nursing care 3 Flashcards
(86 cards)
1
Q
Legal concerns for drug admin
- A nurse must
A
- have knowledge of the laws that direct, define and limit your scope
- be able to recognise the limits of your own knowledge and scope
- have knowledge of the medicines and poisons act 2014 and medicines and poisons regulations 2016
2
Q
Medication safety
- standard 4
A
- health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicine.
- clinical workforce accurately records a pts med history and that the history is available through out the episode of care.
- clinician provides a complete list of pts medication to the receiving clinician and pt handover care
- clinical workforce informs pts about their options, risks and responsibilities for an agreed medication management plan
3
Q
hight risk meds: APINCH
A
A - antimicrobials P - potassium and other electrolytes, psychotropic medications I - insulin N - narcotics/ opioids C - chemotherapeutic agents H - heparin and other anticoagulants
4
Q
Poisons schedules
- 1-9
A
SCHEDULE 2 - (pharmacy meds) - available to public from pharmacies
SCHEDULE 3 - (pharmacist meds) - sold by retailer under supervision of a pharmacist or supplied by medical practitioner
SCHEDULE 4 - (prescription meds) - supplied on prescription from a pharmacy or medical practitioner
SCHEDULE 5 - (caution) - poisons of a hazardous nature, readily available to public but require caution in handling, storage and use
SCHEDULE 6 - (poison) - poisons that must be available to public but are more hazardous/ poisonous nature than S5
SCHEDULE 7 - (dangerous poison) - poison that require special prescriptions in manufacturing, handling, storage and use
SCHEDULE 8 - ( controlled drugs) - prescription only meds which require restrictions of manufacture, supply, possession
and use to reduce abuse/misuse
SCHEDULE 9 - (prohibited substances) - poisons that are drugs of abuse
5
Q
What is the schedule 8 process
A
- S8s are kept in a double locked cupboard
- red keys and register book - for stock amounts
- 2 nurses must be present through whole process
- 2 rns count total at end of every shift
- errors beed to be ruled and initialed
- is any portion is to be discarded, 2nd nurse must witness and sign
6
Q
what is the nurses role in drug admin
A
- to be administered appropriately and accurately
- responsible for assessing the effectiveness of meds and observing any reactions to drugs
7
Q
different forms of drugs
A
AEROSOL SPRAY - liquid or powder form
AQUEOUS SOLUTION - one or more drugs dissolved in water
AQUEOUS SUSPENSION - one or more drugs finally divided in liquid
CAPLET - solid form, coated
CAPSULE - in a container, powder, liquid or oil
CREAM - non greasy, semi solid
ELIXER - sweetened aromatic sol’n with medication
GEL - semisolid that liquifies when applied to skin
LINIMENT- med mixed with alcohol, oil or emollient and applied to skin
LOZENGE - dissolving med for mouth
LOTION - med in a liquid suspension for the skin
OINTMENT - semisolid prep for one or more meds for skin and mucus membrane
PASTE - like a ointment but thicker
POWDER - internal or external use
SUPPOSITORY - one or more meds shaped for insertion and melts at body temp to release drug
TABLET - compressed powder
TINCTURE - an alcoholic or water-and-alcohole solution prepared from drugs derived from plants
8
Q
Routs of admin
A
- oral
- sublingual
- buccul
- rectal
- vaginal
- topical
- subcutaneous
- iv
- im
- intradermal
- inhalation
- epidural
- intrathecal (around spinal chord)
9
Q
TERMINOLOGY: prn stat bd/bid tds/tid qid mane nocte pv pr ng mdi po neb picc peg cvc pca
A
PRN - pro re nata ( as needed) STAT - statim ( give immediately) BD/BID - twice a day TDS/TID - three times a day QID - four times a day MANE - morning NOCTE - night PV - per vagina PR - per rectum NG - nasogastic MDI - metered dose inhaler PO - per oral NEB - nebuliser PICC - peripherally inserted central catherter PEG - percutaneous enteral gastrostomy CVC - central venous catheter PCA - pt controlled analgesia
10
Q
6 RIGHTS
A
person, drug, dose, route, date/time, documentation
11
Q
subcut injection sites
A
upper arm
abdomen
anterior and lateral thighs
sub scapular area of back
12
Q
subcut angle of injection
A
- inject on a 45 degree angle and 16mm needle is less than 25mm of tissue can be grasped
- inject on 90 degree angle is 50mm or more tissue can be grasped with skin hold taught
13
Q
5 main types o insulin in aus
A
RAPID ONSET FAST ACTING INSULIN - clear in colour - 1-20 min action - pt must eat immediately after - eg. novorapid SHORT ACTING - clear in colour - 30 min acting - have injection 30 mins before eating - eg. actrapid INTERMEDIATE - cloudy in colour due to zinc or protamine to delay action - works 1 1/2 hrs after injection - gently shake to mix - eg. protaphase MIXED - cloudy in colour - rapid and intermediate mixed (505/50 or 30/70) - eg. novomix LONG ACTING - once or twice a day dose - lasts up to 24 hrs - eg. lantus
14
Q
INSULIN
can be given by?
considerations for nurse
A
CAN BE GIVEN BY: syringe, insulin vile or pen device with pre filled insulin cartridge and disposable needle
NURSNG COSIDERATIONS:
- always alternate injection site
- become familiar with documentation and flow chard
- always check BGLs prior to giving insulin
- check local policies
15
Q
intramuscular injection sites and how to locate them
A
DORSOGLUTEAL: dorsogluteal muscle is located in upper outer region of buttocks, draw imaginary line from greater trochanter to illiac spin. injection site is upper right corner
VACTUS LATERALIS: one hand space above knee and one hand space bellow greater trochanter, middle 3rd of muscle is best site
VENTROGLUTEAL: place palm of hand over greater trochanter, index finger palpating illiac spine and iddle finger pointing towards illiac crest. V formed in injection site.
16
Q
respiratory rates throughout lifespan
A
INFANT: 40-80bpm (abdominal breathing)
CHILDREN: 25bpm
LATE ADOLESENCE - ADULTS: 12-18bpm
17
Q
factors affecting respiratory function
A
- AGE: older adults have less elasticity of airways, decreased cough reflex and decreased lung expansion
- ENVIROMENT: heat, cold, pollution, inhalation of certain dusts
LIFESTYLE: can predispose lung disease, dusts/asbestosis eg. farmers - BEHAVIOURAL ISSUES: smoking, alcohol, exercise
- MEDICATIOS: can decrease rate and depths of respiration eg. narcotics
- STRESS: psychological and physiological responses (hypreventilation)
18
Q
hypoxia causes
A
- HYPOVENTILATION: inadequate alveolar ventilation due to resp conditons, CNS disorders and drugs
- IMPAIRED DIFFUSION: of O2 from alvioli to arterial blood resulting in hypoxemia
- REDUCED HAEMOGLOBIN: O2 saturation due to sever anaemia
19
Q
sigs and symptoms of hypoxia (low oxygen)
A
- rapid luse
- tachypnoea
- intercostal retraction
- increased restlessness
- nasal flaring
- cyanosis
20
Q
appearance of hypoxia
A
- face is drawn and anxious/tired
- sitting position = tripod
- fatigued and lethargic
- clubbed fingers and toes
21
Q
differnt O2 delivery devices
A
- nasal cannula/prongs
- hudson mask (simple face mask)
- venturi mask
- non rebreather mask
- partial re breather
- tent mask
- non-invasive ventilation (NIV)
22
Q
what are nasal cannula/ prong?
benefits?
disadvantages?
A
- delivers a low concentration at flow rates of 2-4L per min
- used in non-critical situations and long term use
- prongs sit in the nose with tubing tucked behind ears
BENEFITS: improved comfort, less claustrophobia, can eat, drink and talk
DISADVANTAGES: nasal dryness and discomfort
23
Q
what is a Hudson mask?
A
- maintains flow above 5L to prevent re-breathing of exerted CO2
- concentration of 45-70% O2
- side ports on mask allow room air to enter mask and allow CO2 to leave
- long term use can lead to pressure injuries to nose and face
24
Q
What is a venturi mask?
A
- provides oxygen concentration of 24-50%
- colour coded nozzels enable varied concentrations of O2
- nozzel have prescribed amount of O2 flow written on device
25
what is a non-rebreather mask
- has an attached reservoir bag with a one way valve, which does not allow exhaled gases to enter bag
- exhaled air is directed through a one way valve which prevents the inhalation of room air and re-inhaled exhaled air
- delivers higher oxygen concentrations of 85-90% with flow rates between 10-15L per min
26
what is a partial re-breather mask
partial and non-rebreather nursing considerations
- only have one valves rather than 2 - allows for air entrainment resulting in lower oxygen concentration delivery
- Co2 is exhaled through side ports
- used for emergency situations
NURSING CONCIDERATIONS
- dont let bag totally deflate or oxygen tubing disconnect - pt may be at risk of rebreathing their Co2
- close monitoring of pt and system to ensure adequate ventilation and that connections are secure
27
what is a tent mask
- can replace o2 mask when pt cannot tolerate face mask
- varying levels of o2 is supplied: 30-50% concentration at 4-8L per min
- skin needs assessing as it can become damp or chafed
- can be humidified
28
what is non-invasive ventilation (NIV)
- delivers positive breaths to the spontaneously breathing pt
- specific intranasal cannula/mask
- indications can include: COPD, asthma
29
types of chest tubes - where they are inserted
rationals for use
```
INTERCOSTAL CATHETER (ICCs) - inserted into upper anterior thorax
SUBCOSTAL CATHETER (SCCs) - inserted into mediastinal space bellow rib cage
UNDERWATER SEAL DRAINS (UWSD)
```
RATIONAL FOR USE: to drain
- air (pneumothorax)
- blood (haemothorax)
- pleural effusions (accumulation of pleural fluid)
- pus (empyema)
30
chest drains are inserted following?
3 main components of chest drainage systems
inserted following:
- cardiothoracic surgery
- after chest trauma
- a spontaneous pneumothorax
- any condition resulting in accumulation of content in pleural space
3 main components:
1. collection chamber: collects fluid drained
2. suction control source and/or vent: allows air to excape
3. a water seal (one way valve): prevents air from re-entering the chest on inspiration
31
what is a nurses role in chest drains
WHILE INSERTED: base line obs, offer prescribed meds, x-ray to ensure position, ensure dressing and connections secure
POST INSERTION: documenting, observations, educating pt/family
32
chest drain complications and what to do
ACCIDENTAL DISCONNECTION: avoid clamping and try to reconnect drainage system immediately
OCCLUSION/ BLOCKAGE: check for kinking if tube, review for clots or blockage of tube, try tapping or pinching tube to remove occlusion, may need to change tube or drainage set, monitor pt closely - may lead to tension pneumo
AIR LEAKAGE: secure all connections of drainage tube, secure dressing site (airtight dressing), note for surgical emphysema
ACCIDENTAL REMOVAL: cover insertion sit, call for urgent help, closely monitor pt
EXCESSIVE DRAINAGE: drainage may increase significantly in amount, if acute - urgent dr review, if slow bleed - monitor pt closely with strict FBC (full blood count)
INFECTION: may get local or systemic infection
SUBCUTANEOUS EMPHYSEMA: collection of air under skin, can indicate a leak in drainage system, may need to re-suture drain at site
33
factors that affect cardiac output
HEART RATE:
- influenced by autonomic nervous system, bp, hormones and meds
- chronotropes drug effects change the HR: positive chronotropes increase HR and negative decrease HR
CONTRACTILITY:
- intrpoic state of the heart - strength of contractions
- infulenced by autonomic nervous system and meds
- postive intropic drugs increase contractility and negative decrease contractility
34
how do beta blockers affect cardiac output
they decrease arterial blood pressure
35
what is pre load (pre stretch) - heart
- degree to which muscle fibers are stretched at the end os diastole
- depends on blood returning from venous circulation as increased volume causes increased stretch
- if not much fluid in vessels pre stretch will decrease
- heart will beat more effectively with preload
36
what causes at pt to have a low preload
clinical signs of a low preload
LOW PRELOAD = low fluid (dehydration)
CLINICAL SIGNS:
dehydration - poor skin, dry lips, bad capillary refill, decreased HR
37
what is afterload - heart
- the resistance agains which the heart must pump to eject blood into the circulation
- left ventricle pumps blood into the higher pressure systemic arterial system that requires more work than right ventricle
- vasoconstriction increases afterload (increased cardiac workload)
- vasodilation decreases afterload
38
1. the hearts inability to effectively pump can cause?
2. impaired tissue perfusion can cause?
3. alterations at cellular level and blood volume can cause?
1. - chest pain, SOB, nausea, diaphoresis, cardiac failure
2. peripheral vascular disease (poor blood flow)
- decrease peripheral pulses, pallor, cool extremities, decreased hair distribution
3. anaemia
- chronic fatigue, SOB, pallor, hypotension
39
what are the risk factors or cardiovascular disease
| modifiable, non-modifiable, other factors
MODIFIABLE: high cholesterol, smoking, diabetes, obesity, physical activity
NON-MODIFIABLE: heredity, age, gender
OTHER FACTORS: health status, social, economical, environmental, cultural
40
what is an ECG (electrocardiogram)
- traces the electrical conductivity of a heart from 12 different angles over 10 seconds
- electrodes on skin transmit electric impulses to graphic recorder
- detects arrhythmias, alterations in cunductions
- a normal heart conductivity is called a sinus rhythm
41
lead placements of an ECG
```
- 6 chest leads, 4 limb leads
LIMB PLACEMENT:
- right wrist, right ankle, left wrist, lest ankle
CHEAT PLACEMENT:
- v1: 4th intercostal (right)
-v2: 4th intercostal (left)
- v3: between vi and v4
- v4: midclavicular
- v5: 5th intercostal (anterior axillary line)
- v6: 5th intercostal (midaxillary line)
```
42
why do a ECG
- to identify pathological conditions
- obtain a base line for comparison prior to stressful intervention
- ongoing comparison
43
DEFFINTIONS
- P wave
- QRS complex
- T wave
- PR interval
- QRS interval
- QT interval
P WAVE: depolarisation and contraction of atria
QRS COMPLEX: depolarisation and contraction of ventricles
T WAVE: repolarisation of ventricles
PR INTERVAL: from start of impulse thru to atrium
QRS INTERVAL: time taken for impulses to spread thru to both ventricles
QT INTERVAL: total electrical activity of ventricles
44
how to work out the rate on ECG
count how many R waves are in 15 big squares and x by 20
45
IV site care
V.I.P score?
- strict aseptic technique when caring for a line, dressing changes 3-7 days if cvc or picc
- swab port this alcohol wipe prior to admin, secure line and protect with appropriate dressing
- not any complaints of pain by pt
V.I.P = visual infusion phlebis score
46
IV complication and meaning
PHLEBIS: inflammation of the vein
OCCLUSION: blockage, non-thrombotic or thrombotic
INFILTRATION: iv fluid leaking into the tissue around the vein, fluids continue to be delivered but iv tip not in vein, can cause compartment syndrome
EXTRAVASATION: infiltration of vesicants - substance more caustic than iv fluids, can cause blistering, burning or sever tissue damage
INFECTION: iv related sepsis associated with poor technique, can be life threatening
47
parenteral fluid and electrolyte replacement
- essential when pts unable to take food and fluids orally
- replacement into intravascular space
- prescribed by Dr
- nurse administers and maintains IVT
48
classifications of IV fluids
CRYSTALLOIDS: contain water, dextrose and/or electrolytes
can be:
- isotonic: same concentrate of solutes as blood plasma
- hypotonic: treats cell dehydration, swells cell
- hypertonic: draws fluid out of cell and into vascular compartment
COLLOID: has an increased osmotic pressure and remain in intravascular space longer and is delivered through PIV, CVC, PICC
49
why is 5% dextrose avoided in pts with severe head injuries
- because of what the body does to sugar once its infused
| - reduces serum sodium levels, increases amount of water in the brain which increases intercrainial pressure
50
hypervolaemia?
what does it cause?
signs/symptoms?
treatment?
fluid volume excess
CAUSES: renal impairment, heart failure, mental confusion
SIGNS/SYMPTOMS: oedema, wight gain, jugular vein distention, SOB
TREATMENT: diuretics, fluid restrictions, sodium restrictions
51
hypovolaemia?
what does it cause?
signs/symptoms?
treatment?
fluid volume deficit
CAUSES: dehydration, vomiting, diarrhoea, fever, chronic kidney disease
SIGNS/SYMPTOMS: dry mucous membranes, oliguria, dizziness, weakness
TREATMENTS: fluid admin
52
hypernatraemia?
what does it cause?
signs/symptoms?
treatment?
serum sodium >145mmol/L
CAUSES: water deprivation, diarrhoea, hypertonic tube feeding, low body weight
SIGNS/SYMPTOMS: dry mucous membranes, restlessness, irritability, seizures
TREATMENT: gradual infusion of hypertonic electrolytes or isotonic saline solution
53
hyponaturaemia?
what does it cause?
signs/symptoms?
treatment?
serum sodium <138mmol/L
CAUSES: loss of GI fluids, kidney disease, excessive water intake
SIGNS/SYMPTOMS: nausea/vomiting, lethargy, confusion, muscle cramps
TREATMENTS: gradual sodium replacement, water restrictions
54
hyperkalaemia?
what does it cause?
signs/symptoms?
treatment?
high serum potassium >5mmol/L
CAUSES: impaired renal function, impaired tubular function
SIGNS/SYMPTOMS: arrhythmias, weakness, paraethesia, ECG changes
TREATMENTS: dialysis, iv insulin, sodium polystyrene
55
hypokalaemia?
what does it cause?
signs/symptoms?
treatment?
low serum potassium <3.5mmol/L
CAUSES: vomiting, diarrhoea, nasogastric suction
SIGNS/SYMPTOMS: fatigue, weakness, confusion, muscle cramps
TREATMENTS: oral or iv potassium admin
56
what do neuromuscular/neurosensory disorders do
examples of disorders
affect the nerves that control voluntary muscles
EXAMPLES: multiple sclerosis, parkinsons disease, stroke, muscular dystrophy
57
different states of awareness and explanations
FULL CONSCIOUSNESS: alert, orientates to time, place, person, understand written/verbal words
DISORIENTATED: not orientated to time, place, person
CONFUSION: reduced awareness, easily bewildered, poor memory, impaired judgment
SEMI-COMATOSE: can be aroused by extreme or repeated stimuli
COMA: state of deep unarousable unconsciousness, will not respond to sensory or verbal stimuli
58
what are sensory alterations
factors contributing to alterations in behaviour of the pt
59
different types of sensory alterations
SENSORY DEPRIVATION: a decrease in meaningful stimuli with alterations in perception, cognition and emotion.
- risks: pts confined in a non-stimulating healthcare setting, impaired vision or hearing, mobility restrictions, confined to bed rest, meds affecting CNS.
SENSORY OVERLOAD: person unable to process/manage the amount or intensity of sensory stimuli
- factors contributing: pain, dyspnoea, anxiety, noisy setting, meds
SENSORY IMPAIRMENT: compromised reception, perception of 1 or more of the senses eg. blindness and deafness
60
what is locked in syndrome
medical condition resulting from a stroke that damages part of the brainstem, in which the body and most facial muscles are paralysed but consciousness remains and ability to move eyes is preserved (vegetable)
61
PERRLA
```
P- pupils
E- equal
R- round
RL- reaction to light
A accommodation
```
62
side effects of opioids
- respiratory depression
- sedation
- nausea and vomiting
- urinary retention
- blurred vision
- constipation
63
what are PCAs
- patient controlled analgesia pump
- pt self admin doses of analgesia through IV with pre-determined dose of opioids
- used in acute pain
- usually S8 meds
64
what is a niki pump
- battery powered, lockable IV/subcut infusion pump
- can take it home
- palliative care pr persistant pain
65
what is the goal/purpose of a blood infusion
to replace lost WBC and RBC or proteins to allow the body to transport o2 and Co2, to clot, to fight infection and maintain fluid levels
66
types of blood products and what they are used for
WHOLE BLOOD: used for acute haemorrhage, replaces blood volume
PACKED RBCs: for increased o2 carrying ability anaemia
AUTOLOGOUS RBCs: replacement for elective surgery. pt donates own blood
PLATELETS: bleeding disorders and deficiencies
FRESH FROZEN PLASMA (FFP): promotes blood volume and proteins
CLOTTING FACTORS AND CRYOPRECIPITATE: clotting factor deficiency
67
blood types
who they can give blood to
who they can receive blood from
TYPES: give blood to receive blood from
A+ A+,AB+ A+,A-,O+,O-
O+ O+,AB+ . O+,O-
B+ B+,AB+ B+,B-,O+,O-
AB+ AB+ EVERYONE
A- A+,A-,AB+,AB- A-,O-
O- EVERYONE O-
B- B+,B-,AB+,AB- B-,O-
AB- AB+,AB- AB-,A-,B-,O-
68
types of reactions to blood infusions
clinical signs
nursing interventions
HAEMOLYTIC REACTIONS
- clinical signs: febrile, chills, headache, SOB, chest pain, hypotention
- nursing interventions: stop transfusion, ring RMO, monitor obs and FBC, urinalysis, check blood pack and paperwork for discrepancies
ALLERGIC REACTION:
- clinical signs: itching, rash, wheezing
- nursing interventions: stop transfusion, keep IV line open with normal saline, check blood pack and pt ID labels are correct, notify RMO
FLUID OVERLOAD:
- clinical signs: dyspnoea, chest pain, anxiety, blood tinged sputum, fine crackles on auscultation of chest
- nursing interventions: stop transfusion, notify medical staff, obs, check med chart for frusemide, FBC
69
what are PICC lines (peripherally inserted central catheter)
- venous catheter inserted via the brachial, basilic or cephalic veins and advanced until tip is located in superior vena cava
- used for admin of IV meds, fluids and taking bloods
70
management of a PICC
- only 10ml syringe
- routine flush's
- inspect sight once a shift
- no flash back required = high risk of occlusion of lumen
71
what are CVC lines (central venous catheter)
- catheter that terminates at or close to the heart
- inserted centrally or peripherally
-use for infusions, heamodynamic monitoring
inserted in Jagular vein or femoral vein
72
what is a TPN IV (total parenteral nutrition)
what does it contain
indications
complications
- nutrition though large vein
- use for impaired absorption or non functional GIT
- admin through cvc/picc
CONTAINS: dextrose, h2o, fat, proteins, electrolytes, vitamins, minerals, fatty acids
INDICATIONS: pts with sever malnutrition, sever burns, bowel disease, metastatic cancer
COMPLICATIONS: infection, electrolyte and glucose imbalances
73
what is the clinical reasoning cycle
steps of clinical reason cycle
- formal decision making tool
- facilitates problem solving
STEPS:
1. consider pt situation
2. collect info
3. process info
4. identify problems/issues
5. establish goals
6. take actions
7. evaluate outcomes
8. reflect on process
74
ISOBAR
identify, situation, observation, background, assessment, recommendations
75
examples of life limiting and palliative care illnesses
```
cancer
heart disease
COPD
dementia
heart failure
chronic liver disease
renal disease
frail old people
```
76
SPICT
- supportive and palliative care indicator tool
| - guid to identifying people at risk f deteriorating and dyeing
77
1. emergency surgery =
| 2. elective surgery =
1. preserving function or life
| 2. not life threatening, improving pt life
78
factors affecting surgical outcome
```
age
malnutrition
obesity
cardiac conditions
blood disorders
renal disease
meds
mental state
```
79
```
URINE DEFINITIONS
enuresis
nocturnal enuresis
diuretic
nocturnal frequency
polyuria
oliguria
anuria
micturition
dysuria
urinary hesitance
urinary retention
residual urine
neurogenic bladder
```
enuresis: involuntary urniation
nocturnal enuresis: involuntary urination at night
diuretic: drug causing increase urine output
nocturnal frequency: excessive urination at night
polyuria: production of abnormally large volumes of dilute urine
oliguria: low urine output
anuria: failure of kidneys to produce urine
micturition: action of urinating
dysuria: painful/ difficult unrination
urinary hesitance: trouble starting or maintaing urine stream
urinary retention: inability to completely or partially empty bladder
residual urine: urine remaining in the bladder
neurogenic bladder: lack of control due to brain, spinal chord or nerve damage
80
what are wound drains
- reduce possible entry of microorganisms
- inserted during surgery
- sutured in place and connected to bottle that has low suction
- aids in removing excess exudate that may interfere with granulation of tissue
81
indications for closed wound drain
- abscessed cavity: prevents premature closure
- insecure intra-abdominal wound
- anticipated exudate: tissues that contain minute secretory glands
- risk of peritonitis
- traumatic surgery
82
types of drains
JACKSON PRATT: soft pliable tube, had bulb that recreates low negative pressure vacuum - so body tissues arnt sucked in
REDIVAC, VARIVAC, HAEMOVAC: high negative pressure drain
PIGTAIL: small lumen with coil, used for drainaing single cavity
PENROSE: flat ribbon-like, applied to external end to absorb
83
nursing considerations for wound care
- support and education
- prevent infection
- maintain patency of drain
- maintain skin integrity
- contain exudate, observe type and amount
- observe for complications, discomfort, loss of skin integrity, infection, dislodgment, blockage, loss of suction
84
removing a wound drain
- must be document by medical team to remove
- give pre-analgesia prior to removal
- clean site and remove anchoring suture, gently move drain to loosen, remove in a smooth continuous motion, send tip of drain for cultures to patho, apply occlusive and absorbent dressing
- document removal and drainage amount on FBC and progress notes
85
negative pressure wound therapy (NPWT)
- assists and accelerates wound healing
- AKA vac therapy
- controlled topical negative pressure is applied to entire wound
- foam dressing changed every 2nd day
- continuous therapy for first 48 hrs
- followed by intermittent therapy (5min on 2 min off) for increased granulation of tissue formation
86
benefits of negative pressure wound therapy
- increased local, functional blood perfusion
- increased nutrition delivery to wounded tissue
- accelerated granulation
- decreased wound bacterial counts
- reduced localised oedema
- moist wound healing
- facilities epithelialisation
