with mucous shreds

81
Q

people with urostomy should

A

maintain adequate fluid intake

monitor for signs/symptoms of UTI

82
Q

ideal stoma should..

A
  • 2.5cm, visible for pt
  • location of lumen: apex of stoma
  • colour: red = indicates adequate circulation
  • shape: round
  • location on body: smooth surface
83
Q

frequency of appliance change

A
  • depends on output, shape, abdo contours
  • colostomy: q5-7 days
  • ileostomy: q3-6 days
  • urostomy: q3-7days
84
Q

chemical damage of peri stomal skin

A

output in contact with skin

shallow moist, burning, pain

tx: new appliance

85
Q

mechanical damage of peri stomal

A

stripping of dermis d/t inappropriate removal

denuded, wet, bleeding, painful

tx: client teaching

86
Q

indications for suctioning

A
  • visible secretions
  • course crackles or gurgling on auscultation
  • suspected aspiration of gastric or upper airway secretions
  • increased resp distress
  • decrease O2 sats
87
Q

symptoms associated with hypoxia and hypercapnia

A
  • decreased spO2
  • increased HR BP

increased RR

  • anxiety
  • decreased ability to concentrate
  • lethargy
  • decreased LOC
  • dizziness
88
Q

types of suctioning

A
  • oropharangeal
  • orotracheal
  • nasopharangeal
  • nasotracheal
89
Q

characteristics of oropharangeal suctioning

A
  • remove pharangeal secretions through mouth
  • clean gloves
  • insert with suction into mouth, move catheter around mouth, pharnyx, gumline
  • encourage coughing
  • rinse with water
90
Q

indications for tracheal suctioning

A
  • maintain patent airway & remove saliva, pulmonary secretions, blood, vomit, foregin material
  • stimulate cough
  • obtain a sputum sample to identify & treat pulmonary infection
91
Q

equipment needed for nasopharangeal

A
  • sterile saline
  • appropriate sized sterile sunctioning catheter
  • water based lube
  • sterile bowl
  • wall suctioning
  • sterile gloves
92
Q

position for nasopharangeal/nasotracheal

A

semifowlers / upright

93
Q

do you need to preoxygenate for nasophar/trach

A

YES

94
Q

do you put the sterile glove on ur dominant hand during sterile suctioning

A

YES, and clean glove on nondom

95
Q

describe nasopharangeal

A
  • attach to wall suction
  • insert along naris, during inhalation NO SUCTION
  • phar = 16cm, trache = 20cm
  • intermittent suction & rotate catheter on removal
  • 10 - 15 sec
  • flush with NS
  • apply O2 & wait 1 min if another pass required
96
Q

how many passes total for suctioning allowed

A

2

97
Q

complications associated with tracheal suctioning

A
  • hypoxemia (O2 level low in blood)
  • cardiac arrhythmias
  • atelectasis
  • mucosal trauma
  • infection
  • increased intracranial pressure
  • laryngospasm
  • aspiration
98
Q

documentation for suctioning

A
  • amount, consistency, colour of secretions
  • # of suction attempts
  • resp status pre/post
  • skin colour
  • O2 sats pre/during/post
  • RR, HR
  • pt tolerance
99
Q

A blood group

A

RBC = A

antibodies in plasma = ANTI-B

antigens in RBC = A ANTIGEN

100
Q

B blood group

A

RBC = B

antibodies in plasma = ANTI-A

antigens in RBC = B ANTIGEN

101
Q

AB blood group

A

RBC = AB

antibodies in plasma = NONE

antigens in RBC = A & B ANTIGENS

102
Q

O blood gorup

A

RBC = O

antibodies in plasma = ANTI A & ANTI B

antigens in RBC = NONE

103
Q

O- is

A

universal donor

104
Q

O donor can give blood too

A

AB, B, A, O

105
Q

A donor can give blood too

A

AB, A

106
Q

B donor can give blood too

A

AB, B

107
Q

AB donor can give blood too

A

AB

108
Q

AB recipient can receive blood from

A

O, A, B, AB

UNIVERSAL RECIPIENT

109
Q

B recevier of blood can get

A

O, B

110
Q

A receiver of blood can get

A

O, A

111
Q

O receiver of blood can get

A

O

112
Q

Transfusion options:

  1. A+
  2. A-
  3. B+
  4. B-
  5. AB+
  6. AB-
  7. O+
  8. O-
A
  1. A+, A-, O+, O-
  2. A-, O-
  3. B+, B-, O+, O-
  4. B-, O-
  5. A+, A-, B+, B-, O+, O-
  6. A-, B-, O-
  7. O=, O-
  8. O-
113
Q

blood component

A
  • therapeutic component of blood

RBC, platelets, plasma, cryporecipitate

114
Q

blood product

A

product derived from human blood or plasma and produced by a manufacturing process (albumin, immunoglobulin)

115
Q

blood is living tissue so…

A

various anticoagulants and preservatives are used to maintain shelf life (35-42days)

116
Q

pre-transfusion..

A

informed consent REQUIRED

order for blood documented in pt medical chart & on relevant request forms

117
Q

blood product order should specify

A
  • # of units in mls required
  • rate or duration of infusion
  • special requirements
118
Q

gauge for blood products

A

18-20

large enough to allow flow rate and avoid cell damage

119
Q

per pt assessment for blood transfusion

A
  • 30 mins prior & before spiking bag
  • baseline VS & chest auscultation & review fluid balance for high risk pts
120
Q

what is compatible with blood

A

NS

121
Q

administration set for blood

A
  • micron filter
  • prime administration set wtih compatible fluid to end hte line
122
Q

how quick to initiate transfusion

A

within 20 mins of removal from temperature controlled storage

123
Q

at first, blood transfusions should infuse..

A

1ml/kg/hr up to max 50ml/hr for 1st 15 mins

124
Q

if there are no signs of transufsion reaction during first 15 mins then adjust flow rate?

A

YES

125
Q

blood products must infused within

A

4 hrs of spiking

126
Q

pt monitoring blood transfusion

A
  • observe 1st 15 mins start each unit
  • record VS 15 mins after start, 60 mins after start, & hourly during transfusion
127
Q

how often change blood tubing

A

2 units or every 4 hrs

128
Q

symptoms of transfusion reactions

A
  • temp > 38.0 / change of 1 degree
  • hypotension/shock
  • rigors
  • anxiety
  • back/chest pain
  • N & V
  • SOB
  • tachycardia
  • generalized flushing
  • rash > 25% of body
  • urticaria
  • hypothermia
  • headache
129
Q

types of transfusion reactions

A
  • acute hemolytic
  • febrile, nonhemolytic
  • mild allergic
  • anaphylactic
  • circulatory overlaod
  • sepsis
130
Q

suspected transfusion reaction..

A
  1. STOP transfusion
  2. Administer 0.9% NS
  3. Reassess patient VS
  4. Seek assistance
  5. Reconfirm unique identifiers on both patient and Blood product
  6. Call Transfusion lab immediately if an error has occurred
  7. Administer resuscitative care
  8. Report suspected reaction
131
Q

completion of transfusion

A
  • stop infusion when bag empty
  • flush set withNS
  • disconnect line
  • VS within 1hr of completion
  • perform post transfusion BW PRN
  • continue to monitor for SX transfusion reaction
132
Q

what is tracheostomy tube

A

surgically incision in trachea below larynx

4-10cm tube inserted through stoma into trachea

133
Q

indications for tracheostomy

A
  • maintain patent airway by bypassing upper airway obstructions
134
Q

components of tracheostomy tube

A

outer cannula

plug

cuff, inflation line, balloon

inner cannula

obturator

135
Q

why are trache pts more prone to lung infections?

A

bypassing upper airway so the air is not filtered from nares, not moist, not warmed

136
Q

indications for tracheal suctioning

A
  • maintain patent airway by removing secretions
  • improve resp status (easier resps, increase O2 sats)
  • prevent infection cuased by retained secretions
137
Q

do you suction prior to performing trach care

A

yess because you need to remove secretions so not occlude outer cannula when inner cannula removed

&&

decrease risk of airway being blocked by secretions

138
Q

trach suctioning pressure

A

80-120

139
Q

what is risk of using too much suction during trach

A

tracheal tissue damage

140
Q

describe trach suctioning

A
  • insert catheter into trach until meet with resistance at bifurcation, withdraw 1cm before intermittent suctioning
  • NO suction while inserting
  • max 10 sec from insertion to withdrawal
  • max 2 times
  • hyperoxygenate 1 min inbetween suction
141
Q

complications of suctioning

A

hypoxemia

hypoxia

atelectasis

mucosal damage

infection

142
Q

how often change trach stuff

A

q12 hr / PRN

143
Q

why do we perform trach care

A

maintain patent airway, prevent infection, promote comfort

144
Q

unexpected outcomes of trach care

A
  • accidental decannulation while handling
  • infection
  • tracheal wall necrosis
  • skin breakdown around peri-stoma
145
Q

verifying safe peds dosages: body weight method

A
  1. convert weight from lbs to kg
  2. calculate safe dose in mg/kg (multiply mg/kg by weight)
  3. compare ordered dose to rec dose & decide if safe
  4. calculate amount to give
146
Q

weight conversion

A

1kg = 2.2lbs

147
Q

different restraints

A
  • physical: pineal
  • chemical = medications
  • environmental = locked unit
148
Q

target behaviours are

A
  • pacing/wandering
  • unsafe mobility
  • impaired safety awareness
  • unable to follow instructions
  • imminent danger to self/others
  • pulling tubes
149
Q

alternatives to restrains

A
  • reorienting
  • 1:1
  • reposition/mobilization
  • change environment
  • use calm, simple statements
  • decrease stimulation
  • toileting, food, fluids, needs
  • pain assessment
150
Q

chemical restraint before physical?

A

YES

151
Q
A

CP4 (4 decks)

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