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How many inches do you lubricate a Foley catheter for the female patient?
How many inches do you lubricate a Foley catheter for the male patient?
Once you see urine in the tubing during insertion of an indwelling Foley what do you do?
Advance 2 more inches
What is important to remember to do after catheterizing a male who is uncircumcised?
Replace foreskin if retracted earlier.
What is the problem called when there is swelling of the glans penis from not Replace foreskin if retracted earlier?
If the patient complained of severe pain when you tried to inflate the Foley balloon, what is happening?
The balloon is being inflated in the urethra, not in the bladder.
What nursing intervention would you do to decrease sudden Pt pain while inflating a Foley balloon?
Deflate the balloon fully.
How far must the Foley catheter be inserted for a male client?
Experts recommend insertion to the "Y" bifurcation.
What supplies are needed to remove a Foley catheter?
- disposable towel
- clean gloves
- sterile syringe
Sterile Dressings: What must you do before changing the dressing?
Remove binders and tapes.
What supplies are needed before changing a sterile dressing?
Surgical dressing kit & sterile gloves
How do you clean a sterile incision?
For lengthwise incisions, the first swab is on the incision and along its length. Then each subsequent swab (minimum 2 and up to 4) on alternating sides of the incision and parallel to it.
How do you clean an incision with a Penrose drain?
Starting around the drain and spiraling out from there.
What do you assess when looking at the wound for a dressing change?
- # of sutures or staples
- approximation - it will be "approximate" (closed) or "open" (e.g. 5 mm, middle of distal half)
- drainage: amount, odor and color/clarity.
What do you write when you are done changing the dressing?
Date, time, initials on an extra piece of tape, then affix on existing tape.
What is the proper position used to suction an unconscious client?
Lateral position facing you.
How do you test the equipment before using?
Kink the hose to verify suction.
How do you suction the alert client?
Semi-fowlers with head turned to one side.
How soon must you change the Yankeur suction catheter?
Q 24 hrs.
When do you rinse the suction catheter?
After each use.
What is the mmHg for wall suction?
60-80: neonate, 80-100: children, 80-120: adults
What is the mmHg for portable suction?
- 10-15 inches Hg was taught I believe. My wife, who has done plenty of ICU suctioning, says to always use the least amount of pressure that will get the job done to avoid any trauma to the mucosal
- or other tissues.
At what flow rate is supplemental humidity necessary for oxygen therapy? and why?
- Above 4 L/min
- Dry gasses dehydrate respiratory mucous membranes
At what flow rate is supplemental humidity NOT necessary for oxygen therapy? and why?
- From 1-2 L/min via cannula
- There is sufficient humidity inhaled from the atmospheric air.
List the safety precautions for oxygen therapy safety precautions
- "No smoking, Oxygen in Use" signage
- Adherence to no smoking
- Instruct client and visitors to hazards of smoking with oxygen use
- Make sure all electrical devices are in good working order to prevent sparks.
- Avoid wool and synthetics that can create static discharge. Wear cotton clothes and use cotton bed clothes
- Avoid alcohol, acetone, and nail polish in Pt room.
- Make sure all electrical medical equipment is grounded.
- Know location and use of fire extinguishers.
A Simple oxygen mask delivers...
5-8 L/min @ 40-60%
Partial rebreather mask delivers...
6-10 L/min @ 60-80%
Non rebreather mask delivers...
10-15 L/min @ 95-100%
Venturi mask delivers...
4-10 L/min @ 24-50%
Nasal Cannula delivers...
1-6 L/min @ 24-45%
Face tent provides...
4-8 L/min @ 30-50%
List the (5) physiological effects of heat therapy
- Increased cellular metabolism
- Increased capillary permeability
- Increased inflammation
- Sedative effect
Heat is used for clients with: (list 3) Musculoskeletal problems
- Joint stiffness
- Muscle spasms
List the physiological effects of cold therapy
- Decreases inflammation, slows bacterial growth
- Decreases capillary permeability
- Decreases cellular metabolism
- Local anesthetic effect
Cold is used for clients with sport injuries (list 3):
Cold limits, i.e. when contraindicated
- Open wounds
- Impaired circulation
- Allergy or hypersensitivity to cold
Heat Therapy, i.e. when contraindicated
- The first 24 hours after a traumatic injury. Heat increases bleeding and swelling.
Important elements of an Incident Report
- It is usually written to document accidents. Sometimes infections or loss of personal effects.
- Identify Pt by name (and initials) and MRN
- Date, time and place
- Describe only FACTS as YOU SAW them - no conclusions.
- State clients comments using direct quotes.
- ID all witnesses
- ID and equipment by serial #
- ID and meds by name and dose
Do not refer to incident rpt in Pt records
Person who identifies that an incident has occurred writes report, e.g. nurse who finds med error even if they did not administermed.
What are the documentation systems currently in use?
- Source-oriented record
- Problem-oriented record
- PIE - Problems, Interventions, Evaluations model
- Focus charting
- CBE - Charting by Exception
- Case Managent
All can be implemented via computer or paper
Source Oriented Charting is...
Each person or department making notations is a seperate section of Pt chart
Narrative Charting characteristics...
- Not usually used by itself
- Usually chronological in nature
- Questions usually answered:
- My eval or Pt response to interventions
Problem-Oriented Medical Record (POMR): Definition and components?
Charting is done by all participants for each problem the client has, e.g. all of the charting (docs, nurses, etc.) for a "broken leg" is done in the broke leg section. If there is another prblem, e.g. deep laceration to arm, it is charted in its own section.
Drawbacks include assessments and interventions affecting two problems must be repeated.
- Problem List
- Plan of Care
- Progress Notes
How are progress notes in a POMR chart headed?
Like the plan of care, entries are made by docs, nurses, etc. In the Progress notes, they are numbered (if on paper) to correspoind to the problem from the problem list, and they are also, whether paper or computer, coded by type of entry, i.e. SOAP and SOAPIER, as follows:
Summarize Focus Charting
Makes client and clients concerns/strength the focus of care.
- Usually 3 columns:
- Progress Notes
The Progress Notes follow the DAR format:
- D-Data (e.g. assessment)
Case Management Characteristics?
- Cost-effective model
- Uses Critical pathways with established times for care
- Work best for Pts with 1 or 2 diagnosis and few individualized needs
- Pts with multiple problems or unpredictable course of symptoms, e.g. neurologic, are difficult to doc on critical path.
Kardexes: Key elements?
Flow Sheets with
- Graphic Record - vitals, etc.
- Skin assessment (Branden)
- ug - mcg
- IU - international unit
- QOD - every other day
- QD - every day
- SC or SQ - subq or subcutaneous
- AS - left ear
- AD - right ear
- AU - both ears
Format of information for telephone reports
- SBAR Communication
- Your name unit
- Pt name & problem
Disadvantages/Risks of heat therapy
- Increased cappilaqry permeability may lead to edema or an increase in preexiting edema.
- When applied to a large area, it could cause excessiove peripheral vasodialation leading a drop on BP and subsequent fainting.
refers to a stiffening of arteries.
a condition in which an artery wall thickens (and the lumen gets smaller!!!) as a result of the accumulation of fatty materials such as cholesterol.
Conditions that necessitate precautions in the use of hot and cold applications:
- Neurosensory impairment
- Impaired mental status
- Impaired circulation
- Immediately after injury or surgery - NO HEAT - increases bleeding and swelling
- Open wounds - NO COLD decresed blood flow inghibits healing
What is the HOT/COLD Rebound Phenomena?
- HEAT - max vasodialation occurs in 20-30 minutes, BEYOND 30-45 results in tissue conjestion and vasoconstriction occur for unknown reasons at which point burns are a risk because heat cannot be dispelled adequately via blood circulation.
- COLD - Vasoconstriction occurs up to about 15C(60°F), but below that vasodialtion occurs as a protection against freezing, e.g. red (lots of flowig blood) ears and nose in winter.
How does heat help joint stiffness?
By deacreasing the viscosity of synovial fluid and increasing tissue distensibility.
Follow up for any hot/cold therapy?
Return to Pt after 15 minutes and eval skin for any untoward signs, e.g. redness
Hot Water Bottle Temp Therapy ranges?
- Normal adult and child over 2: 115-125°F
- Debilitated or unconcious adult or child under 2: 105-115°F
- To soak perineal or rectal area
Cooling Sponge Bath...
- ONLY for Pt with temps above 104°F
Room air contains how much oxygen?
How to tell when an IV needle is NOT in the vein?
- Infiltration- nonvesicant
- Coolness of skin around site
- Skin blanching
- Edema at, above or below
- Absense of "pinkish" blood return
- Extravasation - escape of vesicant (blister causing, sever tissue injury or necrosis OUTSIDE of vein)
- Pain, tenderness or discomfort
- Change in temp of skin
- Burning at insertion site
- Phlebitis - inflammation of the vein (mechanical, chemical or bacteriological)
- Redness at site
- Paslpable cord along vein
- Increase in temperature
If oxygen saturation is less than 85%...
Nurse can treat with oxygen and THEN get an order
Green leafy foods will...
How does STRESS increase your risk of infection?
It releases the steroid Cortisol (hydrocortisone) from the adrenal gland, which increases blood glucose levels, which provides a "better" growth medium for bacteria.
How often do we need to change various parts of an IV?
- Bag - Q24 hrs
- Tubing - Q72 hrs
- Sites - Q72 hrs
- Dressing(transparent) Q72 hr or with Site change
What is a Saline or Heparin Lock?
IV access, no continuous fluid
IV Flush Protocols
- SL or Saline Lock or Heparin Lock (all same thing): 1-2 mL NS Q8-12 hrs
- PICC lines or Central lines (Central line is shorter term than PICC): 10 mL NS folowed by 300 units heparin, after each use or daily
- Nasal Cannula: 1-6 L/min @ 24-45%
- Face tent: 4-8 L/min @ 30-50%
- Venturi mask: 4-10 L/min @ 24-50%
- Simple face mask: 5-8 L/min @ 40-60%
- Partial rebreather: 6-10 L/min @ 60-80% (bag to remain inflated on inspiration otherwise increase flow rate)
- Non rebreather: 10-15 L/min @ 95-100%