Therapeutic Skills Flashcards
(187 cards)
1
Q
Acute vs chronic wound
A
Acute wounds follow and timely and orderly healing process.
Expected to heal ex: surgical wound
Chronic wounds do not easily heal and return to normal appearance and function
Ex: pressure injury
2
Q
Wound healing: primary secondary and tertiary intentions
A
- Primary intention: wound with little loss of tissue
Wounds heal with skin well approximated. Little risk of injection. Ex: surgical wound - Secondary intention: wounds involving tissue loss. Heal from wound bed up.
Open wounds that become filled with scar tissue. Higher risk of infection. Ex: pressure injury, burn, severe laceration. - Tertiary intention: delayed primary closure (intentional or unintentional)
Wound left open, then closes
3
Q
Phase of wound healing
A
- Reaction- inflammatory response: begins minutes after injury till about 3 days
- skin red, controls bleeding, delivers blood and cells to injured area, epithelial cells to wound site - Regeneration- epithelial proliferation & migration: 3 to 24 days
Regeneration of tissue: fills wound via epithelialization
3. Maturation- reestablishment of epithelial layer & remodeling : up to 2 years Collagen fibers (scar tissue) continue to gain strength.
4
Q
Serous
A
Cleary watery fluid (exudate)
5
Q
Sanguineous
A
Bright red exudate
Indicates active bleeding
6
Q
Serosanguinous
A
Blood mixed with clear fluid.
Pale, red and watery
7
Q
Purulent
A
Green, yellow, brown, thick exudate.
8
Q
How would you assess an acute wound?
All dogs don’t continuously play (with) Paul
A
- Wound appearance (size, shape, colour, edges approximated)
- Wound drainage (serous, sanguineous, serosanguinous, purulent)
- Presence of drains (Jackson-Pratt, hemovac, penrose)
- Closure of wound (staples, sutures, steri strips)
- Palpation of wound
- Pain
9
Q
Describe a Jackson-Pratt drain (J-P)
A
A little bulb that acts as a suction device. Tube is placed directly in the wound, as fluid is suctioned it fills up the tube.
10
Q
Describe a hemovac drain?
A
For larger wounds. Tube is placed inside person during surgery. The other end is circular device that creates suction to remove fluids
11
Q
Describe a Penrose drain
A
Often used for head or neck surgeries. It’s a latex tube.
Tube is placed inside body, pin on top not attached to anything to prevent tube from slipping. Exudate comes out around tube, not from tube.
Skin around at risk for breakdown.
Usually an order to pull out 1 to 2 cm a day for healing
12
Q
4 patterns of stitches
A
Intermittent: each stitch is tied
Continuous: one tie at the beginning and end
Blanket continuous: one tie at the beginning, tie at the end, loops through each stitch
Retention: reinforcement along the wound
13
Q
You palpate a wound and it is extremely tender, red and warm to touch. What do you think?
A
Infection
14
Q
How can you minimize pain when doing a dressing change for a wound?
A
Pre medicating
Administer analgesic 30 to 45 mins prior
15
Q
Debridement:
A
Removal of damaged tissue or foreign objects from wound
16
Q
How is nutrition linked to wound healing?
A
Optimal nutrition facilitates wound healing , maintain immune competence, which decreases the risk of infection.
Poor nutrition= delayed wound healing
17
Q
What are the 3 layers of surgical dressings
A
- Contact layer (covers wound)
- Absorbent layer (reservoir for excess secretion)
- Outer protective layer (prevents external contaminates from reaching wound)
18
Q
Purpose of wound dressing
Many People Think Men ShoulD Help
A
- Protect from microorganisms
- Aid in homeostasis
- Promote healing via drainage
- Protect patient from seeing wound if unpleasant
- Promotes thermal insulation
- Provides moist environment to promote cell migrating and growing
- Support/splints wounds
19
Q
How do you clean wound and skin?
A
Saline solution. Use gauze, only once then throw out
Clean dirtiest to cleanest, wound being cleanest.
20
Q
Irrigating a wound
Principles
A
Gets rid of debris and dead tissue to promote healing
- Fluid should flow out so wound bed is not furthered damaged
- Liquid should flow from least to most contaminated
- Use low pressure (larger syringe, lower psi)
21
Q
How to prepare a client for a wound change
A
- Administer analgesic if necessary
- explain steps to lessen anxiety
- Gather all supplies before you begin
- answer all questions about procedure or wound
22
Q
Why would you obtain a wound culture?
A
Ex: purulent drainage, increased pain, temp or drainage
And reason to suspect infection
23
Q
How do you obtain a culture
A
- Clean wound thoroughly
- Swab healthiest looking tissue
- Rotate in 1 cm by 1cm area
- Apply pressure with swab to draw up fluid
- Put swab in sterile container and label.
24
Q
Packing a wound principles
A
- pack to elimate dead space
- Should be loose, contacting all wound surfaces and at skin level
- Assess for tunneling/undermining
- Protect skin integrity around wound to avoid maceration
25
What is undermining or tunneling?
When there is a dead space tunnel from the wound. Described in terms of direction and length. Head is 12 o clock.
26
Why may leaches or maggots be put on a wound?
Leaches such blood and secrete a chemical to stop clotting. So they promote blood to that area which aids in healing
Maggots only eat dead tissue. So they promote healthy tissue healing
27
What does bandaging do?
```
Creates pressure
Immobilize body part (sprained ankle)
Support a wound (abdominal binder)
Reduces or prevents edema
Securing a splint
Securing a dressing
```
28
What are complication of wound healing?
1. Hemorrhage (internal or external)
2. Infection
3. Dehiscence (total seperation of wound layers)
4. Evisceration (visceral organs protrude out)
5. Fistula (passage way between 2 spaces where there shouldn't be one)
29
What are signs there is a hemorrhage from a wound complication
Some bleeding is expected
External hemorrhage you would see
Internal: swelling or distension, more drainage in drain than expected, may progress to hypovolemic shock
30
What are signs of an infected wound
```
Pain/tenderness
Erythema
Edema
Inflammation of wound edges
Purulent discharge
Warmth at site, fever
Foul odour
Increased WBCs
Delayed healing
```
31
What are risk behaviors for dehiscence and nursing teaching to avoid?
Coughing, sneezing, vomitting, sitting up in chair (abdominal wound)
Nurse educate to brace with pillow when sneezing or coughing
32
What do you do if a patient experiences evisceration?
Place sterile towels soaked in sterile saline over area
| Observe for signs of shock while preparing patient for emergency surgery.
33
What is an SSI
Surgical site infection
Happens in 2 to 5 patients, most common HAI
34
What is hyperemia
| How is it assessed
Vasodilation
Assessed by blanching. If area blanches it is called blanching hyperemia
If it does not it is called non blanching hyperemia and can indicate deep tissue damage
35
Pressure ulcer stages
Stage 1: intact skin with localized area of non blanching erythema.
Stage 2: partial-thickness loss of skin in the epidermis, dermis is exposed Wound bed is viable, pink or red, moist.
May have an intact or ruptured serum filled blister
Stage 3: full-thickness loss of skin, subcutaneous layer is exposed.
Granular tissue and epibole (rolled wound edges) are often present
Slough and eschar may be present
Undermining/tunneling may occur
Stage 4: full thickness skin and tissue loss with exposed or palpable fascia, muscle, tendon, cartilage, ligament or bone.
Slough, eschar, epibole, or tunneling may be present
36
Unstagable ulcer
Full thickness skin and tissue loss in which extend of tissue damage within ulcer cannot be confirmed due to too much slough and eschar.
37
Suspected deep tissue injury
Intact or non intact skin with president non blanchable deep red, purple, maroon discoloration.
Pain or temp changed often came before skin colour changes
38
The 10 Rights of Medication
```
Right PATIENT
Right MEDICATION
Right REASON
Right DOSE
Right TIME AND FREQUENCY
Right ROUTE
Right REFUSE
Right PATIENT EDUCATION
Right EVALUATION
```
39
Routes of medication
Oral (mouth and tubes)
Parenteral (injections)
Topical (skin)
40
Oral medications
Solids- tablets, capsule, casulets
Liquids- elixir
Aersol- puffer, meter dosed (attached to device), dry powder inhaler (break pill)
Lozenge
Sustained release- enteric coated pills that dissolve in GI tract
41
How to protect a patient from aspiration?
- determine presence of gag reflex, assess cough and ability to swallow
- prepare oral med in easiest form to swallow
- give thickened liquor or fruit nectar if cannot tolerate thin liquids
- patient should be side lying or sitting up
- if they have unilateral weakness, put pill on stronger side
- administer 1 pill at a time
- encourage them to drink full glass of water and hold their cup themselves
- if high risk, see if you can administer an alternative way.
42
Medication action: onset
The time if takes from medication administered to producing a response.
43
Medication action: peak
The time it takes for the medication to reach to highest effective concentration
44
Medication action: trough
Minimum blood serum concentration of medication. Typically reached before next scheduled dose is due.
45
Medication action: duration
The time in which medication is present enough to produce a response
46
Medication action: plateau
Blood serum concentration of a medication has been reached and is maintained after repeated fixed doses
47
Topical medications
Lotions
Ointment
Paste
Disc or patch
48
How do apply topical medication
Wear gloves
Cleans wound prior
Remove old patch prior to putting new patch on
49
Ophthalmic medications:
Eye
Ointment: lower lid
Drops: in eye
50
Otic medication
Ear
Over 3: up back and away
Under 3: back and down
51
Nasal medication/instillations
Position head so gravity will help med reach targeted sinus area
52
Parenteral route
Subcutaneous layer
Intramuscular
Intravenous
Intradermal
53
Reconstitution
Adding a diluent or solvent to dissolve a powder.
Depending on how much diluent is added to vial, concentration or strength changes
54
Identify parts of a needle
Tip: needle attaches
Barrel: med goes in there
Plunger: pushes into barrel
55
3 types of syringes
Hypodermic syringe: 3 ml marking, can be different. Goes down in 0.5 ml
Tuberculin syringe: 1 ml marking. 0.01 ml intervals for accuracy
Insulin syringe: in units instead of ml
56
Types of needles
Hypodermic needle: creates slits instead of holes. Holds medication in when withdrawing
Blunt needles (with out with filter) used for accessing vials and ampules
57
Size of needle for IM
Children?
Adults?
22 to 25 G
Children- 7/8 to 1 inch
Adults- 5/8 to 1 inch
58
Size for needle for SC?
25 G
5/8 inch
59
Size for ID
26 to 27 G
1 cm
60
How do you prepare medication from vial
1. Clean top of vial
2. Draw air into syringe, equal to amount of liquid you're taking out of vial and inject into vial
3. Invert vial and draw medication out. Will flow naturally, then use plunger
4. Tap needle to get rid of bubbles
61
Can you mix medication into one syringe?
Yes, good way to give pt less medication.
| As long as meds are compatible
62
Mixing two insulins in one syringe
| Principles
1. Do not contaminate. Maintain aseptic technique
2. Clean tops and inject air into both vials and withdraw clear first
3. ensure final dose is accurate
CLEAR BEFORE CLOUDY
63
Angles of injections
IM: 90 degrees
SC: 45 (to 90) degrees
IV: 25 degrees
ID: 5 to 15 degrees
64
Intradermal injections
When is it used?
Where? Sites?
Max volume?
How?
Allergy testing or TB test
Dermis- inner arm or upper back
0.01-0.1 ml
Use a tuberculin syringe
5 to 15 degrees angle with a 26-27 G needle (1 cm in length)
Bleb appears during injection
65
Subcutaneous Injection
When?
Where?
Max volume?
How?
Insulin or LWMH
Subcutaneous layer (abdomen, back of arms, thigh)
0.5 to 1 mL
25 G needle (5/8 inch length)
45 degree for slim clients, 90 degrees for those with more
Not within 5 cm of umbilicus
66
Intramuscular Injection
When/why?
Where?
Max volume?
How
Fastest absorption bc of more vascularity (10 to 30 min)
Less risk of tissue damage compared to SC
Good for irritating meds bc of less nerve endings
Sites: ventrogluteal, deltoid, vastus lateralis
Small children and infants 1 ml
Children, older adults, very thin 2 ml
Adults, 3 ml
22 to 25 G needle (5/8 to 1 inch)
67
Ventrogluteal site
Preferred site for IM injections for >1 .except for deltoid (immunizations)
Muscle is thick, free of nerves and blood vessels. Subcutaneous layer is thin
68
How do you landmark ventrogluteal
Rt hand for Lt hip. Lt hand for rt hip
Heal of hand on greater trochanter.
Point thumb towards groin, fingers towards head.
Index finger towards ASIS and middle finger back along iliac crest towards buttocks.
Site is in triangle
69
Vastus lateralis
Site of choice for infants, autoinjectors and patients who do their own injections.
Muscle is thick and well developed. Easy to access.
70
How to palpate vastus lateralis
Handbreadth above the knee and handbreadth below greater trochanter.
Put 1 finger on epicondyle of femur, one on greater trochanter. Find the middle
71
Deltoid site
Why
Max volume
Best for immunization and emergencies.
Axillary, radial, brachial, ulnar nerves and brachial artery are in area
Only small amount < 1 ml
72
How to landmark deltoid site
Center of deltoid muscle
3 to 5 cm (3 fingers) below acromion process
Never give below axilla line
73
Describe the z track method
| Or zig zag
For highly irritating substances (seals into muscle layer)
Pull skin and underlying tissue to side about 2.5 to 3.5 cm
Hold skin taught and inject slowly
Leave needle in place for 10 seconds
Withdraw needle and release skin
74
What rate should medication be injected?
1 ml per 10 sec in adults
75
How long should you observe clients after vaccinations
15 mins look for swelling and difficulty breathing
| If high risk allergies. Watch for 30 mins
76
When you would not use the ventrogluteal site for an IM injections
Patients under 1 would use vastus lateralis
Vaccines in deltoid
Any other contraindication, like cast or injury to the area
Preferred site
77
What are some comfort techniques when giving a child or infant a needle?
Breastfeeding- reduces pain and infection
Oral sucrose- reduces crying
Seated position
Distraction
Rubbing (gate control theory)
Oral analgesic or topical anesthetic
Other forms of administration if possible
78
What is a needle stick injury
Caused by needles that accidently puncture skin
79
What is the risk dependent on if you get a needle stick injury?
```
Type of needle
Type and depth of injury
Amount of blood
Amount of virus or stage of illness
Susceptibility of HCP.
```
80
What do you do if you are stuck with a needle?
FIRST AID: wash with warm water and soap. Let it bleed for 30 to 60 sec. Don't stop The bleeding or put pressure to continue it.
REPORT: supervisor, occupational health etc
MEDICAL ATTENTION ASAP: pep (post exposure prophylaxis) should be taken in 4 hrs.
Blood testing done to assess risk of exposure
DOCUMENT incident
81
What are 3 factors you consider when choosing a needle of an injection
What type of tissue should I be injecting into? IM, SC, ID?
What is the size and weight of my patients?
What is the viscosity of the fluid to be injected?
82
Why is insulin injected vs administered orally?
Insulin is a protein, so it would be broken down in GI tract.
83
What are some techniques to reduce pain when giving a patient an injection?
Use a sharp bevelled needle in the smallest length and gauge needed
Position patient to have least muscular tension
User proper injection site by anatomically marking
Divert patients attention (ask open ended questions, tell a kid to wiggle their toes)
Insert needle quick and smoothly. Hold syringe straight.
Inject meds slowly (1ml/10 sec)
84
What are the prescribers, pharmacists and nurses role in medication?
Prescriber orders meds
Pharmacist dispenses meds
Nurse administers med
85
What are 3 types of medication orders?
Medical directive: not for a specific patient
Ex: epinephrine for anaphylaxis or oxytocin for PPH
Direct orders: for a specific client
Ex: routine, not, STAT, prn
Verbal orders: orders given on phone and transcribed repeat back to decrease chance of error
often done when physician is remote and will have to come and sign asap
86
Components of a complete medication order
1. Patients full name (may include unique identifier)
2. Date and time order was written
3. Medication name (generic or trade)
4. Dose
5. Route of administration
6. Time and frequency of administration
7. Signature of provider
87
What is the pharmacists role in medication
Prepares and distributes medication. Responsible for ensure orders are valid and accurate. Provides info on side effects, toxicity, interaction, incompatibility etc
Can administer meds, like flu shot
Can prescribe some meds or extend ongoing prescriptions.
88
Medication standard practice of cno.
| Nurses must poses what to administer meds safeoy
```
Authority; within 5 controlled acts or delegated
Competence:
Knowledge
Skill
Judgement
```
89
To give meds safety, a nurse must know
```
Drug classification
Why it is being given
Normal dosage range
Usual routes of administration
Usual actions of med
Expected side effects
Potential harmful side effects and what to do
Peak action and duration
Time of onset depending on route
If you should do a pre assessment and evaluation.
```
90
What is polypharmacy?
Multiple drugs are prescribed to treat a single ailment or condition.
Common with older adults
91
What is opioid naive?
Those who have never had opioid have very low tolerance.
Those who have been on it for a long time build tolerance quickly and may need a dose that could be dangerous to someone who never took it
92
Important subjective info when assessing a patient's med use
```
Medication history
History of allergies
Med information
Diet
Pts perceptual or coordination problems
Knowledge understanding and attitude towards meds use
Client and families learning needs
```
93
BPG for med administration
```
Prepare alone. No distractions
Use 10 rights of medication
Only give meds you prepare
Watch patients take each med. Don't leave unattended
Know generic and trade names.
```
94
Medication administration consideration for children and infants
Ask parent/guardian best way to administer
Use simple language
Disposable syringe for accuracy
Consider variations in size, weight and body surface area
95
Medication considerations for older adults
Physiological changes associated with aging
Can be more sensitive to meds, absorption and excretion may be different than expected
Simplify med plan
Be aware of polypharmacy
Encourage fluids if not contraindicated
96
What is a medication error?
Ant event that causes or leads to a patient either receiving the wrong med or failing to receive an appropriate med
Error of commission (wrong med)
Error of omission (missed dose)
97
What is high alert medication
Drugs that bear a heightened risk for causing significant harm if used in error
98
What is TALL man lettering?
To distinguish between meds with similar names
Ex buPROPion vs busPIRone
99
Medication reconciliation process
1. Obtain a complete and accurate list of current med
2. Use list when writing admission, transfer, or discharge
3. compare each list against the admission, transfer, or discharge. Bring any discrepancies to attention of prescriber.
This list accompanies patient to next care site.
100
What do you do if you you make a med error
1. Notify prescriber
2. Determine action: how long should they be monitored, is treatment needed
3. Treat and/or monitor adverse reaction. Document
4. Report error (incident report) which should include pt identifier, time and where, and a factual description of what happen, and corrective actions.
101
Why measure vital signs?
```
Provide info about the effectiveness of
Circulatory
Respiratory
Neural and
Endocrine body functions
```
Quick way to monitor a patient's condition, identify problems, or evaluating effectiveness of treatment.
102
When would you measure vitals
Minimum= order
Before/after: surgery, treatment, medication
Change in clients condition
Non specific symptoms (dizzy, headache, etc)
103
What is body temperature?
Surface?
Core?
Heat produced - heat loss = body temp
36 to 37 celcuis
Surface: fluctuates depends on environment
Skin, mouth, axilla (36 to 38)
Core: stays relatively constant
Rectum, temporal, tympanic, esophagus, pulmonary artery, urinary bladder (38)
104
Factors that affect temperature?
Age- extremes
Exercise- raises temp
Hormone levels- progesterone rise around ovulation causes decrease in temp
Circadian rhythm- ppl who work 9 to 5 coolest in early morning
Stress- can make us hot and sweaty
Environment- hot or cold
105
Oral temp:
| When to use and when not to
Place probe under tongue to side of center near sublingual artery (37.0)
Use: awake, can follow instructions, older than 4
Not: unconscious or unresponsive, confused, intubated, oral surgery
106
Axillary temp
When to use
When not to
Place under arm and have patient hold arm down
(36.5 ave= must susceptible to environment)
To use: adults and children, ppl with O2 masks
Not: profuse sweating
107
Rectal temp
When to use
When not to
Sims position, lubricate probe, insert 3 to 3.5 cm (37.5)
When to use: children under 2, when other methods can't be used
Not: infants under 2 months or premature infants, diarrhea, rectal bleeding or surgery
Most accurate core temp
108
Tympanic membrane thermometer
When to use
When not to use
Over 3: pull ear back, away and up
Under 3: pull ear back and down
Probe pointed toward PT's nose
(37.0)
When to use: adults and children, O2 mask
Not to use: hearing aids, ear infection, surgery
109
What is pulse? Why measure?
Palpable bounding blood flow noted at various parts of body
| Provides information about the status of the circulatory system
110
Pulse sites:
TEMPORAL: over temporal bone, above and lateral to eye
CAROTID: along medial edge of sternomastoid in neck.
APICAL: PMI site. 5th intercostal space at left midclavicular line
BRACHIAL: between groove of bicep and tricep at Antecubital fossa.
RADIAL: radial/thumb side of wrist
ULNAR: ulnar/pinky side of wrist
FEMUR: below inguinal ligament. Halfway between pubis symphysis and ASIS
POPLITEAL: behind knee in popliteal fossa
DORSALIS PEDIS: top of dorsum side of foot
POSTERIOR TIBIAL: inner side of ankle, below medial malleolus
111
Pulse norms for adults and infants?
Adults: 60 to 100 BPM
Infants: 120 to 160 BPM
112
What factors affect pulse?
EXERCISE: initially increases, long term decreases
TEMPERATURE: fever and heat increase, hypothermia decreases
EMOTIONS: anxiety increases. Relaxation decreases
PAIN: acute increases, unrelieved ongoing decreases
MEDICATIONS
HEMORRHAGE: increase at first, lowers due to blood loss
POSTURAL CHANGE: stand and sitting increase, lying down decreases
PULMONARY CONDITION: poor oxygen increases
113
How do you rate a pulse strength
0: absent or not palpable
1+: weak, threads
2+: normal, strong
3+: bounding, full (normal after exercise)
114
How to you assess a rate?
Rhythm (regular count for 30 x 2, irregular count for 60)
Rate
Strength (0 to 3+)
Equal on both sides
115
What is bradycardia?
Low pulse
Less than 60 BPM
Can be normal for athletes
116
Tachycardia?
High pulse
Greater than 100 BPM
Normal during exercise or if pt is anxious
117
Dysrhythmias or arrhythmia
Abnormal rhythm consistently
More common in older adults
118
Sinus arrhythmia
Pulse increases with inspiration, decreases with exhalation
Can be normal for older adults and children
119
Pulse deficit
Different between apical and radial pulse.
| Difference shows if heart is not contracting efficiently and failing to transmit waves to the peripheral pulse site
120
What is respiration
The exchange of gasses between the blood and the atmosphere and between blood and cells.
121
Normal respiration rates in adults and infants
Adults: 12 to 20
Infants: 30 to 60
122
What are factors that affect respiration?
Exercise: increase rate and depth
Acute pain: short shallow breathing
Anxiety: increases rate and depth
Smoking: increases rate
Medication
Neurological injury: decreases rate and alters rhythm
Hemoglobin function: increase rate and depth
123
How to do you assess respiration?
Rate
Depth
Rhythm
Sound
124
What is one respiration cycle
Inhalation and exhalation
125
Bradypnea
Slow breathing rate
| Under 12 breaths per minute
126
Tachypnea
Fast breathing rate
| Over 20 breaths a min
127
Hyperpnea
Laboured, increased depth and rate
| Normal when exercising
128
Apnea
Pauses in breaths
| If too long can lead to respiratory arrest
129
Dyspnea
Difficult breathing; breathlessness
130
What is blood pressure influenced by?
```
Cardiac output
Stroke volume
Peripheral resistance
Elasticity of vessels
Circulation blood volume
Blood viscosity
```
131
What is blood pressure?
The force of blood pushing against the side of the vessel wall
132
What is systole and diastolic pressure?
Systole: the maximum pressure felt in the artery during ventricle contraction
Diastole: the elastic recoil, or resting pressure the blood exerts constantly between each contraction
133
```
BP for adults
Optimal:
Normal:
Hypertension:
Hypotension:
```
Optimal: 120/80
Normal: 135/85
Hypertension: 140/90
Hypotension: <90/_
134
Factors that affect BP
Age: increases with age
Stress: fear, anxiety increase BP
Ethnicity: south Asian, native American and those of African decent have higher BP
Daily variations: rise in afternoon, lowest at night and early morning
Medication
Activity, Weight and Lifestyle
135
How do you measure BP
Manual: auscultate with stethoscope and sphygmomanometer
Automatic
Arterial line (ICU)
136
What happens if cuff is too big or too small when taking BP?
Too big= lower BP
TOo small= higher BP
Should be width: 40% of arm and length: 2/3 of arm
137
What would you do if you had to take BP on a patient that had axilla lymph nodes removed?
Can cause edema so use lower limb
138
Describe the 5 Korotkoff sounds
1. A sharp thud (systole)
2. Blowing or whooshing sounds
3. A softer thump
4. Softer blowing or whooshing sounds
5. Silence (diastole)
139
Describe the two step method for taking BP
1. Take palpable BP
Palpate brachial or carotid artery, inflate 30 mmHg where pulse disappeared (systole BP)
2. Auscultate brachial artery
Inflate 30 mmHg above palpated systole. Deflate 2 to 3 mmHg/second
Good when you don't know a person's baseline. Can do 1 step if you do.
140
Auscultatory gap
A period when sound disappears during auscultation of BP
Usually for 10 to 40 mmHg
Can cause an underestimation of systole, or overestimation of diastole
Occurs in 5 percent of those with hypertension. Not clear why.
141
The 5th vital sign:
Pain
142
Comprehensive pain assessment
1. History of current pain experience (subjective)
- PQRSTU-AAA and pain scale
2. Direct observation of behavioural and physiological response of the client (HR, BP)
143
How does a fever work as a defence mechanism?
During a febrile episode, WBC production is stimulated.
Stimulates production of interferon (virus fighting substance)
Reduces concentration of iron in blood, suppresses growth of bacteria
144
What teaching would you provide a client with fever
Finish full course of antibiotics
Encourage fluids and rest
Promote heat loss (limit blankets, keep bed linen dry)
145
Why give bed baths?
```
Cleanse skin
Reduce body odour
Reduce risk of infection
Promote circulation
Promote relaxation
Promote nurse/client relationship
Perform skin and mental assessment
Perform ROM exercises
```
146
Describe types of bed baths?
Complete: patient is totally dependent and requires total hygiene care. Work with 2 ppl
Partial: encourage pt to wash areas they can, while they dangle on bed. Nurse helps with hard to reach areas
Bag bath: warmed toilettes that don't need water. Done in ER
Shower or bath
147
Principles of giving a bath
Provide privacy
Maintain warmth
Promote independence
Anticipate needs- bring supplies first. Never leave alone in shower
Maintain safety: hip height for bed, breaks on, call bells, temp of water
Respecting choices
148
Benefits of back rub?
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Stimulates circulation,
Reduces risk of pressure injury
Relieves muscular tension
Promotes relaxation and comfort
Promotes nurse client relationship
```
Don't run red areas can be broken capillaries and make it worse
149
Perineal care:
Penis; retract foreskin, dry well
Vagina: from front to back
Catheter care: cleanse from insertion out. Look for damage at insertion site
150
Nail and foot care
Assess:
Inspect surface of fingers, toes, feet and nails
Colour and temp
Cap refill
Look for: fungal, infection, hammertoe
Skin breakdown common in between toes, ankles and heels, so dry well
Trimming nails is high risk for people with diabetes, peripheral vascular disease
151
Oral hygiene care
Reduces incidence of pneumonia (especially when intubated)
BPG is too perform, instruct or remind 2x a day
Special needs: stomatitis, O2 therapy, unconscious
152
Oral Care for unconscious patients
Patient lie on side with HOB drained.
Assess gag reflex with tongue blade
Have suction on hand
Insert padded tongue blade gently between molars
Assess tongue, mouth, cheeks, lips for fungal infections or dehydration
Clean mouth with toothbrush or toothette (chlorhexidine or water)
Might need syringe bulb to rinse
Lip Care
153
Oral Care: dentures
Encourage self care if possible
Breakable: keep in denture cup, wash in sick with towel at bottom with water
Store in tepid water
Assess gums and mucous membrane
Assess fit: if they lose weight they can be loose. Too tight is painful
154
Hair and scalp care:
Brush and comb hair
Easier to wash hair in shower
For bed bound client: use portable hair basin in bed. Or shower caps with dry shampoo
Shaving: electric razors better to avoid cuts.
Shave face, legs, armpits
155
Eye, ear and nasal care
Eyes: if crusted, soak with cloth with warm water for a few mins. If not blinking reflex, lubricate eye with patch or drops.
Ears: hearing aids kept in safe place and cleaned
Nasal: oxygen is drying so use lubricant around nose. Be aware of skin breakdown behind ears.
156
Principles of bed making
Linen should be clean, dry and wrinkle free
| Principles of asepsis followed: hold away from uniform, do not shape, place directly in hamper.
157
Making an unoccupied bed:
Open: top covers folded back
Closes: good during day to not encourage residents to get into bed
Surgical: open at side
158
Making an occupied bed:
Roll clients on side to change one side of bed at a time
Careful of contamination. New sheets should be on bottom.
- bottom sheet/mattress pad
- drawsheet
- sheet and blanket on top
159
Fowler's position
High Fowler's: 90 degrees
Fowler's: 45 degree
Low Fowler's: 30 degrees.
Anything above 30 degrees risks breakdown on sacrum
160
Trendelenburg
| Reverse Trendelenburg
Legs higher than head
Head higher than legs
161
Pressure redistributing surface/ support surface
Specialized devices designed to redistribute pressure to reduce incidence or pressure injury.
162
What mmHg is enough pressure to close a capillary?
| How is that related to positioning of clients
It takes 32 mmHg to close a capillary and therefore reduce blood flow to the area.
When a pt is in bed for a prolonged period of time, they are susceptible to skin break down and pressure injury.
Reposition q2hrs minimum
163
Factors that influence personal hygiene
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Social practices
Personal preferences
Body image
Socioeconomic status
Health beliefs and motivation
Cultural variables
Physical condition
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164
Who is at greatest risk for skin breakdown in perineal area?
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In dwelling catheter
Recovering from rectal or genital surgery
Recovering from childbirth
Uncircumcised males
Incontinent
Morbidly obese
While having menstrual period
```
165
Risk factors for nurses getting hurt?
Previous history of back pain
Lack of personal physical conditioning
Not taking time to obtain help
Rushing
Slippery or uneven floor
Staffing levels, patient assignments, availability of equipment
Reaching, lifting, twisting, heavy loads etc
166
Body mechanics is:
The coordinated efforts of the musculoskeletal and nervous systems to maintain balance, body alignment, and posture while bending, lifting, twisting and performing ADLs
Body mechanics alone are not sufficient, safe handling techniques and equipment must be available.
167
Ergonomics
Fitting job to worker
168
Traditional lifting principles and nursing
Don't apply.
| Patients are unpredictable in movement, awkwardly shaped, cannot hold close to our body, heavy.
169
Principles of safe client/patient handling (SPH)
1. Ask for help
2. Use patient transfer devices where possible
3. Encourage patient to assist
4. Stand in close proximity to patient
5. Tighten core muscles, keep back neck pelvis and feet aligned.
6. Avoid twisting. Try to work infront of you, or point toes in direction your moving
7. Bend knees and keep feet wide apart
8. Lift with arms and legs. NOT back.
170
Safe patient handling programs
```
Patient assessments and algorithms
Proper equipment (SPH aids)
Staff training
Minimal or no lift policy
Sometimes resource nurse.
```
171
SPH aids
Aids all of most of the load and reduces friction of the cloth against skin to reduce injuries.
1. Mechanical Lift: ceiling or Hoyer: patient site in sling attached to machine, machine bears load
2. Transfer board: role patient to side, slide.under. slip to next bed/stretcher.
3. Transfer/gait belt: use when pt can bear some weight. Do up around core, 2 fingers can fit in and not on spine. Over clothing.
4. Trapeze bar: pt can assist with repositioning. Can be used for exercise.
172
Before moving a bed ridden patient, safety considerations are:
```
Have appropriate equipment
Ensure you have help if required
Hand hygiene
Breaks are on
Explain procedure to patient
Patient wearing appropriate footwear
Allow patient to dangle
```
173
Risks of immobility
METABOLIC CHANGE: decreased metabolic rate = decreased weight and muscle atrophy
Altered metabolism of protein, fat, carbs cause fluid and electrolyte imbalance
Decreased calcium leads to pathological fractures
GI CHANGE: GI disturbances like constipation and diarrhea. Causes dehydration with further causes an electrolyte imbalance. Risk of bowel obstruction
RESPIRATION CHANGE: increase risk for respiratory complications including atelectasis and hypostatic pneumonia. Decreased productive cough and increase mucous (good for bacteria). Decrease O2 consumption which increases recovery time
Lungs lobe or both collapse.
CARDIOVASCULAR CHANGES: orthostatic hypotension, increased workload on heart, decreased cardiac output. Thrombus formation from lack of moving and decreased vessel wall integrity. Emboli is a risk. Decrease fluid volume, increased blood pooling in legs.
MUSCULOSKELETAL CHANGES: decreased endurance, strength, stability and balance, ROM. Atophy, fatigue with activity, osteoporosis, contractures. Can be temporary or permanent impairments or disabilities
URINARY ELIMATION CHANGES: Urinary stasis (ureter and kidneys on same level as bladder)
UTIs and renal calculi, inability to void or completely empty bladder
INTEGUMENTARY CHANGES: pressure injuries
174
Common psychological changes that occur with immobilization.
```
Decreased social interaction
Social isolation
Sensory deprivation
Loss of independence
Roles change.
```
175
Range of motion for patient who is on bed rest
Active ROM: pt able to move all joints independently
Passive ROM: support joint above and below and move joint through ROM for pt
Begin asap.
Assess patients ability to participate
Movements should be slow and smooth. Repeat each movement 5 x a season.
176
Ambulation devices
1. Walker: elbows flexed 15 to 30 degrees, handle at wrist crease
2. Cane: quad or traditional. Quad better for stability.
Greater trochanter height on stronger side.
3. Crutches.
Axilla crutches: 2-3 fingers below axilla. Elbows flexed 20 to 25 degrees. Weight in hands.
Forearm crutches: 2.5 cm below elbow crease, elbows flexed 20 to 25 degrees
177
Ambulating clients
- Assess the patient: vitals, balance, coordination, LOC, pain
- assess environment
- proper footwear
- dangle 1 to 2 mins
- support patient by waste (center of gravity)
- use assisted devices as necessary
178
Pressure Injuries;
Impaired skin integrity from unrelieved prolong pressure. (As a result of prolonged ischemia)
179
Bony prominences at risk for pressure injuries
```
Back of Head, ears
Shoulder bones
Elbows
Hips
Sacrum
Knees
Heels
Ankles
```
180
Friction vs shear forces
Friction: the force of two surfaces moving against each other's. Affects the epidermis layer.
Ex: skin is dragged across bed linens
Shear: the force exerted parallel to the skin. Results in gravity pushing down on the body and friction between the patient and surface.
Skin and subcutaneous layer adhere to bed, muscle and bone slide with body. Causes necrosis to underlying tissue and tunnelling
Ex:
181
How to prevent pressure ulcers:
```
Maintain good body alignment
Reposition every 2 hrs
Use positioning devices to protect bony prominences
Joints should be slightly flexed
Avoid skin to skin
Keep bed clean, dry and wrinkle free.
```
182
Devices for positioning
Pillow: elevated certain body parts. Provides support
Wedge pillow (abduction): keep hips abducted post hip replacement
Foot boot: prevents footdrop contracture. Keeps foot flexed and weight of blankets off toes
Trochanter roll: can use sandbags. Prevents hips from externally rolling
Hand rolls: maintains thumb in slight abduction. Prevents hand contractures
Trapeze bar:: assists in repositioning.
183
Supine position
Lying flat on back. Supports may be used under head and arms and hands.
Transfers, sleeping, assessments, cpr
184
Prone position
Lying on stomach, face usually turned to one side.
Can out support under hips and feet.
Injuries to back, babies in NICU
185
Side lying position (or lateral)
Lying on side, top leg bent and resting on pillow in front. Top arm bent and resting on pillow
Majority of weight on shoulder and hip
Surgery on left arm, put them on right
186
Sims position
Similar to side lying. Bottom arm pulled behind body. Pillow under arm in front. Pillow between knees and ankles.
Weight is on shoulder and clavicle
Ex. Mouth care for unconscious pt. Rectal temp
187
30 degrees side lying position
Pillow between legs. Patient is on 30 degrees angle. Least amount of pressure and friction on greater trochanter.
Often HOB raised 30 degrees or lower.
Ex. Patient with pressure ulcer.
