Term
| Spirituality comes from the latin word: ________ |
|
Definition
|
|
Term
| Definition of Spirituality |
|
Definition
| It is the act of connecting to systems such as God, nature, or other people to find meaning in relationships. (Everyone has spirituality, but not everyone has religion and that is where the difference is) |
|
|
Term
| Definition of Spiritual Well Being |
|
Definition
| A spiritual healthy person has an awareness to a Supreme Being - has a meaningful purpose in life, has relationships that are loving, has a forgiving attitude, and recognition of limitations of being human. |
|
|
Term
|
Definition
| it is associated with a "state of doing" or a specific system of practices associated with a particular denomination, sect or form of worship. |
|
|
Term
| What spiritual problems will make us look at our spiritualness more? |
|
Definition
| Acute, chronic & terminal illnesses. Also, near death experiences. |
|
|
Term
| Who are the spiritual theorists we discussed in class? |
|
Definition
| Lawrence Kohlberg & James Fowler. Didn't go into, but know that there are spiritual stages. |
|
|
Term
| Assessment of spiritual health is on: |
|
Definition
| Faith/Belief Systems, Life & Self-responsibility, Life Satisfaction, Culture, Fellowship & Community (might ask a pt., "who do you turn to for help?", Ritual & Practice (whatever it is the person holds dear. Can be eating practices, certain songs, birth & death practices) |
|
|
Term
| In class we looked at cases & assessed spiritual needs. Name the 3 categories & give examples within each. |
|
Definition
**MEANING & PURPOSE (Victor Frankel the Holocaust survivor looks for meaning w/in the camp and then Rick Warren who wrote the book the Purpose Driven Life where he interviews 250 people asking what is the meaning of life?)
**LOVE & RELATEDNESS (it is important for a child to experience unconditional love, have a system where they're rewarded honestly w/ realistic discipline and a support system that is dependable and truthful)
**FORGIVENESS (Carl Meninger believed that if 75% of people could forgive other or themselves they could walk out of the mental hosp.) |
|
|
Term
| Did we cover nursing diagnosis for spiritual well-being vs. distress? why not? |
|
Definition
| No, we didn't cover b/c we haven't been trained |
|
|
Term
| Implementation. Just by being you - you can help meet spiritual needs. How? |
|
Definition
| Establish Presence, Support Systems, Diet Therapies, Support Rituals (a lot of people have these & they can be hard in the hospital, but there is a chapel in most hospitals), Prayer & Meditation (is it appropriate for a nurse to pray with a patient? It is if the patient asks you to and you're comfortable with it. Can ask them to lead the prayer. If not, tell them about the chapel. |
|
|
Term
| How can you establish a spiritual presence for your patient? |
|
Definition
| Empathy, Encouragement, Touch, Listening intently, Loving Concern & kindness, faithfulness and a positive attitude. |
|
|
Term
| When evaluating the patient, how can we know their spiritual needs are met? |
|
Definition
| They might verbalize more hope. |
|
|
Term
| Vital signs are very important b/c they are our _______ for our patient. |
|
Definition
|
|
Term
| Can we assign any vital signs to AP? |
|
Definition
| You can assign all vital signs to AP. Never assign them to an unstable patient though. |
|
|
Term
| When do we give vital signs? |
|
Definition
| *when the client is admitted *pre & post-op *before, during and after giving meds that affect cardiovascular, respiratory and temperature control function *When the clients general physical condition changes (in LOC or increased pain), when the client reports non-specific symptoms ("feeling funny" or "different") *before and after nursing interventions influence vital signs (before a client previously on bedrest ambulates or when a client performs ROM exercises) |
|
|
Term
| Be sure you know that ____ will affect vital signs. |
|
Definition
Age
ex/ elderly have a baseline temp. that might be lower. TEMPERATURE DECREASES WITH AGE. Also, Newborns & infants have much higher respiratory rates then adults. Newborns, infants and children have a lower BP reading though. |
|
|
Term
| What is the normal oral temperature? |
|
Definition
| 98.4-100.4 F (36-38 C). Most important is to record how you took it. Rectal temp is usually 1 degree higher then oral. Axillary (armpit) is usually 1 degree lower then oral. |
|
|
Term
| Do you need to wear gloves (and DON't FORGET for skills check-off!!) when you take the thermometer in or out? |
|
Definition
| OUT. Don't need gloves when putting it in. |
|
|
Term
| If your patient just ate a bowl of ice chips or was smoking - do these things affect oral temperature accuracy? |
|
Definition
| Yes, you need to wait 30 minutes. Smoking can also affect HR & BP. |
|
|
Term
| What is the most accurate pulse reading? |
|
Definition
| apical. taken with 3 fingers on the radial to count (usually 15 seconds x 4 or 30 seconds x 2). If those are irregular in any way, take it again and count for a full minute. |
|
|
Term
| What is the normal pulse? |
|
Definition
|
|
Term
| What is the most commonly missed vital? |
|
Definition
| Respirations. Because the electronic roll around does not measure respirations. Respirations are the key to telling first if the patient is having problems! You have to have an airway first. So, if you don't have respirations then you don't have an airway. Make sure you count respirations and do it accurately. |
|
|
Term
| What are the normal adult respirations? How does it alter in children? |
|
Definition
| Normal adult respirations: 12-20 per minute. Children breathe much faster & have higher numbers normally. |
|
|
Term
| What is the normal blood pressure reading for an adult? |
|
Definition
|
|
Term
| What is the first number in blood pressure & what is the second? |
|
Definition
| Systolic (heart contracting)/Diastolic (heart at rest) |
|
|
Term
| Can changes in posture (sitting and crossing your legs) increase your BP? |
|
Definition
| Yes, posture can increase BP. Even noise can increase HR. |
|
|
Term
| What factors can affect readings? |
|
Definition
| Equipment errors, operator errors, improper fitting equipment, environment (noise) |
|
|
Term
| What happens to the reading if you use too large or too small of a cuff? |
|
Definition
| If it is too narrow it will have a false high. If it is too wide, it will have a false low. |
|
|
Term
| What is the best way to take respirations? |
|
Definition
| A skillful nurse does not let the patient know that respiratory rate is being taken. The respiratory rate should be counted immediately after the pulse is taken while the nurse's fingers are on the patients wrist. It is often helpful to place the patient's arm in a relaxed position across the abdomen so that the nurse's hand will rise and fall with the respiratory cycle. The depth of the respiration, respiration rhythm should be assessed as well as the rate. |
|
|
Term
| What are the pulse taking sites? |
|
Definition
| The sites are CAROTID (sternocleidomastoid muscle in neck), BRACHIAL (inside elbow of arm=groove between biceps and triceps in antecubital fossa) RADIAL (radial or thumb side of forearm at wrist), FEMORAL (back of thigh), POPLITEAL (behind knee), DORSALIS PEDIS (along top of foot between tendons of great & first toe) and APICAL (4th - 5th intercostal space at left midclavicular line - site used to ausculate for apical pulse) |
|
|
Term
| What do you do if you want to delegate vital signs to AP? |
|
Definition
| Remember, the nurse still has total responsibility for knowing all info related to the client. If you delegate the vitals make sure to give that person any special instructions needed to complete the task. If you're delegating vital signs you will ALWAYS tell them to immediately report ANY odd findings to you right away. Then you go back and check them yourself. Vitals are NEVER delegated if the patient is unstable or is being used to evaluate a treatment or medication where you're unsure. |
|
|
Term
| Notes to remember on taking BP |
|
Definition
| Elevate to the level of the heart, locate cuff 1 inch above brachial artery, center arrow above/on brachial artery, close pressure bulb, continue palpating nerve, inflate cuff to 30 points above, do not allow chest piece to touch clothing, allow to fall 2-4 mm Hg per second, when sound starts (is systolic) and when it stops (it's diastolic). |
|
|
Term
| Development of an infection occurs in a cycle that depends on the presence of all of the following elements: (What are the 6 parts to the chain of infection?) |
|
Definition
| Infectious Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry, Host |
|
|
Term
| What is the single most important way to prevent the spread of infection? |
|
Definition
|
|
Term
| Though handwashing is the most effective way to stop the spread of microorganisms. In 34 studies of handwashing, HCW's washed their hands only ____% of the time. |
|
Definition
|
|
Term
| Which microorganism is not killed by an alcohol hand rub? You absolutely have to wash your hands... |
|
Definition
|
|
Term
| what are the hand hygiene methods? |
|
Definition
| 1. Soap + Water 2. Alcohol hand rub (to get perfectly clean, do both) |
|
|
Term
| When should nurses wash their hands? |
|
Definition
| before & after caring for a client, when hands are visibly soiled, after contact with sources of microorganism, after an invasive procedure, and after removing gloves (often forgotten!) Also after changing bed linens. (Never throw bed linens on the floor! Make sure linens get in the bag and then down the shoot) |
|
|
Term
| What are some examples of medical asepsis? |
|
Definition
| Changing the bed linens, washing hands, wearing gloves, proper disposal of needles, utilizing isolation precautions when appropriate |
|
|
Term
| What area of the sterile field is considered sterile? |
|
Definition
| Only the top surface, one inch in from edges that are above the HC providers waist. Once you set-up a sterile field, you never leave it! Need something? Call for someone else to bring it. |
|
|
Term
| Sterile Solution needs what info applied right when you open it? Why? |
|
Definition
| Date & Time b/c it is only good for 24 hours. Also, remember to pour with label in palm of hand (b/c you don't want solution to run down the label and mess up the print.) Find an open sterile solution without a date & time? Throw it away. |
|
|
Term
| If you open a new bottle and you are going to leave it in the patient's room, what info do you write on the bottle? |
|
Definition
| The date and time it was opened and your initials. |
|
|
Term
| If there is an opened bottle in the patient's room without the date it was opened written on it, what do you do with the bottle? |
|
Definition
| Discard it, throw it away! |
|
|
Term
| When removing contaminated gloves, why is it important to grab the palm pocket first? |
|
Definition
| To minimize contamination your underlying skin and keep microorganisms inside gloves when disposing them. |
|
|
Term
| Why do you always remove your gloves, dispose of them, and wash your hands before leaving the patient's room? |
|
Definition
| To reduce the risk of cross contamination with other patients. |
|
|
Term
| How do you remove your gown, gloves and mask when leaving the room of a patient in isolation to prevent contamination of your hands and uniform? |
|
Definition
| Remove gloves first using sterile procedure you know & was talked about previously. Then wash hands. Then remove mask by untying lower string first and avoiding contact with contaminated portion of mask, and then remove gown by grasping along inside of neck and pulling off while rolling it up with soiled side inside. Discard in appropriate spot. |
|
|
Term
| When putting gloves on, which one goes on first? |
|
Definition
| Dominant hand. With the other slide on & can push down with the other. |
|
|
Term
| A change in the 2007 Isolation Precaution Guideline... The term "nosocomial infection" will be replaced with the term: |
|
Definition
| "Healthcare associated infections" (HAIs) |
|
|
Term
| A change in the 2007 Isolation Precaution Guideline... What is the respiratory hygiene/cough etiquette? |
|
Definition
|
|
Term
|
Definition
| (aka clean technique) includes procedures used to reduce and prevent the spread of microorganisms. Hand hygiene, using clean gloves to prevent direct contact with blood or body fluids, and cleaning the environment routinely are examples of medical asepsis. Principles of medical asepsis are commonly followed in the home, as in washing hands before preparing food. |
|
|
Term
|
Definition
| (aka sterile technique) requires a nurse to use different precautions from those of medical asepsis. Surgical asepsis includes procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area. In surgical asepsis an area or object is considered contaminated if touched by any object that is not sterile. For example, a tear in a surgical glove exposes the outside of the glove to the skin surface. Nurses working with a sterile field or sterile equipment must understand that the slightest break in technique results in contamination. |
|
|
Term
| Surgical Asepsis should be used in the following situations: |
|
Definition
| In procedure that require intentional perforation of the client's skin (like inserting IV catheters or giving injections), When the skin's integrity is broken as a result of trauma surgical incision or burns, During procedures that involve insertion of catheters or surgical instruments into sterile body cavities. The nurse will use sterile asepsis technique at the clients bedside for: insertivg IV or urinary catheters, suctioning the tracheobronchial airway, and reapplying sterile dressings. |
|
|
Term
| Critical items that must be sterile: |
|
Definition
| surgical instruments, IV catheters, urinary catheters, needles. |
|
|
Term
| Semi-critical items for sterilization that must be disinfected and sterilized: |
|
Definition
| respiratory suction tubing and catheters, endotracheal tubes, gastrointestinal endoscopes |
|
|
Term
| Noncritical items that come in contact with skin, but not mucous membranes must be clean (disinfected): |
|
Definition
| bedpans, blood pressure cuffs, linens, stethoscopes, food utensils. |
|
|
Term
| There are 3 transmission based isolation categories. Name them... |
|
Definition
| 1. airborne precautions 2. droplet precautions 3. contact precautions |
|
|
Term
| Explain Airborne Precautions |
|
Definition
| The disease is droplet nuclei smaller than 5 um; measles; chickenpox (varicella); disseminated varicella zoster; pulmonary or laryngeal TB. Barrier protection is a private room, negative-pressure airflow of at least six exchanges per hour; mask or respiratory protection device. |
|
|
Term
| Explain Droplet precautions: |
|
Definition
| The disease is droplets larger than 5 um; diptheria (pharyngeal); rubella, streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children; pertussis, mumps, mycoplasmal pneumonia, meningococcal pneumonia or sepsis; pneumonic plague. Barrier protection is a private room or cohort clients; mask. |
|
|
Term
| Explain Contact precautions: |
|
Definition
| Disease is direct client or environmental contact; colonization or infection with multidrug-resistant organism; respiratory synctial virus, shigella and other enteric pathogens; major wound infections; herpes simplex; scabies. Barrier protection is a private room or cohort clients: gloves, gowns. |
|
|
Term
| "Personal Protective Equipment" is what for a nurse? Why do we use it? |
|
Definition
| Gowns, masks, protective eyewear, and gloves. Primary reason for gowning is to prevent soiling clothes during contact with the client. Gowns help HC providers from coming in contact with infected material and blood or body fluid. Full face protection (with eyes, nose and mouth covered) should be worn when splashing or spraying of blood or body fluid into the face is anticipated. Masks should also be worn when working with a client placed on airborne or droplet precautions. Gloves help to prevent the transmission of pathogens by direct and indirect contact. Clean, nonsterile gloves should be worn when touching blood, body fluid, secretions, excretions and contaminated items. Hand hygiene should be performed immediately after removing gloves. |
|
|
Term
| When is an antiseptic hand wash ok? |
|
Definition
| Before and after direct contact with patients when hands are not visibly soiled or contaminated, after touching equipment or furniture near a patient, and after removing gloves. Apply a quarter size amount of hand rub, cover all surfaces and rub until dry. Research shows that alcohol-based hand-rub is superior to soap or antimicrobial soap, and it saves staff time. Hand washing with soap and water takes, on average, 56 minutes in an eight-hour shift compared to only 18 minutes in an eight-hour shift when using alcohol-based handrubs. |
|
|
Term
| What are some examples of medical asepsis? |
|
Definition
| changing bed linens, washing hands, wearing gloves, proper disposal of needles, utilizing isolation precautions whenever appropriate |
|
|
Term
|
Definition
| 1. mask 2. goggles (if indicated) 3. Gown (cover wrist and tie in back) 4. Gloves (pull up over cuff) |
|
|
Term
| Undonning or Removing Isolation Garb: |
|
Definition
| 1. Gloves 2. Mask (untie lower string first & DO NOT touch outer surface) 3. Gown (untie, let fall from shoulders, hold inside out at shoulders, and fold inside out, discard) 4. Goggles (if used). Then perform hand hygiene. |
|
|
Term
| How do you put on sterile gloves? |
|
Definition
| 1. open package 2. pull glove over dominant hand touching only interior cuff that is folded back 3. slip fingers underneath second glove's cuff 4. pulling second glove over non-dominant hand 5. hands interlocked |
|
|
Term
| What are the standard/universal precautions? |
|
Definition
| Std precautions apply to blood, all body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes. Hands are washed between client contacts, after contact with blood, body fluids, secretions, and excretions and after contact with equipment or articles contaminated by them; and immediately after gloves are removed. Gloves are worn when touching blood, body fluids, secretions, excretions, nonintact skin, mucous membranes, or contaminated items. Gloves should be removed and hand hygiene performed between client care. Masks, eye protection, or face shields are worn if client care activities may generate splashes or sprays of blood or body fluid. Gowns are worn if soiling of clothing is likely from blood or body fluid. Perform hand hygiene after removing gown. Client care equip. is properly cleaned and reprocessed, and single-use items are discarded. Contaminated linen is placed in leakproof bag and handled so as to prevent skin and mucous membrane exposure. All sharp instruments and needles are discarded in a puncture-resistant container. Safety devices must be enabled after use to prevent injury. |
|
|
Term
| Why is "screening" important? |
|
Definition
| 1. Allows for early recognition of a possible health problem (most important to remember) 2. Provides opportunity for self-testing who already have an existing health problem 3. Identifies need for further testing to be done |
|
|
Term
| Are screenings "diagnostic" for illness/disease? Diagnostic = identification by the process of elimination. |
|
Definition
| no, screenings are NOT diagnostic. |
|
|
Term
| What are the normal characteristics of urine in relation to color, clarity and odor? |
|
Definition
| Yellow to amber, clear without a strong or foul odor. |
|
|
Term
| What test do we use for urinalysis? |
|
Definition
| Dipstick (multistix) test - it tests for blood, ketone, leukocytes, nitrite, glucose, protein, pH |
|
|
Term
| When is the optimal time to obtain a urine specimen? |
|
Definition
| First urine in the morning produces the best specimen. |
|
|
Term
| Blood on urinalysis might mean: |
|
Definition
| RBC's indicate if kidney disease or damage has occured, as well as trauma or surgery. May also indicate contamination from menses. |
|
|
Term
| Ketone presence on urinalysis might mean: |
|
Definition
| presence of ketones suggests dehydration, starvation or poorly controlled diabetes |
|
|
Term
| Leukocytes on urinalysis might mean: |
|
Definition
|
|
Term
| Nitrite on urinalysis might mean: |
|
Definition
|
|
Term
| Glucose on urinalysis might mean: |
|
Definition
| Glucose presence indicates diabetes |
|
|
Term
| Protein on urinalysis might mean: |
|
Definition
| Protein presence indicates renal disease or damage. |
|
|
Term
|
Definition
| Normal pH is 4.6-8.0. An increase or decrease indicates alteration in acid-base balance. |
|
|
Term
| What are the normal characteristics of feces? |
|
Definition
| Brown, soft but formed, diameter of rectum, with pungent odor. |
|
|
Term
| Occult Fecal Blood Testing tests for blood in feces indicating _________________. |
|
Definition
|
|
Term
| When testing for blood in feces, what will often be recommended for the diet? |
|
Definition
| best if refrain from red meat for 48 hours before test is taken. Increased residue is desired. Should also be free of alcohol, nSAID's, iron and vitamin C. Diet should also be high in fiber. |
|
|
Term
| What are the directions for fecal occult blood testing? What does a blue discoloration indicate? |
|
Definition
| Place a thin smear of stool on each circle (from different parts of the feces specimen), close flap and let dry 24 hours, open opposite side of card & drop reagent into each circle and on test area. Blue discoloration in circle indicates a presence of blood. Clients usually collect 3 specimens on 3 different days. The more positive it is, the bluer it gets. |
|
|
Term
| False positives can be obtained on the fecal occult blood test if the client has: |
|
Definition
| bleeding disorder or GI irritation/disorder or is on anticoagulants. |
|
|
Term
| What is the primary purpose of blood glucose testing? |
|
Definition
| Assist client in maintaining blood sugar within normal limits. Permit ease of self-monitoring. Aid in monitoring effectiveness of treatment for hypo/hyperglycemia. |
|
|
Term
| When is the best time to perform capillary blood glucose monitoring? |
|
Definition
| Before meals or two hours after meals |
|
|
Term
| Why is it important to prick the side of the finger, not the finger pad? |
|
Definition
| Less nerve endings, capillaries are closer to the skin, pads too thick making it difficult to obtain a "good" droplet of blood. |
|
|
Term
| Describe how to perform a blood glucose test using a blood glucose monitor (present general principles in light of the fact that there are many monitors available for use and procedures may vary somewhat). Include what part of he body is the best for obtaining an accurate specimen. |
|
Definition
Side of the fingertip is the most accurate.
1.)Turn on meter
2.)Select Patient Test
3.)Enter operator ID
4.)Enter patient ID
5.)select test strip lot number
6.) Apply blood to test strip
7.) Insert test strip into meter-blood side up
8.)Read results when test is complete
9.)Remove test strip
10.)Document on appropriate tool |
|
|
Term
| What are the normal parameters for blood glucose? |
|
Definition
| Fasting: 70-110 or 80-120, depending on lab parameters. Anything greater than the high range is considered Hyperglycemia. If it is less than the lower limit then it is considered Hypoglycemia. Levels 2 hours after a meal<140mg/dl. between 140-200mg/dl ther eis some impaired glucose tolerance. Levels >200 mg/dl indicates possible diagnosis of diabetes. |
|
|
Term
| What factors can affect the accuracy of blood glucose monitoring? |
|
Definition
| Location on body where blood is obtained, poorly calibrated machine, out of date strips or improperly stored strips. |
|
|
Term
| What procedure should be followed when disposing lancets? |
|
Definition
| Dispose in sharps container |
|
|
Term
| How often is self monitoring of blood glucose done? |
|
Definition
| Done atleast QID (4 times a day) & more often if indicated. |
|
|
Term
|
Definition
| First thing in the morning, before bedtime and before meals. |
|
|
Term
| How is it best to get the blood once you've pricked the side of their finger? |
|
Definition
| It is best to get the blood to hang freely & catch on the strip, instead of blotting the strip onto the finger. |
|
|
Term
| If you use alcohol before pricking the patient you need to: |
|
Definition
| make sure it is totally dry. |
|
|
Term
|
Definition
| Lab run serum blood test that indicates BS control over past 3 months. Looks long-term at glucose over 3 months and can't really be deceived by this. Every diabetic should have this done every 3 months. Diabetics should be <7% for adequate control. A lot of diabetics run 8, 9 and higher. But we want it close to 6. |
|
|
Term
| What is SMBG (glucose monitoring) ? |
|
Definition
| Self monitoring of blood glucose, what the hospitals use. They are less accurate if result is very hi or low. The hospital does not go lower then 40. They want you to draw a venous blood draw and send it to the lab. Go ahead and treat them. |
|
|
Term
| Do you want to date test strips when you open them or does it not matter? |
|
Definition
| Yes, ALWAYS date test strips when opened. |
|
|
Term
| Test strips are good for ___________. |
|
Definition
|
|
Term
| QC strips are good for ___________. |
|
Definition
|
|
Term
| What is a high blood glucose reading? |
|
Definition
| Result is above 500 mg/dl |
|
|
Term
| What is a low blood glucose reading? |
|
Definition
|
|
Term
| Another name for the Fecal Occult Blood Testing is.... |
|
Definition
| Guaiac test, which measures microscopic amounts of blood in feces. |
|
|
Term
|
Definition
| A disruption of normal anatomical structure & function - involves organs and can be internal or external |
|
|
Term
| What are the 3 types of Wound Healing? |
|
Definition
| Primary intention, Secondary intention, Tertiary intention |
|
|
Term
| What type of wound healing is this? The wound is clean, straight line with little loss of tissue, Wound closures were used (suture, staples, steri-strips), heals through collagen synthesis, normally heals rapidly with minimal scarring. |
|
Definition
| Primary Intention Healing. A good example of this is a surgical incision. |
|
|
Term
| What type of wound healing is this? Takes place in large wounds that have considerable tissue loss. Healing occurs by formation of granulation tissue (will be red b/c it is blood vessels coming in). These types of wounds have a greater chance of infection b/c they are open and bacteria can enter. The healing time is longer & the scars are larger. |
|
Definition
|
|
Term
| What type of wound healing is this? They are prone to become infected or are already infected. Infected wounds left open until free of debris. May be called "delayed primary closure." |
|
Definition
| Tertiary Intention. They are usually a surgical incision that goes bad, abdominal wounds. |
|
|
Term
| What will the wound healing time depend on? |
|
Definition
| Depends on the extent of the wound (primary heals quicker than secondary, tertiary), The bodies general state of health (age is a factor. obviously the young heal faster then the old), Nutrition (prolonged healing if in poor nutrition. Need protein!), Systematic Response (fever, elevated WBC count, area is warm, red, swollen, malaise, N & V). |
|
|
Term
| _______ tissue is red moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. |
|
Definition
|
|
Term
| Explain the phases of wound repair |
|
Definition
| 1st stage is INFLAMMATORY which begins within a minute to 3 or so days. 2nd stage is PROLIFERATION which lasts 3-4 days to 24 days. Here granulation tissue is developed as wound heals. 3rd stage is MATURATION which is 30 days to 1-2 years. THe scar develop scar tissue which is not elastic, holds skin together, has no blood supply, no collagen and no hair. |
|
|
Term
| What is the purpose of scar tissue? |
|
Definition
| Scar tissue is a filler & holds the skin together. Scar tissue does not have hair, skin, blood supply & you don't feel. Does have a good purpose though which is to hold it together. If scar tissue on heart though, you can lose ability - part of the heart won't beat. |
|
|
Term
| Name the complications of wound healing: |
|
Definition
| Hemorrhage, Infection, Dehiscence, Evisceration, Fistulas, Keloids |
|
|
Term
| _________ is a dislodged clot, a slipped suture or a vessel nicked. |
|
Definition
|
|
Term
| Of your patient has a bright red blood in their dressing, you see S & S of shock (low BP & higher pulse), complains of wet sensation on dressing and has feelings of restlessness or weakness (could be internal bleeding-BP drops, skin is pallor + cold & clammy).... what is this likely? |
|
Definition
| Hemorrhage (a complication of wound healing). |
|
|
Term
| When would you expect to see signs of hemorrhage? What should you do? |
|
Definition
| Signs of hemorrhage show up immediately after injury. If surgery, takes 24-48 hours. Vitals are monitored very closely post-op b/c looking for bleeding, possibility of hemorrhage. If you have to change their dressing b/c of so much blood then write it in the chart, circle it & note how much it drained. If there is a lot of blood? Need to reinforce it. Check their vitals & ask them how they're feeling. So when you call the doc you can say their vitals moved to this. Typically doctors will change the pt.'s dressing the first time. |
|
|
Term
| When is infection most likely to occur? What effects will the patient have when infection is occuring? |
|
Definition
| 2-7 days post-op. Fever, leukocytosis (increased WBC's), erythema (red around the wound), purulent drainage. Patient may have persistent pain in their incision. Patient has a general feeling of malaise. |
|
|
Term
| When the wound is partially or totally separated (not well approximated)... What is this? What do you write down? |
|
Definition
| Dehiscence - it is not uncommon & can often be fixed w/ steri-strips, but sometimes not. You will report whether it is proximal or distal (farthest from head) and count how many suture spaces long it is. |
|
|
Term
| What patients are high at risk for dehiscence? When does dehiscence occur? What feeling might your patient report? |
|
Definition
| Obese patients... there is not as much blood in obese patients skin layers. Dehiscence can occur after a sudden strain: patient could be coughing maybe. Patient might get a sensation of "something giving away." |
|
|
Term
|
Definition
| When abdominal organs protrude out the wound opening! Very serious. |
|
|
Term
| What should a nurse do when evisceration occurs? |
|
Definition
| Nursing intervention will include covering wound immediately with a sterile towel soaked in sterile NS (which will reduce chances of bacterial invasion & drying). Obviously, notify the physician. and prepare for emergency surgery. |
|
|
Term
|
Definition
| Abnormal passage between 2 organs or between an organ and the outside of the body. Happens b/c of poor healing, excessive or unusual drainage. |
|
|
Term
| Fistulas ______ the risk of infection. They also ______ the risk of fluid & electrolyte imbalance. |
|
Definition
|
|
Term
| Some examples of fistulas are: |
|
Definition
| Intestinal out of skin. or stool out the vagina. |
|
|
Term
| What are excessive scarring with altered collagen synthesis? It is painful and tends to itch. It is unexplainable, unpredictable and unavoidable in some people. They are more common in people with darker skin. |
|
Definition
|
|
Term
| What type of wound drainage is clear fluid? |
|
Definition
|
|
Term
| what type of wound drainage is clear with some blood? |
|
Definition
|
|
Term
| What type of wound drainage is red + bloody? |
|
Definition
|
|
Term
| What type of wound drainage is pussy, yellow, brown & is a sign of infection? |
|
Definition
|
|
Term
| What factors impair wound healing? |
|
Definition
| Age, Malnutrition, Obesity, Impaired oxygenation, Smoking, Drugs, Diabetes, Radiation, Wound Stress |
|
|
Term
| Why do we apply dressings? When do we remove the dressing? |
|
Definition
| We apply different dressings for different types of wounds. We apply dressings to promote wound healing & promote healing by absorbing drainage & debriding the wound. It is common to remove the dressing from a surgical wound when the wounds stop draining. |
|
|
Term
| What is the purpose of a Wet-to-Dry dressing? Give an example of when this dressing would be used. |
|
Definition
| The purpose of Wet-to-Dry is to "pull-out" all the stuff in the wound. The wound cannot heal if there is stuff in there. We use these to "debride the wound." Example: motorcycle skid will require the wet-to-dry dress to have the wound "debrided" to draw out the gravel. Will change a few times a day, will be painful (give meds 30 minutes before) and always indicate time you changed it on their chart! |
|
|
Term
| What are the purposes of the Wound V.A.C.? |
|
Definition
| Utilizes negative pressure, draws edges of the wound together, removes fluid from wound and treats acute or chronic wounds (Important to know that Wound V.A.C.'s work for both acute AND chronic wounds!) Also works for infected & not infected wounds. |
|
|
Term
| How do we cleanse wounds and drainage sites? |
|
Definition
| The cleaning agent SHOULD BE NONCYTOTOXIC (normal saline or commercial wound cleaners), always clean LEAST contaminated to MOST contaminated area, use gentle friction and NEVER use the SAME piece of gauze to cleanse around the incision or around a drain twice. |
|
|
Term
| What are the Drains & Tubes? |
|
Definition
| Purpose of inserting a drain into or near a surgical wound is if a large amount of drainage is expected. |
|
|
Term
| What are the drains and tubes we looked at? |
|
Definition
| 1. Penrose Drain (tube w/ safety pin to keep tube from slipping into the wound) 2. Hemovac & Jackson Pratt exert a constant low pressure as long as the suction device is fully compressed. 3. Wound Vac - also utilizes negative pressure to assist going from open to closed wound. |
|
|
Term
| Assessment of Wounds includes: |
|
Definition
| 1. size, shape & location 2. Type (open/closed) 3. Skin closures: sutures, staples or steri-strips 4. Approximation of Edges (well-approximated or not) 5. Granulation/Epithelialization (whether it is present or not) 6. Signs of Infection (Infected or free of infection) 7. Wound Drainage (amount, color, odor) 8. Patency of Wound Drainage (does the drain work? is it open? May be full & need to be emptied!) 9. Surrounding skin conditions. 10. Patients response to palpation 11. Pain |
|
|
Term
| We need to give support to patients b/c wounds can have what psychological effects? |
|
Definition
| Pain, Anxiety, Fear, Alteration of Self-Concept (esp. wounds on face or a Hysterectomy on bikini line). Be aware the patients have extreme feelings about wounds. Do NOT become insensitive about wounds. |
|
|
Term
| There are 4 stages of pressure ulcers. Explain Stage I.... |
|
Definition
| Stage I: Intact skin w/ NONBLANCHABLE redness of a localized area, usually over a bony prominence (sacrum, heels, elbows). Darkly pigmented skin may not have visible blanching; its color may differ form surrounding area though. |
|
|
Term
| Explain Stage II of pressure ulcers |
|
Definition
| PARTIAL-thickness SKIN LOSS INVOLVING EPIDERMIS, DERMIS, or BOTH. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. |
|
|
Term
| Explain Stage III of Pressure Ulcers |
|
Definition
| Stage III: FULL-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining & tunneling. |
|
|
Term
| Explain Stage IV Pressure Ulcers: |
|
Definition
| Stage IV: FULL-thickness tissue loss with EXPOSED BONE, TENDON or MUSCLE. Slough or eschar may be present on some parts of the wound. OFTEN includes undermining or tunneling. |
|
|
Term
| Explain a Suspected Deep Tissue Injury (DTI): |
|
Definition
| Purple or Maroon localized area of discolored INTACT skin or blood-filled blister. It is d/t damage of underlying soft tissue from pressure and/or shear. LOOKS LIKE A REALLY BAD BRUISE. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. |
|
|
Term
| What is an "Unstageable" Pressure Ulcer like? |
|
Definition
| Unstageable: FULL thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar is removed to expose the base of the wound the true depth and stage cannot be determined. |
|
|
Term
|
Definition
| viscous yellow layer of dead tissue often covering wounds |
|
|
Term
|
Definition
| Thick, black, dry, leathery necrotic tissue seen over wound covering underlying skin. It must be removed before healing can begin. |
|
|
Term
| What is abnormal reactive hyperemia? |
|
Definition
| Nonblanching erythema (redness) when you apply pressure. This indicates deep tissue damage is probable. Signifies a potential pressure ulcer. |
|
|
Term
| What causes pressure ulcers? |
|
Definition
| 1. PRESSURE (intensity, duration, tissue intolerance) 2. SHEARING (when tissue layers slide against each other resulting in angulation or blood vessels. Prevented by using a pull sheet) 3. FRICTION (when the skin rubs against another surface & affects the epidermis and dermis layers - similar to a mild burn) 4. MACERATION (softening of the tissues when soaking in a fluid like urine or stool. 5. MACERATION FROM INCONTINENCE 6. YEAST 7. NUTRITIONAL DEBILITATION (good nutrition is necessary for wound healing) |
|
|
Term
| What happens when a patient develops a yeast infection? |
|
Definition
| If a yeast infection is present it may be exacerbated by a moisture barrier. Want to obtain order from physician for antifungal cream or powder). |
|
|
Term
| Who is at risk for pressure ulcers? |
|
Definition
| Elderly, immobilized, malnourished, obese, unresponsive, ventilated, surgical procedure lasting 3 hours or more, incontinence, restrained, neurological deficits, immunosuppressed. |
|
|
Term
| How do you as a nurse prevent pressure ulcers? |
|
Definition
| Turn patient every 2 hours, use positioning devices (foam, pillows), maintain head of bed at low degree of elevation, elevate heels off the bed, cleanse skin when soiled, avoid massaging over red areas, moisturize dry skin, consider pressure reducing surface, avoid positioning directly on the trochanter, use draw sheet to move patient, chair-bound individuals should use a pressure reducing device in the chair, should be repositioned at least every hour (every 15 minutes if you can), do NOT USE A DONUT! |
|
|
Term
| What degree of turn is best/most effective for turning a patient? |
|
Definition
| 30 degree lateral position should prevent positioning directly over the bony prominence. |
|
|
Term
| Why is it important to maintain the head of the bed as low as possible? |
|
Definition
| To prevent shearing forces. (When tissue layers slide against eachother resulting in angulation or bloodvessels - want to use a pull sheet) |
|
|
Term
| How do malnutrition & age play roles in developing pressure ulcers? |
|
Definition
| NUTRITION is fundamental to normal cellular integrity and tissue repair; INCREASED AGE affects all phases of wound healing. A decrease in the functioning of the macrophage leads to a delayed inflammatory response, delayed collagen synthesis, and slower epithelialization. |
|
|
Term
| How does the nurse assess for pressure ulcers? |
|
Definition
| Nurse needs to check under tubing, restraints, splints, harir, skin folds, pressure points. Uses Risk Management Tools: Norton Scale, Gosnell Scale and Braden Scale. (Do not need to know the difference, but just know they assist the risk management of pressure ulcers). |
|
|
Term
| What should the nurse do when she encounters a patient with eschar? |
|
Definition
| Debride the wound. Debridemtne is the removal of nonviable, necrotic tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed and to provide a clean base necessary for healing. |
|
|
Term
| Should you massage reddened areas? |
|
Definition
| NO, do not massage reddened areas! |
|
|
Term
| List several different dressing used in treating pressure ulcers... |
|
Definition
| GAUZE (protects, absorbs, packs, delivers agents to wounds, debrides) GAUZE IMPREGNATED (protection for skin grafts and donor sites, non-harmful to healing wounds, does not stick to wound) TRANSPARENT FILM DRESSINGS (moist wound healing, protects against friction, semi permeable, wound is visible) HYDROCOLLOIDS (moist wound healing, protects against friction, translucent to opaque, impermeable, odor on removal, autolytic debridement, not recommended for infected wounds or poor skin integrity) HYDRO-GELS (sheets & gels: moist wound healing, non-adhesive, fills dead space, cooling effect, not recommended for woulds with excess drainage) FOAMS: (moist wound healing, absorptive, autolytic debridement with topical meds, nonadhesive and adhesive) CALCIUM ALGINATES & HYDROFIBERS: (moisture retentive, fills dead space, absorptive, nonadherent) SILVER (foams, alginates, hydrofibers-moist wound healing, mgmt of infected wounds, wounds at risk for infection , absorptive) WOUND VAC: (NEGATIVE PRESSURE WOUND THERAPY-suctions drainage from the wounds, creates a vacuum which inc blood supply, granulation tissue begins to fill the wound) GROWTH FACTORS (becaplermin is a platelet derived growth factor, delivered directly to the ulcer, used for treating ulcers usually on the lower extremities of patients with DM, generic becaplermin is not available) |
|
|
Term
| Why is it important to document pressure ulcers? |
|
Definition
| DOCUMENT ON ADMISSION - b/c insurance co.'s will no longer pay for care of ulcers that develop while pt. is in the hospital. Document any ulcers already present for legal and insurance records. DOCUMENT When they occur later on during hospitalization - we document for interventions and optimum outcomes. We DOCUMENT BEFORE DISCHARGE to assess what the family needs to do. |
|
|
Term
| What is granulation tissue? |
|
Definition
| Granulation tissue is red moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. |
|
|
Term
| What is the purpose of using a wet-to-dry dressing? how does it work? |
|
Definition
| A wet-to-dry dressing is used for mechanical debridement. The first layers that are in contact with the wound are moistened 4 x 4's. This absorbs drainage and adheres to debris. The final layer is a layer of dry gauze; this pulls moisture from the wound. |
|
|
Term
| Is Wet-to-Dry Dressing considered Medical (clean) or Surgical (sterile) technique? |
|
Definition
| Medical/Clean technique b/c the wound is already considered contaminated. |
|
|
Term
| Are all wounds and incisions cleansed with Betadine? |
|
Definition
| No! betadine is cytotoxic. Only use betadine if physician ordered. Wounds should be cleaned with normal saline. |
|
|
Term
| While changing your patient's dressing, you noticed a foul odor and yellow drainage, what's happening? |
|
Definition
| Probably an infection. Call the physician and be prepared to administer antibiotics. Be sure to use proper technique to dispose of the dressing and monitor the patient for a fever or other signs of infection. |
|
|
Term
| Your patient has just returned to his room for surgery. His chart has an order "Reinforce dressing PRN." What does this mean? |
|
Definition
| This very common order means to "add dressings as needed; do not remove the original dressing." The surgeon does not want accidental interruption in the suture line or bleeding. The physician will want to be the first to change the dressing. |
|
|
Term
| Do sterile gloves need to be worn with all dressing changes? |
|
Definition
| Not necessarily. Research indicates that there is no difference in healing rates for surgical wounds when clean technique rather than sterile technique is utilized. However, if the wound is to be touched directly or if the patient is immunocompromised, sterile gloves must be worn. The nurse is responsible for evaluating the need for clean versus sterile technique. Follow hospital protocol and physician orders. AND REMEMBER THE WET-TO-DRY DRESSING IS NOT STERILE TECHNIQUE, BUT CLEAN AS THE WOUND IS ALREADY CONTAMINATED! |
|
|
Term
| When changing your patient's dressing, you notice that the Jackson Pratt has abruptly stopped draining. What do you think is the reason? What should you do? |
|
Definition
| Possibly a blocked tube. First, be certain there is adequate suction (compress the bulb). Notify the physician if there continues to be a lack of drainage. If fluid is allowed to accumulate in the tissues, wound healing will not occur at an optimal rate and risk of infection increases. |
|
|
Term
| How do you remove a Jackson Pratt drain? |
|
Definition
| First an order mst be written and this procedure (removing a Jackson-Pratt) must be protocol for your agency. Then the Jackson-Pratt bulb should be emptied and decompressed so that there is no suction against the tissues as the drain tubing is removed. A dressing and tape should be ready. A disposable pad or towel should be used, when the tube is out, apply the dressing and tape and dispose of the Jackson-Pratt properly (usually double bagged) or according to the policy of the agency. |
|
|
Term
| What type of wounds is the transparent dressing indicated as a nursing intervention? |
|
Definition
| Small, superficial wound such as partial thickness wounds or to protect the skin. |
|
|
Term
| If the nurse observes a yellowish fluid under a transparent dressing is this a sign of infection? |
|
Definition
| No, not in itself. This may be body fluids that are assisting the wound to heal. Assess for other signs of infection. |
|
|
Term
| What functions does the "Occlusive" dressing have? |
|
Definition
| Absorption of drainage, Maintains wound moisture, slowly liquefies necrotic debris, impermeable to bacteria and other contaminants, self-adhesive and molds well, preventive dressing for high-risk friction areas, may be left in place for 3-5 days, minimizing skin trauma and disruption of healing. |
|
|
Term
| What is the purpose of the Wound V.A.C.? |
|
Definition
| The Wound V.A.C. is a device that assists in wound closure by applying localized negative pressure to remove fluid and draw the edges of a wound together. It accelerates wound healing by promoting granulation tissue and increasing circulation. |
|
|
Term
| How does the nurse promote normal urination? |
|
Definition
| Adequate fluid intake by IV or by mouth, Residual Urine is eliminated by preventing infections. Women tend to be more prone to infections in urinary tract b/c their urethra is shorter than a mans urethra. |
|
|
Term
| What interventions can a nurse utilize to stimulate urination? |
|
Definition
| Assist the patient to relax, Assume the normal position for voiding (women sitting position-not the prone position and men please assist them to STAND!), Use normal toilet facilities, Sound of running water, Stroking inner thigh, esp. for women, pour warm water over a female perineum (be sure to measure with a graduated cup so you can subtract from amount of urine voided). |
|
|
Term
| How does a nurse assess for a distended bladder? |
|
Definition
| Inspection, palpation, percussion, Bladder Volume Indicator (BVI) a sonogram to see bladder and how much urine is in bladder approximately; noninvasive way to see if a patient is retaining urine to see if patient needs to be catheterized; only catheterize if necessary) ex/spinal injury pt |
|
|
Term
| What are the purposes of catheterization? |
|
Definition
| relieve urinary retention, obtain sterile urine specimen, measure residual urine, maintain empty bladder during surgery, monitor hourly urine output for critically ill patients, monitor temperature, provide access for instilling mediation into the bladder, management of urinary incontinence. |
|
|
Term
| When should a nurse catheterize a client? |
|
Definition
| Catheters are not to be used unless absolutely necessary & take them out as quickly as possible, catheters are a sterile procedure, have a high risk for trauma and infection and require nursing interventions after procedure too. |
|
|
Term
| What type of catheter would you use for intermittent need? |
|
Definition
|
|
Term
| What type of catheter would you use for up to 3 weeks need? |
|
Definition
| Latex & Rubber (make sure there is no latex allergy) |
|
|
Term
| What type of catheter would you use for long term use? |
|
Definition
| Silicon & Teflon impregnated with silver - to cut down on infection |
|
|
Term
| What range of balloon size in catheters is most common? |
|
Definition
|
|
Term
| What are the types of urinary catheter? |
|
Definition
| 1. STRAIGHT OR INTERMITTENT (are the in/out catheters, usually plastic) 2. FOLEY or INDWELLING or RETENTION (stay in, have balloon) 3. TRIPLE LUMEN OR IRRIGATING 4. COUDE (curve on end, used on men with prostate problems). Different types of catheters are used for different circumstances. |
|
|
Term
| Why is a balloon present on an indwelling catheter? |
|
Definition
| To keep the catheter in the bladder. |
|
|
Term
|
Definition
| Build up of secretions or encrustation at the catheter insertion site is a source of irritation and potential infection. Nurses provide perieal hygiene at least 3 x's a day or as needed for a client with a retention catheter. Soap & water are effective in reducing the number of organisms around the urethra. Accidentally advancing the catheter up into the bladder during cleansing increases the risk of introducing bacteria into the bladder. |
|
|
Term
| When setting up the sterile field for catherization, why does the nurse leave the catheter in the sterile box even while checking the balloon? Why should the nurse lubricate the catheter just before the catheter is inserted? |
|
Definition
| These practices decrease the chance of contamination. Minimize the amount of manipulation of the catheter as much as possible and avoid inadvertent "flopping" the tip of the catheter over the edge of the box when testing the balloon. |
|
|
Term
| why does the nurse discard the cotton balls (remember they will be heavier with Betadine) and other contaminated items carefully into the trash bag? What can be conveniently placed on the bed and used as a trashbag? |
|
Definition
| To avoid contaminating the sterile field - do NOT carry used cotton balls over the sterile field to place in waste container. The foley catheterization bag can be used as a convenient trashbag when the edges are folded back and placed to the far side of the sterile field for easy access. |
|
|
Term
| What is the greatest risk for a client with an indwelling or Foley catheter? What can be done to reduce the risk of this complication? |
|
Definition
| Nosocomial Infection - Good Perineal Care - proper cleansing with soap & water, washing inside of labia minora, drying thoroughly and AVOID THE USE OF POWDER. |
|
|
Term
| What info does the nurse document after completing a catheterization? |
|
Definition
| How procedure was tolerated, size of catheter and material catheter is made of, urine characteristics - color, consistency, odor and amount. |
|
|
Term
| What should the nurse do if she/he does not see urine catheterizing a female client? |
|
Definition
| Check to see if the catheter is in the vagina instead of the urethra. DISCUSS -what is done next? Leave catheter in, obtain new catheter, cleanse area again and attempt catheterization again. |
|
|
Term
| what should the nurse do if the primary care provider orders closed catheter irrigation, but the catheter does not have an injection port. |
|
Definition
| Replace drainage tubing with the type that does have an injection port. |
|
|
Term
| Why is the catheter itself taped to the client's leg instead of the collection tubing? |
|
Definition
| There will be less tension on the bladder and the tape will remain on better. |
|
|
Term
| What should the nurse do if they cannot pass the catheter in a male client? |
|
Definition
| Try different angles of the penis, partially remove and attempt passing again, try different size (but larger catheters are stiffer) Do not try a size smaller than a 14 French, squirt sterile lube into urethra prior to procedure, obtain order for coude' catheter - if still unable to pass, get order for catheterization with guide wire and have appropriate personnel reattempt catheterization. |
|
|
Term
| What should the nurse be sure to do after catheterizing an uncircumcised male? |
|
Definition
|
|
Term
| What is the proper way of removing an indwelling catheter? |
|
Definition
| 1. perform hand hygiene 2. close the curtain or close door 3. raise the bed to the appropriate working height. If the side rails are raised, lower the side rail on the working side. 4. Organize the equipment for removal of the catheter. 5. Position the client and cover with a bath blanket, exposing only the perineal area: Females are in the dorsal recumbent position. Males are in the supine position. 6. Place waterproof pad: Females-between thighs (if in supine position) and Males-over male's thighs. 7. Obtain a sterile urine speciment if required. 8. Remove the adhesive tape or Velcro tube holder used to secure and anchor the catheter. 9. Insert the hub of the syringe into the inflation valve (balloon port). Aspirate the entire amount of fluid used to inflate the balloon. Never use force to make the syringe fit into the valve. 11. Pull the catheter out smoothly & slowly. Stop pulling if resistance is met. If so, the balloon is probably still inflated. Aspirate again to ensure that all fluid has been removed. If resistance is still felt, notify the physician. 12. Wrap the contaminated catheter in a waterproof pad. Unhook the collection bag and drainage tubing form the bed. 13. When catheter care and/or removal is completed: reposition the client as necessary. cleanse the perineum and remove any adhesive residue from the skin. Lower the level of the bed and position the side rails back up. Measure and empty the contents of the collection bag. Dispose of all contaminated supplies correctly, remove gloves and perform hand hygiene. |
|
|
Term
| What do you record in the nurses notes following a catheter removal? |
|
Definition
| Record that you removed it, the time of the removal, condition of the urethral meatus, and the character of the urine. |
|
|
Term
| Don't forget to DEFLATE THE BALLOON! Note the amount of fluid on the balloon port, pull syringe back as hard as you can; take syringe off before pulling balloon out. What should you note following removal? |
|
Definition
| Note the first voiding post removal, document amount and time for first 24 hours. If no voiding within 6-8 hours, assess for bladder distention. may need to reinsert the catheter. |
|
|
Term
| Why is bladder irrigation utilized? |
|
Definition
| Instillation of sterile solution into bladder via catheter. It will maintain the patency of the catheter, dilute solid particles to facilitate passage through the tube, prevents bladder distention and discomfort from obstruction. |
|
|
Term
| What is a continuous bladder irrigation (CBI)? |
|
Definition
| Often used after prostate surgery if blood in urine - used to prevent blood from clotting. |
|
|
Term
| What do you always place on chart after documenting? |
|
Definition
| Date, Time & signature (1st initial. Last Name and credentials "SN" ex/ J.Hegeman, SN |
|
|
Term
| If you make a mistake document, is it okay to scribble it out? |
|
Definition
| No! Only draw a single line through & then initial it. |
|
|
Term
| What is the purpose of keeping patient records? |
|
Definition
| Communication, Legal Documentation, Financial Billing, Education, Research, Auditing-Monitoring (can look back & see how effective you've been). |
|
|
Term
| Guidelines for documenting and reporting. They have to be: |
|
Definition
| Factual, Accurate (concise, clear & spell correctly, re-read documents), Complete, Current (as soon as you can document, do it, use military time), Organized (be concise & logical... head to toe). |
|
|
Term
| What words do we not use in reporting? |
|
Definition
| Appears, Seems or Apparently. These are all suggestive words & are not factual. |
|
|
Term
| What is the legal perspective on documentation? |
|
Definition
| If it is not documented, then it wasn't done. If it is poorly documented, then it was poorly done. If it is incorrectly documented, then it is fraudulent. You have to see it. |
|
|
Term
| ________________ is anything written on printed that is relied on as a record or proof for an authorized person. |
|
Definition
| Documentation. It lets other people you work with look back at charts as proof of everything you did. Documentation needs to be accurate, comprehensive and flexible enough to retrieve the critical data (can't just say low BP - say what it was, be specific!) needs to have an accurate assessment that is detailed and current so you can pass the care/charts on. Charting has to reflect practice! |
|
|
Term
| What is the name of the group who requires us to meet their charting standards? They do tracers on a patients chart to make sure it is adequate and tells all the pieces of the puzzle. |
|
Definition
| JCAHO. Also have the DRG (diagnosis related group) |
|
|
Term
|
Definition
| Health Insurance Portability & Accountability Act. It is Privacy Protection for clients care. We will always make clients aware of privacy practices, Ensure clients' access to their medical information (they own their information!), we must receive client consent before info is released, Provide recourse if privacy protections are violated. You cannot document your neighbors info. It is VERY important to maintain that confidentiality of your patient. |
|
|
Term
| _________ documentation is the tradition method for recording nursing care. It is simply the use of a storylike format to document info specific to the client conditions and nursing care. __________ charting, however, has many disadvantages, including the tendency to have repetitious info, to be time consuming and to require the reader to sort through much info to locate desired data. |
|
Definition
|
|
Term
| The ____________________________ is a method of documentation that places emphasis on the client's problems. Data are organized by problem or diagnosis. |
|
Definition
| Problem Oriented Medical Record (POMR) |
|
|
Term
| In a _________ record the client's chart is organized so that each discipline (nurse, medicine, social work, respiratory therapy) has a separate section in which to record data. |
|
Definition
| Source. One advantage of Source Records is that caregivers can easily lovate the proper section of the record in which to make entries. A disadvantage of the source record is that details about a specific problem may be distributed throughout the record. |
|
|
Term
| ______________________ is an approach that is used to eliminate redundancy, ensure concise documentation, emphasize abnormal findings, and id trends in clinical care. It significantly reduces charting time. In other words, the nurse writes a progress note only when the standardized statement on the form is not met. Assumption is all standards aremet unless otherwise documented. |
|
Definition
| Charting By Exception (CBE) |
|
|
Term
| Case Management Plan & Critical Pathways Documentation: |
|
Definition
| Incorporates a multidisciplinary approach to documenting client care. In many organizations the standardized plan of care is summarized into critical pathways for a specidic disease or condition. The critical pathways are are multidisciplinary care plans that include client problems, key interventions, and expected outcomes w/in a time frame. Ex/post open heart there is a 5 day critical pathway. You should come off machine & walk 5,000 ft. It talks about mobility, diet, completing therapy.... a lot of pieces w/in 5 days-that is the critical pathway. A 'variance' would be documented whenever the activities on critical pathway are not completed & cannot meet expected outcomes... that happens a lot too. |
|
|
Term
| Progress Notes helps HC team members monitor & record the progress of client's problems. One way is the SOAP charting. Explain it... |
|
Definition
| SOAP (S=subjective data=verbalizations of the client, O=Objective data=that which is measured & observed, A=assessment=diagnosis based on the data, P=Plan=what the caregiver plans to do. So collect data about the clients problems, draw conclusions, and develop a plan of care. The nurse numbers each soap note & titles it according to the problem on the list. |
|
|
Term
| Explain the PIE charting method |
|
Definition
| Another progress note method is PIE & it is similar to SOAP in its problem oriented method. Difference is PIE charts use nursing origin, while SOAP originates from medical records. PIE does not include assessment info in its narrative info either. The narrative note includes P-problem, I-intervention, and E-evaluation. The PIE notes are numbered or labeled according to the clients problems. Resolved problems are dropped from daily documentation after the nurse's review. Continuing problems are documented daily. |
|
|
Term
| A third narrative format is _____ charting. It involves the use of DAR notes. |
|
Definition
| Focus, DAR: D=data, both subjective & objective, A=action r nursing intervention, and R+response of the client (i.e. evaluation of effectiveness). Distinction of Focus/DAR charting is its movement away from charting only problems, which are negative connotation. Instead charts are structured according to client concerns: a sign or symptom, a condition, a nursing diagnosis, a behavior, a significant event, or a change in a client's condition. Documentation is written in accordance with the nursing process. Nurses want to include any client concerns, not just problem areas, and critical thinking is encouraged. |
|
|
Term
| SBAR is what is required by JCAHO... what's it stand for? |
|
Definition
| Situation, Background, Assessment & Recommendations. It's a framework for communication between HC provider & patient that is easy to remember & focused in even critical situations. |
|
|
Term
| The Commandments on Documentation: |
|
Definition
| **Cross out all errors with a single line **record only the facts-5 senses **Do not chart opinions **Begin with date & time **end with signature, including title |
|
|
Term
| Is it okay to rarely chart for a friend? |
|
Definition
| Never, you only chart for yourself. |
|
|
Term
| What are the record keeping forms we discussed? |
|
Definition
| FLOW SHEET: (allow nurses to quickly and easily enter assessment data about the client, including vital signs, routine repetitive care-like hygiene, ambulation, meals, weights, safety measure and restraint checks) KARDEX: (quick reference for nurses giving change of shift reports or walking rounds, they're a "flip-over" file or notebook) ACUITY RECORDS: determine hours of care & staff needed for patient care. A patient with more need has higher acuity. STANDARDIZED CARE PLANS: (plans based on the institutions standards are preprinted, established guidelines that are used to care for clients who have similar health problems.) DISCHARGE SUMMARY FORMS: when they're supposed to follow-up, who they're supposed to follow-up with, medication instructions, potential food interactions, etc.. |
|
|
Term
| Discuss other documentation like with Home Care, Long-Term Care & Computerized Documentation... |
|
Definition
| Home Care: it is very complex & difficult to document in home health care, you're only there for a short time & you have to document a lot. Family is also witnessing so you can't chart documentation that is inaccurate obviously) LONG-TERM CARE: that when your clients become residents. It is regulated by Medicare, but you only need vitals once a week or month. Your documentation could be much less. COMPUTERIZED: most are windows based, charting by exception. if you write a narrative, spell check it. We're moving towards this in KC. |
|
|
Term
| What info is commonly found on a Kardex? |
|
Definition
| Info commonly found on the client care summary or Kardex includes the following: basic demographic data (age, religion), Physician's name, primary medical diagnosis, current physician's treatment orders to be carried out by the nurse, nursing care plan, nursing orders, scheduled tests & procedures, safety precautions to use in client's care, factors related to activities of daily living, person to contact, allergies |
|
|
Term
|
Definition
| 1. do read what other providers have written before providing care & before charting your care. 2. Do time & date all entries. 3. Do use flow sheets. Keep info flow sheets current. Do chart as you make observations & provide care. 4. Do write your own observations and sign your own name. Sign & initial every time. 5. Do describe patient's behavior. Do use direct patient quotes when appropriate. 6. Do record exactly what happens to patient and interventions given. Do be factual & complete. 7. Do draw a single line through an error. Mark this entry as "error" and sign your name. 8. Do use the next available line to chart. 9. Do document patient's curent status and response to medical & nursing care. 10. do write legibly. do use ink. do use accepted chart forms. Do use only approved abbreviations. |
|
|
Term
|
Definition
| 1. don't begin charting until you check the name and identifying number on the patient's chart and on each page. 2. don't chart procedures or interventions in advance. 3. don't clutter notes w/ repetitive or frequently changing data already charted on the flow sheet. 4. don't make or sign an entry for someone else. don't change an entry because someone tells you to. 5. don't label a patient or show bias. 6. don't try to cover up a mistake or incident by inaccuracy or omission. 7. Don't use "white out" or erase an error. Don't throw away notes with an error on them. 8. Don't squeeze in a missed entry or "leave space" for someone else who forgot to chart. Don't write in the margin. 9. Don't use meaningless words and phrases such as "good day" or "no complaints." 10. Don't use notebook paper or pencil. |
|
|
Term
|
Definition
| anything WRITTEN or PRINTED that is relied on as a record for patient care in an institution such as a hospital, outpatient area, doctor's office, or other agencies such as visiting nurses association. |
|
|
Term
| Accreditation agencies specify guidelines for documentation. What is one of the most important of these accreditation agencies? What is their acronym? |
|
Definition
| THe Joint Commission (TJC) |
|
|
Term
| How are diagnosis-related group (DRG) designations related to charting? |
|
Definition
| Medicare reimburses hospitals a set dollar amount for each one. |
|
|
Term
| Confidentiality is a legal & ethical responsibility of the nurse. Who has legitimate access to a client's records? |
|
Definition
| Staff directly involved with the specific client. |
|
|
Term
| Who is responsible for protecting records from unauthorized readers? |
|
Definition
|
|
Term
| What legislation took effect in 2003 to protect patient privacy? and its acronym. |
|
Definition
| Health Insurance Portability and Accountability Act (HIPAA). We all have to complete HIPAA before entering the clinic. ALso if you ever go to the Dr. you sign the form stating you know about the act. |
|
|
Term
| What are at least 3 key elements of this legislation? |
|
Definition
| 1. Client education on privacy protections. 2. Ensuring clients access to their medical records. 3. Receiving client consent before info is released. |
|
|
Term
| How is info about clients exchanged between various shifts of nurses and between units of nurses during a transfer from one unit to another? How can confidentiality be maintained during this exchange of info? |
|
Definition
| By speaking directly to the nurse who will be taking over care of the patient. |
|
|
Term
| What are the 4 types of Reports? |
|
Definition
| 1. Change of Shift Reports 2. Telephone Reports 3. Transfer Reports 4. Incident Reports |
|
|
Term
| Info on Change of Shift Reports: |
|
Definition
| Nurse gives is to the next shift nursing team. The reason for change of shift reports is to let the nurse coming on know important care information. The info that should be included in a change of shift report is: background info, assessment, nursing diagnosis, teaching plan, treatments, family info, discharge plan, priority needs. |
|
|
Term
| Info in Telephone Reports: |
|
Definition
| The nurse gives the telephone reports to the physician. The reason telephone reports are done is because of a change in a clients status. Info that should be included in a telephone report is vital signs and status change. |
|
|
Term
| Info in Transfer Reports: |
|
Definition
| The nurse gives this report to the receiving nurse. The reason for transfer reports is because the patient is changing units. Info that is included in a transfer reports is: clients name, age, primary physician, medical diagnosis, summaro of progress, current health status, allergies, emergency code status, current nursing diagnosis or problem & care plan, critical assessment or interventions to be completed after transfer, need for any special equipment. |
|
|
Term
| List 4 things that should be included in change of shift report and 4 things that should not be included. |
|
Definition
| 4 things that should be on a change of shift report: Essential background Info, Nursing Diagnosis and HC problems, Objective measures and observations about clients condition, Significant info about family members. 4 things that should NOT be on a change of shift report: Don't review all routine care, Don't review all biographical info, Don't use critical comments, Don't describe basic steps of procedure. |
|
|
Term
| What is a big advantage of a verbal shift report? |
|
Definition
| Allows the receiving nurse to ask questions |
|
|
Term
| What is an advantage to the taped shift report? |
|
Definition
| No interruptions, is quick and concise. |
|
|
Term
|
Definition
| Communication, Legal Documentation, Financial Billing, Education, Research, Auditing-Monitoring |
|
|
Term
| Who communicates with the patient? |
|
Definition
| Nurse, physician & AP. Communication is critical to continuity of care. |
|
|
Term
| What is the most important reason for accurate documentation? |
|
Definition
|
|
Term
| What are the 4 most common issues in malpractice cased by inadequate documentation? |
|
Definition
| a.) Failing to record pertinent health or drug information b.) failing to record nursing actions c.) failing to record that medications have been given d.) failing to record drug reactions or changes in clients condition |
|
|
Term
| What is the only ok exception for charting for someone else? |
|
Definition
| If caregiver has left unit for the day and calls with info that needs to be documented, include the name of the source of info in the entry and include that the info was provided via telephone. |
|
|
Term
| What do you begin & end each recording entry with? |
|
Definition
| Begin each entry with time, and end with your signature and title. This guideline ensures that correct sequence of events is recorded. Signature documents who is accountable for care delivered. DO NOT wait until the end of the shift to record important changes that occurred several hours earlier; be sure to sign each entry. |
|
|
Term
| How are records a necessity for financial billing? |
|
Definition
| Audits take place to make sure that patients received the care ordered and billed to various agencies. Nursing documentation is often essential. |
|
|
Term
| How are records used for research? |
|
Definition
| Help with improving patient satisfaction with care received. have patient fill out form stating their care & improvements that may need to be made. Also could look at the charts and see frequency of care staff in each room. |
|
|
Term
| Are even the nurse records audited/monitored? by who? |
|
Definition
| Yes, by JCAHO requirements... they relate to standards and quality improvement comes from records kept. |
|
|
Term
| What are the 5 characteristics of good documentation? |
|
Definition
| Factual, Accurate, Complete, Current and ORganized |
|
|
Term
| Describe Charting by Exception (CBE): |
|
Definition
| This is what is used by Research Med. Center & most HCA institutions. CBE focuses on documenting deviations from the established norm or abnormal findings. This approach also reduces documentation time & highlights trends or changes in the client's condition. |
|
|
Term
| What is a major problem with CBE? |
|
Definition
| The nurse may not be disciplined in documenting by exception - creating a legal risk. |
|
|
Term
| What are Problem Oriented Medical Records (POMR)? How do Progress Notes in the form of SOAP or SOAPIE notes interface with POMR? |
|
Definition
| POMR is a method of documentation that emphasizes the client's problems. SOAP or SOAPIE document subjective and objective data, so the client's concerns and problems, along with accurate measurements should be documented using this type of data record. |
|
|
Term
| What are some of the advantages of computerized documentation? It is becoming the common practice in many HC facilities. |
|
Definition
| Increases time with client, better access to info, enhanced quality of documentation, reduced errors of omission, reduced hospital cost (saves trees), increased nurse job satisfaction. |
|
|
Term
| What are the legal implications unique to computerized charting? What is the nurses' role in relation to these implications? |
|
Definition
| Protections of patient information, confidentiality of access to computer records (DON'T give out password), LOG OFF computer after use. |
|
|
Term
| List 3 factors critical to maintaining password and subsequently, confidentiality of client info. |
|
Definition
| 1. Frequent and random changing of passwords 2. Password with letters, numbers & symbols 3. Don't tell anyone your password |
|
|
Term
| Military time is almost universally used when charting. One reason is the ability for computers to recognize the difference between AM and PM. One way to easily calculate time is, after 12 noon, add 10 to the current time plus 2 more and you have th military equivalent. (ie. 3 PM = 3 now + 10 = 13. Add 2 more. 13 +2 = 15. 3 PM=1500. Convert the following times: a.) 9 PM b.) 4:40 PM c.) 12:45 PM d.)6:32 AM e.) 12:45 AM |
|
Definition
a.) 9 PM=2100
b.) 4:40 PM=1640
c.) 12:45 PM= 1245
d.) 6:32 AM= 0632
e.) 12:45 AM=0045 |
|
|
Term
| Describe what at Admission Nursing History Form is and give 3 reasons why its thorough completion is integral to the development of the client's plan of care. |
|
Definition
| The form a nurse completes when a patient is admitted. It provides patient history, nurse does complete assessment to id relevant nursing diagnoses and problems, and provides baseline data to compare with changes in patient condition. |
|
|
Term
| What are Flow Sheets & Graphic Records and how do they interface with CBE? |
|
Definition
| Flow Sheets & Graphic Records are forms that allow nurses to quickly and easily enter assessment data about the client, including vital signs and routine repetitive care, such as hygiene measures, ambulation, meals, weights, and safety and restraint checks. It interfaces b/c it allows the nurse to document any changes in the patient status and see when the change occured. |
|
|
Term
| The Client Care Summary (aka KARDEX since its origin was a flip chart type of file) is used to provide a "quick reference" for nurses in regard to client care, labs scheduled, allergies, etc... Why are entries into the Client Care SUmmary in many institutions done in pencil? |
|
Definition
| Kardex entries are done in pencil b/c of the need for frequent revisions as the client's needs change. |
|
|
Term
| How could the Client Care Summary be a valuable tool during change of shift report? |
|
Definition
| it has the info that is needed to be given during report and is an easy reference instead of going to the electronic chart. plus every nurse on shift can look at one book and not write notes on a piece of paper on what to tell the receiving nurse at the end of the day. |
|
|
Term
| Source Records allow each discipline to have their own record upon which to document. What is one advantage & one major drawback to this type of charting? |
|
Definition
| An advantage to Source Records is it allows caregivers to easily locate the proper section of the record in which to make entries. One disadvantage to source records is the details of a specific problem can get scattered throughout the record. |
|
|
Term
| An ___________ report is completed when a client's health care experience is not consistent with the routine operation of the agency. It covers anything out of the ordinary. Give some examples of this kind of report. |
|
Definition
| Incident. Ex's: patient falls, needle stick injuries, visitor having symptoms of illness, medication administration errors, accidental omission of ordered therapies, circumstances that led to injury or a risk for pt. injury. More ex's are if a patient loses their dentures or other belongings, a patients purse is stolen and anything out of the ordinary is to be filled out in an incident report. |
|
|
Term
| For legal purposes, do we write "incident report" on the patient record? |
|
Definition
| Fill the report out & send it to the proper place, but do not document this in the patient record. Never mention the incident in your documentation! |
|
|
Term
| Is it ok to print or photocopy just a small section of a client's chart? |
|
Definition
| No, NEVER print OR photocopy ANY PART of a client's chart!!! |
|
|
Term
| Can a nurse discuss a client to other clients or staff not involved in that patient's care? |
|
Definition
| No, nurses are legally and ethically obligated to keep info about clients confidential. Nurses may not discuss client's exams, observations, conversations, or treatments with other clients or staff not involved in their care. Only staff directly involved in a specific client's care has legitimate access to the records. However, clients have the right to request copies of their medical records & that is fine... they own their own information! In most situations, clients are required to give written permission for release of their medical info. |
|
|
Term
| What is the purpose of urinary elimination? |
|
Definition
|
|
Term
| What organs are effected by urinary elimination? |
|
Definition
| All organs of the urinary system: kidneys, ureters, bladder, urethra |
|
|
Term
|
Definition
| Plastic or rubber tube inserted into the urinary bladder under strict aseptic (sterile) conditions. It isused to drain urine from the bladder & may be inserted for single or long-term use. In some instances, it may be inserted surgically through the abdominal wall into the bladder. This procedure is called suprapubic catheterization. |
|
|
Term
| What is the main danger of catheterizing a client? |
|
Definition
|
|
Term
| What factors affect a persons urinary elimination? |
|
Definition
| Age, Sociocultural, Psychological, Muscle Tone, Fluid Intake, Disease Conditions, Surgical, Medications, Diagnostics |
|
|
Term
| What is the straight single-use catheter? It is introduced long enough to drain the bladder (5-10 minutes). When the bladder is empty, you should immediately withdraw the catheter. |
|
Definition
|
|
Term
| These catheters remain in place for a longer period of time until a client is able to void completely and voluntarily or as long as accurate measurements are needed. What are they? |
|
Definition
| Indwelling or Foley Catheters |
|
|
Term
| What material is an intermittent catheter (single use) made of? |
|
Definition
|
|
Term
| What material is a catheter used for up to 3 weeks. |
|
Definition
| Latex or Rubber Catheters. Be aware of allergies to either material. |
|
|
Term
| What material are catheters that are best suited for long-term use (2-3 months) made of? Why? |
|
Definition
| Pure Silicon or Teflon catheters - b/c they cause less encrustation at the urethral meatus. |
|
|
Term
| What catheter is used for males with prostate hypertrophy (prostate cancer) and why? |
|
Definition
| Coude (elbowed/curved) catheters b/c they're less traumatic during insertion b/c it is stiffer & easier to control then a Foley. |
|
|
Term
| What size catheters would you select for children, women & men? Why? |
|
Definition
| Catheter size is determined by the size of the patients urethral canal. The French system is used: the larger the gauge #, the larger the catheter size. Children=8-10 French. Women=14-16 French, Men=16-18 French. The smallest catheter size possible is used to prevent trauma. |
|
|
Term
| What do balloon sizes generally range from in the indwelling catheters? |
|
Definition
| Balloon sizes range from 3 mL (pediatric) way up to 75 mL for post-op volumes. Normal balloon size ranges in adults are 5 mL - 30 mL size used after prostatectomies to provide homeostasis of the prostatic bed. |
|
|
Term
| What allergy do you check before selecting a catheter? |
|
Definition
| Latex allergies. B/c latex/rubber catheter may cause a severe allergic reaction. |
|
|
Term
| What is a condom catheter? |
|
Definition
| it is a sheath made form soft, pliable rubber that slips over the penis. The condom is held in place by a special adhesive strip. It may be worn continuously or at night only, depending on the client's needs. The distal end of the condom has ad adapter that connects to urinary drainage tubing that may be affected to a leg drainage bag. Often this is a nursing-instituted procedure, but check policies to determine if a physician's order is required. |
|
|
Term
| When/why are condom catheters used? |
|
Definition
| They're recommended for male clients that have complete & spontaneous bladder incontinence. |
|
|
Term
| What nursing considerations are required when obtaining a urine specimen form a client with an indwelling catheter? |
|
Definition
| Whether you will use aseptic (sterile) or clean technique. For specimen's from a straight catheter you will use aseptic technique. Obtaining a specimen from an indwelling catheter just requires clean technique. |
|
|
Term
| What approximate length are male & female urethras? |
|
Definition
| Male Urethra=20 cm (8 inches) & is a urinary canal + a passageway for cells and secretions from reproductive organs. Females=4-6.5 cm (1.5-2.5 inches) & it permits flow of urine from the body only. |
|
|
Term
| When the nurse removes a catheter, what is the time limit that the client should have voided by? |
|
Definition
| within 6-8 hours and they need to void at least 250 mL. |
|
|
Term
| What is the hourly amount of urine that should be produced that indicates adequate renal function? |
|
Definition
|
|
Term
| Explain good catheter care... |
|
Definition
| Perineal care cleansing of the first 4 inches of the catheter as it exits the urinary meatus should be completed at least once every 8 hours. The use of powders & lotions on the perineum is not allowed b/c it promotes infection. |
|
|
Term
| The correct sequence for inserting an indwelling Foley catheter is as follows: |
|
Definition
| 1. gather supplies and bring them to the beside 2. perform hand hygiene 3. explain the procedure to the client 4. position and drape the client 5. prepare your sterile field 6. clean client using antiseptic swabs 7. catheterize the client. 8. inflate the balloon 9. attach catheter to bedside drainage bag 10. monitor client tolerance to the procedure 11. and perform ongoing assessment and documentation |
|
|
Term
| A __________ straight catheter may be used when a client needs a single sterile urine specimen. |
|
Definition
|
|
Term
| A client who is going to have major ABD surgery requires an _______________ catheter to be inserted before surgery or at the time of surgery. |
|
Definition
|
|
Term
| an incontinent male that is able to empty his bladder fully may have a __________ catheter applied. |
|
Definition
|
|
Term
| If the urine output from a Foley catheter is less then ___ mL per hour, the nurse should ensure that the tubing or catheter is kink free and assess the client for S & S of renal failure and/or dehydration. |
|
Definition
|
|
Term
| If a clients catheter was removed at 10 am, the client would need to void at what time? |
|
Definition
| Between 6-8 hours.... so between 4-6 pm |
|
|
Term
| a client with a spinal cord injury should be assessed for bladder fullness frequently, and urine output should be monitored closely to prevent ___________________. |
|
Definition
|
|
Term
| What are the S & S of a UTI? |
|
Definition
| fever, elevated pulse, lower ABD pain, and dysuria (painful urination). THe physician should be notified. |
|
|
Term
| If you have difficulty inserting a catheter in a male client, _______ enlargement should be considered. What do you do? |
|
Definition
| prostate. Nonforceful pressure cn be applied unti the prostatic sphincter relaxes. |
|
|
Term
| If the catheter leaks after insertion... what are some possible causes to consider? |
|
Definition
| size of the catheter is too small, the balloon is deflated, or the catheter may have slipped out of the bladder. |
|
|
Term
| A correct example of documenting a catheter insertion is: |
|
Definition
| 16 French Foley catheter inserted, tolerated well, output is 875 mL clear, yellow urine, pain free, urine specimen sent to lab. |
|
|
Term
| If the urine is not clear, what might the patient have? |
|
Definition
|
|
Term
| What if the urine has a strong odor? |
|
Definition
| odor is caused by ammonia, urine has set too long. |
|
|
Term
| The _________________ tells you how much approximately is in the bladder. It is a noninvasive way to tell if the patient needs to be catheterized. We only want to catheterize when we really have to. This saves the patient form being catheterized unnecessarily. |
|
Definition
| Bladder Volume Indicator (BVI) |
|
|
Term
| WHy would you do a continuous bladder irrigation? |
|
Definition
| removal of blood clots. do not let the blood clots shut off the catheter. Might have to speed up the CBI to get the clots out. |
|
|
Term
| How often are condom catheters changed? Who are these used for? |
|
Definition
| Daily. Condom catheters are used for comatose or incontinent men. |
|
|
Term
| Is urinary incontinence a normal part of aging? |
|
Definition
| No! Urinary incontinence is NOT a normal part of aging. |
|
|
Term
| What are some treatment options for urinary incontinence? |
|
Definition
| diet, bladder retraining or habit training (get up every 2 hours to go to bathroom), prompted voiding, pelvic floor exercises (kegels), Vaginal cones-feminine personal trainer, biofeedback, selfcatheterization (sometimes people catheterize themselves-if spinal injury or something like that), pharmacological treatment, surgical intervention, collagen implantation. |
|
|
Term
| What is important for you as a nurse to do for incontinent patients? |
|
Definition
| Maintain good skin integrity & be caring in your care (it is very hard on the patient to be incontinent) |
|
|
Term
| How does a nurse promote normal urination? |
|
Definition
| assist the patient to relax, assume to normal position for voiding (men=stand, women=sit up in bed/high Fowlers position), use normal toilet facilities, sound of running water helps to relieve, stroking inner thigh (esp. for women) will stimulate to urinate, pour warm water over female perineum |
|
|
Term
|
Definition
| an artificial (or surgical) opening of an internal organ of the body to the surface (usually in the abdominal area) |
|
|
Term
| Why does an individual need an ostomy? |
|
Definition
| a surgical procedure in which an opening is made to allow the passage of intestinal contents from the bowel or urine from the bladder. |
|
|
Term
|
Definition
| drainage from the stoma (surgical opening) |
|
|
Term
| What are the 3 types of learning a client experiences with an ostomy? |
|
Definition
| Psychomotor-learning goes form foreign to common, Cognitive-to learn why you are doing something (why pouch gets too full, why you had a leak), Affective-most important, what patient perceives from everyone he comes in contact with-peoples attitude towards you with an ostomy. |
|
|
Term
| What type of learning depends on various individuals reactions to the person with an ostomy. What part of learning will you as a nurse have a big affect one? |
|
Definition
|
|
Term
| What are the stages of adaptation for an ostomy patient? |
|
Definition
| 1.) shock 2.) Defensive Retreat 3.) Acknowledgement 4.) Adaptation & Resolution |
|
|
Term
| What should an individual with an ostomy do when she/he is experiencing itching under the appliance? |
|
Definition
| A good skin barrier protects the skin, prevents irritation from repeated removal of the pouch, and is comfortable for he client to wear. Contact physician in case of allergy to pouch. |
|
|
Term
| when the nurse cuts appliance/skin barrier to fit the stoma, how much larger should the nurse cute the opening in the appliance/skin barrier? |
|
Definition
|
|
Term
| What should the client report to the physician according to an ostomy? |
|
Definition
| If there is severe watery discharge lasting more then 4-5 hours. If there is not stoma output when associated with the following: 1. Nausea & Vomiting (blockage) 2. Abdominal Cramps lasting longer then 3-4 hours 3. Distended Abdomen (blockage) |
|
|
Term
| What should the client report to a Wound/Continent Nurse (sometimes call an ET nurse-enterostomal therapy nurse) |
|
Definition
| Excessive and/or persistent stomal bleeding, swelling or elongation of the stoma, changes in the color of the stoma, cuts or ulceration of the stoma, skin irritation or ulceration any bulging of the skin around the stoma, persistent burning or itching under the pouch |
|
|
Term
| Directions for Enemas... and what are the 5 types of Enemas? |
|
Definition
| Bag is 12-18 inches above the anus, run it lsowly to avoid cramping, takes about 10 minutes, clean gloves, document. 1. Tap water enema 2. Saline (1 tsp. salt per liter) 3. Soap Suds (Castille Soap) 4. Hypertonic 5. Oil Retention |
|
|
Term
| What is the purpose of enemas? |
|
Definition
| Break up stool, stretch rectal wall, initiate the defecation response. |
|
|
Term
| What position should the client be in for an enema? |
|
Definition
| Sim's position on left side so colon is going downhill; one knee over, one shoulder over |
|
|
Term
|
Definition
| Hard stool, straining at stool, 1-3 days w/o going |
|
|
Term
|
Definition
| Hard, formed stool lodged in the rectum |
|
|
Term
| What are the nursing implications in removing an impaction? |
|
Definition
| A PHYSICIAN's ORDER IS REQUIRED. Record results of removal by describing fecal characteristics, assess client's vitals and determine client's level of comfort. Ausculate bowel sounds and gently palpate abdomen. Observe for rectal bleeding, diarrhea, changes from baseline vital signs and increasing pain or abdominal distention. Watch for vagus nerve reaction. |
|
|
Term
| What is fecal incontinence? |
|
Definition
| Inability to control the passage of flatus and feces from the anus. |
|
|
Term
|
Definition
| accumulation of gas in the opening of the intestine. Caused by decrease in GI motility. |
|
|
Term
| What is the proper position for defecation? |
|
Definition
|
|
Term
| What are suppositories & why are they used? |
|
Definition
| meds placed in the rectum to trigger the defecatory reflex |
|
|
Term
| During instillation of the enema, the patient states he/she cannot hold it any longer. What should you do? |
|
Definition
| Lower the enema container to decrease the force of the solution. If still unable to hold, place bedpan and continue slowly instilling the remaining solution. May be effective enough to stimlate peristalsis. |
|
|
Term
| During or following an enema, the patient's abdomen becomes rigid & distended, with severe cramping. What should you do & why? |
|
Definition
| This may indicate a perforation of the bowel. Remove tubing immediately & assess for signs of distress: check vitals, dysrhythmias? notify the physician immediately. |
|
|
Term
| What are important factors to document after a cleansing enema? |
|
Definition
| Amount of flatus expelled, amount of solution expelled, color & consistency, general reaction of the client-how the enema was tolerated. |
|
|
Term
| Discuss what to do when a large volume enema is retained for greater then 1 hour? |
|
Definition
| Position patient on side, lubricate and reinsert tube from enema set-up into rectum, lower bag below the patient's body to promote siphoning of solution from rectum, document results. |
|
|
Term
| Discuss the difference between the administration of an oil retention and Fleets enema. |
|
Definition
| Oil retention enema should be given at room temp. and not warmed. By giving it at room temp, it minimizes the muscular stimulation causing peristalsis. Oil retention enema needs to be retained 30 minutes to adequately lubricate a mass of feces or its passage. |
|
|
Term
| How close should the nurse fit the ostomy appliance to the stoma? whY? |
|
Definition
| it should be 1/16-1/18 of an inch around the stoma. This will prevent the effluent from irritating the skin and causing breakdown. Some flanges are now custom sized and made of material that is moldable, so a good fit is more common. |
|
|
Term
| While the nurse is digitally removing a fecal impaction, the client states he/she is feeling odd. What should the nurse do? |
|
Definition
| The nurse should stop the procedure & assess the patient. Determine the pulse first. Removing a fecal impaction can stimulate the VAGUS NERVE. If the patient is experiencing bradycardia (HR below 60 bpm). Stop the procedure immediately, and assess the patient's vitals until it returns to normal. Meanwhile notify the physician. Be prepared for possible cardiopulmonary resuscitation. |
|
|
Term
| Why should the stoma be measured for a good fit? |
|
Definition
| The stoma will shrink for 6 weeks up to 6 months and it should be measured until the stoma is a stable size. In the hospital a universal ostomy pouch is used and the nurse must measure to obtain a satisfactory fit (1/16-1/18 inch around stoma) |
|
|
Term
| Ostomies are often done in the _______ colon. |
|
Definition
|
|
Term
| Ileosomy is in the ______ intestine. Colostomy is in the ______ intestine, usually the sigmoid colon b/c it has to be low enough to be formed. |
|
Definition
| Ileostomy=small, Colostomy=large intestine |
|
|
Term
| What color should the stoma be at all times? |
|
Definition
|
|
Term
| Determine the best time for routine changes of bowel & urine? |
|
Definition
| Both are usually in the morning, but the patient may have their own preference of their best time. |
|
|
Term
| When do we empty ostomy pouches? Include other directions for ostomies.. |
|
Definition
| When they are half full. If it is too full then it is very hard to drain w/o making a mess. Be sure to properly use closure device and track effluent on back of flange. |
|
|
Term
| We do not use powder with catheters, but do we use it with stomas/ostomy bags? |
|
Definition
| Yes, use powders (Stoma Adhesive Powder) will keep from getting yeast. |
|
|
Term
| If you have a bleeding, elongating or swelling stoma - who do you report that to? |
|
Definition
| E.T./Ostomy Nurse clinian |
|
|
Term
| If the stoma color changes, is cut & irritated, smells, itches or skin around the stoma is bulging... who do we report this to? |
|
Definition
| E.T. Nurse/Ostomy Nurse Clinician |
|
|
Term
| If there is a severe water discharge for more then 4-5 hours from stoma, who do we report this to? |
|
Definition
|
|
Term
| If there is N & V, abdominal cramps for more then 3-4 hours and/or distended abdomen... who do you report this to? |
|
Definition
|
|
Term
| Why type of ostomy is a colostomy irrigation utilized with? |
|
Definition
| Sigmoid & it has to be formed stool |
|
|
Term
| How can yeast complicate ostomy bags? |
|
Definition
| It is irritating obviously and the bag will not stick to the skin. |
|
|
Term
| What are dilated & engorged veins in the lining of the rectum? They are caused by increased pressure from venous pressure. |
|
Definition
|
|
Term
| _______ is decreased frequency of bowel movements. Can be caused by: meds, depression, diet, pregnancy and decreased activity. |
|
Definition
|
|
Term
| Tap Water enemas stimulate peristalsis & soften stools. They're also called ______ solutions. What is a potential hazard of this enema? |
|
Definition
| hypotonic, hazards: toxicity & circulatory overload if given too many in a short period of time. |
|
|
Term
| ______ enemas are for individuals that are unable to tolerate large amounts of fluid. |
|
Definition
|
|
Term
| What is the best enema option for infants & children to stimulate peristalsis? |
|
Definition
|
|
Term
| What enema causes bowel irritation and dilates the colon? Why type do we use? |
|
Definition
|
|
Term
| What is the correct volume for cleansing enema for an adult? |
|
Definition
|
|
Term
| WHen would a cleansing enema be contraindicated? |
|
Definition
| If the patient has already had 3 enemas. |
|
|
Term
| What observations does a nurse make about the BM following an enema? |
|
Definition
| Color, Consistency, Odor, Presence of blood/Mucus, Amount of stool and fluid passed |
|
|
Term
| If the abdomen becomes rigid and distended during an enema what should the nurse do? |
|
Definition
| Stop the enema, notify the HC provider and obtain vitals |
|
|
Term
| If during an enema abdominal pain and cramping develop, what should you do? |
|
Definition
| Slow the rate of instillation |
|
|
Term
| If bleeding occurs during an enema, what do you do? |
|
Definition
| Stop the enema administration, notify the HC provider, obtain vitals |
|
|
Term
| What does the nurse document on enema administration? |
|
Definition
| type of enema given, amount of fluid given, the return after the enema, assessment before, during & after the procedure, any calls placed to the physician, patient tolerance of procedure. |
|
|
Term
| Differentiate between Colostomy, Ileostomy and Urostomy? |
|
Definition
| Colostomy=surgical opening in colon, is thicker and a semi-formed stool, ILEOSTOMY=surgical opening in ileum, bypasses large intestine so stoolare liquid, frequently contain digestive enzymes, and must be bagged at all times. UROSTOMY=urinary |
|
|
Term
|
Definition
| a method of diverting the urinary flow by transplanting the ureters into a prepared and isolated segment of the ileum, which is sutured closed on one end. The other end is connected to an opening in the abdominal wall. Urine is collected there in a special receptacle. |
|
|
Term
| What is a loop colostomy? |
|
Definition
| Performed in a medical emergency, has 2 openings through 1 stoma. The proximal end drains stool and the distal end drains mucus. |
|
|
Term
| What is an end colostomy? |
|
Definition
| One stoma formed from the proximal end of the bowel with the distal portion of the GI tract either removed or sewn closed. Usually end treatment of colorectal cancer. |
|
|
Term
| What is a double barrel colostomy? |
|
Definition
| Bowel is surgically severed and the 2 ends are brought to the abdomen. Consists of 2 distinct stomas proximal functioning and distal non-funcitoning. Distal may excrete mucus. |
|
|
Term
| What is Kock or Indiana pouch? |
|
Definition
| Created using the patients small intestine, detubularizing its cylindrical shape an creating a spherical reservoir. The pouch has a continent stoma so the patient can stick an external catheter into it and drain. |
|
|
Term
| Why is a pouch used in an incontinent ostomy? |
|
Definition
| To protect the skin from stool or urine irritation. Also an incontinent ostomy has liquid excreting all the time so a patient needs something to catch it so the stool or urine doesn't get on the patient. |
|
|
Term
|
Definition
| a custom cut piece of adhesive that foes around the stoma to protect the skin for fluids |
|
|
Term
| Why is skin integrity so important around the stoma? |
|
Definition
| Integrity of the skin can indicate leaking, cleaning, irritation and other problems. |
|
|
Term
| Who is not a candidate for valsalva maneuver? |
|
Definition
| increased intracranial pressure, spinal cord injury, glaucoma, cardiac... Try to keep these peoples stool softened so they don't have to use the vagus nerve (slows heart down). These are people who die on the toilet b/c their HR is so slow. |
|
|
Term
| What are the 6 rights of Medication Administration? |
|
Definition
| Right CLIENT (check 3 times in validation for teachers), Right DRUG (check 3 times - document pt's full name, date & time, drug name, the route, the dosage, the time & frequency of the medication) Right DoOSE, Right TIME, Right ROUTE, Right DOCUMENTATION (need the signature of MD or PA who wrote the order) |
|
|
Term
| Are we allowed to take phone/verbal orders? |
|
Definition
| Yes, document the phone order & write it down while on the phone & READ IT BACK. Physicians don't want to wait on the phone, but it is for everyones protection. The physician flags those charts and then they have to sign it w/in 24 hours. There are many place (ICU) that DO NOT take phone orders though. You will tell the doctor, I'm sorry, send one of your residents up. |
|
|
Term
| When is the right time to give scheduled medications? |
|
Definition
| Routinely give within 30 minutes before & after scheduled time. Meds are given on a schedule for a reason. |
|
|
Term
| What do you do if you make a medication error? |
|
Definition
| Best thing to do is to say you did it. Call the doctor... own up to it & look for ways to help. Just need to be as careful as possible. Mistakes will mark your life forever, you will never forget them. Of course you'd fill out an incident report. |
|
|
Term
| What route are "non-parenteral" meds given? |
|
Definition
| Oral, cream, lotion, ointment, paste,patch applied directly to skin, inhaled, instilled into the eye, instilled in the ear, instilled in the rectum, instilled in the vagina. |
|
|
Term
| What are the most commonly reported side effects reported related to drug administration? |
|
Definition
| Anorexia, nausea, vomiting, dizziness, drowsiness, dry mouth, abdominal gas, constipation, diarrhea |
|
|
Term
| What clients are at higher risk for developing side effects? |
|
Definition
| clients taking a med for the first time, very young & very old clients, women, clients taking more then 4-5 meds (polypharmacy), clients who are extremely underweight or overweight, clients with renal and/or hepatic disease, clients with altered blood flow conditions, clients with a past hisotry of an adverse med reaction, clients with depression and/or anxiety, clients with sensory deprivation and/or overload, clients who abuse alcohol, street medications, clients who self-medicate with OTC meds. |
|
|
Term
| Medications must be maintained at a ______________ level to have a desired effect. |
|
Definition
| Therapeutic (Terms that relate to establishing this are onset of med action, peak action, duration of action, plateau) |
|
|
Term
| This is the time it takes after a med is administered for it to produce a response |
|
Definition
| Onset of medication action |
|
|
Term
| This is the time it takes for a med to reach its highest effective concentration. |
|
Definition
|
|
Term
| This is the length of time during which the medication is present in a concentration great enough to produce a response |
|
Definition
|
|
Term
| This is the blood serum concentration reached and maintained after repeated, fixed doses. |
|
Definition
|
|
Term
| How do older adults respond differently to drugs... |
|
Definition
| distribution, metabolism, absorption, excretion, circulation |
|
|
Term
| How is Distribution in an older adult different for a drug? |
|
Definition
| A decrease in lean mass with increase in adipose resulting n decline of water stores - this can raise concentration of water soluble drugs such as digoxin. |
|
|
Term
| How is Metabolism in an older adult different for a drug? |
|
Definition
| The liver shrinks decreasing blood flow through an organ slowing metabolism of drugs 1/2 or 2/3 of young adults. |
|
|
Term
| How is Absorption in an older adult different for a drug? |
|
Definition
| Gastric emptying slows and GI motility decreases negatively affecting absorption capacity of cells and active transport. |
|
|
Term
| How is Excretion in an older adult different for a drug? |
|
Definition
| a decline in renal blood flow, GFR, renal tubular secretion and reabsorption, as well as number of nephrons slows removal of wastes and lengthens half life of renally excreted drugs |
|
|
Term
| How is Circulation in an older adult different for a drug? |
|
Definition
| Vascular nerve control is less stable making antihypertensives and digoxin related drugs effects more pronounced. |
|
|
Term
|
Definition
| over prescribing of prescription drugs increasing the potential for drug interactions. common in older adults who are taking drugs for multiple medical disorders. |
|
|
Term
| What are the 6 rights of medication administration? |
|
Definition
| patient, medication, time, route, dose, documentation |
|
|
Term
| Differentiate between "stat" "now" and "on call" med orders... |
|
Definition
| Stat-means to be given immediately. Now-means as soon as available, usually within an hour. On Call-means the operating room will notify the nurse when is the appropriate time. |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| What does a PRN med mean? |
|
Definition
|
|
Term
|
Definition
| QID=4 times during the day. q 6 hours=given around the clock |
|
|
Term
| How does charting a PRN drug differ from charting a routine drug? |
|
Definition
| Charting of a PRN drug requires that the time be indicated. It also requires a follow up nurses note in regard to patient response. |
|
|
Term
| What should nurse check before administering any medication? |
|
Definition
| Client's wristband with name, patient ID number and wristband that tells allergies. |
|
|
Term
| What are the components of a medication order? |
|
Definition
| Clients full name, date order is written, med name, dose, route, time and frequency, and signature of MD, PA or NP. |
|
|
Term
| In accordance with The Patient Care Partnership client's have what right sin relation to medication administration? In relation to these rights, what is the nurses responsibility? |
|
Definition
| Medication's name, purpose, action, and potential side effects, refuse a med, have med history assessed including potential and established allergies, experimental nature of such therapies and consent attained, safely receive medication according to the 6 rights, receive appropriate supportive therapy, not receive any unnecessary meds. Subsequently, nurses must have the knowledge to answer client's questions in a courteous and professional manner. |
|
|
Term
| After administering meds, nurses are responsible for monitoring and providing what 3 things? |
|
Definition
| Monitoring clients' responses to meds, providing client education to them or their family about medication regimen, informing the physician when meds are effective, ineffective or unnecessary. |
|
|
Term
| What is noncompliance and what is the nurses role when she or he identifies a client is exhibiting this behavior? |
|
Definition
| Noncompliance with when the client is either not taking the medication as prescribed or is not taking the med at all. The nurse should assess the reason for the noncompliance and provide education, or help locate a source of alternative/generic drug if the reason is financial. |
|
|
Term
| Where do topical meds go? |
|
Definition
| skin, nasal, opthalmic, optic |
|
|
Term
| where do instillations go? |
|
Definition
|
|
Term
|
Definition
| they're inhaled with an inhaler |
|
|
Term
|
Definition
| Ophthalmic, vaginal, bladder, rectum |
|
|
Term
| How do you administer ear drops? |
|
Definition
| Have client assume lying-position with ear to be treated face up, or client can be in a chair at the bedside. Perform hand hygiene & gloves if drainage is possible. Straighten ear canal by pulling auricle down & back (children under 3) or up and out (adult, above 3). Put drops in while holding dropper 1 cm above ear canal. Ask client to remain in side-lying position 2-3 minutes. Apply gentle massage unless it is painful. |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| OPhthalmic administration of meds... what do you do? |
|
Definition
| clean eyes if necessary, place in conjunctival sac. If patient blinks or closes eye? repeat procedure. |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| What is the procedure with Metered Dose Inhalants (MDI)? What do you often need? |
|
Definition
| Shake, hold in 3 point position, spray-inhale, hold breath 10 seconds. repeat after 20-30 seconds if indicated. wait between 2-5 minutes between inhalations if it is different medications. If they have problems? A spacer is often needed to make sure they get all of the meds. |
|
|
Term
| What do Dry Powder Inhalations (DPI) include? |
|
Definition
| Contain propellants or any other ingredients, it contains only the meds & often don't need a spacer. |
|
|
Term
| What are parenteral medications? |
|
Definition
| Injections used to instill meds into the body tissue |
|
|
Term
| Why do we use parenteral meds? |
|
Definition
| injected drugs act faster than oral meds, we use parenteral meds when a patient cannot take their med in other methods. |
|
|
Term
| Why do parenteral meds pose a greater risk? |
|
Definition
| Because it is invasive, it's a greater risk |
|
|
Term
| What are the different degrees used for Intramuscular, Subcutaneous and Intradermal? |
|
Definition
| Intramuscular=90 degree angle, straight in way down to muscle. Subcutaneous can be 90 degrees (if obese) or 45 degrees (if skinny). Intradermal=15 degrees b/c you're barely going through the dermis. |
|
|
Term
| Where are intravenous injections (IV) going? |
|
Definition
|
|
Term
| How do we protect against infection when giving injections? |
|
Definition
| Perform hand hygiene atleast 10-15 seconds, add the time, date and your initials to the vial you open, swab the top of the open or unopened vial with alcohol before piercing, avoid letting the needle touch contaminated surfaces, swab the injection site with alcohol to clean the site. |
|
|
Term
| Syringe & Needle size is chosen by the nurse based on: |
|
Definition
| type of med being given, volume of solution to inject, route of the injection, clients body size (obese might need longer needle & skinny might need shorter) |
|
|
Term
| What is the most common subcutaneous injection? |
|
Definition
|
|
Term
| How do you know which needle is for insulin? |
|
Definition
| Orange & is measured in units |
|
|
Term
| Should we rotate the site of injection for insulin patients? |
|
Definition
| Yes, very important. Diabetics have insulin pens that they use for rotating sites. |
|
|
Term
| What needle do you use to draw out of a vial or glass ampule you wrapped and broke? |
|
Definition
|
|
Term
| Is recapping a needle okay? |
|
Definition
| Never recap a needle. If you HAVE to recap (which you're not supposed to do) then leave cap on its side on table & recap there. |
|
|
Term
| Where are you injecting subcutaneous? |
|
Definition
| Placing med into the loose connective tissue under the dermis. Injection site should be free of infection, skin lesions, bony prominences, and large underlying muscle & nerves. |
|
|
Term
| What things can affect the subcutaneous tissue? |
|
Definition
| Physical exercise & if you aply something hot or cold on them |
|
|
Term
| What equipment do you need for a subcutaneous injection? |
|
Definition
| 1-3 mL syringe, 25-27 gauge needle, 3/8-5/8 of an inch, small sterile gauze pad or bandaid, alcohol swab, ampule or vial of medication, disposable gloves, medication administration record. |
|
|
Term
| What angle are intradermal injections done at? Which way does the needle go? Examples of Intradermal. |
|
Definition
| Inject at 5-15 degrees, always make sure bevel is UP. Ex's of intradermal: TB skin tests & allergy screening tests. |
|
|
Term
| ALways inform the AP about a medications side effects, right? |
|
Definition
| Yes, itching or whatever... tell them to check in on her. make sure they know to report things to you immediately. |
|
|
Term
| Intramuscular Injections involve placing medication into deep muscle tissue. IM injections provide a ______ medication absorption. |
|
Definition
|
|
Term
| Is there less or more danger of tissue damage with IM injections? |
|
Definition
|
|
Term
| THe IM route does pose a risk of what? What do we do to prevent this? |
|
Definition
| IM route poses a risk of injecting medication directly into a blood vessel. IM is the only injectiong that you must asperate (go in, pull up & if you see blood in chamber then discard immediately! DO NOT forget this!) |
|
|
Term
| IM injections require a ________ needle. |
|
Definition
|
|
Term
| IM injections can deliver ___ volumes of fluid. how much? |
|
Definition
|
|
Term
| What are the 3 common sites chosen for IM injections? When selecting a site, it is important to choose the right one to prevent nerve damage. |
|
Definition
|
|
Term
| What angle do intramuscular injection go in at? |
|
Definition
|
|
Term
| ____ is what can be really toxic to skin & want it trapped in the muscle. |
|
Definition
|
|
Term
| Is it okay to recap AFTER the injection b/c it is done & you don't have to worry about sterility anymore? |
|
Definition
| No!!! NEVER recap needles before OR after! Safe practice to protect you against needle sticks. |
|
|
Term
| Needles vary in length from 1/4 to 3 inches. The nurse chooses the needle length according to the: |
|
Definition
| client's size and weight and the type of tissue it will be injected into. A child or slender adult generally requires a shorter needle. The nurse uses longer needles (1-1 1/2 inches) for intramuscular injections and a shorter needle (3/8 to 5/8 inch) for subcutaneous injections. |
|
|
Term
| Needle diameter is measured by gauge. As the gauge becomes smaller, the needle diameter becomes ________. |
|
Definition
| Larger. So a 25 gauge needle has a 5/8 inch length & will be smaller then a 19 gauge needle who has a 1 1/2 inch length. The smaller the number, the larger diameter of the needle. |
|
|
Term
| If air bubbles are aspirated, is it okay to aspirate air into the ampule? |
|
Definition
| No do not expel air. To expel excess air bubble, remove needle from ampule. hold syringe with needle pointing up. Tap side of syringe to cause bubbles to rise toward needle. Draw back slightly on plunger and then push plunger upward to expel air. Do not eject fluid. |
|
|
Term
| What needle size is most common for intramuscular (IM) injections? |
|
Definition
| 22-27, but 23G is most common for IM |
|
|
Term
| What needle size range is subcutaneous? |
|
Definition
|
|
Term
| What needle size is for intradermal (ID) injections? |
|
Definition
| 26-27 G needle for Intradermal (ID) injection |
|
|
Term
| What makes an insulin syringe different from a Tuberculin syringe? |
|
Definition
| Size and Gauge. Insulin syringe size is for Sub Q injections where Tuberculin syringe is for Intradermal injections. Also, Insulin syringe’s are measured in Units where TB syringe is in mL. |
|
|
Term
| What is the purpose of positioning the client correctly before giving the injection? |
|
Definition
| Facilitate the ease of administering the injection, reduce muscular tension and to make sure that the client’s position is not contraindicated by medical condition |
|
|
Term
| Why is it important to verify that the medications are compatible before mixing them? |
|
Definition
| I’m guessing for safety purposes. If you mix incompatible medications, it could have severe adverse affects on the patient. |
|
|
Term
| What is the purpose for changing the needle after drawing up the medications from the vial? |
|
Definition
| Inserting needle through a rubber stopper dulls beveled tip. New needle is sharper. Because no fluid is along shaft, needle will not track medication through tissues. Also ensures you have correct needle length and gauge for route. |
|
|
Term
| Why do you inject air into a vial? |
|
Definition
| To create a negative pressure in the vial that allows for easier drawing of the medication into the syringe. Injecting into a vial’s airspace prevents formation of bubbles and inaccuracy in dose. |
|
|
Term
| Why should air not be expelled into the ampule? |
|
Definition
| Because the air pressure forces fluid out of the ampule and medication will be lost. |
|
|
Term
| What is the purpose of the Z-rack technique? |
|
Definition
| Used when performing IM injections. It minimizes local skin irritation by sealing the medication in the muscle tissue |
|
|
Term
| What parts of the syringe must be kept sterile? |
|
Definition
| bevel and the shaft. also, avoid touching the plunger. |
|
|
Term
| What do you do if you aspirate blood? |
|
Definition
| Remove the syringe and discard it. Try again with a new syringe. |
|
|
