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