Lab midterm

Normal output

-Normal output: 2 mL/kg/hr

Catheter size

Females: 14-18 size Male: 16-18 size

Complications of a CVAD: Occlusion

-A CVAD can become occluded secondary to clamping or kinking the catheter, the tip coming in contact with the vessel wall, thrombosis, or precipitate buildup in the lumen. -Clinical manifestations of catheter occlusion include a sluggish infusion or aspiration, or being unable to infuse and/or aspirate. -Management of catheter occlusion includes the following steps: -Instruct patient to change position, , and cough -Assess for and alleviate clamping or kinking -Flush with normal saline using a 10-mL syringe; do not force flush -Fluoroscopy to determine cause and site Instillation of anticoagulant or thrombolytic agents

Transfusion reactions for blood

-A blood transfusion reaction is an adverse effect to blood therapy. -The following steps should be taken when witnessing a transfusion reaction 1. Discontinue the transfusion 2. Maintain a patent IV with saline solution 3. Notify blood bank and HCP immediately 4. Re-check identifying tag & number 5. Monitor VS & UO 6. Treat symptoms per HCP order 7. Send blood bag & tubing to blood bank for examination 8. Collect blood & urine samples at intervals to evaluate hemolysis 9. Document on transfusion reaction form & patient chart -Signs and Symptoms o FeverChills o Chest or flank pain o Tachycardia o Dyspnea o Hypotensiono AKI o Cardiac arrest

Complications of a CVAD: Pneumothorax

-A pneumothorax can occur if the pleura is perforated during insertion. Clinical manifestations include decreased or absent breath sounds, respiratory distress (cyanosis, dyspnea, tachypnea), chest pain, or distended unilateral chest. Management includes -oxygen administration, -semi-Fowler's position, -Chest tube insertion (sometimes)

Documentation of IVs

-Date/ time of insertionType, length, and gauge of the catheter insertion -Number and location of attempts -Type of dressing used on the site -Nurses initials and credentials

How will you select your site?

-Accessibility -Purpose of IV access Small vein acceptable: -Routine intermittent meds -Small-moderate volumes of fluid -Non-irritating drug infusions (Heparin) Large vein necessary: -Fluid resuscitation -Blood products -Anticipated longevity of site Considerations: Patient's size, age, overall condition Adults -Upper extremities over lower extremities (CDC) -Hand over upper arm, wrist (CDC) -Avoid joints -Avoid interfering with ADL's Previous IV sites: -Place first IV distal -Subsequent attempts are proximal Considerations: -Left or right handed -Avoid edema/bruising -Avoid side of mastectomy -Arm of dialysis shunt is contraindicated -Avoid side of paralysis "Field sticks" or questionable asepsis: -Restart ASAP: check agency policy

Check

-After placing an IV line and regulating the flow rate, maintain the IV system. -The frequency and options for maintaining the system are identified in agency policies. -An important component of patient care is maintaining the integrity of an IV line to prevent infection. Inserting an IV line under appropriate aseptic technique reduces the chances of contamination from the patient's skin microflora. -After insertion, the conscientious use of infection control principles, including thorough hand hygiene before and after handling any part of the IV system, and maintaining sterility of the system during tubing and fluid container changes, prevents infection. -Always maintain the integrity of an IV system. Never disconnect tubing because it becomes tangled, or it might seem more convenient for positioning or moving a patient or applying a gown. If a patient needs more room to maneuver, use aseptic technique to add extension tubing to an IV line. -However, keep the use of extension tubing to a minimum because each connection of tubing provides an opportunity for contamination. -Never let IV tubing touch the floor. -IV tubing contains needleless injection ports through which syringes or other adaptors can be inserted for medication administration. Patients receiving IV therapy over several days require periodic changes of IV fluid containers. It is important to organize tasks so you can change containers rapidly before a thrombus forms in the catheter. -Recommended frequency of IV tubing change depends on whether it is used for continuous or intermittent infusion. -To prevent the accidental disruption of an IV system, a patient often needs assistance with hygiene, comfort measures, meals, and ambulation. -Nurses monitor vigilantly for complications of IV therapy, which include fluid overload, infiltration, phlebitis, local infection, and bleeding at the infusion site. -The signs and symptoms of complications often arise rapidly; this highlights the importance of frequent assessment of patients receiving IV therapy.

Equipment needed for a PIV

-Alcohol swabs or chlorhexidine -Angio-catheter -Tape -Stat-lock -Tourniquet -Transparent dressing -Saline lock -NS 10 mL flush

Potassium (KCl)

-Always use a pump Memorize your max: -10 mEg/50 mL peripherally over 1 hour -20 mEg/100 mL centrally over 1 hour -Never by any source more than 20 mEq/ hr -Never PUSH potassium -Never ADD to a bag -May require cardiac monitoring -Assess peripheral sites at least hourly; very irritating to the vein

Maintain a moist environment

-Autolytic debridement is the removal of dead tissue via lysis of necrotic tissue by the white blood cells and natural enzymes of the body. You accomplish this by using dressings that support moisture at the wound surface -Moisture is important for a wound bed as it helps support the movement of epithelial cells and wound closure -Moisture is important for the wound to heal -Use foam dressing & hydrocolloid to promote moisture

CVAD vs PIV

-CVAD's allow for immediate access to the central venous system, a reduced need for multiple venipunctures, and also a decreased risk of extravasation injury. -CVADs are placed into large blood vessels such as the subclavian vein or jugular vein. -The disadvantages of CVADs include that they increase risk of systemic infection, and insertion is considered invasive

Nursing management

-Catheter and insertion site assessment includes inspection of the site for redness, edema, warmth, drainage, and tenderness or pain. -Observation of the catheter for misplacement or slippage is important. -Perform a comprehensive pain assessment, particularly noting any complaints of chest or neck discomfort, arm pain, or pain at the insertion site. Perform dressing changes and cleansing of the catheter insertion site using strict sterile technique. Institutional policies may vary. -Transparent semipermeable dressings or gauze and tape. -A chlorhexidine-based preparation is the cleansing agent of choice. Its effects last longer than either povidone-iodine or isopropyl alcohol, offering improved killing of bacteria. -When using chlorhexidine, cleansing the skin with friction is critical to infection prevention.

CAUTI

-Catheter associated urinary tract infection -80% of HAI -lengthen hospital stay -Increase morbidity and mortality -not covered by insurance -each day catheter is in incerases likelyhood of infection -nosocomial infection

CVAD (central venous access device)

-Central venous access devices (CVADs) are catheters placed in large blood vessels (e.g., subclavian vein, jugular vein) of people who require frequent or special access to the vascular system. -There are three main types of CVADs: -centrally inserted catheters -peripherally inserted central catheters (PICCs) -implanted ports. -A physician may place any of these devices; a nurse with specialized training can insert PICCs. -Permit frequent, continuous, rapid, or intermittent administration of fluids and drugs -Allow for giving drugs that are potentially vesicants -Used to administer blood/blood products and parenteral nutrition -Used for hemodynamic monitoring -Useful for patients with limited peripheral vascular access or need for long-term vascular access Advantage: -Immediate access -Reduced venipunctures -Decreased risk of extravasation/infiltration Disadvantage: -Increasd risk of systemic infection -Invasive procedure

1: Centrally inserted catheter

-Centrally inserted catheters (also called central venous catheters [CVCs] -Inserted into vein in the neck (jugular), chest (subclavian), or groin (femoral) with the tip resting in the distal end of the superior vena cava -Tunneled: Other end through subcutaneous tissue exiting through the chest or adomen wall making its way to subclavian vein then into superior vena cava -Non-tunneled Enters straight into subclavian venin then into superior vena cava -Dacton cuff stabilizes catheter & decreases incidence of infection by impeding bacteria migration along the catheter beyond the cuff. -Single, double, triple, or quad lumen Examples of long-term (tunneled) catheters: -Hickman -Groshong

Nursing management cont.

-Change injection caps at regular intervals according to institution policy or if they are damaged from excessive punctures. -Use strict sterile technique. Teach the patient to turn the head to the opposite side of the CVAD insertion site during cap change. If the catheter cannot be clamped, instruct the patient to lie flat in bed and perform the Valsalva maneuver whenever the catheter is open to air to prevent an air embolism. -Flushing is one of the most effective ways to maintain lumen patency and to prevent occlusion of the CVAD. It also keeps incompatible drugs or fluids from mixing. -Use a normal saline solution in a syringe that has a barrel capacity of 10 mL or more to avoid excess pressure on the catheter. -If you feel resistance, do not apply force. This could result in a ruptured catheter or create an embolism if a thrombus is present. Because of the risk of contamination and infection, prefilled syringes or single-dose vials are preferred over multiple-dose vials. =The push-pause technique creates turbulence within the catheter lumen, promoting the removal of debris that adheres to the catheter lumen. -This technique involves injecting the saline with a rapid alternating push-pause motion, instilling 1 to 2 mL with each push on the syringe plunger.

Indwelling Cath specimen

-Clamp drainage tube below port -Allow sufficient time to accumulate urine (about 20 min) -Swab sample port -Insert needle on appropriate sized syringe -Aspirate urine -Unclamp tubing -Transfer urine into appropriate container -Do not collect from drainage bag!!

Complications of a CVAD: Infection

-Clinical manifestations of infection can be local (redness, tenderness, purulent drainage, warmth, edema) or systemic (fever, chills, malaise). -Management of infection includes the following: Local -Culture of drainage from site -Warm, moist compresses -Catheter removal if indicated Systemic -Blood cultures -Antibiotic therapy -Antipyretic therapy -Catheter removal if indicated

Pain assessment

-Comprehensive pain assesssment includes asking patient about pain, quality of life, functionality, and interventions that work (or those that dont't) -Requires a detailed physical exam -Includes emotional & psychological aspect of pain -Primary pain is the pain that matters most right now HOW DO YOU THINK PAIN ASSESSMENTS ARE DIFFERENT FOR EOL CARE? Numeric pain scale: -0-10 Visual analog scale: -No pain to worst possible pain Wong-Baker FACES Pain Rating Scale -Shows faces of how the person is feeling -can be used with patients who have mild dementia or for those who are unable to understand a numeric pain scale, and children around 4-8 years old. -However, can use this one with anyone Adult Non-Verbal Pain Scale -Looks at face, activity, guarding, vital signs, respiratory -may be used for assessing intubated and nonincubated critically ill adults. -It consists of four pain indicator areas scored from 0 to 2, with a total score ranging from 0 to 8. A score above 2 indicates pain. PAIN AD Pain Scale (Advanced Dementia) -Looks at breathing, negative vocalization, facial expresssion, body language, consolability

Care for a patient with an indwelling urinary catheter?

-Considering the risk for a UTI increases with the use of an indwelling catheter, continuous care and observation is needed. -Aseptic technique should always be utilized. -These patients require regular perineal hygiene (especially after a bowel movement). -Minimal standard of care is to receive catheter care every 8 hours. -Empty the drainage bag when it is ½ full. -Any patient with an indwelling catheter should have their urinary meatus assessed for damage or infection as insertion and removal can cause trauma.

Skin assessment

-Continually assess skin for signs of breakdown and/or ulcer development -Always clean least contaminated to most contaminated (wound is most clean part)

Death Rattle

-Distressing symptom for caregivers -Does not appear to cause pain or discomfort -Sounds like wet gurgling, snoring, or moaning -Cool patient's room, turn on a fan or open window, minimize liquids if not sallowing, increase humidity -Turn patient on side, raise head, suction secretions if possible

Nursing care

-Dressing: drain sponge -Cath care: same concerns as foley -Cleans skin in circular fashion away from site (clean to dirty)

Performing Venipuncture

-Educate your patient -Hand washing/ gloves -Apply tourniquet -Palpate site (find vein) -Cleanse -Insert and advance needle/cannula (Bevel up 20-30o angle) -Direct stick -Puncture skin -Lower angle -Advance until blood flash back -Advance another 2 mm -Holding needle absolutely still, advance cannula -Remove tourniquet -Remove needle -Remove (or retract) needle -Connect saline-lock (Why do we use a saline-lock? prevent juices form coming out) -Secure the insertion site (How? Why?) Once you clean site DONT PALPATE ANYMORE

Extravasation Injuries

-Extravasate = to exude from or pass out of a vessel into the tissues. -Vasoactive meds very caustic to tissue. -Extravasation is when a vesicant drug (chemotherapy medication or other drug) leaks outside the vein onto or into the skin, causing a reaction. -In chemotherapy, drugs are classified into two broad categories based on the effect they have on tissues when they extravasate - irritants and vesicants -The leakage of certain drugs called vesicants out of a vein into the tissue around it. -Vesicants cause blistering and other tissue injury that may be severe and can lead to tissue necrosis (tissue death). The recommended approach to the treatment of extravasation includes the following steps 1. Stop the intravenous push or infusion immediately if the patient admits to a burning sensation or complains of pain. 2. The catheter or needles should not be removed immediately but should be left in place to attempt aspiration of fluid from the extravasated area. Aspiration of the drug and surrounding fluid should be attempted with 3-5 ml of blood. If available, injection of reversal agents through the infiltrated catheter allows delivery to the same injured tissue plane. 3. Remove the needle. 4. Elevate the affected limb to minimize swelling and to encourage lymphatic resorption of the drug. 5. Apply warm or cold compresses as indicated. This decision is usually based on physician preference and the type of drug extravasated. Cold compression may reduce subsequent inflammation and necrosis caused by most agents. In general, cold compression is recommended for extravasation of all vesicant or irritant drugs except for the vinca alkaloids (vincristine, vinblastine, vinorelbine), epipodophyllotoxins (etoposide), and vasopressors because cold worsens tissue ulceration caused by these drugs. Cold compresses should be applied for 20 min, 3 or 4 times/day, for the first 48-72 hrs after extravasation occurs. Hot compresses are sometimes preferred for specific drug extravasation (e.g., vinca alkaloids, phenytoin, vasopressors, contrast media) to modify viscosity, increase local blood flow, and enhance drug removal. 6. Debridement and excision of necrotic tissue should be considered if pain continues for 1-2 wks. Surgical flushing with normal saline is often used for severe hyperosmolar extravasations. Assessment and surgical decompression of compartment syndrome may be necessary in certain cases

How do you remove an indwelling urinary catheter?

-First educate the patient on the procedure about to begin -Position patient with waterproof pad under the buttocks and cover with bath blanket, exposing only genital area and catheter. -Males should be placed in a supine position -Females should be placed in dorsal recumbent position(lithotomy) -Remove the catheter securement device and free drainage tubing -If needed, provide hygiene in genital area (soap, water) -Move syringe plunger up and down to loosen and then withdrawplunger to 0.5mL. -Insert hub of syringe into inflation valve (balloon port) -Allow balloon fluid to drain into syringe by gravity -Make sure the entire amount of fluid is removed by comparing removed amounts to volume are needed forinflation -Pull catheter out smoothly and slow. Ensure that it is intact -If you note any resistance, repeat last step to remove remaining water. -Wrap the contaminated waterproof pad. -Unhook collection bad and drainage tubing from bed -Reposition patient and do some hygiene

Pump is alarming, what are you going to check?

-First: What does alarm say? -Patient: Infilatration? PIV patent? Flush with NS. Location of IV? reposition patient -Equipment: AIr in tubing? Tubing threaded correctly? Battery? Check clamps & connections -Check the site: infiltration? phlebitis? -Infusion: Common irritants include KCl, antibiotics, cold solution? -Intervene: Change site, warm (or cold) packs, slow infusion, Dilute medication

Complications of IV therapy

-Fluid & electrolyte imbalances -Fluid volume overload (lung crackles, SOB, BP changes, JVD, edema, I>O -Bruising/hematoma -Infiltration (cool), non-vesicant -Phlebitis (warm) -Extravasation, vesicant -Septicemia Book answer: circulatory overload, infiltration/extravasation, phlebitis, infection, and bleeding. -Circulatory overload occurs when IV solutions are infused too rapidly, or too great of a volume. -Infiltration is when IV fluids enter subcutaneous tissues around the site. -Extravasation is when a tissue damaging drug enters tissues around the site. -Phlebitis is the inflammation of a vein

Tracheostomy learning objectives

-Identify airway adjuncts, their rationale for use, and key nursing considerations -Discuss the nursing care of a patient with a tracheostomy -Review steps in tracheostomy care & suctioning (in lab) -Demonstrate tracheostomy care & suctioning (in lab)

EOL learning objectives

-Improve confidence inproviding EOL nursing ccare -Gain basic understanding of physiological processes at EOL -Increase familiarity with the best evidence based practice EOL treatments -Raise awareness of ethical questions that may arise -Devlop communication tools to integrate cultural & spiritual beliefs in your EOL care -Understand the different types of care plans for patinets at teh EOL -Get an idea of the tasks associated with EOL

Foley complications

-Infections -encrustations -leakge -bladder spasm -ureteral erosion -caliculi -eurethra erosion -epididymitis -urethritis -fistula/ stricture formation -bladder cancer -IF YOU BREAK STERILE TECHNIQUE, JUST STOP & DO IT AGAIN.

IV Therapy:

-Is a medication Is sterile: -All ports must be cleaned every time -Care in maintaining sterility of fluid & pathway Has immediate effects: -Fluid overload -Medication errors

Double effect of pain meds in EOL care

-It is more important to treat the dying for their pain than worry about the respiratory depression -The hospice care artilcle said the double effect theory has little actual backing -Manging pain is most important in EOL

Urinary Diversions

-Like an ostomy for pee Illeum Conduit: -ileum is resected and an internal pouch formed, required external appliance Kock's reservoir: -nipple valves; self-catch q 2-4- Indiana Pouch: -larger than Kocks continent Neo bladder: -no stoma

Rationale for intravenous access

-Maintain F & E balance -Med administration -Blood or blood products -Parenteral nutrition

Cleaning a wound

-One way the text highlights to deliver proper pressure is to use a 19 G angiocatheter and a 35 mL syringe. This irrigates the wound at 8 psi -It is important to remember that when irrigating the wound, the nurse should allow the fluid to flow from least to most contaminated areas. -When cleaning the skin it is important to avoid using soap or hot water -Wound irrigation is a from of cleaning a pressure injury -It involves using fluid to remove cellular debris, surface bacteria, and wound exudate -Preferred cleaning agents would be NS which none cytotoxic and does not kill or damage cells, especially fibroblasts

Hospice E kit

-Morphine liquid- used to treat pain and shortness of breath -Lorazepam- can be used to treat anxiety, nausea or insomnia -Atropine- used to treat wet respirations, also known as the death rattle (slow HR and resp) -Levsin- an anti-cholinergic like atropine, also used to treat wet respirations -Haloperidol- can treat agitation and terminal restlessness -Compazine (prochlorperazine) - in either pill or rectal suppository form, this medication is used to treat nausea and vomiting -Metoclopramid -Promethazine- an anti-emetic like Compazine, Phenergan is used to treat nausea and vomiting -Dulcolax (Bisacodyl) - rectal suppositories to treat constipation -Senna- a plant-based laxative used to treat constipation -Acetaminophen -Tylenol suppository used to treat fever

Confronting myths

-Native American patients will not discuss death & dying -Severely ill Native American pts will not choose DNR status -Native American patients will not utilize hospice services if offered

How often do you change tubing?

-No more frequently than 72 hours (hospital policy) Exceptions: -Blood: 2 units of blood -TPN, Lipids: Q 24 hours (require more changes bc bacteria likes it more) -Propofol: Q 6-12 hours (often with every bottle or every other bottle) -Immunosuppressed patients

How is non-viable tissue removed?

-Nonviable tissue is removed through the process of debridement. -Mechanical: This type includes the use of high-pressure irrigation, pulsatile high-pressure lavage, and whirlpool treatments. -Autolytic: Removal of non-viable tissue by lysis of necrotic tissues by the WBC and enzymes of the body. This is done by using dressings that promote moisture at the surface of the wound. (transparent film, hydrocolloid dressings). -Chemical: This type of debridement uses topical enzyme preparation such as Dakin's solution or sterile maggots. This results in the breakdown of necrotic tissues. This tissue is either broken down or ingested. -Sharp/surgical: This process involves using sharp tools such as a scalpel or scissors to remove non-viable tissue. This is often times done by the physician, or advanced practice nurses. (Perry & Potter, 2020, p. 1206)

Drip rate

-Pace at which the fluid moves from the bag into the patient. Macro: Bigger drops, fewer drops to equal mL -10/gtt/mL -15 gtt/mL -20 gtt/mL Micro: For smaller volumes & shorter infusion periods -60 gtt/mL

Wound repair

-Partial-thickness wound repair: inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers -Full-thickness wound repair: hemostasis, inflammatory, proliferative, and maturation Hemostasis - the action of platelets and cytokines forms a haematoma and causes vasoconstriction, limiting blood loss at the affected area -The close proximity of the wound edges allows for ease of clot formation and prevents infection by forming a scab Inflammatory phase - a cellular inflammatory response acts to remove any cell debris and pathogens present Proliferation - cytokines released by inflammatory cells drive the proliferation of the fibroblasts and the formation of granulation tissue -Angiogenesis is promoted by the presence of growth mediators (e.g VEGF), allowing for further maturation of the granulation tissue; the production of collagen by fibroblasts allows for closure of the wound after around a week Remodelling - devascularisation of the region occurs, and the fibroblasts undergo apoptosis Complications of wound healing -Hemorrhage -Infection -Dehiscence (edges have separated, wound re-opens) -Evisceration (wound dehiscence & abdominal organs come out) Factors affecting wound healing -Nutrition -Tissue perfusion -Age -Psychosocial impact of wounds -mobility Normal protein: 1 g/kg/day If you have ulcer: 1/8-2 g/kg/day

Intermittent Cath Specimen

-Perform straight catheterization -When the initial flow flows out put in bucket (discard) -Then catch urine in sterile cup -Comnplete drainage of bladder

2: Peripherally Inserted Central Catheter (PICC)

-Peripherally inserted central catheters (PICCs) are central venous catheters inserted into a vein in the arm rather than a vein in the neck or chest. -They are inserted at or just above the antecubital fossa (specifically basilic vein due to its large diameter, although there are other options like cephalic) and advanced to a position with the tip ending in the distal one third of the superior vena cava. -PICCs are single- or multiple-lumen, nontunneled, and are up to 60 cm in length with gauges ranging from 24 to 16. -They are used with patients who need vascular access for 1 week to 6 months but can be in place for longer periods. -Do not use the arm with the PICC for blood pressure readings or blood drawing. Advantages -Lower infection rate -Fewer insertion-related complications -Decreased cost Complications -Catheter occlusion -Phlebitis

Steps after death

-Provider pronounces time of death (listens for breathing, heartbeat) -Contact family -Provider completes Death Packet -Contact donor services -Contact OMI/funeral home

Straight Cath Procedure Home

-Pt perform a clean technique How is this different from inpatient setting?: -In hospital there's a higher risk of infection/ HAI

Syringe pumps

-Pumps that deliver small amounts of fluids at slow rates from medication filled syringes -Intermittent admin of meds -IV pushes, especially over time > 5 min

Removing CVAD's

-Removal of CVADs is done according to institution policy and the nurse's scope of practice. -In many agencies, nurses with demonstrated competency can remove PICCs and nontunneled central venous catheters. The procedure involves removing any sutures and then gently withdrawing the catheter while instructing the patient to perform the Valsalva maneuver as the last 5 to 10 cm of the catheter is withdrawn. -Pressure should be immediately applied to the site with sterile gauze to prevent air from entering and to control bleeding. Inspect the catheter tip to determine that it is intact. -After bleeding has stopped, apply an antiseptic ointment and sterile dressing to the site.

List essential assessments prior to inserting a straight or indwelling catheter?

-Review the patient's medical record noting previous catheterizations (including size, response, and time of catheterization) -Check for conditions that may affect the passage of a catheter like an enlarged prostate gland or urethral strictures -Meds taken like anticholinergics & lasix -Do a physical assessment of the patient body and see any potential risk of placing a urinary catheter such as skin breakdown, UTIs etc. -Do a urine analyses to make sure WBC are not elevated or if BUN and creatinine are within normal ranges for kidney function Gather lab and diagnostic data -Collect specimens when orders are present -See any potential signs of infection -Increase WBC's BUN and creatinine levels

Maintenance

-Secure catheter -maintain gravity drainage (keep free of kinks) -cath care -measure and empty drainage bag Q 4 and PRN

3: Implanted infusion port

-These are surgically implanted CVC connected to a port. -The tip of the catheter lies in whichever vein is desired. -These are very good for long-term therapies and also have a low risk of infection. -These often are more cosmetically pleasing to the patient as well. -Drugs are placed in the port's reservoir either by a direct injection or through injection into an already established IV line. -After being filled, the reservoir slowly releases the medicine into the bloodstream. -Regular flushing is required to avoid the formation of "sludge" (accumulation of clotted blood and drug precipitate) within the port septum.

Maintaining a healthy wound environment

-To maintain a wound environment that is healthy, the nurse should prevent and manage infection, clean the wound, remove nonviable tissue, maintain the wound in a moist environment, eliminate dead space, control odor, eliminate or minimize pain, and protect the wound, as well as peri-wound skin. -Superficial skin injuries only need cleansing (soap and water) -Material used to close wounds include adhesive strips, sutures, staples and tissue adhesiveso -Using adhesion strips instead of sutures decreases the level of scaring and easier to keep clean -Dressing material is used to keep the wound clean and slightly moist is used to promote epithelization -Avoid using powders; dry the skin which causes irritation and bacterial growth -Make sure the patient is on a high calorie diet/ protein and given plenty of fluids to promotetissue growth -Ensure that a proper dressing is placed on the correct staged pressure injury

Why and how to manage exudate. Type of dressing

-Too much exudate will effect wound d healing -Assess color, odor, consistency, volume -Dressing include foam dressing, hydroccoloid dressing

Non-pharm intervetnions

-Transcutaneous electrical nerve stimulation -Touch/therapeutic touch/Prayer -Acupuncture & acupressure -Biofeedback, guided imagery -Distraction -Relaxation, meditation -Hypnosis -Activity: gentle movement -Massage

Responsibilities in EOL Care

-Treat people with compassion & respect -Listen -Communicate clearly -Educate early & often -Acknowledge & address pain -Seek advice! -Take care of yourself & colleagues

EOL symptom management approach

-Treatment must be consistent w the wished of the patient -Use muldidimensional apprach: physical, psychological, spiritual, social, cultural, situational -Treat symptoms & pain with pharm & non-harm methods -Goal is the greatest degree of comfort & quality of life, balance symptom managemnt with side effects of pharm interventions & educate caregivers

Health history for foleys

-Urgency/ hesitancy -Fluids they drink -Stress incontinence -UTI history -Benign prostate hypertrophy issues

Urinary Catheter kit

-Urinary bag -Foley catheter with the foley -forseps -sterile gloves -saline

PEDS urine collection

-Use a bag on infants to catch urine specimen

Important points

-Use smallest Cather and balloon (too small then urine can come out so go size up) -Lubricate generously when inserting -Sterile technique -Keep system closed if possible -Secure catheter to prevent movement

Angio-catheter

-Use smallest gauge appropriate -Consider size and depth of vein -Types of fluid to infuse: Blood: 18 g or larger preferred Fluid resuscitation: the larger the better Crystalloids: Smaller gauge Medications: Smaller gauge

Indications for catheterization

-When an acute illness of urinary elimination occurs, it may require straight catheterization. -For more long-term issues indwelling catheterization may be needed. However indwelling catheterization can be short term (less than 2 weeks) or longer than a month. -Acute urinary retention or bladder outlet -accurate measurement in critically ill pts -periop for selected surgical procedures -prolonged immobilization (end of life, stroke, handicapped) -healing of open sacral or perineal wounds in incontinent pts

Type of solutions four wounds

-When we are dealing with pressure ulcers, it is important to use non-cytotoxic cleaners. -The reasoning for only using non-cytotoxic cleaners is that they do not damage or kill fibroblasts and other healing tissues. NS: -Used as a cleanser for most wounds -Cleans dirty and necrotic tissue -Preferred Povidone Iodineo -Cytotoxic to healthy skin cells and granulated tissues -Broad spectrum antimicrobial effective against Staph. -May cause local irritation Hydrogen peroxide -Cytotoxic to healthy cells and granulating tissues -Helps lift debris from the wound surface -Ineffective at killing bacteria Dakins solution sodium Hypochlorite -Cytotoxic to healthy cells and granulating tissues -Bactericidal effect against most organism -Controls infection -Irigate from least to most contaminated areas, 35mL syringe at 8psi

Complications of a CVAD: Embolism

-can occur secondary to catheter breakage, dislodgment of thrombus, and/or the entry of air into the circulation. -Clinical manifestations of embolism include chest pain, respiratory distress (dyspnea, tachypnea, hypoxia, cyanosis), hypotension, and tachycardia. -Management of embolism includes the following steps: -Administer oxygen -Clamp catheter -Place patient on left side with head down (air emboli) -Notify physician

How do we collect a specimen for timed specimens

-have pt void and put in the toilet and the timer starts! -every time they void after that we collect -may need special container or preservative (put on ice) -start time at void -Identify end void -collect all urine within the collection time (if lost or contaminated, must restart collection) -Keep on ice -At end time, void & collect

Non-Invasive methods: condom catheter

-pt who are dribbling indications -male -fairly accurate I&O -moisture control -obtain non-sterile specimen (UAP can do it)

UTI prevention

-scrupulous sterile technique -closed system -catheter care can be done by techs Reduce irritation -smaller catheter -secure catheter -prevent stasis -bag should stay below the waist and never on the floor -fluids Maintain sterility of the bag -avoid contamination of drain tube -keep off floor -Remove ASAP

Inappropriate uses

-substitution. for nursing care of incontinent pts -urine tests when pt can voluntarily void (however in the ED we can do that even if the pt can void/ culture sensitivity taken into consideration) -prolonged post op duration without appropriate indications (pt says they are pain but we still have to pull that ish out)

Suprapubic catheters

-surgically inserted into bladder above pubis Indications: -Post-op GU surgery -Long term catherizations (less risk of infection than Foley catheter)

Sites to avoid for a PIV

1. Do not use hand veins for older adults or ambulatory patients. 2. Avoid foot veins for adults because of increased risk for thrombophlebitis. 3. Venipuncture is contraindicated in infected sites. 4. Avoid an extremity with a vascular graft/fistula, or on the same side as a mastectomy. 5. Avoid sites most proximal to a distal site already used. Using distal site first allows the use of a proximal site later.

Delagations for UAP

1Applying a condom cathetera. Skill can be delegated to a NAP: first instruct them to do the following -Inform the nurse if there is any redness, swelling or skin irritation or breakdown of glans penis or penile shaft -Be sensitive to privacy needs or patient Follow the manufacture directions for applying a condom catheter and securing the device 2) Collecting a midstream (clean-catch) Skill can be delated to a NAP. -If appropriate the nurse can instruct an alert patient who is physically able to collect the specimen -It is the nurse's responsibility to ensure the specimen is retrieved when ordered -Consider the patient mobility restrictions and inform the nurse when specimen is obtained -Inform the nurse if the patient is unable to initiate the stream or has pain or burning of on urination -Inform the nurse if the specimen looks dark, cloudy or contains mucous 3) Inserting a straight or indwelling cathetera. -This skill cannot be delegated. The nurse is responsible for assessing the needs for and evaluation of catherization. -The nurse directs the NAP to i. Help the patient positioning, focus lighting, empty urine form collection bad and help with perineal care -Report post procedure patient discomfort or catheter leakage -Report any abnormal color or amount of urine to the nurse 4) Performing indwelling catheter carea. -Although perineal care can be delegated to the NAP, Proper assessment and care of the indwelling catheter a is the responsibility of the nurse. patient. -If the patient has trauma or surgical procedures that involve the perineal area, do not delegate this task -The NAP can be instructed to: -Report patient discomfort and perineal pain, discharge, perineal rash, and/or odor. -Report condition of the catheter and drainage tubing (e.g., leaks, encrustations). -Report any discolored or foul-smelling urine. 5) Closed catheter irrigation. -Cannot be delegated to a NAP. Direct the NAP to Report patient complains of abdominal pain or discomfort, leakage of urine amount Report presence of blood Monitor and report I&O

Advance directive vs. code status

Advance directive: -Document outlining EOL wishes -It can be simple to very detailed. The document addresses things like prolonging life or not, nutritional support, ventilatory support, pain control. -Most care facilities ask patients for copies of their AD on admission; and offer help to create one should the patient like. Code status: -Provider's order based on patient's wishes -Code status is a formal provider order that tells caregivers in health care how to proceed in the event of deterioration or cardiac or respiratory arrest.

Assisting with elimination

Assisting with elimination -Privacy Physiological positioning: -bedside commode -stand or dangle at bedside -high fowlers -revers trendelenberg Methods of stimulating voiding -run water in sink -massage the lower abdomen -place a warm washcloth on the abdomen -pour warm water over the perineum with client positioned on toilet or bedpan -sitz bath

Complications of a CVAD: Catheter migration

Catheter migration or displacement can also occur. -Clinical manifestations would include sluggish infusion or aspiration, edema of chest or neck during infusion, patient complaint of gurgling sound in ear, dysrhythmias, or increased external catheter length. -The CVAD will need to be removed and replaced.

Stages of pressure injuries

Classification of pressure injuries -Stage 1: Non-blanchable erythema of intact skin -Stage 2: Partial-thickness skin loss with exposed dermis -Stage 3: Full-thickness skin loss -Stage 4: Pressure Injury: Full-thickness skin and tissue loss

Pressure injury types

Deep tissue pressure injury (DTPI) -Purple or Maroon -Slough: fatty stuff -Eschar: black/necrotic (If progressed) -Exudate (If progressed) Wound classifications: Process of wound healing -Partial-thickness wounds: visible tissue (no fat/muscle/bone) deep red or blister -Full-thickness wounds: visible fat/ bone/ muscle -Primary intention: occurs in wounds with dermal edges that are close together (e.g a scalpel incision). It is usually faster than by secondary intention (stage 1-2) -Secondary intention: occurs when the sides of the wound are not opposed, therefore healing must occur from the bottom of the wound upwards. (3-4)

Discontinuing IV access

Equipment -Clean gloves -2x2 -Tape -Alcohol wipes Technique -Remove tape and dressing -While applying pressure, remove angio -Assess for intact catheter -Apply dressing or bandaid

EOL specific symptoms in the last days of life

Dyspnea -SOB due to clinical condition, anxiety, dying -Cheyne-stokes (deeper faster breaths followed by no breathing, then repeats) Can be difficult for family as they wait for patients final breathe -Managed with opioids & anxiolytics -Opioids decrease air hunger by decreasing the respiratory drive, increasing blood flow in the brain, and alleviating anxiety. Pruritis -Itching from disease process, dry skin, malnutrition of dehydration -Moistening lotions, hydrocortisone cream, cetrizine or Benadryl, infrequent bathing, gentle soaps & lotions Hiccups -Symptom of dying -Baclofen (mild muscle relaxant/antispasmodic) -Metoclopramide (delayed gastric emptying, reflux, nausea) -Haloperidol (antipsychotic- for hiccups?) -Shorter acting benzodiazepines -Simethicone (anti-gas, antacid, chewable tab) Tricks to stop hiccups -Tricks to stop hiccups include holding breath, Excessive secretions -Decreased swallowing creates more saliva -May be related to disease process -Atropine (anticholinergic) -Scopalamine patch (anticholinergic) Agitation -Sometimes called terminal restlessness or terminal agitation -Can be caused by metabolilc disturbance, pain, fever, decreased blood flow to brain, constipation, & emotional turmoil -Haloperidol (antipsychotic) -Short acting benzo Delirium -Manifestations are confusion, inattention, impaire memory, hallucinations -Can be caused by meds & condition -Antipsychotics like risperidone, haloperidol Constipation -Caused by decreased activity & mobility, decreased fluid and flood intake, & opioid use -Laxative drink like miralax -Stool softener like colace, senna -Dulcolax suppository -Fluids, prune juice, apple juice Insomnia -Caused by unrelieved pain or symptoms, meds, environmental or emotional stressors -Encourage relaxation techniques, manage environmental stressors, develop & implement a wake- sleep cycle & stick to it -Trazodone: antihistaminergic, sedating -Mirtazapine: Antidepressant with sleepy side effect Nausea: -Caused by clinical condition, decreased intake, constipation, or medications -Small amounts of fluids -Prochlorperazine: antipsychotic, antiemetic, sleepy side effect -Haloperidol: antipsychotic -Ondansetron: serotonin blocker anti-emetic -Promethazine: strong sedating antihistamine/antiemetic Dry mouth -Dyspnea, meds cause dry mouth -Biotene mouth wash -Lip moisturizer as needed -Moistened mouth swabs -Humidify the environment -PO intake?

TPN/PPN

Explain the differences between TPN and PPN. How does administering TPN/PPN differ from any other IV infusion? What are key nursing considerations when caring for a patient on TPN/PPN? -Total Parenteral Nutrition is used as a last resort when a patient cannot receive nutrition properly due to an underlying digestive issue o TPN provides a high concentration of nutrients and calories which requires less volume to be infused o TPN is transfused within a major vein in the neck or chest Peripheral Parenteral Nutrition is meant to be used supplementary to other forms of nutrition hence it provides a lower concentration of calories as compared to TPN. o PPN is not meant to be used long term since it can damage the veins -PPN is delivered through a peripheral intravenous catheter Nursing Considerations o Be aware of the flow rate of nutrients being received by the patiento =Report any issues I the catheter location such as edema, redness or fluid escapeo Measure patient I/O to make to sure they are not having any complications in voiding o Explain to the patient the differences between TPN/ PPN o Auscultate lung's if giving a TPN Potential sign of fluid overlaod

Preparation of Patient

Explain the procedure and rationale Anesthetic? -Infiltration with Lidocaine -Emla cream -Tell the patient when you are going to insert the needle

Common Presenting symptoms

Female: -Pain, difficulty voiding -Difficulty controlling urine -Incontinence: stress (history of pregnancies) -Burning, itching Male: -Pain -Difficulty voiding-hesitancy, frequency, stream -Incontinence, dribbling

clean catch (midstream)

Goal: -to collect uncontaminated urine sample -Easiest to do on toilet -Wash hands -Have sterile cup open, ready to use uncontaminated Men -Cleanse penis with circular motion from meatus outward Women -spread labia with non-dominant hand and hold apart -clean area, moving from front (above urethral orifice) to back (toward anus). , repeat front-to-back motion 3 times (begin with left side, then right side, then center) -start urine stream, waste initial flow -catch urine in midstream with sterile cup (collect 30- -remove cup before urine stops -complete voiding -Transport specimen to laboratory within 15 to 30 minutes or refrigerate immediately.

Implementation

Health Promotion: -Preventive of pressure -Topical skin care and incontinence management -Positioning Q4h -Support services : no donut type Acute Care -Management of pressure ulcer Wound management -Debridement -Protection -Education -Nutritional status

Wound dressings

If a wound produces excessive exudate it can be removed from an absorbent dressing Hydrocolloid dressings such as Duoderm forms a hydrogel over the wound. When the dressing is removed the hydrogel gel stays/ providesa moist environment for the wound to heal -Algantes With sloughy wounds that also produce exudate, the alginate dressing provides a moist cover to prevent the wound from drying out and allowing the wound to heal more quickly. foam dressings are an effective tool for moist wound healing and are particularly useful in preventing dressing-related trauma, managing exuding wounds, and minimizing dressingdiscomfort and pain. -Transparent dressing used to prevent shearing and friction forces

intermittent Catheter (single use, straight catheter)

Indications -fluid retention -urine specimen Advantages -less chance of infection -longer a foley is in place the higher the rate of UTI Disadvantage -pt still can't urinate after 8 hours so we put a fowley Whats a PVR and why do we measure it -post void residual: how much urine is the bladder after the pt pees -If they have a high PVR they have a higher risk for infection= pylonephritis which is a kidney infection

Phlebitis & Infiltration

Infiltration: -Occurs when an IV catheter becomes dislodged, or a vein ruptures, and IV fluids inadvertently enter subcutaneous tissue around the venipuncture site. -When the IV fluid contains additives that damage tissue, extravasation occurs. S&S: -Cool -Trouble w flushing/meds -Swelling Phlebitis: -(i.e., inflammation of a vein) results from chemical, mechanical, or bacterial causes. Fluid volume excess occurs when the fluid is administered too rapidly. S&S: -Warm -Redness -Tender on palpation How to reduce risk?: -Using good sized vein, correect rate, proper dilution, smallest gauge possible -Discontinue IV access after infusion of the prescribed amount of fluid; when infiltration, phlebitis, or local infection occurs; or if the IV catheter develops a thrombus at its tip

Bladder irrigation

Open and closed procedures: open: -when I pull apart catheter and attach a syringe and irrigate closed (CBI): -best/ two irritation bags/ three way lumen/ the fluid coming out should be running fast and make sure the fluid is pink/ have tech drain bag / monitor I&O -Indications: Post op GU If we have 3000ml bag and we put it in our pt and we collect only 3500 from the bag which part is urine= 500 when is it done: -when there's a lot of sediment in the fowley and it's clogging it/ rarely done -sometimes with chemo

Care plan types

Palliative: -Symptom relief -Improve quality of life -Does not need to be terminal illness Hospice: -6 months left to live -No curative treatment -Symptom management if desired Comfort care: -Hospital: Based order set -Based on best practices

RN assessment, monitoring and maintenance of IV's

Patency -Check Q shift, before meds/procedures, troubleshooting. Flushing -Drawback GENTLY and look for flashback, then flush. -Check for swelling, ease of flushing. -Clamp saline-lock between uses. PIV site -Assess when flushing, meds, dressing changes. Minimum EVERY shift. -Look for swelling, pain, coolness, redness, and DATE. Concern - leaking, temp change, pain, edema. Date - Insertion date, dsg change Dressing change - PRN if damp, loose, soiled.

Special Cases: babies, children, gerontology

Peds: -Scalp, saphenous vein (leg) in babies -Feet in children -22-26 gauge needles Geriatric: -Fragile skin & veins -Use smallest catheter possible -Avoid back of hand -Maybe no tourniquet -frequent assessment

Pressure injuries

Pressure injuries -Pressure ulcer, decubitus ulcer, or bed sore Pathogenesis -Pressure intensity -Tissue ischemia -Blanching -Pressure duration -Tissue tolerance Shearing and Friction issues

Prevent infection.

Preventing an infection is important when treating a pressure injury -We want to prevent or manage infection because a wound will not progress through the normal phases of healing if it is infected. -Two of the major ways to prevent infection is to clean the wound and removing nonviable tissue. -To clean a wound, one would use irrigation with saline (Least contaminated to most, inner to outer). To remove nonviable tissue, one would use debridement

IV Terminology

Primary tubing: Primary longer, main IV fluid Secondar tubing: Secondary smaller, fluid in addition to primary -Secondary bag needs to be hung higher than primary Intermittent: Ex: IVP q 4 hours Continuous: Continuous infusion Piggyback (IVPB): Secondary infusion IV bolus: Large volume, short time, use port nearest to site, clamp other tubing IV push (IVP): Small volume, short time (slow IV push over several minutes) Saline lock: Usually peripheral IV on standby (pigtail) Spike: Part of tubing that goes in fluid bag Drip chamber: Portion where you can see drops dropping Roller clamp: How you control flow Injection port: Place you can inject while primary tubing is running Filters: Used for blood products or other meds that form percipitates Y-Tubing: Blood administration set

Urine sample collection

Purpose: -Urinalysis -Culture & sensitivity -Creatinine clearance -Products of metabolism

Skin

Skin: Epidermis: -Top layer of skin Dermis -Inner layer of skin -Collagen Dermal-epidermal junction -Separates dermis and epidermis

IV Start kit contents

Typically includes: -Sterile Gauze -Chlorhexedine -IV extension tubing (set) -Tourniquet -Statlock stabilization device -Tegaderm (clear dressing) -Tape strips -Small roll clear tape

Removal

What supplies do we need -clean gloves -10cc syringe -chucks pad -deflate the balloon What do you need to assess -assess the GU area and the need to void 6-8 hours -make sure you put a HAT (cup that measures how much) so we can see it What do you need to document -blood -we need to see the urine collection after the catheter is removed (if pt said they peed and flushed it we need to do it again) -document removal and how the pt tolerated it -output after Cather is removed what should you monitor post-removal -Them voiding on their own what if opt not voiding post removal -

Leg bag

clean leg bad with soap and water -once week use vinegar to rinse out the sudimodis (bacteria) in bad

Coude catheter

only put in pts who have prostates -used if we can get it in with a foley -the tip should always point up when going into the meatus