Intermediate nursing 4

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Terms in this set (116)
2nd type of anesthesiaRegional-nerve block;loss of sensation in am area of the body no loss of conscioness Injected along the nerve3rd type of anesthesiaConscious sedation-Local injection plus intravenous sedation causing a depressed level of consciousness4th type of anesthesiaLocal anesthesia-injected or applied topically at the desired site causing a loss of sensationPreoperative pt instructionsDIET AND RESTRICTION(NPO)-foods and fluid are usually restricted 6-8 hours before surgery REST AND ACTIVITY-pt must rest after surgery; every 1-2 hrs after surgery pt must perform leg, range of motion,turning coughing,and deep breathing exercises ELIMINATION-enema may be ordered for colon surgery,ask pt to empty bladder unless there's a catheter in place prior to pre-op meds administered GOALS-Prepared physically and emotionally,able to demonstrate exercises,verbalize underatanding of procedure1st step in gaining surgical consentPt is responsible for reading all info on consent form verbalize understanding signing form in ink2nd step in gaining surgical consentNurse/corpsman must make sure the form is done prior to pre-op meds,anesthesia and procedure/surgery3rd step in gaining surgical consentA third party witness is always required4th step in gaining surgical consentProvider must explain the need fpr the procedure,provide a description of the procedure including risk and benefits and discuss any alternative treatmentSurgical ✔list1.Signed and witnessed consent 2.Signed anesthesia pre-op note 3.Pt has removed-nail polish/makeup,hair pieces/wigs,jewelry,glasses,dentures,and prosthetic devices 4.Last time pt voided 5.Pt NPO status 6.Pt allergies noted 7.Placement of pts id and allergy band2 items pt must identify1.Surgical procedure performed 2. Site of surgeryPillowUsedti splint the abdomen fir deep breathing and coughing exercisesPurpose of pneumatic stocking devicePrevent thrombus formation while improving venous return of blood to the heart2 common pulmonary complications post-opPneumonia-inflammatory condition of the lungs Atelectasis-a collasped or airless state of all or part of the lungSigns of pneumoniaFever, increased sputum, purulent sputum,cough,dyspnea,malaise,abnormal breath soundsSigns of atelectasisChest pain,dyspneaSigns of thrombophlebitisPain or warmth in calf Swollen leg Warm area to touch on leg Possible temperature elevationPreventive interventions fpr thrombophlebitisEncourage leg exercises Keep patient well hydrated Ebcourage ambulation Use anti-embolic stocking or devices2 rules regarding dressing post-op1.If dressing is stained outline the area with a pen and note the time 2.The surgical site/dressing must be cbecked every hour for the 1st four hrs then every 2hrs if bleeding has not reoccurredSurgical woundDehiscence-the separation of layers of the surgical wound Evisceration-the viscera thrusting out through the surgical incisionAtelectasisA collasped or airless state;all or part of the lungsExpectorantaid in loosening and removal of secretionsHypoxemiaDecreased O2 concentration in the bloodHypoxiaReduction of O2 in the body tissuePeak flowTool used to measure effects of respiratory therapyPlueraLining of the lungs and chest wallPleural spaceSmall space between the visceral and parietal pleuraPneumothoraxCollection of air in thr pleural spaceRales(or crackles)Crackling,rattling,or bubble sounds that occur when air enters smaller fluid filled airways during inspirationRhonchirumbling or gurgling soumds heard on expirationVesicular breath soundsNormal inspiratory sounds w/little or no noise heard throughout exhalationPurpose of deep breathing and coughingPrevent atelectasis and move secretions to large airways to be expectoratedCauses of atelectasis and pneumoniaDecreased ventilation from anesthesia and from painHugh coughProduced with coughing exercisesPurposes of peak expiratory flow1.Pt w/asthma to estimate lung capacity 2.Determine if medication therapy is achieving results Values will be used my doctor to determine pt progressionFactors that influence peak flow expiratory flowAge Height GenderPostural drainageUses gravity to clean secretions from air passagewaysCommon areas of postural drainage1.Posterior basal segments 2.Right middle love and lingular(nipple line) segments of left upper lobe 3.Apical segments of upper lobeChest percussionStriking the chest wall over the area being drained with cupped hands4 areas never to percuss overKidneys Soft tissue(breast) Sternum SpineReasons to discontinue percussion/vibrationTachycardia Palpitations Dyspnea Chest pain Fatigue LightheadednessPurpose of chest tubes1.Provide reexpansion of the lung caused by air,blood,or fluid in the pleural space Drainage permits reexpansion of a collasped lungWater seal or dry suctionChest drainage classificationComplications for pt w/chest tubes1.Traumatic removal of tube 2.Infection 3.Pneumothorax or hemothorax 4.Occlusion 5.Tension Pneumothorax 6.Tubing disconnectionBCD'sBubbling-ensure water in suction chamber is bubbling gently at 20 cm Connection-check the connection and wrap all tubing connection With adhesive tape Dressing and drainage-monitor dressing a.d drainage frequentlySigns and symptoms of chest tube dysfunction require nurse notification1.sudden onset of dyspnea,rapid shallow breathing,or cyanosis 2.complaint of cheat pressure 3.subcutaneous emphysema 4.increased temperature 5.signs of infection at insertion site 6.sucking sounds 7.drainage increase of 100 mL/hr 8.sudden change in color or type of drainage 9.drainage stopsPurposes of tracheostomy care1.maintain the patency of the artificial airway prevent infection of the lungsHigh fowler's positionPosition pt should be in for tracheostomy careWound prevention1.preventing infection,preventing further injury to the wound and nearby tissues,preventing blood loss and painWhite blood cells(WBC)Body defense systemFacts about WBCs1.when microbes enter the body WBC rush to the site 2.continually on the lookout for signs of disease 3.when a microbe os located WBC will atyack in a variety of ways 4.have a short life cycle one a few days to a few weeks drop of blood can contain from 7000-25000 WBC at a time 6.infection present WBC number rises significantlyCauses of woundsSurgical incision Trauma Pressure ulcers from poor skin care and immobility circulatory ulcers from decreased blood flow through the arteries and veinsInflammationThe localized protective reponse brought on by injury or destruction of tissuesPurpose of inflamation1.neutralize and destroy harmful agents 2.limit their spread to other tissues in the body 3.prepare damaged tissues for repairPhases of wound healing1.inflammatory 2.proliferation 3.remodeling(maturation)Stages of wound healing1.primary 2.secondary 3.tertiary intentionsFactors that affect healingType of wound Nutrition Lifestyle Medication Age Infection Chronic illnessComplication of wound healingHemorrhage Infection DehiscencePurpose of laceration repairStop bleeding Prevent infection Preserve function Restore appearanceSuture/staple removalRequire removal before complete healing typically 7-14 daysStage 1 Pressure UlcerRed deep pink or mottled skinStage 2 Pressure UlcerPartial thickness skin loss involving epidermis and/or dermisStage 3 Pressure UlcerFull thickness skin loss subcutaneous tissue is damaged or neuroticStage 4 PressureFull thickness skin loss that looksvlike a deep craterCauses of pressure ulcersPressure in combination with shear and/or frictionTwo types of circulatory ulcerStasis(venous) Arterial2 Wound assement1.Color of wound and surrounding tissues Approximation of wound edgesWound evaluationAsses Monitor for signs of systemic infection Note drainage Size of woundSerous drainageClear to straw color watery fluidSanguineous drainageBloody drainageSerosanguineous drainageThin clear to straw color watery drainage that is blood tingedPurulent drainageThick green yellow or brown drainageSigns of infection in burn ptChange in color Purplish discoloration Change in thickness Greenish discharge or purulent drainage FeverSigns of dehydrationThirst Lightheadedness or dizziness Weakness Dry skin Decreased urine outputHow burn size is estimatedRule of nines methedDebridementRemoval of nonviable necrotic tissueWound debridementRemoval of dirt foreign objects damaged tissue and cellular debrisReasons for debridementWound is infected Large amounts of drainage Contains black necrotic materialSharp debridementUsing scissors forceps or a scalpel bladeEnzymatic debridementUsing topical substances that brak down dead tissueAutolytic debridementUsing body's enzymes to break down tissueMechanical debridementPhysical removal of debris by irragation hydrotherapy or wet-to-dry dressing applicationPurpose of burn debridementRemove deadvtissue as new tissue growth occursReason for hydrotherapyBathing of a pt in a tub/tank of water to facilitate cleansing Easily removes dead tissue and topical medications Facilitates total assessment of the burnDry dressingPrevent microorganisms from entering or escaping from the wound and absorbs drainageWet-to-dry dressingFor infected necrotic wounds Moistened and packed into the woundWet-to-wet dressingUsed on clean open woundsTypes of dry dressingDry steralize gauze Telfa-non-adherent dressing Surgipads or abdominal(ABD) padsPurposes of cold treatmentsDecrease swelling Decrease painForm of cold applicationCold compress Packs Ice bags/collar Hypothermia blanketsChange cold compress15-20 minutes4 Purposes of heat applications1.provide general comfort and speed healling 2.for pt with muscoskeletal problems 3. Reduce pain 4. Increase blood supply in the area,brings O2 and nutrients and removes waste and excess fluid3 types of turns used in elastic wraps1.circular 2.spiral 3. Spiral reverseCopingAdjusting tovor solving problemsEmpathyAbility to imagine what others feelMourningExpression of griefSeriously or very seriously III list navmed 6320/5Form used to inform commands and notify next of kin of the pts conditionFears of death and dyingAbandonment Fear of suffering extreme pain Loss of control Becoming dependent Body alteration Loss of dignity Financial ruin Fear of the unknownStages od dyingDenial Anger Bargaining Depression AcceptancePhysical effects pf stressDry mouth Rapid pulse Rapid shallow breathing Sweaty palms or increased perspiration Skakiness and tremors Increased B/P Muscle tension Rapid speech Inability to control tearsActions to deal with stressExercise Get enough sleep and rest Eat healthy Plan for personal quiet time3 postmortem tag locationRight wrist Right greatctoe on an adult or ankle of infant Outside of sheet at chest levelCode cart inventoriedEvery monthDefibrillator checkedAt least dailyO2 tank checkedAt least dailySuction checkedAt least dailyNumber of people to complete pt transferTwo