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GWCC Block 2 nursing

Health problems that increase surgical risk Malnutrition; Obesity; Cardiac complications; Blood coagulation disorders; Upper Respiratory/COPD; Renal disease; Diabetes mellitus; Uncontrolled neuro disease (seizures)
Why is obesity an increased surgical risk? leads to hypertension, impaired cardio function, impaired respiration. Delayed would healing b/c adipose tissue impedes circulation.
Why does renal disease have increased surgical risk? Regulation of body fluids, electrolyte, acid/base balance, excretion of drugs and toxins
Why does liver disease have increased surgical risk? impairs ability to detoxify/metabolize meds. Liver makes proteins (prothrombin for clotting and others for wound healing).
Why does diabetes mellitus have increased surgical risk? Delayed wound healing, predisposes patient for wound infection
The use of what meds can increase surgical risk? anticoagulants; tranquilizers; cortocosteriods; diuretics
topical anesthesia applied directly to skin, mucous membranes, wounds. Xylocaine & benzocaine
local anesthesia (infiltration) injected into a specific area. Lidocaine & tetracaine 0.1%
nerve block anesthetic agent is injected around a nerve or group of nerves. Major (brachial plexis - arm) and minor (facial)
intravenous (Bier) block occlusion tourniquet is applied to prevent infiltration/aborption beyond the extremity. Used most for arms, hands & wrists.
spinal anesthesia (SAB- subarachnoid block) lumbar puncture between L2 and S1. Low (saddle block- perineal/rectal); Mid (below umbilicus- hernia, appendectomies), High (reaching nipple line- csections)
epidural (peridural) anesthesia injected med into epidural space, the area inside the spinal column but outside dura mater.
conscious sedation minimal depression of LOC so client can retain patent airway and respond to commands. IV narcotics: fentanyl, diazepam (valium), Versed. Induces amnesia and higher pain threshold, prompt reversal of effects.
Position during immediate postanesthetic stage for an unconscious client. On the side, face slightly down to allow drainage. No pillow. Elevate upper arm on pillow to allow maximum respiration. Artificial airway remains in place until client starts to gag/cough.
Patients are released from PACU when . . . conscious, oriented, able to breathe freely, cough, stable vital signs for 30 minutes, protective reflexes (gag, swallow) intact, move all extremities, I&O 30ml/hr, afebrile, dressings dry/intact, no overt drainage
Post-op patient vital schedule every 15 minutes until vital signs stable; every hour for the next four hours; every 4 hours for the next 2 days.
What do nurses assess post-operatively? LOC; vital signs; skin color/temp; comfort; fluid balance; dressing & bedclothes (for hemorrhage); drains and tubes.
Pneumonia signs elevated temperature, cough, expectoration of blood-tinged or purulent sputum, dyspnea, chest pain.
atelectasis signs dyspnea tachypnea, tachycardia, diaphoresis, anxiety, pleural pain, decreased chest wall movement, dull/absent breath sounds, decreased O2 sat, sudden chest pain, SOB, cyanosis, shock (tachycardia w/ low BP)
pulmonary embolism signs sudden chest pain, SOB, cyanosis, shock (tachycardia w/ low BP)
hemorrhage signs excess bleeding, increased pain, increased abdominal girth, swelling or bruising around incision
hypovolemic shock signs rapid, weak pulse, dyspnea, tachypnea, restlessness and anxiety, urine less than 30mL/hour, decreased BP, cool clammy skin, thirst, pallor
thrombophlebitis inflammation of veins: aching, cramping pain, affected area swollen, red and hot to touch, vein feels hard, discomfort in calf when foot is dorsiflexed or when client walks (Homan's sign)
thrombus stationary clot
embolus clot that has become dislodged
Assessing surgical wounds (6) appearance (color, approximation of wound edges); size, drainage (color, consistency, odor, degree of bandage saturation); swelling; pain, drains or tube (security, placement, character of drainage, functioning of drainage apparatus)
Sequential signs of healing for primary intention (surgical) wounds 1. Absence of bleeding/formation of clot; 2. inflammation of wound edges for 1-3 days; 3. reduction in inflammation, bridge and closed in 7-10 days; 4. scar formation; 5. diminished scar over time
Guidelines for cleaning a wound with a penrose drain The Penrose drain is considered to be less clean than the surgical incision because of the drainage from the Penrose drain. Clean the main surgical incision first. Then clean the Penrose drain using different equipment/dressing/cleaning supplies.
When removing tape, pull the tape ____ the wound. Towards- to prevent straining the incision.
When changing bandages that involve a Penrose drain, make sure not to pull the bandage off without making sure that the drain is not attached to the bandage! Sometimes the drain may stick to the bandage.
If using forceps to assist in cleaning a wound . . keep the forcep tips lower than the handles at all times to prevent contamination and fluid traveling up the handle and to the nurse's wrist, and back to the tips.
A double-lumen NG tube is used for: suctioning the stomach of secretions. The larger lumen allows delivery of liquids or removal of secretions. The smaller lumen allows for airflow into the stomach, which prevents vacuum pressure in the stomach/adherence to the stomach wall.
What is a nasoenteric tube? a longer tube (longer than the NG tube) that is inserted into the top part of the small intestine.
How to measure an NG tube measure from the tip of the nose to the tip of the earlobe, and then down to the tip of the xiphoid.
What position should the client's head be in when inserting an NG tube? hyper-extend the neck to reduce the curvature of the nasopharyngeal junction.
How should the NG tube be guided in? direct the tube along the floor of the nostril and towards the ear on that side. This avoids nasal turbinates along the lateral wall.
When placing an NG tube, and the client begins to gag and retch, what should the nurse do? Ask the client to tilt the head forward and encourage the client to drink and swallow. Tilting the head forward facilitates passage of the tube into the posterior pharynx and esophagus rather than the larynx.
Gastric pH should be at: 1 to 5. 6 or grater indicates the tube is in the respiratory tract or lower in the intestinal tract.
Before removing an NG tube: instill 50mL of air into the tube to clear it of gastric contents.
Define bolus feeding use a syringe to deliver the formula
Define continuous feeding administered over a 24 hour period at a constant flow
Define cyclic feeding continuous feeding that is administered in less than 24 hours (12 or 16 hours, usually overnight)
Open systems of formula can hang for 8-12 hours
Closed systems of formula can hang for 48 hours if sterile technique is used
If more than ___mL is aspirated when checking residuals before the next feeding, check with the nurse in charge or agency policy. 100
When using a prefilled bottle for tube-feeding, hang it on an IV pole about ___ inches above tube insertion point. 12
For continuous feedings, check residual every ___hours. 4-8
Hyperinflate with ambu bag: 3-5 times before performing suction or trach care. Do not do this if the client has copious secretions, as it can cause the secretions to go further down in the airway.
What should the setting be when using suction? 80-120
Hyperoxygenation of client on ventilator: turn it on 100% O2 for 2 minutes prior to suction/trach care
Insert the suction catheter ___ inches. Withdraw the catheter ___ cm before applying suction to prevent damage to bifurcation of trachea. 5 inches, 2 cm (0.4 to 0.8 inches)
Allow ____ minutes between suctions to allow for client recovery. 1 minute
Isotonic Solutions Normal Saline (0.9% NaCl); Lactated Ringers; D5W (5% dextrose in water)
Veins used for IV infusion in the hand/arms metacarpal, basilic, cephalic
Basilic vein is on the __ side of the arm. The Cephalic vein is on the __ side of the arm. Basilic- pinky; Cephalic- thumb
A central venous catheter is usually placed in ___ and the end is__. Risks include___. subclavian or jugular vein, with distal tep resting in the superior vena cava just above the right atrium. Risks include hemothorax, pneumothorax, cardiac perforation, thrombosis, infection.
Peripherally inserted central venous catheters (PICC lines) are usually placed ____. The advantage of a PICC line is ___. in the basilic or cephalic vein just abouve or below the antecubital space of the right arm with tip resting in superior vena cava. Eliminates risk of pneumothorax.
For routine hydration and intermittent therapies use a ___ gauge IV catheter. 20 (ideal) to 27
For transfusion therapies use a ___ gauge IV catheter. 20
For neonates or clients with fragile veins use ___ gauge IV catheter. 24-27
The over-the-needle catheter should be inserted at __ angle. 15-30 degrees, with bevel up
Label the IV site with: date, time, size of catheter, and initials
For a butterfly needle, insert it in the direction of ___. blood flow.
pleural effusion fluid that accumulates in the pleural space of the lungs
pneumothorax air in the pleural space
hemothorax blood in the pleural space
What FR size is used for chest tubes? 14 F for uncomplicated cases, 18 F for thick secretions.
What do you ask the patient to do during removal of the chest tube? valsalva maneuver
When using a dry suction unit for chest tube collection, set the wall suction at ___ to achieve a -20 pressure on the unit. at least 80
What does a nurse assess in a pt with a chest tube? crepitis, constant air flow in the unit (instead of normal tidal volume).
If a pt with a chest tube gets more than ___mL/hr it is a hemorrhage 100
If a chest tube becomes clotted, ___. contact the physician. Don't try to unclot it yourself.
artifact during an ECG, when the patient is moving or when using electrodes that are too dry. Abnormal reading.
60-cycle interference electrical problems with ECG unit
wandering baselines caused by breathing and electrodes moving too much during ECG
P wave depolarization of atria (sinus node)
QRS complex depolarization of ventricles
T wave re-polarization of ventricles
Where is a specimen collected from a chest tube? Directly from the tube. Not from the collection unit.
When the ___ , a pt with a chest tube is considered healed. tidal stops moving
TKO "to keep open" referring to the order to keep the IV open and flow moving. Usually set to 20-30mL/hr for this purpose
When prepping an area for IV/vein puncture ___. use a chloroprep to go vigorously back and forth.
Every time you change an IV site, you have to move ___. up from the last site.
Do not draw blood ___ an IV site. above
When trying to get an IV placed, the RN should only try __ times before getting another RN. 2
Place the tourniquet ___. It should not be kept on longer than ___. 6 inches above the site. 2 minutes.
What is the formula for calculating gtts/min? (volume/hour x drip factor on bag) divided by 60 min
How long can IV tubing last? 2 days
How long can bags hang (saline)? 24 hours
How long can catheters last? 2-4 days
How long can TPN hang? 24 hours
What kind of needle/catheter should be used for which circumstance when drawing blood? tube holders- standard; syringe- fragile veins; butterfly- large amt. of blood being taken, children, or difficult sticks.
When puncturing a vein, do NOT ___. put your finger above the needle!
V1 4th intercostal space to right of sternum
V2 4th intercostal space to left of sternum
V4 mid-clavicular line & 5th intercostal space
V6 mid-axillary line, horizonal V4
V5 between V4 & V2
V3 between V4 & V2
Created by: AmericanChai