2431 Unit 3 BP
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| Early s/s hypoxemia | may be rapid and obvious or may be insidious and gradual; confusion (1st), dyspnea, sob, restlessness, tachycardia, tachypnea, anxiety, cyanosis
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| disorders that benefit from a humidifier: | sinus disorders
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| 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)
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| nasopharyngeal airway | keeps the tongue from falling back into the throat along with oropharyngeal airway
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| 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
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| 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
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| trach suctioning continued: | aseptic (sterile) technique used for airway suctioning(nasal, tracheostomy, pharyngeal)
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| 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
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| supplies needed for chest tube removal: | suture kit, petroleum jelly, dry gauze, tape (check this - not sure)
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| amount of fluid increase needed to thin secretions: | 2-3 L
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| incentive spirometer use: | used to expand lungs and prevent atelectasis; GET DIRECTIONS FOR USE
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| 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
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| 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.
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| 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.
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| 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)
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| 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)
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| retractions | muscles move inward on inspiration
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| trach care teaching for home pt's | avoid crowded areas; keep house clean and free of dust; disinfect equipment with bleach
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| abdominal binder - best used for whom? | surgeries with large incisions (abdominal)
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| 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
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| assessment data that must e accurate for anesthesia | height and weight
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| informed consent | surgeon should obtain; RN witnesses signature; LVN - be sure it is in chart; parent must sign if patient is under 18
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| telephone consent | two nurses should listen when phone consent given
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| purpose of TCDB | prevent atelectasis; prevent pneumonia; prevent DVTs; promote healing
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| 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
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| administering prep meds - best time to do so | give anti-anxiety meds after the pt has emptied their bladder
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| jewelry placement prior to surgery | off or covered with tape
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| items needed to be ready for post op patient | clean bed, emesis basin, suction, oxygen
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| same day surgery recovery and teaching | do not drive or make important decisions for 24 hours after surgery
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| 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
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| best position for post op patient that remains drowsy and difficult to arouse | on side
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| marking drainage | outline on dressing, reinforce with more bandages
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| normal urine output | 30 mL/hr
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| 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
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| primary intention | wound has little tissue loss - edges of wound are approximate and only slight chance of infection
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| abrasions | scraping away layers of skin
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| purulent | containing pus
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| Jackson Pratt drain emptying procedure | After emptying drainage, compress the bulb of device to activate it when reapplying
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| Telfa | non-adherant pad used so skin doesn't come off
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| Montgomery straps | for frequent dressing changes; used to hold dressing in place
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| ecchymosis | flat, hemorrhagic blue or purplish patch on skin or mucous membrane; bruising
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| removing dressings - including wet to dry dressing | remove from corners first; use NS if sticking
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| removing staples | squeeze and rock back and forth to remove
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| chest tube care | mark each shift
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| s/s internal hemorrhage | restlessness, anxiety, increased HR, decreased BP
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| irrigating non-infected wounds | use asceptic technique, use sterile gloves, keep syring tip 1" from wound surface, use sterile NS
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| independent nursing interventions to relieve gas pains | drink through straw, Simethecone, etc.
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| 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
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| 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
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| 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
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