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2431 Unit 3 BP

Early s/s hypoxemia may be rapid and obvious or may be insidious and gradual; confusion (1st), dyspnea, sob, restlessness, tachycardia, tachypnea, anxiety, cyanosis
disorders that benefit from a humidifier: sinus disorders
types of masks for O2 delivery: nasal cannula, venturi mask (can adjust to specific percentage of O2), face mask, tracheostomy collar, face tent, non-rebreathing mask, partial rebreathing mask (PAGE 523)
nasopharyngeal airway keeps the tongue from falling back into the throat along with oropharyngeal airway
trach suctioning: required for pts unable to clear secretions from their own airway effectively; nasopharyngeal or oral suction; can be performed with a Uankaur suction tip or with a 14-16 Fr suction catheter attached to wall suction; negative pressure set 80-120 mmHg
trach suctioning continued: preoxygenate pt for 1 minute; moisten catheter tip in sterile saline solution and suction a small bit to test the suction system; apply suction while rotating and withdrawing the catheter (for no more than 10 seconds); SKILL ON PG. 533-535
trach suctioning continued: aseptic (sterile) technique used for airway suctioning(nasal, tracheostomy, pharyngeal)
Nasotracheal suctioning (always try oral suction before nasopharyngeal) Maintain patent airway by removing accumulated secretions; involves upper air passages of nose, mouth, pharynx; used most often for infants, gravely debilitated or unconscious, and those with ineffective cough; suction pressure between 80 and 120 mm Hg
supplies needed for chest tube removal: suture kit, petroleum jelly, dry gauze, tape (check this - not sure)
amount of fluid increase needed to thin secretions: 2-3 L
incentive spirometer use: used to expand lungs and prevent atelectasis; GET DIRECTIONS FOR USE
position of pt with SOB with emphysema picture on pg. 532; position pt who is very sob in the orthopneic position, using pillows on the over-the-bed table
trach care: done every 8 hrs or as needed to keep secretions from becoming dried; suction and clean skin around stoma; change dressing; clean inner cannula if there is one; replace ties that hold the tube in place when they are soiled.
trach care continued: used 1/2 strength peroxide and 1/2 NS; pt in semi-Fowler's position or supine; document number of times suctioned, type of technique used (sterile), characteristics of secretions, any problems encountered.
causes of hypoxia: (pg. 509) obstruction of airway (tongue, mucous, inflammation, occlusion, burns, COPD, water); restricted movement of thoracic cage or pleura (from surgery, injury, pneumothorax, extreme obesity, disease)
more causes of hypoxia: decreased neuromuscular function (depressed CNS, drugs, coma, disease); disturbance in diffusion of gases (disease, trauma, emboli, tumor, respiratory distress syndrome); environmental causes (high altitude)
retractions muscles move inward on inspiration
trach care teaching for home pt's avoid crowded areas; keep house clean and free of dust; disinfect equipment with bleach
abdominal binder - best used for whom? surgeries with large incisions (abdominal)
stages of anesthesia Stage I - stage of analgesia; Stage II (KEEP ROOM QUIET) excitement phase; Stage III - surgical anesthesia stage; Stage IV - complete respiratory depression
assessment data that must e accurate for anesthesia height and weight
informed consent surgeon should obtain; RN witnesses signature; LVN - be sure it is in chart; parent must sign if patient is under 18
telephone consent two nurses should listen when phone consent given
purpose of TCDB prevent atelectasis; prevent pneumonia; prevent DVTs; promote healing
surgical skin prep pt may be asked to shower with special antibacterial cleanser; body hair may be removed; dressed in gown w/o underwear; hair covered with surgical cap; dentures most often removed; jewelry removed or taped
administering prep meds - best time to do so give anti-anxiety meds after the pt has emptied their bladder
jewelry placement prior to surgery off or covered with tape
items needed to be ready for post op patient clean bed, emesis basin, suction, oxygen
same day surgery recovery and teaching do not drive or make important decisions for 24 hours after surgery
frequency of vital signs in PACU every 15 minutes for first hour; every 30 minutes for next 2 hours; every hour for 4 hours or until pt is totally recovered and vs have returned to normal
best position for post op patient that remains drowsy and difficult to arouse on side
marking drainage outline on dressing, reinforce with more bandages
normal urine output 30 mL/hr
procedure for assisting pt OOB for first time following surgery raise HOB; have them get up slowly; dangle feet on side of bed; move slowly to prevent dizziness and injury from falling
primary intention wound has little tissue loss - edges of wound are approximate and only slight chance of infection
abrasions scraping away layers of skin
purulent containing pus
Jackson Pratt drain emptying procedure After emptying drainage, compress the bulb of device to activate it when reapplying
Telfa non-adherant pad used so skin doesn't come off
Montgomery straps for frequent dressing changes; used to hold dressing in place
ecchymosis flat, hemorrhagic blue or purplish patch on skin or mucous membrane; bruising
removing dressings - including wet to dry dressing remove from corners first; use NS if sticking
removing staples squeeze and rock back and forth to remove
chest tube care mark each shift
s/s internal hemorrhage restlessness, anxiety, increased HR, decreased BP
irrigating non-infected wounds use asceptic technique, use sterile gloves, keep syring tip 1" from wound surface, use sterile NS
independent nursing interventions to relieve gas pains drink through straw, Simethecone, etc.
sterile dressing change procedure check order; determine if pt ready; gather supplies; hand hygeine, gloves, inspect wound - note degree of healing, presnece of pus, necrosis, check for odor, drainage, condition of sutures; wash hands again; set up sterile field; change dressing
sterile dressing change procedure continued use separate swab from top to bottom on each side of incision and continue outward; use separate swab from wound edge outward then other side from top to bottom; do not cleanse directly over wound unless excessive drainage
sterile dressing change procedure continued cleanse drain sites using circular motion from the drain outward; use circular motion; discard in biohazard bag; document conditionof wound, including subjective statements of pt, objective observations, health teaching performed for wound care
Created by: akgalyean