AI Exam 3 Objectives
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27 terms
Terms | Definitions |
|---|---|
 Obtaining Sterile Urine Specimen from a Foley | - using a blunt needle and a 5cc syringe, obtain from port - never get sample from receptacle (drainage bag) - always use sterile technique while collecting urine specimen from an indwelling cath - if there is no urine present in tube clamp the tube below the access port briefly (no longer than 30 min) to allow urine to accumulate - clean the access port with an antiseptic swab and attach the needle |
| Instructions for a Clean Catch Urine Specimen | - clean catch = midstream - obtain only midsream urine in specimen cup; avoid catching beginning and end |
| 24 Hour Urine Specimen | - first voided specimen is not included - everything after first void goes into a bucket and is kept on ice/in fridge - important to collect all urine voided during the 24 hr period - start at a certain time; empty bladder at this time (discard that specimen) then 24 hrs later have pt empty bladder again (add this to previously collected urine) |
| Urinalysis Lab Values | - examine for physical color and appearance (cloudy/clear, color) - urine should not contain: blood, WBCs, RBCs, hemaglobin, nitrates, glucose, ketones, protein, bilirubin - pH ~ 6 (4.6-8) - specific gravity: 1.015-1.025 - Infection: WBCs and nitrates (a byproduct of bacteria) |
| Post-Residual Void | - bladder ultra sound (prefered) - intermittent/straight cath (risk for infection) - 50 mL = adequate bladder emptying - 150 mL = inc risk for UTI so cath may be needed |
| NG Tube Safety and Concerns | - aspiration - inserting tube into trachea/lung - Always verify placement: aspirate residual and assess visually and for pH <5.5; x-ray; tube measurement (mark on tube) |
| NG Tube Med Admin | - verify placement immediately before giving meds - leave off suction for 30-45 min after administering and aspirate residual before hooking up to suction to check stomach content |
| Dobhoff Tube | - smaller and more flexible than other NGs - provides pt greater comfort and less trauma to nares - used only for administering nourishment and meds (not for GI drainage - no suction) - Placed using a guide wire - difficult to aspirate bc of small size and flexibility; check placement by x-ray |
| Wound Dressings | - keep wound moist, promoting healing - allows wound fluids to keep surface of the wound moist and covered wounds can help pts cope with alteration in body image - frequency of dressing changes depends on amt of drainage (dressing should never be saturated), provider's preference, and nature of wound |
| Dressings: Transparent Films | - small partial thickness wounds with minimal drainage - stage I pressure ulcers - cover dressings for gels, foams, and guaze - secure IV catheters, nasal cannulas - chest tube dressing - central venous access devices |
| Dressings: Hydrocolloids | - partial and full thickness wounds - light to moderate drainage - necrosis or slough - NOT for infected wounds |
| Dressings: Hydrogels | - partial and full thickness - necrotic - burns - dry wounds - minimal exudate - infected wounds |
| Dressings: Alginates | - moderate to heavy exudate - infected or noninfected - partial and full thickness - tunneling - moist red and yellow - NOT for minimal drainage or dry eschar |
| Dressings: Foams | - absorb light to heavy amts of drainage - use around tubes and drains - NOT for dry eschar |
| Dressings: Antimicrobials | - draining - exudate - nonhealing - protect from bacterial contamination and reduce bacterial contamination - acute and chronic wounds |
| Dressings: Collagens | - partial and full thickness - infected and noninfected - skin grafts - donor sites - tunneling - moist red and yellow - minimal to heavy exudate |
| Dressings: Composites | - partial and full thickness - minimal to heavy exudate - necrotic tissue - mixed granulation and necrotic tissue - infected wounds |
| Pressure Ulcer Prevention | - assess at risk pts regularly (bony prominence) - cleanse skin routinely and when soiling occurs (mild agent, minimal friction, no hot water) - maintain higher humidity in environ and moisturize dry skin - avoid massage over bony prominences - protect skin from moisture (incontinence, wound drainage) - minimize friction and shearing forces - investigate inadequate diet and provide supplements when needed - improve or maintain mobility and ROM |
| Braden Scale for Skin Breakdown | - No Risk 19-23 - Mild Risk 15-18 - Moderate Risk 13-14 - High Risk 10-12 - Very High 9 and below - Sensory Perception; Moisture; Activity; Mobility; Nutrition: Friction and Shear |
| Shearing Force | - when one layer of tissue slides over another layer - separates skin from underlying tissues, small bld vessels and capillaries in the area are stretched and possibly tear resulting in dec circulation in tissue under skin - pts who are pulled rather than lifted in bed/chair; sliding down in bed/chair |
| High Risk for Pressure Ulcers | - aging skin - chronic illness - immobility - malnutrition (protein and calorie deficient) - fecal and urinary incontinence (moisture) - altered LOC; spinal cord and brain injuries; neuromuscular disordres |
| Nutritional Factors Facilitating Healing | - wound healing requires adequate protein, carbs, fats, vits, and mins - calories and prots: rebuild cells/tissue - Vit A&C: epithelialization and collagen synth - Zinc: proliferation of cells - Fluids: optimal cell fxn - All phases of wound healing process are slowed or inadequate in pt with poor nutrition and fliuid balance |
| Pre-Op Teaching | - TCDB (turn, cough, deep breathing): helps clear off anesthesia and prevent atelectasis - incentinve spirometer, diaphragmatic breathing - leg, feet, arm exercises; SCDs; TEDs: prevent DVTs - wound care: tubes/drains, inciscional splinting - diet, pain mgmt, exericse and activity level; fear/anxiety about surgery |
| Post-Op Coughing | - sit up and lean slightly forward, splinting incision with interlaced fingers or pillow - breathe with diaphragm - breathe in fully with mouth slightly open and 'hack' out sharply for 3 short breaths - keeping mouth open, take a quick deep breath and immediately give strong cough once or twice - helps clear secretions from chest, may cause some discomfort but won't harm incision |
| Risk for Post-Op Impaired Wound Healing | - pts who are diabetic, obese, and/or on steroids - pts with nutritional deficits (especially carbs) - chronic illness |
| S&S of Post-Op Hemorrhage | - dec BP, inc pulse - restlessness, disorientation - cool, clammy skin; cyanosis; pallor - thirst, dec UO - +/- sanguineous drainage |
| Pain Meds in Elderly | - acetaminophen may be used cautiously for mild to moderate pain - NSAIDs have potential for renal and gastric complications and a proton pump inhibitor should also be prescribed - Use IM and IV analgesics cautiously becuase decreased circulation poses a risk for reduced absorption of opioids |
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