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105 test #2
| Question | Answer |
|---|---|
| nasal cannula | 1-6 L/min; 24-44% O2 |
| simple mask | provides reservoir 5-8 L/min; 50 -60% |
| non-rebreather mask | large reservoir; 8-10 L/min; 60-100% |
| pulse oximetry | non-invasive measurement of oxygen level in hemoglobin |
| tracheostomy | a surgical opening in the trachea just below the larynx |
| endotracheal tubes | most commonly inserted in clients who have had general anesthetics or for those in emergency situations in which mechanical ventilation is required |
| tracheostomy care | know the type of trach tube patient has, clear out mucus every 8 hours |
| suctioning | aspiration of secretions through a catherter that is connected to a suction machine or wall suction outlet |
| suctioning purpose | remove secretions and clear the airway |
| pressure for orolpharyngeal, nasopharyngeal, endotracheal, and tracheostomy suctioning | 80 - 100 mmHg |
| Oral suctioning is a ________ procedure | non-sterile |
| Nasal suctioning is a _________ procedure | sterile |
| Endotracheal/Tracheostomy suctioning is a _______ procedure | sterile |
| Types of catheters | flexible and rigid/yankauer |
| flexible catheters | sized by outer diameter, less than 1/2 diameter of artificial airway |
| Rigid/Yankauer catheters | pre-oxygenate 100% 1 min before suction, advance quickly, suction time 10-15 sec, may need to reoxygenate |
| Deep breathing techniques | incentive spirometery |
| deep breathing technique goals | inflate the lung, prevent alveolar collapse (atelectasis), treat or prevent complications (related to post op or lack of mobility) |
| Coaching a patient for IS | fowler's or semi-fowler's, encourage max effort, push stomach out, hold breath at end inspiration for 3-5sec, relax and exhale |
| Goals for IS | deep breaths are the goal, not fast deep breaths which may hyperventilate the patient, low CO2 cause dizziness, may cause fainting |
| Make sure you do this with IS | take frequent breaks to prevent hyperventilation, encourage the patient to cough, use a pillow to splint any incisions during coughing |
| Procedure of IS | introduce the device, seal lips around mouthpiece, breathe slow and deep, flow or volume indicator as a motivator, breath hold, splint/cough |
| medication administration 6 rights | right drug, right dose, right time, right route, right patient, right documentation |
| must know medication | action, duration, expected effect, contra-indications, normal dose range, compatibilities, side effects |
| a medication error is a right gone wrong...if it happens what do you do? | care for patient, call MD/supervisor, and document |
| Non-parenteral routes | oral and topical routes |
| oral routes | sublingual/buccal and enteral |
| topical routes | dermatologic, ophthalmic/otic, nasal, rectal/vaginal, inhalers |
| key points for giving injection | no recapping, "scoop" method, restrain children if needed, if you aspirate blood, withdraw needle, throw away, and prepare another syringe |
| Luer-Lok syringe | needle is twisted on the tip |
| non Luer-Lok syringe | smooth, graduated tip |
| Check what for vial medication | multi or single dose and check date and time opened |
| Reconstituting medication from a powder reminders | Draw up correct amount and kind of diluent, mix medication completely, multi-dose vials - document concentration of dose on label, date, & time, and change needle |
| Intradermal injection examples | TB testing and allergy testing |
| Intradermal angle | 5-15 degrees |
| intradermal needle size | small size needle 26-27 gauge, 1/4" to 1/2" |
| intradermal volume of solution | 0.01 - 0.1 ml |
| intradermal sites | create a bleb on the ventral forearm, upper chest or the back beneath the scapula |
| how do you want the needle tip facing in an intradermal injection? | bevel up |
| subcutaneous injection angle | 45 to 90 degrees - body mass |
| subcutaneous needle size | small size needle 25 gauge ( 1/2 - 5/8 inch) |
| subcutaneous injection volume | 0.5 - 1 ml |
| what dont you do with subcutaneous injections and why? | do not aspirate because it can cause tissue trauma |
| intramuscular injection needle size | needle size for average adult is 21-25 gauge with 1-1 1/2" |
| intramuscular injection angle | 90 degrees |
| intramuscular injection volume | 1-2 ml recommended |
| intramuscular sites | deltoid, ventrogluteal, vastas lateralis |
| deltoid injections typically are used for what? | vaccines |
| vastis lateralis injections are usually used on who? | < 1 years of age |
| z-track method | prevents seepage of the medication into the subcutaneous tissues and subsequent discomfort |
| surgical asepsis | absence of all microorganisms and spores |
| when to use sterile technique | during procedures that require intertional perforation of the skin, skin integrity is broken, and entering a sterile body cavity |
| Maintaining a sterile field | only sterile items on sterile field, open dispense and transfer items w/o contamination, do not reach across sterile field, if sterile barrier has been cut wet or torn consider contaminated, do not place near open windows or doors |
| Principles of surgical asepsis | movement in and around sterile field must not contaminate sterile field, must be established immediately, never before, not covered, always be in view, no touch technique |
| golden rule of surgical asepsis | when in doubt, it is contaminated |
| key points of sterile gloves | find the thumb, keep thumb of gloved hand out of the way when donning the second glove, and be aware of closeness of gloves to table |
| staple removal | 1) place tip under staple, 2) squeeze handle, 3) gently lift, 4) release handles, 5) assess for healing edge ridge |
| steri strips | gently cleanse suture line, inspect incision, apply tincure of benzion in not allergic, apply steri strip, remove backing |
| dry wound dressing indications | drainage, direct pressure, support, immobilize, protection |
| how do you clean a wound? | cleanest to dirtiest |
| wound assessment | location, size, and edges approximated |
| wound appearance | color, pink, beefy red granulation tissue |
| eschar | black, dead tissue |
| slough | yellow dead tissue |
| purulent | pus |
| serous | clear drainage |
| serosanguineous | clear, bright bloody; "new" |
| sanguineous | dark red blood, usually old blood |
| where would you culture an aerobic wound? | on the surface |
| where would you culture an anaerobic wound? | deep in the tissue |
| 2nd most common wound infection | nosocomial infection |
| a wound is infected if...? | purulent drainage is present |
| signs and symptoms of infection | warmth, redness, pain, swelling, purulent drainage |
| surgical wound infection can happen in? | 4th or 5th day |
| contaminated wound can get infected in? | 2 or 3 days |
| primary intention wound | clean wound, edges well approximated, capillary bridge in 3-4 days |
| secondary intention wound | extensive tissue loss, longer healing time, > chance of infection, more scar tissue |
| wound dehiscence | separation of wound edges at suture line, appearance of underlying tissues, occurs 6-8 days post surgery |
| wound evisceration | protrusion of internal organs and tissues through incision |
| intervention for wound evisceration | cover with sterile moist saline, call doc ASAP, surgical emergency |
| principles of wound cleaning | use separate swab for each stroke, circular motion moving outward, least contaminated to most contaminated |
| solutions to avoid | hydrogen peroxide and betadine |
| best solution to use | normal saline |
| why use dressings? | prevent infection, provide comfort, support wound healing |
| types of dressing | absorbent (gauze), non-abherent (telfa), transparent (tegaderm), and hydrocolloid (duoderm) |
| wound packing | moist vs dripping wet, dressing in contact with wound bed, not packed to tight, and no dead air spaces |
| montgomery straps | commonly used for wounds requiring frequent dressing changes |
| montgomery strap rationale | prevent skin irritation and discomfort caused by removing the adhesive each time the dressing is changed |
| types of drains | penrose, jackson-pratt, hemovac/constavac |
| penrose drain | a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing |
| Jackson-Pratt drain | a portable drainage suction device used in closed wound drainage systems |
| Hemovac drain | a portable drainage suction device used in closed wound drainage systems |
| ostomy types | bowel diversions and urinary diversions |
| bowel diversions are? | certain diseases cause conditions that prevent normal passage of feces through rectum |
| what do you do for a bowel diversion? | temporary or permanent artificial opening are created in the abdominal wall - i.e. colostomy or ileostomy |
| indications for urinary diversion? | bladder cancer, trauma, bladder injury d/t radiation, neurogenic bladder or chronic cystitis |
| urinary stoma is created to? | divert the flow of urine from the kidneys directly to the abdominal surface |
| purpose of pouching | contain effluent or drainage and to protect the skin surrounding the stoma |
| stoma | artificial opening of the bowel into abdominal wall |
| colostomy | surgical opening of colon |
| ileostomy | surgical opening of ileum |
| ostomy care | drainage system, skin care, odor control, monitor for leakage, self-image |
Created by:
laurenkraemer
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