344 FUNDAMENTALS REVIEW (part 1)

o Cane should be level with the hip joint with patient’s arm comfortably bent when patient is walking

o Patient should hold cane on their stronger side and move cane forward first, followed by the weaker leg then the stronger (3-point gait)

o Patient should be encouraged to stand up straight and looking forward, so safety and posture isn’t jeopardized

• no risk

• continue to assess per agency timeline

• at risk

• identify areas of risk

• select at least one intervention WITHIN risk category & implement

• moderate risk

• identify areas of risk

• select at least one intervention from each risk category & implement

• refer WOCN

• high risk

• select ALL APPROPRIATE INTERVENTIONS including at least ONE UNDERLINED intervention

• refer to WOCN

• all of the above

• pressure reduction support is required

• refer to WOCN

Wound, Ostomy, and Continence Nurse

• Reduce pressure on ankles and feet

• Inspect feet and ankles daily

• Instruct to avoid hot water and heating

• Educate patients and caregivers about causes and risk factors for

  pressure ulcer development

• Establish a bowel and bladder program for incontinent patients

• Cleanse gently after each incontinent episode

• Encourage appropriate hydration

• Instruct to apply skin barrier ointments to protect skin

• Instruct to avoid diapers to contain effluent (waste) except when patient is out of bed to walk or in a chair

• Consult with WOCN

• Identify fungal infections, notify MD, and treat quickly

• Order low air loss bed to dry constantly moist skin

• Position chair-bound patients when seated with attention to anatomy, postural alignment, distribution of weight and support of feet

• Instruct to reposition chair-bound individuals every hour if they cannot perform pressure relief exercises every 15 mins

• Encourage increased activity

• Order specialty bed or overlay to reduce pressure. Continue turning but increase frequency

• Instruct to turn and reposition at least 2-4 hours on a pressure reducing mattress or 2 hours while in bed or chair

• Inspect bony prominences every day/visit

• Place “at risk” individuals on pressure reduction surface

• Refer to physical and/or occupational therapist

• Evaluate nutritional status of patients at risk by obtaining recent diet

• Encourage liquid nutritional supplements as ordered

• Instruct to increase protein intake

• Instruct to supplement diet with multivitamin

• Consult with nutritionist

• Monitor weights, intake/output, count calories if indicated

• Assess lab parameters to determine nutritional status (low albumin, pre-albumin, transferrin, total lymphocyte count blood levels correlate to decreased wound healing and increased pressure ulcers)

• Use turning sheets or pads to reposition. Trapeze bar to encourage patient to assist

• Elevate head of bed no more than 30 degrees

• Protect vulnerable areas from friction by applying t__ransparent film, socks, or elbow protectors__

• Instruct to avoid excessive rubbing when cleansing and drying skin

• Instruct to avoid soap. Use moisturizer on dry skin and bony prominences daily

• Instruct not to massage reddened bony prominences

• Avoid foam rings, donuts, and sheepskin

• Lower head of bed 1 hour after meals or tube feeding. If not possible, assess sacral region more frequently

• Preferred methods to decrease incidence of patient and staff injuries

• Patient is placed in harness and lifted to a point where feet are just

  touching the ground

• Patient walks holding onto lift device

• Weight is fully supported by lift device and prevents falls and injuries

• should be used for patients with an unsteady gait or generalized weakness

• applied snugly patient’s waist, leaving only enough room for the nurse to grasp the belt firmly during ambulation

• if the patient has a weaker side, the nurse should stand on that side and hold the gait belt firmly at the back of the patient’s waist while ambulating

• Made of plastic-like material to reduce friction

• Linens easily slide over the board, facilitating bed linen changes

• Patients can be repositioned or transferred with minimum force

true

• Have patient blow their nose first

• Tilt patient’s head slightly back or have patient lie in supine position

  with head tilted back

• Have patient breathe out through mouth

• Insert the deliver service 1/3 inch into one nostril, have patient plug

  opposite nostril, and do not touch inside the nares with device because

  it may cause sneezing and contamination

• Administer drops or spray as patient inhales through nose

• Have patient exhale through mouth

• Keep patient’s head tilted back for several mins while patient continues to breathe through mouth

• The patient should not eat or drink anything until medication is completely dissolved

• Medications should not be chewed, swallowed, or taken with liquids

• Nurse should use standard precautions because the nurse’s hand may come in contact with oral secretions

• Buccal med is placed in the side of the mouth against the inner cheek

• Alternate cheeks to avoid mucosal irritation o Sublingual med is placed under the tongue

• Check pH levels just before intermittent feedings if placement of tube is questioned

• Assess exit of location marking to ensure NGT hasn’t moved

• Flush before and after med admin

• Check residual volume if patient is already on feed

  • If residual amount is less than 250 mL or half the amount of last feed, proceed with new feeding; do not proceed if gastric residual volume exceeds 500 mL

• Ensure nutritional feeding solution is as order and check expiration date o Ensure feeding is at room temp; shake container thoroughly and clean top with alcohol swab before opening

• Measure feeding amount (for continuous feeding, use not more than the amount require for 4 hours plus the amount needed for priming and tubing)

• Fill pump tubing with irritation solution to prime tubing (if not automatic)

• Flush NGT with irritation solution before initiating feeding

• Label feed bag with type, strength, amount, date and time – a new set should be used every 24 hours

• Should be < 5 if placed correct

• 6 or > indicate tube has been inadvertently placed in a lung or intestines

• If NGT placed correctly, pH of 4.5-6 may be due to medications or feedings

• characteristics

• What is the quality of the pain? Stabbing, burning, etc?

• onset

• when did the pain start? was it gradual or sudden?

• location

• where is the pain located? does it radiate?

• duration

• how long does the pain last? is it intermittent?

• severity

• on a scale of 1-10, how bad is it with 10 being the worst?

• pattern

• what makes it better or worse

• associated factors

• what other symptoms occurs with the pain?

1. 0 (relaxed muscles) → neutral expression

2. 1 (grimace) → tight facial muscles

1. 0 (no cry) → quiet, no crying

2. 1 (whiper) → mild moaning, intermittent

3. 2 (vigorous cry) → loud scream, shrill, continuous

1. 0 (relaxed) - usual pattern for this infant

2. 1 (change in breathing) - irregular, faster than usual, gagging

1. 0 (relaxed/restrained) → no rigidity occasional random movement

2. 1 (flexed/extended) → tense, rigid, rapid extension/flexion

1. 0 (relaxed/restrained) → no rigidity, occassional random movement

2. 1 (flexed/extended) → tense, straight legs, rapid extension/flexion

1. 0 (sleeping/awake) → quiet, peaceful sleeping, random movement

2. 1 (fussy) → alert, restless, thrashing

• Convenient, cost-effective, comfortable with low stress for patient

• Certain oral tablets formulated to dissolve on contact with tongue

• Inappropriate for patients with nausea/vomiting; contraindicated for patients with swallowing difficulty

• Can irritate GI lining, have unpleasant taste, or discolor teeth

• Patient must be A&Ox4 to safely administer

• Cannot be used with simultaneous gastric suctioning or before various diagnostic or surgical procedures

• Possible irregular or slow absorption

• Can be used if oral route is contraindicated

• More rapid response than oral or topical

• Can be used for critically ill patients for long-term therapy

• IV route can decrease discomfort and can better control absorption if peripheral infusion is compromised

• Sterile technique must be used as the skin barrier is compromised

• More costly to formulate and administer

• Affected by circulatory status

• Can produce anxiety

• peripheral inserted central catheter

• used in patients that need long- term IV therapy because it can be inserted in a vein in the arm that has lower rates of complications compared to other types of CVCs

• Also used in patients with failed IV access with short peripheral catheters

true

Inserted in the cephalic or basilic vein or antecubital space and threaded up until it rests in the superior vena cava outside the right atrium

central-line associated bloodstream infection (CLABSI)

true

• central venous catheter/central venous access device

• inserted into a major vein in the arm or chest and the tip lies in the superior vena cava, outside the right atrium

  • allows rapid infusion of large amounts of fluid

  • irritating meds & hypertonic solutions are rapidly diluted → reducing phlebitis

  • can be used for blood draws for patients needing frequent lab monitoring

  • allows monitoring of central venous pressure

trauma & massive fluid/blood administration

large volume, viscous solutions

children & geriatric

Phlebitis is when a vein (a blood vessel that carries blood back to the heart) gets swollen and painful. This can happen when a blood clot forms in the vein or when the vein is irritated. It usually happens in the legs. The symptoms include redness, warmth, and swelling in the affected area. Treatment may include medicine or wearing special stockings.

• Contains amino acids, glucose, lipids, vitamins, minerals, electrolytes, and trace elements

• Provides calories, protein building blocks, and fluid needed to promote wound healing and meet metabolic requirements

• Used when patient is unable to meet nutritional and metabolic demands through oral intake or surgery requires bowel rest

• Central line must be used to administer

• Designate separate lumen and label; do not infuse other substances into

  this line

• Ensure vitamin K has been ordered (vitamin K is produced largely by

  intestinal bacteria that currently may be absent, but is needed to

  produce clotting factors in the gut)

• Do not use TPN after 24 hours; discard any unused solution

• Assess vitals q4h, daily weight, and I&O

• Administer slowly in beginning, increase slowly, and wean off gradually; do not suddenly stop, hang D10 if line runs dry (prevents hypovolemic shock)

• Higher risk for infection; use strict sterile technique during IV care

• Patient can develop hyperglycemia due to high levels of dextrose

  • Insulin often ordered and BG checked routinely

Catheter occlusion

• IV flow is sluggish or stopped

• Attempts to flush catheter are met with resistance

• Assess tubing site for obstructions

• Attempt to flush catheter with normal saline; do not force (can cause embolism)

• If peripheral IV, discontinue site and start a new one

• If CVC, notify PCP or IV team

Catheter-related infection

• Pain at site, tenderness, erythema, swelling, increased emp, purulent drainage

• Fever, chills, tachycardia, hypotension, complaints of headache, backache

• Prevention is key – use aseptic technique during site care and insertion

• Rotate sites per agency protocol

• Assess site frequently

• If symptoms evident,

  discontinue IV and start

  in a new location

• Place used catheter in sterile container and send to lab for culture

  sensitivity testing

• Notify PCP of findings

• Do not discontinue CVC

  without physician’s order

phlebitis

• Tenderness, redness, swelling at site

• Pain, burning, heat along vein (especially during infusion)

• Palpable venous cord

• Discontinue catheter immediately if infection suspected; send catheter tip for culture

• Clean insertion site with disinfectant

• Apply warm moist compress for 20 min 3- 4x/day

• Use opposite extremity when inserting new IV

• Use small gauge, stabilize catheter securely to minimize movement or rotate sites to avoid phlebitis

infiltration

swelling, tenderness, coolness, firmness of extremities, & blanching of the skin

• assess q2h

• Discontinue infusion, remove catheter

• Apply pressure at site to stop bleeding

• Apply warm compress to increase circulation for isotonic/hypotonic solutions

• Apply cold compress for hyperosmolar

• Use skin marker to outline area of visible damage to assess change

• If leaking, cover area with sterile dressing

• Use opposite extremity for new IV insertion

Extravasation

• Similar to infiltration

• Burning and discomfort

• Blistering is a late sign

• Know which meds are considered vesicants (dopamine, norepinephrine, high concentrations of electrolytes, certain antibiotics)

• Vesicant solutions/meds should be infused slowly and through a CVC

• Discontinue site, start new IV on opposite extremity

• Notify PCP and obtain orders for treatment or antidote

• Use skin marker to outline area of visible damage to assess change

• Cautious use of cold or warm compress

• Never apply pressure

Necessary to maintain the patient’s oxygen and carbon dioxide transport capacity, for clotting, to maintain oncotic pressure, and to protect from infection

1. allergic response → common; based on hypersensitivity response to foreign plasma proteins

2. acute hemolytic reactions → occurs when antigen-antibody

   reaction due to ABO or Rh incompatibilities; can result from errors in mislabeling, improper crossmatching, or errors in patient/blood verification at bedside

3. febrile nonhemolytic reactions → occurs when patient reacts

   to the white blood cells in doner blood; occurs in 6% in all transfusions

4. bacterial contamination → occurs during the donation or

   preparation of blood, usually by organisms capable of surviving cold temp

5. circulatory overload → occurs when whole blood is transfused to quickly or packed red blood cells lead to a fluid shift from the interstitial to vascular space s

Acute hemolytic reaction

Febrile nonhemolytic reaction

Bacterial contamination

circulatory overload

local erythema, hives, itching, asthmatic wheezing

laryngeal swelling, dyspnea, tachypnea, chest pain, cardiac arrest

• Stop transfusion

• Notify ordering physician

• Administer antihistamines

• Continue to assess patient, monitor vitals

• Document reaction, treatment, and response

Chills, fever, facial flushing, burning along vein, lumbar or flank pain, chest pain, shock

• Stop transfusion

• Remove tubing and replace with new IV tubing and normal saline at keep-vein-open rate

• Notify ordering physician

• Notify blood bank

• Monitor vitals

• Have emergency equipment availabl

• Send remaining blood, blood tubing and filter, and a sample of patient blood and urine to lab e

• Document reaction, treatment, and response

• Defined as 2° F rise in body temp

• Chills and malaise

• Stop transfusion

• Notify ordering physician

• Notify blood bank

• Administer antipyretics

  and/or antihistamines

• Document reaction,

  treatment, and response

• Can be avoided by using

  leukocyte-reduced components or washed red blood cell s

Abdominal cramping, chills, diarrhea, fever, shock, onset of renal failure, vomiting

• Infuse blood in less than 4h; stop after 4h

• Change administration sets q4h

• Stop transfusion if symptoms occur

• Notify ordering physician

• Administer antibiotics, corticosteroids, and epinephrine

• Have emergency equipment available

• Instruct patient to contact PCP if symptoms occur

Signs of fluid volume excess – dyspnea, headache, tachycardia, hypertension, distended jugular veins

• Stop infusion

• Use PRBCs instead of

  whole blood

• Notify ordering physician

• Administer oxygen PRN

• Administer diuretics PRN

• Instruct patient to contact PCP if symptoms occur

Encourage to perform oral hygiene independently

• Oral care should be performed at least every morning and evening

• The nurse or UAP performs this procedure for patients who cannot

  clean their own dentures

• Gloves should be worn

• Unconscious or intubated patients may not be able to swallow own saliva; oral care should be provided q2h by using a toothbrush and a small amount of water or a moistened toothette

• Unconscious patients are at risk for aspiration; place patient on their side to avoid aspiration

• (client’s personal space) – 8 inches to 4 feet from patient

• Reserved for affectively close people that have permission to approach; most procedures and interventions are performed at this distance

• Always ask permission and inform patient of what you’re doing

false, Cannot be delegated to UAP; respiratory therapist may wish to care for or assist with care

Tracheostomy ties will cut into the patient’s skin, causing trauma and providing site for infection… therefore Velcro tracheostomy tube holder is recommended

false! Nurses need to maintain a sterile procedure for trach care and suctioning to prevent microorganisms from entering the respiratory system and causing infection

face mask, shield, clean gloves

Patient should be in fowler or semi-fowler position

respiratory status

• PPE: face mask, shield, clean gloves

• Patient should be in fowler or semi-fowler position

• Assess respiratory status before and after procedure

• Place bag-valve-mask at head of bed and ensure it has 100% oxygen airflow

• Set pressure of suction device to 80-100 mmHg continuous

• Insert catheter 12-13 cm into trach and withdraw catheter slowly while rotating and moving thumb on and off suction control; suction on the way out, not going in

• Maximum time for each suction should be 10-15 seconds

• Place trach oxygen mask and let patient catch their breath before proceeding to suction again

Atelectasis

• Anesthesia, prolonged bed rest, shallow breathing can decrease movement of the diaphragm and chest wall, which results in hypoventilation, leading to small airway obstructions from retained secretions → a.k.a atelectasis

• Patients who have abdominal or chest surgery are at risk for hypoventilation and atelectasis because incisional pain may result in shallow breathing

incentive spirometer

• Patient should be in semi-fowler or fowler if possible

• Instruct patient to inhale slowly with the mouth on the mouthpiece

• Inhale as much as possible and hold that breath for 3-5 seconds

• Remove mouthpiece and exhale slowly

• Repeat each in halation and exhalation 5-12 times

• End with two controlled coughs

• Perform this exercise every 1-2 hrs