Shared Flashcard Set


Nursing Fundamentals
Undergraduate 3

Additional Nursing Flashcards




Data Collection
Health history - subjective data during interview
Physical Assessment (review of systems) and diagnostic test - objective data

part of health assessment process
Components of Health History
Demographic info
source of history
chief concern
history of present illness
past health history/current status
Family history
Social History
Health promotion behaviors
Physical Assessment Order (4)
Inspect, palpate, percuss and auscultate

abdomen: inspect, auscultate, percuss, palpate
First step, begins with first interaction and throughout

Uses senses of vision, smell and hearing to observe and detect any normal or abnormal findings
Inspects for size, shape, color, symmetry and position.
touching to determine size, consistency, texture, temperature, location and tenderness of an organ or body part.

Tender areas last
Deeper palpation for abdomen

Hand: Dorsal-temp, ulnar/finger base-vibration, Fingertips-pulsation, position, texture, size, consistency, finger/thumb-grab
tapping body parts with fingers, fists or small instruments to evaluate size, location, tenderness, and presence or absence of fluid or air in body organs and to detect any abnormalities

direct: striking body to elicit sounds
indirect: placing hand flat on body for surface for sound
fist: tenderness over kidneys, liver and gallbladder
technique to listen to sounds produced by the body

evaluated for amplitude/intensity, pitch/frequency, duration and quality

diaphragm-high pitched sounds; bell for low pitched
systolic BP
occurs during ventricular systole of the heart, when the ventricles force blood into the aorta and represents the maximum amount of pressure exerted on the arteries
diastolic BP
occurs ventricular diastole of the heart, when the ventricles relax and exert the minial pressure against arterial walls, and represents the minimum amount of pressure exerted on the arteries
Heat Loss from the body
Conduction - transfer of heat from body, directly to another surface (immersed in cold water)

Convection - dispersion of heat by air currents (wind)

Evaporation - dispersion of heat through water vapor

Radiation - transfer of heat from one object to another object without contact (cold room
Age temp differences
Newborns: 36.5-37.5 C (97.7-99.5 F)

older adults (loss of subQ) - 36 C

Temp rises slightly with ovulation and menses
Menopause may increase it up to 4 C

Injury/illness increases body temp. Fever is the bodys infectious/inflammatory response
Tympanic Technique
Pull ear up and back for an adult
Pull down and back for child under 3

Snugly into outer ear canal and scan till signal; no infants 3m and under
Temportal Technique
Remove camp, wipe lens with alcohol

While pressing scan, hold probe flat again forehead, moving it gently across forehead over the temporal artery and then touch the skin behind the earlobe then release scan
Hyperthermia Interventions (above 39 C)
-Obtain blood culture specimen if ordered then administer antibiotics as prescribed from results
-Assess/monitor WBC, sedimentation rates and electrolytes as ordered
-Avoid shivering
Provide fluids, rest and antipyretecs (aspirin (not adults w viral/chilred=Reye syndrome), tylenol, advil), oral hygiene, dry clothing/linens
-Offer blankets during chills, remove when warm
-Prevent shivering as this increases energy demand
-Keep head covered and maintain environment temp
Hypothermia Interventions (below 35 C)
Provide warm environmental temp, heated humidified oxygen, a warming blankey, friction to extremities, and/or warmed oral and IV fluids

Continuous cardiac monitoring
Keep emergency resuscitation equipment on standby
Measurements of pulse
Strength (0=absent, 1+=diminished, weak, 2+=brisk/expected, 3+=Increased, 4+=Bounding)
Equality-symmetrical in quality and quantity
pulse deficit
apical rate faster than the radial rate
factors leading to tachycardia
exercise, fever, meds (epinephrine, beta2-adrenergic agonists), changing from lying down to sitting or standing, acute pain, hyperthyroidism, anemia/hypoxemia, stress/anxiety/fear, hypovolemia, shock, heart failure
factors leading to bradycardia
long term physical fitness, hypothermia, medications (beta blockers, calcium channel blockers), changing from standing or sitting to lying down, chronic pain, hypothyroidism
Apical pulse rate
located at fifth intercostal space at the left midclavicular line

For assessing HR of an infant, rapid rates (over 100bpm), irregular rhythms, and rates prior to administration of cardiac medications

Always count a full minute
Processes of respiration
Ventilation - exchange of o2 and co2 in the lungs; measure with RR, rhythm and depth

diffusion - exchange of o2 and co2 between alveoli and red blood cells; measure with pulse oximetry

Perfusion - flow of blood to and from pulmonary capillaries; measure with pulse oximetry
Hypoxemia Interventions (SAO2 below 90%)
Confirm probe is place properly
-Correlate with Radial or apical
-Confirm O2 delivery system is functioning
-Deep breathing encouragement, possible suctioning, asses for signs and check for hyperthermia
-Place in semi-->Fowlers
Postural (orthostatic) hypotension
BP falls when client changes position from lying to sitting or standing
dizziness, weakness, fainting
May result from: peripheral vasodilation, med side effect, fluid depletion, anemia, prolonged bedrest

Assess: take BP and HR in supine then sitting or standing, wait 1-5 minutes then reassess BP and HR

SBP decreased more than 20mmHG
DBP decreased more than 10mmHG
HR increased 10-20%
Head and Neck Inspection and Palpation
Head-skull,size, depressions, masses, tenderness, deformities, masses, symmetry

Face-symmetry, involuntary movements
CNV (trigeminal) - motor - palpate massester/temporal muscles/joint as client clenches teeth
CNVII (facial) - test symmetrical movement with smiles, frowns, eyebrows, showing teeth, etc

Neck: symmetical muscles, equal shoulders, ROM (chin to chest flexion, ear to shoulder bilateral flexion, chin up hyperextension), CNXI (spinal accessory) - shrug shoulders against resistance

Lymph nodes - nonpalpable, nontender, not visible, use finger pads and move skin over tissue in circular motion

Trachea-inspect/palpate for deviation-should be midline
Thyroid gland

First, check lower half of clients neck to see if visible then with a sip of water

Repeat from behind as client tips her head forward, use left hand to displace trachea and place right fingers between sternomastoid muscle and trachae
Feel for movement of gland as it moves up with trachea and larynax
Repeat for both sides

If enlarged, auscultate - presence of a bruit indicates abnormal increase in blood flow
Eye exam sequence
Visual acuity, Extraocular movements (EOMs), visual fields, external structures, internal structures
Visual Acuity
measures CNII (optic)

Use snellen chart with client 20ft from it-ask to read smallest line possible. First number indicated number of feet away, second is distance a normal sighted would be: normal: 20/20: this is used for myopia (impaired far vision)

Presbyopia (impaired near vision) uses Rosenbaum eye chart 14inches from the face

Ishihara test - color vision
Extraocular movements EOMs
determine coordination of eye muscles with three tests (CNIII, CNIV, CNVI)

1. corneal light reflex
2. Strabismus with cover/uncovertest
3. Six cardinal position gaze with H test watching for nystagmus
Externam Structures Abnormalities
-edema/redness in lacrimal gland
-bulging or crossing of eyes
-ptosis: eyelid covers pupil
-Cloudy lense: cataracts
-Illuminated iris: glaucoma
External Structures

P - pupils should be clear
E- equal in size between 3-5cm
R - Round in shape
R - Reactive to light both directly and consensually when a light is directed into one pupil then the other
A - Accommodation of pupils when they dilate to look at an object far and then converge and constrict to focus near
Internal Exam Findings
-optic disk is light pink or more yellow than surrounding retina
-Retina should be without lesions and color will be dark pink, or light pink with lighter skin
-arteries and veins are found at a 2:3 ratio without nicking
-the macula may not be readily visible with pupil dilation but may be briefly glimpsed when looking directly into light
Eye Paepation
palpate lacrimal apparatus to assess for tenderness and to see if discharge is expressed from lacrimal duct. There should be none noted except tears
Ear/Throat/Nose/Mouth cranial nerves
CNVII (acoustic): hearing
CNI (olfactory): smell
CNVII (facial) and CNIX (glossopharyngeal): taste
CNXII (hypoglossal): tongue movement and strength
CNIX and CNX (vagus): mouth movement of soft palate and gag reflex, swallowing and speech
Ear/Throat/Nose/Mouth cranial nerves
CNVII (acoustic): hearing
CNI (olfactory): smell
CNVII (facial) and CNIX (glossopharyngeal): taste
CNXII (hypoglossal): tongue movement and strength
CNIX and CNX (vagus): mouth movement of soft palate and gag reflex, swallowing and speech
Auditory Tests
Whisper test - cover one ear, whisper in other: client should hear clearly 30-60cm away

Rinne Test - tuning form against mastoid bone and have client state when they cant hear it, then do it in front of ear: Air conduction greater than bone 2:1 ratio

Weber test: place tuning fork on top of head, ask which ear/both its heard best:should be heard equal in both
Brest inspection positions
1. arms at side
2. arms above head
3. hands on hips pressing firmly
4. leaning forward

men: in sitting or lying position with arms at the side only
Breast examination
wear gloves if skin is not intact
feel for lumps using finger pads of four fingers

best position: lying down with arm up by her head and a small pillow under shoulder of side being examined

Palpate using circular, wedge or vertical strip pattern from sternum to posterior axillary line, and from clavicle to the bra line
posterior thorax palpation
align thumbs parallel along spine at the level of the tenth rib with hands flattened around clients back

instruct to take a deep breath and thumbs should move outward approximately 2in during insp
Thorax percussion
should result in resonance

dullness - fluid or solid tissue (pneumonia or tumor)
hyperresonance - presence of air (pneumothorax or emphysema)
Thorax normal auscultation sounds
bronchial: loud, high-pitched, longer expiration over trachea
Bronchovesicular: medium pitch/intensity: over large airways: equal I&E
Vesicular: soft, low pitched: I 3x E over peripheral areas of lungs
abnormal thorax auscultation sounds
Crackles/rales-fine-course popping as air passes through fluid
Wheeze-high pitched whistling, musical as air passes through narrow/obstructed airway: louder on E
Rhonchi-course heard on I or E from fluid or mucus
Plueral friction rub - grating sound produced as inflamed visceral and parietal pleura rub against each other
Cardiac Cycle and Heart Sounds
S1: lub: closure of mitral and tricuspid valves, signals beginning of ventricular systole (contraction) best at apex
S2: dub: closure of aortic and pulmoic valves, signals beginning of ventricular diastole (relaxation) best at aortic area
S3: venticular gallop: rapid ventricular filling: normal in children and young adults heard with bell best
S4: strong atrial contraction: normal in older and athletic adults and children: bell
best heard with bell of stethescope

Blood colume is increased in the hearst or the flow is impeded or altered; a blowing or swishing sound will be heard

systolic murmurs: just after S1
diastolic murmurs: just after S2
Cardiac Landmarks
Aortic - R of S at second ICS
Pulmonic - L of S at second ICS
Erbs point - L of S at third ICS
Tricuspid - L of S at fourth ICS
Apical/mitral (apex) - L midclavicular line at fifth ICS
Three positions for optimal heart sound assessment
1. sitting, leaning forward
2. lying supine
3. turned toward the left side (best position for picking up extra heart sounds or murmurs)

use both diaphragm and bell
peripheral vascular system for bruits
carotid arteries: over the carotid pulse
abdominal aorta: just below the xiphoid process
renal arteries: midclavicular lines above umbilicus on abdomen
Iliac arteries: midclavicular lines below umbilicus
Femoral arteries: over femoral pulses
Blumbergs sign-Rebound tenderness
indication of irritation or inflammation somewhere in abdominal cavity, done in all four quadrants
-apply firm pressure for four seconds with hand at 90 degree angles and fingers extended
-After releaseing pressure, observe clients response to see if pain was elicited and ask

Never deep palpate abdominal mass, tender organs or surgical incisions
Skin color changes
Pallor: loss of color (best noted in face, conjunctivae, nail beds and palms): anemia or lack of blood flow

Cyanosis: bluish (best noted in nail beds, mouth, skin): hypoxia or impaired venous return

Jaundice: yellow-orange of skin, sclera and mucous membranes: liver dysfunction, red blood cell destruction

Erythema: redness (best noted in face, trauma and pressure sore areas): inflammation

shiny/translucent skin without hair on toes and foot is seen with arterial insufficiency
Primary lesions
Macule: nonpalpable, skin color change <1cm - freckle
Papula: palpable, circumscribed, <.5cm - elevated nevus
Nodule/tumor: palpable, circumscribed >.5cm - wart
Vesicle: serous fluid filled < 1cm - blister
Pustule: pus-filled - acne
Wheal: palpable, irregular borders, edematous - insect bite
secondary lesions
Erosion: Lost epidermis, moist surface, no bleeding - ruptured vesicle
Crust: dried blood, serum or pus - scab
Scale: flakes of skin that exfoliate - dandruff
Fissure: linear crack
Ulcer: loss of epidermis and dermis with possible bleeding/scarring - PU
Common spine abnormalities
Kyphosis: exaggerated curbature of the thoracic spine, common in older adults
Lordosis: exaggerated curvature of the lumbar spine; common during toddler years and pregnany
Scoliosis: exaggerated lateral curvature
Levels of Consciousness
Alert – The client is responsive and able to fully respond by opening the eyes and attending to a normal tone of voice and speech. Answers questions spontaneously and appropriately.
Lethargy – The client is able to open the eyes and respond, but is drowsy and falls asleep readily.
Obtundation – The client needs to be lightly shaken to respond, but may be confused and slow to respond.
Stupor – The client requires painful stimuli (pinching a tendon or rubbing the sternum) to achieve a brief
response. The client may not be able to respond verbally.
Coma – There is no response to repeated painful stimuli.
Abnormal Comatose Positioning
Decorticate rigidity – Flexion and internal rotation of upper extremity joints and legs

Decerebrate rigidity – Neck and elbow extension, with the wrists and fingers flexed
Mini-Mental State Examination (MME)
objectively assesses cognitive status

-orientation to time and place
-attention and calculation by counting backwards by 7s
-Registration and recalling of objects
-Language, including naming of objects, following of commands, and the ability to write
Glasgow Coma Scale
baseline assessment of the client’s level of consciousness for ongoing assessment

This assessment looks at eye, verbal, and motor response, and assigns a number value based on the client’s response. The highest value possible is 15, indicating the client is awake and responds appropriately. A score of 3 indicates the client is in a coma.
Nuerological Screening Exam includes
Mental status examination to test cerebral function
Assessment of cranial nerves
Motor function to test cerebellar function
Sensory function
Sensory discrimination
Two-point discrimination – Use open paper clips to determine the distance at which the two points are felt as one. Compare bilaterally. Minimal distance will vary depending on the body part being evaluated.

Stereognosis – Use a familiar object (key, cotton ball) placed in the client’s hand, and ask him to identify it.

Graphesthesia – Ask the client to identify a number drawn on his palm with the blunt end of a pencil
Deep Tendon Reflexes
◯◯ 4+ = Very brisk with clonus
◯◯ 3+ = More brisk than average
◯◯ 2+ = Expected
◯◯ 1+ = Diminished
◯◯ 0 = No response

biceps - flexion of the elbow
brachioradialis - flexion of elbow and pronation of the forearm
triceps - extension of the elbow
patellar - extension of the lower leg
achilles - plantar flexion of the foot
Spiritual rituals and observances
Hinduism: do not prolong life, some are vegetarians, lie on floor while dying with thread placed around neck/wrist, family pours water into mouth and bathes the body, cremated

Buddhism: may refuse care or fast on holy days, vegetarians, avoid alcohol and tobacco, last rites, chanting

Islam: prayer in infants ear at birth, avoid alcohol and pork, fast during Ramadan, confess sins at death with body facing Mecca, washed and enveloped in white cloth with prayer

Judaism: circumcised on eighth day, Kosher diet, someone stays with body

Christianity: some baptize at birth, some fast during lent, some avoid alcohol, tabacco and caffiene, last rites

Mormonism: baptized at 8 by immersion, avoid tabacco, alcohol and caffiene, last rites, communion, bural

Jehovah's Witnesses: do not accept blood transfusions, avoid foods having or prepared with blood
Signs and symptoms of approaching death
Decreased LOC
Muscle relaxation
Labored breathing
Mucus collected in large airways
Incontinence of bowel/bladder
Mottling w. poor circulation
Pupils nonreactive to light
Pulse weakening, dropping BP
Cool extremities
Decreased urine output
Inability to swallow
Foot care
especially important with gait issues and DM

Inspect daily, especially between toes
Use lukewarm water and dry thoroughly
Avoid over-the-counter products that contain alcohol/strong chemicals
Wear clean cotton socks daily
Check shoes for objects, rough seams, or edges
Cut nails straight across and use emery board to file edges
Avoid corn/callus self treatment
Do not apply unprescribed heat
Buy/wear comfy shoes that do not restrict circulation
Contact provider if any signs of infection or inflammation

DM-do not soak feet, file nails do not cut, do not apply lotion between fingers or toes
Preventing aspiration
Position in Fowlers or chair
Support upper back, neck and head
Have client tuck chin when swallowing-help propel down esophagus
Observe for it or pocketing, or dysphagia
Maintain semi-Fowlers at least 1hr after meals
Provide oral hygiene after meals/snacks
Specimen Collection
Fecal Occult Blood:
Explain procedure, Ask client to collect specimen in toilet receptacle, bedpan or bedside commode; Apply gloves and use wooden applicator to place stool on test card window; Either label and send out or put developer drops; blue means blood

Explain; Ask client to collect; Put on gloves and use wooden tongue depressor to transfer stool to specimen container; Label; Gloves/hands; Transport to lab
Varying solutions and additives depending on enema
Tap water/hypotonic solution: stimulates evacuation; never repeated due to water toxicity risks
-Soapsuds: pure castile soap in tap water or saline that acts as irritant to promote peristalsis
-Normal Saline: Safest due to equal osmotic pressure; volume stimulate peristalsis
-Low-volume hypertonic: Good if cannot tolerate high volume enema; Fleet-prepared
-Oil retention: lubricates rectum and color for easier stool passage
-Medicated enema: contains meds to be retained
Enema Procedure
-Prepate solution and pour into enema bag, then close clam
-Explain procedure, have commode ready, and absorbent pads to protect linens
-Position client on left with right leg flexed forward
-Gloves; lubricate tube/nozzle
-Insert 3-4in; 2-3 if child; bag level with hip; squeeze if prepackaged
-Raise 30-45cm; discontinue with cramping or fluid around anus tube
-Ask client to retain amount prescribed, discard, assist for defecation position and remove gloves
Ostomy Care
-Remove pouch from stoma
-Inspect: moist, shiny and pink; peristomal area intact with healthy skin
-Clean: with mild soap/water and dry gently/completely (paste)
-Measure/cut skin barrier; allowing an opening for stoma (barrier pastes)
-Apply: barrier then pouch
-Pouch: fold bottom and place closure clamp

Dispose of used pouches
Bowel Complications (Constipation and Impaction)
-Constipation: difficult/infrequent evacuation of hard, dry feces; improper diet, decreased fluid, lack of exercise, meds; increase fiber/water before laxative; bulk-forming product before others; enemas last resort

-Impaction: stool wedged into rectum with diarrhea fluid leaking; digital removal with lubricated, gloved finger; stool is loosened around edges and then removed in small pieces; be careful of vagus nerve (often preceded by administration of a glycerin or bisacodyl [Dulcolax] suppository
Bowel Complications (Diarrhea, Fecal Incontinence)
Diarrhea: frequent, liquid stools; cause must be determined and treated; possible moisture barrier and meds to slow peristalsis; frequent hand hygiene and good perineal care

Fecal Incontinence: inability to control defecation, often caused by diarrhea; asses for causes: meds, infection, impaction; perianal care and possible moisture barrier
Bowel Complications (Flatulence, Hemorrhoids)
Flatulence: distension of bowel from gas accumulation; may feel cramps/fullness; asses ability to pass gas; encourage ambulation to promote passage of flatus; notify provider if continued

Hemorrhoids: engorged, dilated blood vessels in rectal wall from difficult defecation, pregnancy, liver disease and heart failure; may be itchy, painful and bloody after; moist wipes may be more comfortable; possible application of prescribed ointments or creams
Urinary Elimination factors
-Age: prostate enlargement after 40 years
-Pregnancy: fetus compromises/compresses bladder and 30-50% circulatory volume --> renal workload
-Diet: Sodium decreases
-Muscle of bladder, abdomen and pelvis
-Immobility, disease, spinal cord injury, psychosocial
-Surgical procedure: alters glomerular filtration rate causing decrease; lowel abdominal surgery creates obstructing edema and imflammation
-Meds: Pyridium-orange, Amitriptyline-green/blue, Dopar-brown/black; chemotherapy causes kidney toxic environment
Catheter urine specimen for C&S
Requires sterile specimen from a straight or indwelling catheter obtained using surgical asepsis
-Drain catheters tubing of urine
-Clamp tubing below the port for 20m
-Use surgical asepsis while withdrawing the required amount from the port with a syringe
-Unclamp catheter
Timed urine speciments
-discard first voiding
-collect all others in a container placed on ice
-If client discards urine, timing of specimen must begin again with next voiding
Straight or Indwelling Catheter Insertion
size: 8-10 for children, 14-16 for women and 16-18 for men
-Lower side rail and raise bed to a comfortable height with good light
-Position supine; women-knees apart; men-thighs abducted slighty
-With gloves, wash perineal area
-Set up sterile field
-Put antiseptic on cotton balls and check balloon on catheter, then lubricate lower portion
-Apply sterile drape and cleanse the meatus
-Insert using sterile hand until urine returns + 2.5-5cm
0Stabalize with nondominant hand, inflate balloon if indwelling and pull back gently then secure to clients leg
-Drainage bag goes below level of clients bladder
hearing impaired clients
-sit and face the client
-avoid covering your mouth while speaking
-have client use hearing devices
-speak slowly and clearly without shouting in brief simple worded sentences
-minimize background noise
-lower pitch before increasing volume
-write down what is not understood
-ask for a sign language interpreter if necessary
visually impaired clients
-Call by name before approaching to avoid startling
-Identify yourself and stay within clients visual field
-Give specific info about location of items or areas of building
-Explain before touching
-appraise clothing
-Inform of your departure and make a radio, TV, CD/DVD player, or MP3 player available for use
-describe arrangement of food on tray before leaving
aphasia clients
Loss of ability to understand or express speech

-Greet client and call them by name
-Do not shout, speak clearly and slowly in short sentences
-Pause between statements to allow time to understand and check for comprehension
-Ask questions that require simple answers and allow plenty of time to respond
-Reinforce verbal and non verbal
-Use methods by speech therapist. i.e. picture charts
-Acknowledge frustration expressed in communication
disoriented clients
-Call by name and identify yourself
-Maintain eye contact at eye level
-Use brief, simple sentences with one question at a time and plenty of time to respond
-Avoid lengthy convo
-One direction at a time
-Provide adequate sleep and pain management
sensoriperceptual loss clients continued
Encourage verbalizing feelings about loss
-Orient client to time, person, place and situation (keep a clock in the room and post a calendar; write date visible)
-Provide care they may not be able to perform (reading the menu)
Eye administration
Use surgical aseptic technique
-client sit upright or lie supine, head tilted looking at ceiling
-dominant hand on forehead
-dropper 1-2cm to drop into conjunctival sac
-gentle pressure with finger/tissue on nasolacrimal duct for 30-60s
MDI Inhaler administration
-Remove cap and shake 5-6 times
-Hold with thumb near the mouthpiece and index/middle fingers at top; 2-4cm away from mouth
-deep breath, exhale, tilt head back
-press inhaler and behin a slow deep breath for 3-5s
-Hold breath for 10s then exhale through pursed lips
DPI Inhaler administration
-Take cover off, do not shake!
-follow instructions, may turn wheel
-Exhale completely and place it between lips then deep breath in
-Hold breath 5-10s

Rinse inhaler cap once a day with warm running water and dry completely
Suppository administration
Remove foil wrapper and lubricate if necessary
Rectal: Position in left lateral and insert just beyond internal sphincter; retain 20-30 for defecation stim and 60m for systemic absorption

Vaginal: supine with knees bent, feet flat and close to hips, inserted with applicator, remain for prescribed time
parenteral administration
Vastus lateralis: under 2 years
Ventral gluteal: can be used above 2
Both accommodate 2mL; deltoid 1mL
Tuberculin syringe for solution volumes under .5mL
specific parenteral administration
Intradermal: TB/Allergy testing; .01-1mL solution, 26-27 gauge, 10-15 degrees
SubQ: Insulin/heparin/water soluble, 3/8-5/8in, 25-27 gauge needle, insulin syringe gauge 28-31 max 1.5mL; pinch and inject at 90d
IntraM: irritating meds/oils/aqueous, ventro/dorsogluteal, deltoid, vastus lateralis, 1-1.5in needle, 22-25 gauge, 1-3mL at 90d
Intravenous administration
meds, fluid, blood

short term: catheter, long term: infusion port
Trauma: 16 gauge
Surgical: 18 gauge
children, older adults, medical clients, and stable postop: 22-24 gauge

Peripheral veins in arm or hand; neonates can use veins of head, lower legs and feet
Six Rights to safe medication administration
Right Client: JCo requires to person specific identifiers; check for allergies
Right Medication: check 3 times-selecting container, removing dose, replacing container; leave in package
Right dose: Calculate correct dose and check drug reference for range
Right time: 30 minutes before or after schedules time is acceptable usually
Right route
Right documentation: immediately record pertinent info including client response
Indications of Respiratory sputum specimen collection
For cytology to identify aberrent cells or cancer
-For culture and sensitivity to grow and identify micro-organisms and the antibiotics effective against them
-To identify acid fast bacillua (AFB) to diagnose TB (three consecutive morning samples
Sputum specimen nursing actions
Check prescription, wait 1-2 after client eats in the early morning, perform chest physiotherapy to mobolize secretions, use sterile specimen container for culture/AFB and container with preservatives for cytology and biohazard bag (possible mask/goggles with gloves)

-Fowlers position
-Rinse mouth of oral contaminant then check ability to cough (otherwise endotracheal order with sputum trap)
-Have client breathe deeply 2-4 times then cough deeply
-Expectorate 1-2tsp into sterile cup, redo if not enough
-Maintain sterility, place lid, lavel, put in biohazard bag and deliver to lab within 30m
Chest Physiotherapy
set of techniques to loosen respiratory secretions and move them into central airways to be removed by coughing or suctioning

Percussion: cupped hands; clap rhythmically on chest to break up secretions
Vibrations: use of shaking movement applied during E to help remove secretions
Postural drainage-9 positions to allow secretions to drain by gravity
Chest Physiotherapy indications and preprocedure
-For clients with thick secretions, unable to clear airway
-Contraindicated: pregnant, rib/chest/neck/head injury, intracranial pressure, recent abdominal surgery, pulmonary embolism
-must maintain patent airway and SaO2 of 95-100%

Nursing Actions:
-Schedule: 1hr before meal, 2hr after and before bed-reduce vomiting/aspiration risk
-Administer bronchodilator or nebulizer treatment 30m-1hr before
-Offer emesis basin and facial tissues
Chest Physiotherapy Procedure
Proper positioning: apical section of upper lobes-Fowlers; posterior section of upper-Side-lying; Right lobe-on left side with pillow under chest; left lobe-Trendelenburg
-Apply manual percussion with cupped hands/device
-Cough after each set of vibrations-tense hand/arm; moving heel of hand
-Each position for 10-15m
-Discontinue with faintness/dizziness/dyspnea-hypoxia
-After: lung auscultation ans assess amount, color and character of secretions
-Document and repeat 2-3 per day
Oropharyngeal suctioning
-baseline assessment
-use yankauer or tonsil-tipped rigid suction catheter
After intraprocedure:
-Inset catheter in clients mouth and apply suction and move it around mouth, gum line and pharynx
-Clear catheter and tubing/repeat as needed
Intraprocedure to suctioning
Surgical asepsis: opening suction catheter kit/suctioning other than mouth
-Open sterile suction package and place drape on client chest
-Set up container, touch only outside and pout 100mL of sterile water or .9% NaCl
-Don sterile gloves
-nondominant holds tube; sterile holds sterile catheter
-Connect to tubing, set pressure no higher than 120 mmHg; test suction with sterile water
-Limit suction to 10-15s and 2-3 attempts; clear with sterile water when done
-Document: pre/post assessment, toleration, color/consistency
Nasopharyngeal/tracheal suctioning
-Hyperoxygenate with FiO2 of 100%, lubricate distal 6-8cm with a water-soluble
-Insert during inhalation but dont suction
-Follow natural naris course with slight slant downward (nose to earlobe)
-Apply suction intermittently by covering and releasing port with thumb for 10-15s while withdrawing and rotating with thumb and forefinger
-Allow 20-30s recovery between, repeat a/n; hyperoxygenating before each suctioning pass
Endotracheal suctioning ETS
Outer diameter of no more than 1cm of internal diameter of endo tube; hyperoxygenate with BVM or ventilator with FiO2 of 100%
-Remove BVM/V and insert catheter into lumen; advance till resistance then pull back 1cm
-Apply intermittent suctioning by covering/releasing port with thumb while withdrawing and rotating it with thumb/forefinger 10-15s
-Reattach BVM/V
-Clear catheter/tubing/allow time and repeat if necessary
Single Lumen and Double Lumen Cannula Tracheostomy
Single Lumen: long, single-cannula tube use for clients who have long or thin necks; do not use if have excessive secretions

Double Lumen: three parts
1. outer cannula fit into stoma to keep airway open
2. inner cannula snugly locked into outer cannula
3. Obturator: thin solid tube placed inside teach as guide for inserting outer cannula then removed
-Inner cannula can be removed, cleaned, reused or discarded and replaced
-Useful with excessive excretions
Cuffed versus cuffless tube trach
Cuffed tube: has balloon inflated around outside of distal segment of tube to protect the lower airway by producing a seal from upper airway
-permits mechanical ventilation but does not hold tube in place
-Unable to speak
-Measure pressures to prevent tissue necrosis

Cufflesstube: no balloon; used for clients with long term airway management that have low risk for aspiration
-Not used if on mechanical ventilation but can speak
Fenestrated tube with cuff versus without cuff
FT with cuff: One large or multiple openings in posterior wall with balloon around outside tube; has inner cannula
-allows for mechanical ventilation
-removing inner cannula allows fenestrations to permit air to flow through; client can speak

Without cuff: no balloon; still has inner cannula
-holes wean the client from the tracheostomy
-Removing inner cannula has fenestration permit air flow
-client can speak
Before tracheostomy care
-Explain procedure
-Place in semiF or F
-Keep material at bedside: two extra trach tubes (one client size and one smaller), obturator for existing tube, O2 source, suction catheters and source, manual resuscitation bag
-Provide with methods to communicate; emergency call system and call light
Some Tracheostomy Care Facts
-Provide adequate humidification and hydration to thin secretions and reduce risk of mucous plugs
-Do not suction routinely: PRN (bleeding, mucosal damage, bronchospasm)
-Oral care every 2 hours
-Trach care every 8 hours
-Change every 6-8 weeks
-Reposition every 2 hours to prevent atelectasis and pneumonia
-Eating: upright, chin tucked in to chest; watch aspiration
-Drugs: anti-inflammatory, antibiotic, aerosolized bronchodilater, mucus liquifier
Tracheostomy care every 8 hours
-Suction tube if necessary; sterile
-Remove soiled dressing and excess secretions
-Cotton tipped applicator and gauze pads to clean exporsed surface; hydrogen peroxide then .9% NaCl in circular motion from stoma out
-Clean inner cannula sterily with half strength-fill hydrogen peroxide; rinse with sterile saline
-Clean stoma with half strength H peroxide then sterile saline
-4x4 dressing around trach
-Change ties if soiled, after placing new ones with visible square knot fitting 1-2 fingers
Accidental Decannulation
First 72: not matured: EMERGENCY
-Ventilate with manual resuscitation bag and call for assistance
-hyperextend neck with obturator inserted into tube; quickly and gently replace tube and remove obturator
-Secure and auscultate

Always keep trach obturator and 2 tubes at bedside
-If unable to replace, administer O2 through stoma. If unable through stoma; occlude stoma and administer through mouth/nose
Damage to Trachea
wall necrosis: tissue damage that results when presure of inflated cuff impairs blood flow to tracheal wall

senosis: narrowing of tracheal lumen due to scar formation: resulting from irritation of mucosa fromtracheal tube cuff
-Keep pressure between 14-20mmHg
-Check pressure at least once/8hr
-Keep tube in midline position and prevent pulling or traction on tube
Nasogastric Intubation use
Decompressiong: removal of gases or stomach contents to relieve distention, nausea or vomiting (salem sump, Miller-Abbot, Levin)
Feeding: route of administering nutritional supplements when oral/esophageal passageways cant be used (Duo, Levin, Dobbhoff)
Lavage: Washing out the stomach to treat overdose or ingestion of poison (Ewalk, Levin, Salem sump)
Compression: Applied pressure using an internal balloon to prevent hemorrhage (Sengstaken-Blakemore)
Placement check for NG tube
-Ask client to talk
-Inspect posterior pharynx for coiling
-Aspirate gently to collect gastric content and observe the color
-Test pH (should be 4 or less)
-If prescribed: confirm with x-ray
-DO NOT Inject air into the tube then listen over the abdomen

If tube is not in stomach, advance 5cm and repeat tests
Documentation after removal/discontinuation of NG tube
-Tubing removal and condition
-Volume and description of drainage
-Abdominal assessment
-Last and next bowel movement
-Urine output
NG complications
Excoriation of nares/stomach: apply lubricant as needed to nares; assess color of drainage and report coffee-ground, dark or blood-streaked drainage immediately to provider

Discomfort: Rinse mouth with water for dryness; throat lozenges; frequent oral hygiene

Occlusion leading to distention: irrigate tube per protocol to unclog blockages; tap water may be used with feeding; change position in case tube is against stomach wall
enteral formulas
Polymeric: (1.0-2/0 kcal/mL) milk based, blenderized foods; only if GI tract can absorb whole nutrients
Modular formulas (3.8-4.0 kcal/mL): single macronutrient preperation; not nutritionally complete; added for supplmental nutrition
Elemental formula (1.0-3.0 kcal/mL): predigested nutrients; not nutritionally complete; easier to absorb
Specialty formula (1.0-2/0 kcal/mL): created to meet specific nutritional needs; not nutritionally complete; primarily for those with hepatic failure, respiratory disease or HIV
Enteral access tubes
NG/NI: therapy shorter than 4 weeks; via nose

Gastrostomy or jejunostomy: therapy longer than 4 weeks; inserted surgically

Percutaneous endoscopic gastrostomy PEG or jejunostomy PEJ: therapy longer than 4 weeks; inserted endoscopically
eneteral feeding
-Fowelers; head of bed at least at 30d
-Monitor tube placement and residual (100mL gastric; 10mL intestinal)
-Flush 30-60mL tap water
-Administer feeding (60mL syringe filled with 40-50mL formula; hold tubing above instillation site; if feeding bag-fill with total amount and hang until empty-30m)
-Follow with 60-100mL tap to flush/prevent clog
-Monitor: I&O-24 hr totals, capillary blood glucose every 6hr till max rate is sustained for 24hrs, gastric residual every 4-8hrs)
-Infusion pump for intestinal feeding
NG/Enteral Complications
-gastric residual over 100/10mL: Withhold feeding, notify provider; maintain semi-F; recheck in hour/prescribed
-Diarrhea 3+ times in 24hrs: Notify provider, confer with dietition; provide skin care/protection
-N/V: Withhold feeding; turn client to side; notify provider; check patency; aspirate for residual and auscultate bowels
-Aspiration of formula: Withhold feeding; notify; turn client to side; suction airway; monitor vitals for elevated temp; auscultate breath sounds for congestion; obtain chest x-ray; o2 as indicated
-Skin irritation around tubing: Provide skin barrier from drainage; monitor tube placement
Maintaining a sterile field
only sterile items in the field
prolonged exposure can make items nonsterile
1-inch edges are non sterile
Touch only sterile materials
Below waist or above chest means contamination
Do not turn back or reach across field
hold items to be added at least 6 inches above field
Keep dry
Sterile technique procedure
-Hand hygiene
-Open plastic covering top flap away from body with thumb and index finger
-Side flaps using hand on that side
-Last flap gets turned down toward body
-Pour sterile solutions: remove cap and place face up on surface, hold bottle with label in the palm so solution doesnt run down it, dont touch bottle to site
Don sterile gloves
with the cuff side pointing toward body, use left hand to pick up the right glove by folded bottom edge and pull right gloves onto hand

then place fingers of right hand inside cuff of left glove, lifting it

then adjust
Pouring sterile solution
Remove cap and place face up on DF

Hold w label in palm to avoid drainage onto it

Start with small amounts into available receptacle

Dont let bottle touch site
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