Lab Info: Wounds, Tubes, and IVs Flashcards
(151 cards)
1
Q
If a patient has a pressure ulcer- what should you do to alleviate the pressure?
A
Upload- raise and take pressure off
2
Q
How is a stage 1 pressure ulcer described?
A
Intact skin with nonblanchable redness
3
Q
Where do pressure ulcers usually occur?
A
Over boney prominences
4
Q
On a patient with dark skin- how can you tell they have a stage one pressure ulcer?
A
It may be seen as color hue changes
5
Q
How is stage 2 pressure ulcer described?
A
Partial thickness loss of dermis or open/ruptured serum-filled blister
6
Q
A stage 2 pressure ulcer can also be called this from a sheer effect.
A
A skin tear
7
Q
How is a stage 3 pressure ulcer described?
A
Full thickness tissue loss but bone and muscle ARE NOT EXPOSED
8
Q
On a stage 3 pressure ulcer- the depth of the wound depends on what?
A
Anatomical area of ulcer
9
Q
How is a stage 4 pressure ulcer described?
A
Full thickness tissue loss with exposed bone, tendon, or muscle.
10
Q
In a stage 4 ulcer- what may be present?
A
Eschar or slough
11
Q
What is often included in a stage 4 pressure ulcer?
A
Tunneling
12
Q
What is eschar?
A
Necrotic area that must be debated
13
Q
How is tunneling described and what must you do to it?
A
It tracks from one area to another creating a whole.
YOU MUST PACK IT
14
Q
A hydrophobic dressing does not absorb what?
A
Water
15
Q
A hydrophilic dressing does absorbed what?
A
Water
16
Q
hat are the 6 categories of wound dressings?
A
- Wet-to-moist
- Hydrocolloid
- Impregnated Gauze
- Alginate
- Foams and Hydrophilic
- Non-adherent or Hydrophobic
17
Q
When should a wet to moist dressing?
A
When it is still moist
18
Q
Why is it important to remove a wet to moist dressing while it is still moist?
A
Because It will destroy the granulated tissue when removed if it is dry
19
Q
What does a wet to moist dressing do?
A
Debrides the wound
20
Q
How does a wet to moist dressing work?
A
Water evaporated creating hypertonic solution drawing the fluid from the wound
21
Q
What makes up the moist part of a wet to moist dressing?
A
Sterile saline
22
Q
When placing a wet to moist dressing- what should you avoid?
A
Placing the moist portion on healthy skin
23
Q
What types of wounds would you use a hydrocolloid dressing on?
A
Non-infected partial or full thickness wounds
24
Q
What does a hydrocolloid dressing absorb?
A
Exudate
25
Hydrocolloid dressings are impermeable to what?
Water and bacteria
26
Hydrocolloid dressings create what to help generate granulation tissue?
Moisture
27
What is a main perk of a hydrocolloid dressing?
It conforms to the body shape
28
What should you be careful of when using a hydrocolloid dressing?
Getting stool to sit on it.
29
What is alginate dressings made of?
Highly absorbent seaweed
30
What do you need to have when using an alginate dressing?
A secondary dressing to secure it
31
the alginate dressing's fibers turn into what when placed on a wound.
Gel
32
What are alginate dressings used for?
- diabetic ulcers
- burns
- infected wounds
33
What is the down fall of using alginate dressings?
They're really expensive
34
What must you need when using a foam/hydrophilic dressing and why?
A wrap or secondary bandage because there aren't any adhesive boarders
35
What are the perks of foam/hydrophilic dressings?
- Cushions wounds
- Very absorbed
- Traps exudates
- Protects surrounding tissues
- Can remove without trauma
36
What is required when using a non-adherent/hydrophobic dressing?
Tape or cover dressing to secure
37
What are non-adherent/hydrophobic dressings used for?
- burns
- skin
- grafts
- donor sites
38
What are the advantages of gauze dressings?
- Inexpensive
- Easily accessible
- Can be impregnated with anti-microbial such as silver in use of burns
39
What are the disadvantages of gauze dressings?
- Non-occlusive
- Fibers left in wound can delay healing causing infection
- Non-selective in tissue removal-removes necrotic and granulation tissue
40
What types of wounds do you use transparent film dressings on?
non-draining wounds and IV sites
41
What is created when using a transparent film dressing?
A moist environment
42
What are the two perks of a transparent film dressing?
- impermeable to bacteria
| - Easy to access wound
43
What does a wound V.A.C. increase and how?
Increased circulation by using negative pressure
44
What is the two perks of a wound V.A.C.?
Causes continuous debridement and increasing circulation
45
What is the perk of wound irrigation?
Removes bacteria without injury to healthy tissue
46
What supplies are need for wound irrigation?
- Irrigation kit
- Irrigation fluid
- Absorbent pad
- Clean gloves
- New dressing supplies
47
What type of syringe is provided in an irrigation kit?
A piston syringe
48
What type of solution is usually used when irrigating a wound?
Saline solution
49
When obtaining a wound culture what must you make sure you do with the swab?
Get all side of swab as well as all surfaces of wound
50
What are the steps of obtaining a wound culture?
- Rise wound with sterile saline
- Rotate swab while obtaining specimen
- Crisscross wound top to bottom
- Don't take specimen from exudate or eschar
51
What are the supplies used for taking a wound?
- Wound packing gauze
- Clean and sterile gloves
- Sterile q-tips
- Sterile scissors and forceps
- Sterile dressings
52
What is packing used for?
A tunneling wound
53
What does packing a wound create?
A wick to pull the fluid from the bottom of the wound up
54
When removing a suture what should you do?
Pull up by the knot and just cut from there to slip up
55
How many prongs are on a staple remover?
3
56
What is montgomery straps used for?
A delayed incision closure
57
How often do dressing usually get changed when using a montgomery straps?
q4-6 h
58
What do spiral turns in spiral bandaging prevent?
Tourniquet effect
59
What is spiral bandaging used for?
TO secure a wound dressing or applying compression
60
What are the two things you should do when using a spiral bandaging technique?
- Elevate part to be bandaged
| - Wrap extremity upward applying uniform pressure
61
How much of the bandage on a spiral bandage should overlap?
One half
62
When is a figure-eight bandage used?
To support and limit joint movement
63
What is the first thing you do when applying a figure-eight bandage?
1st anchor bandage around extremity
64
What should you frequently asses for after applying a figure eight bandage?
Assess for changes in CMS
65
What are the steps of applying figure-eight bandage?
- Anchor bandage around extremity
- Make circular turn around heel and back
- Continue to wrap with two-thirds overlap
66
A piggy back medication is prepared in bags that are in this range.
50ml to 250ml
67
What do you do if the primary IV solution is incompatible with your IVPB medication?
You must disconnect the primary IV solution. Cleanse IV port for 15 seconds and flush with 10 ml saline.
68
If there is no primary fluids running in a patient's IV- what should you do before and after administering the IVPB drug?
Pre-flush and post-flush
69
What is the equation used to get a drop factor of an IV solution?
Volume to be infused x drop factor / minutes administered
70
What is the equation used to get the correct dosage of medications needed to administer?
desired/available x volume
71
How long should you clean the IV insertion site with antimicrobial swabs?
15 seconds
72
When post flushing an IVP drug- how long should you flush the first ml of saline?
At the same infusion rate at the IVP medication
73
What do you do if the IV infusion is not compatible with the IVP medication?
Shut off the IV fluids and clamp the line above the injection site
74
If there is no primary IV solution running what do you need to do before and after administering IVP medications?
Pre and post flush with 10 ml of saline
75
If a new PICC line is placed how must the placement be confirmeD?
Through X-Ray
76
What types of flushes are needed with administering medication to a PICC line?
- 10 ml pre-flush
- 10 units/ml heparin flush
- 10 ml post flush
77
What should you follow when administering medications to a PICC line?
SASH
78
What does SASH stand for?
- Salne
- Additive (MEDICATION)
- Saline
- Heparin
79
When administering an IVP medication through a PICC line what must all the medication be prepared in?
10 ml syringe
80
When pushing any types of solution through a PICC line what kind of method should you follow?
The push-pause method
81
When doing a post flush on a PICC line what should you do?
Administer the first ml at the same rate as the previous medication then use the push pause method for the remaining 9 ml.
82
What dictates the amount of heparin you administer to a PICC line?
Hospital protocol
83
What supplies are needed for changing central line dressing?
- Central line dressing kit
- 2 masks
- Clean gloves
- Sterile gloves
- Chloraprep swabs
- Tape
- Sterile occlusive dressings
84
What should you do if the patient has an allergy to chlorhexidine and they need a central line dressing change?
Use 70% alcohol followed by povidone iodine
85
Before you open the central line dressing kit what must you do with the patient?
Apply their mask and ask them to turn their face away from the central line
86
Before you take off the old dressing on a central line what should you do?
- Place the mask on the patient
- Place the mask on you
- Wash hands
- Place on clean gloves
87
What do you need to inspect the central line IV site for?
Loose sutures, inflammation, infiltration, and length of catheter.
88
What type of motion should you use when cleaning a central line site?
A back and forth scrubbing motion for at least 30 seconds
89
Before securing a new dressing on to a central line what should you do?
Clean with chloraprep and allow to dry
90
If a central line site is bleeding and you need to place a new dressing on it -what should you do?
Use a 2x2 gauze
| --Use 2 inch tape and tape all across to make occlusive
91
What are the typical sizes of NG tube used?
14-16 french
92
What type of lubricant should be used for an NG tube?
Water-soluble
93
What are the supplies that are needed to insert a nasogastric tube?
- NG tube
- Lubricant
- Clean gloves
- Stethoscope
- Tape
- Safety pin
- Irrigation kit
- Towel
- Suction equipment
- Glass of water if patient can take fluids
94
What position should the client be placed in before inserting an NG tube?
High fowlers
95
How should you select the nostril you will be inserting the NG tube?
Ask the patient to breathe through one nostril while occluding the other and insert in the one with the greatest airflow
96
How do you determine the length of the nasogastric tube to be inserted?
Measure the tube from the tip of the clients nose, to the earlobe, and to the typhoid process
97
What should the patient do with their head when you are going to insert an NG tube?
Tilt their head forward and support the back of their head to maintain position
98
What should you ask the client to do so you can advance the NG tube to the desire level?
Swallow or drink water if not NPO
99
How do you assess NG tube placement?
- Auscultation with stethoscope over left upper abdomen
- Inject 10-20 ml of air into tube noting air sound in gastric region
- Aspirate to visualize gastric fluid
100
Once the placement of the NG tube is secure what should you do?
- Connect to suction
| - Instill 10-20 ml of air into air vent to ensure patency
101
What supplies do you need to irrigate an NG tube?
- Irrigation kit
- Bottle of normal saline irrigation solution
- Clean gloves
- Saline
- Stethoscope
- Protective pad
102
Before you irrigate an NG tube what should you do first?
Assess placement by auscultation and aspiration
103
How much normal saline solution should you pour into the irrigation container when going to irrigate an NG tube?
50 ml
104
How much normal saline should you draw up out of an irrigation container to irrigate the NG tube?
30 ml in a 60 ml irrigation syringe
105
After you insert the irrigation solution into the NG tube what should you do?
Aspirate to ensure latency and reconnect to suction
106
After irrigating the NG tube and you have reconnected it to the suction what should you do?
Inject 10-20 ml of air into air vent
107
What position should you place the patient in when removing an NG tube?
Semi-fowlers
108
When removing an NG tube- after removing the tube from suction what should you do?
- Instill 50 ml of air into drainage port
- Clamp the tube by pinching it
- Ask client to take a deep breath and hold it
109
Before administering medication to a PEG tube what should you do?
Crush solid medications and dilute each med separately in 30 ml of water
110
When diluting medications before administering to a patient with a PEG tube- how many ml should you use?
30 ml
111
If the patient cannot be placed in a Fowler's position and they need medication administered to a PEG tube- what should you do?
Position the client to be slightly elevated in a right side lying position
112
Before administering a medication through a PEG tube what should you do?
Check the location, insertion site and latency of PEG tube
113
If a patient is receiving Continuous Tube Feedings and you need to give them medications what should you do?
Place the Tube Feeding Pump on Hold
114
If a Tube Feeding Pump is on hold how long will it take the pump's alarm to go off it is not resumed?
5 minutes
115
Why should you clamp the PEG tube or turn on the 3 way stop to the off position before administering medication?
It prevents air from entering the stomach
116
How do you verify the patency of a PEG tube before administering medications?
Instill 15-30 ml of warm water to verify
117
How do you administer medication to a PEG tube?
Slowly pour the diluted medication into the syringe and allow it to flow through the PEG tube by gravity
118
After administering medication through a PEG tube- what must you do even in between medications?
Slowly pour in 15-30 ml of water then clamp the tube
119
Can you administer medications back to back in a PEG tube?
No- you must flush with water. Clamp. Then admin
120
What should you do about the fluid given pre, between, and post last medications through a PEG tube?
Record it on the Intake Record
121
If a patient is on a Continuous Tube Feeding- what should you do after administering medication?
Restart Continuous Tube feeding and verify correct rate
122
If Continuous Tube Feeding is contraindicated by a medication what was given via PEG tube- what should you do?
Administer medication. Then clamp PEG tube or plug the PEG tube to prevent leakage.
123
What is a CVC?
Central Venous Catheter
124
How is a central venous catheter (Central line) described?
A long single or multi-lumen intravenous catheter inserted into the arm or chest and threaten into the large superior vena cava to just above the right atrium
125
How long can a PICC be left in for?
Weeks
126
Where is a PICC inserted and what does it stand for?
Peripherally Inserted Central Catheter- in arm
127
What are central lines used for?
- Long term intravenous therapy
- Chemotherapy
- Parenteral Nutrition
- Infusion of blood products
- Dialysis
- Hemodynamic monitoring
- Frequent blood draws
128
What are the types ov CVC?
- Non-tunneled Central line
- Peripherally Inserted Central Line
- Implanted Ports or Vascular Access Device
- Tunneled Central Line
129
What are the two types of Tunneled Central lines?
Hickman or Broviac
130
Where can non-tunneled Central lines be placed?
Subclavian
Jugular
Femoral
131
How is a Vascular Access Device (VAD) placed
Under the skin into vena cava placed during surgery
132
Implanted Vascular Access Devices have the lowest rate of?
infection
133
What are implanted vascular access devices used for?
Long term use accessed with a huber needle
134
If a patient has a PICC line what can you not do to that arm?
Take BP or venipuncture
135
What is placed on a tunneled central line and what is it used for?
A dacron cuff and decreases infection
136
What is required to maintain patency of a central line?
heparin
137
Never use less than what ml syringe when accessing a central line?
10 ml
138
You must use what when infusing on a central line?
An intravenous pump must be used
139
What type of technique must be used when touching a central line catheter or administering dressing care to it?
Strict aseptic care
140
What type of pressure must be maintained on a central line catheter
Positive pressure
141
How can you maintain a positive pressure on a central line catheter?
Clamp before removing the flush
142
When taking blood from a central line what must you do?
Waste the first draw due to it being contaminated with heparin
143
If a patient is on TPN through a central line- when should their tubing be changed?
q24h
144
What are the potential complications of a central catheter?
- bleeding
- hematoma
- pneumothorax
- hemothorax
- arterial puncture
- dysrhythmias
- Infection
- Air embolism
- Thromboembolism
- Brachial nerve injury
- Thoracic nerve injury
- Venospasm
145
The ideal blood pressure cuff size should have a bladder length that is what percentage of the patients arm circumference?
80%
146
The ideal blood pressure cuff size should have a width that is at least what of the arm circumference?
40%
147
The ideal blood pressure cuff size should have a length-to-width ratio of what?
2:1
148
For an arm circumference of 22 to 26 cm what type of blood pressure cuff should they wear?
small adult size
149
For an arm circumference of 27 to 34 cm what type of blood pressure cuff should they wear?
adult size
150
For an arm circumference of 35-44 cm what type of blood pressure cuff should they wear?
large adult size
151
For an arm circumference of 45-52 cm what type of blood pressure cuff should they wear?
adult thigh size
