(S23) Final Exam (Comp)

(IV) Saline Lock

An intravenous catheter inserted into a vein and left in place for the intermittent administration of medication through its port or as an open line for emergency situations and intermittently flushed with normal saline solution to maintain patency (IV push 3rd semester skill)

(CV) Heart Sounds

HEART SOUNDS S1 is the first of the "lub-dub" sounds, and is loudest at apex. Signals the beginning of systole. During Systole, the midsystolic click is the most common extra sound. S1 Coincides with the carotid artery pulsation and closure of the AV vales. S2 Heart Sound (dub) S2 aortic and pulmonary valve closure. Diastole Loudest at left upper sternal border/base aortic region

(O2) Oxygenation

Nurses Role: Subjective Assessment of current symptoms associated w/ the pts feeling of SOB. Duration of assessment based on pt dyspnea. (SOB 1-10?, other symptoms? Asthma/COPD history? Meds? Supplements? Previous O2 history? Smoke? (Setting up, initiating cannula and mask, nursing care and assessments, humidification) Oxygen flow rate is given in liters/ min Classified: Low Flow (variable FiO2) or High Flow (fixed FiO2) FiO2= concentration of oxygen the patient breaths (room air has oxygen concentration of 21%) Provide humidification for oxygen flow rates > than 4 L/min To provide moisture in the respiratory passages that protect against irritation and infection. Important frequently assessing skin integrity to prevent skin breakdown from constant pressure and/or moisture buildup Safety: •Keep oxygen at least 6ft away from sources of SMOKING fire, elec motors & equipment w/ heating elements •Avoid wearing/using synthetic fabrics (build up static elec) •Keep oils, grease, alcohol, other flammable liquids away, ignite spontaneously •Caution with gas/electric appliances •Ground oxygen concentrators •Secure oxygen tank in holder and away from direct sunlight/heat with adequate airflow •Notify local fire department of home oxygen •Follow prescribed flow rate and ensure you have enough oxygen available prior to leaving home Saturation (Pulse Oximetry): Noninvasive technique attached to pt finger, forehead, nose, foot, ear or toe) measures the arterial oxyhemoglobin sat. (SpO2) of arterial blood •Acceptable range can differ in patients with chronic lung diseases Given as a % to indicate of amount of O2 in hemoglobin vs potentially oxygen carrying capacity of hemoglobin. •Normal range is 95-100% Hypoxia: Early symptoms: R: Restlessness A: Anxiety T: achycardia (hypertension) and Tachypnea Late Symptoms B:radycardia E:xtreme restlessness D:yspnea (difficulty breathing) Additional late symptoms include cyanosis, increased confusion, drowsiness, loss of consciousness. Caused by an inadequate amount of oxygen in the cells. Most common symptoms are dyspnea , an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor and cyanosis. It is often caused by hypoventilation (decreased rate of depth of air movement in the lungs) Atelectasis Partial or complete collapse of the lung Auscultation reveals absence of breath sounds (crackles may be heard if atelectasis is minor/small Can be prevented with use of incentive spirometer, Positioning patient in semi-fowlers, administering oxygen and analgesics (for pain) (O2) Incentive Spirometry (IS) •A device w/ gauge used to encourage patient to maximize lung inflation, exercise lungs after surgery or lung damage, helping to prevent atelectasis or pneumonia, allows measurement of progress.:Upright patient take slow, deep inhalations through mouthpiece and hold for 3 sec3. Monitor progress by height of gauge4. Encourage pt to complete this 10x/ hour while awakePrescription required (O2) Pillow Splinting and Coughing Deep Breathing •Helps remove retained mucus from respiratory tract •Can use splinting for pain management if coughing is painful. (CDB) Have patient take in a deep breath, hold it, slowly exhale and cough. 2x •Repeat several times per shift as patient condition warrants. PEDIATRIC ASSESSMENT FINDINGS: Infants have irregular respiratory patterns that get more regular as they age. Periods of apnea normal as long as no other signs of deficient oxygenation present. •Breath sounds are usually louder and harsher due to the thin chest wall-use pediatric stethoscope •Respiratory rates range from 30-60 at birth to 20-40 early childhood 15-25 late childhood, and 14-20 in mid teen years •AP diameter may have increase/transverse (1:1) or equal until age 5-6 •Thin chest wall, bony cartilage and ribs are soft, more horizontal •Respirations unlabored and quiet •Use diaphragm and abdominal muscles to breathe- rise and fall together •Use of accessory muscles, and nasal flaring, grunting is NOT normal and should be investigated immediately. Geriatric Variations: **Consider starting auscultation at posterior bases and moving towards the apices ▼ thoracic expansion due to calcified cartilage & loss of muscle. Can cause ▼ lung sounds that are harder to hear. ▲ resp rate (compensation for age related changes) •Loss of lung elasticity, ▼ functioning capillaries, resiliency loss •Rigid thoracic wall, weaker muscles, less effective cough; ▲ mucus retention •Kyphosis (thoracic) •Loss of subcutaneous fat, therefore, ribs more prominent ▲ abdominal-diaphragmatic breathing ▲ use of accessory muscles ▲ AP diameter (due to loss of skeletal muscle strength)

Specimen Collection · Key points, step-by-step procedure, normal vs. abnormal findings, nursing interventions, client teaching, and documentation related to specimen collection for: a. Throat culturesterm-3 b. Urine specimens c. Stool specimens d. Blood glucose point-of-care testing using a glucometer

Meds in Urine: pale yellow: diuretics orange/orange-red: Pyridium pink/red: anticoagulants green/greenish-blue: B-Complex Vitamins brown/black: Injectable Iron Compounds

(BP) Estimated Systolic Pressure (ESP)

Palpate brachial pulse on wrist radial artery. Place the cuff on the arm above the brachial artery. Get pulse again, inflate until pulse disappears. Then slowly release valve until pulse returns. (Systolic) Important for pt whose auscultatory end is difficult to determine, like preg pts in shock or exercising, loud environment

(Wounds) Healing

Wound Healing: Primary: wound edges approximated (sutures/staples). Heals quickly, minimal scarring Secondary: wound edges widely separated. Longer healing time, scarring, increased infection risk. Tertiary: wound left open to address infection and then close at a later time

(Inj) IM Z-track Method

Z-Track: To minimize local skin irritation by sealing med in muscle tissue 1. pull overlying skin and sub Q tissue laterally to the side 1 -1.5" 2. inject the needle into the muscle leaving in for 10 seconds after injection, then release the skin. 3. Needle stays in skin for 10 seconds to make sure medication stays in intended injection site, so it doesn't float back up the layers of skin, and might cause irritation or staining

(Wound) Types

(Red) Protect: proliferative stage of healing, reflects normal color. Gentle cleaning with 0.9% Saline. This type of wound can exude small, medium, large and XL amount of drainage. Keep wound bed moist to facilitate formation of granulation tissue and maintain cellular health or apply transparent (No absorption) or hydrocolloid dressings. (Tegaderm, Acuderm, Op-site, Bioclusive, Uniflex, etc) (Yellow) Clean: Presence of exudate or slough.. Drainage can be purulent (whitish, yellow, creamy yellow, yellowish green or beige) Wound must be cleansed. Must remove slough and exudate to promote healing. Will irrigate as one method to remove exudate and slough. This type of wound can exude small to very large amounts of drainage. May also use topicals to decrease microorganism growth. Wet-to-moist, non-adherent, Hydrogel, or other absorptive dressings. Hydrogels (Vigilon, Intrasite Gel, Aquasorb, ClearSite, Nu-Gel, Hypergel, Hydrofiber, Aquacel) Alginates (Sorban, AlgiDerm, Curasorb) Foams (LYOfoam, Allevyn) Silver Dressings (Silvasorb, SilverCel, Aquacel AG) Collagens (BGC Matrix, PROMOGRAN Matrix, Kollagen-Medifil Pads) (Black) Debride: Covered w/ eschar (necrotic tissue) Tissue may be black, brown, tan or gray. For wound to begin to heal, non-viable tissue must be removed (debridement) After debridement, treated as a yellow wound, then a red wound. Biodebridement Sterile maggots can produce substances that are antimicrobial Sharp debridement (Scalpel or scissors) Mechanical debridement (Scrubbing, pulsed lavage or irrigation with pressure, wet-to-dressings. Chemical debridement Collagenase enzymes (Santyl) Papain/urea (Accuzyme) Fibrinolysin (breakdown fibrin like Elase) Autolytic debridement using hydrogels, hydrocolloids, foams, alginates) Pressure Injury Stages: Stage 1: non-blanchable erythema of intact skin Stage 2: partial thickness skin loss with exposed dermis. wound bed is pink and moist Stage 3: full thickness skin loss in which adipose and granulation tissue is visible Stage 4: full thickness and tissue loss with exposed palpable fascia, muscle, tendon, or bone. slough and eschar may be visible Unstageable: full-thickness skin and tissue loss in which extent of tissue damage within ulcer can't be confirmed because it's obscured by slough or eschar. Deep tissue pressure injury: intact or non intact skin with localized area of persistent non-blanchable deep red maroon purple discoloration or epidermal separation, revealing a dark wound bed or blood filled blister Intentional (Surgical): Center Superficial and deep tissue layers of surgical Incision. Dehisced, Eviscerated, Secondary Intention Unintentional: Contamination likely. Usually jagged edges, multiple traumas common, bleeding uncontrolled. Increased risk for infection and longer healing time. Abrasion, Laceration, Puncture Healing Phases: Hemostatis Phase: Immediately after injury: Involved blood vessels constrict and blood clotting begins through platelet activation and clustering. After a short period the blood vessels dilate and capillary permeability increases (plasma and blood components leak into injured area resulting in a liquid called exudate) (1) Inflammatory: begins when wound develops, 4-6 days marked by erythema, pain, oedema, immune sts works to prevent microbial colonization (2) Proliferative: lasts another 4-24 days, granualation tissue fills wound fibroblasts lay collagen, strengthening new tissue. Wound edges contracted epithelial cells migrate from wound margins (3) Maturation phase : can last 21 days-2 years depending on pt wound related factors, duration of wound, pt comorbidities, wound infection status, filled in wound covered, strengthened. Scar tissue forms

(IV) Site Complications

Infection (Site): Infection can occur whenever the skin barrier is broken by the insertion of an IV catheter and bacteria enters the blood stream. Caused by poor hand hygiene, frequent disconnection of tubing, poor insertion technique. Local S&S: Erythema, edema, induration, drainage (may be purulent) at the insertion site. Localized infection may lead to systemic Systemic S&S: Fever, malaise, chills, other vital signs changes. May lead to sepsis. Erythema, redness, warmth, edema, induration, tenderness, possible fever, drainage (may be purulent) at the insertion site. Vascular catheter-associated infection is considered a hospital-acquired condition because it can be prevented using best practices. Nursing Considerations: Discontinue infusion immediately, re-start infusion at a different site. Save the catheter and obtain order to send for a culture if infection is suspected. Notify provider if any systemic symptoms of infection. --Be sure to follow evidence-based infection prevention practices, such as performing hand hygiene, performing a vigorous mechanical scrub of needleless connectors, limiting catheter access, and following sterile no-touch technique during intravenous infusion to reduce the risk of vascular catheter-associated infection. Phlebitis (Site): Localized; inflammation of a vein, caused by mechanical trauma from needle/catheter during insertion of the catheter, or chemical trauma from solution . S&S: pain, edema, erythema, increase skin temperature, tenderness, redness traveling the path of the vein. Local, acute tenderness, redness (may look like a red streak over vein) warmth, and slight edema of the vein above the insertion site. Can lead to infection if not treated properly. TX: infusion must be disconnected, raise the extremity, apply warm compress. risk reduced by routine removal and rotation of sites Nursing Considerations: Discontinue the infusion immediately, re-start infusion at different site. Apply a warm compress to affected site, non-steroidal anti-inflammatory medications. Infiltration (Site): Localized, escape of fluid into the subcutaneous tissue. or surrounding space of venipuncture site. Caused by dislodged needle/IV Cath from vein into SQ space/vessel wall. Occurs when tip of cath slips out of vein, passes through wall of vein or blood vessel wall allows part of the fluid to infuse into the surrounding tissue, resulting in the leakage of IV fluids into the surrounding tissue. S&S: Swelling, pallor, coldness, or pain around the infusion site. Cool to touch. Significant decrease in flow rate. Tx: Should discontinue the site and relocate the IV. If the infiltration is severe, you may consider the application of a compress in addition to elevating the affected limb. Check your institution's policy regarding which type of compress (warm or cold) should be applied. Additionally, clinical pharmacists can also be helpful resources for determining the appropriate type of infiltration treatment. Nursing Considerations: Check infusion site every hour. Discontinue infusion if symptoms occur and re-start the infusion at a different site. infusion must be disconnected, raise the extremity, and apply warm compresses Extravasation (Site): Infiltration of damaging intravenous medications, such as chemotherapy, into the extravascular tissue around the site of infusion. Extravasation causes tissue injury, and depending on the medication, site, and length of exposure, it can cause tissue death, which is also referred to as necrosis. If detected early, extravasation may be treated with medications that help avoid the complication of necrosis Thrombus (Site): Localized; blood clot. Caused by tissue trauma from needle/catheter S&S: Local, acute tenderness, redness, warmth, and slight edema of the vein. IV flow may cease if clot obstructs catheter Nursing Considerations: Discontinue infusion immediately, re-start infusion at a different site. Apply a warm compress as ordered. DO NOT RUB OR MASSAGE AREA.

(Bowel) Enema Adverse Side Effects/Interventions

* Can stimulate the vagus nerve, slowing HR. Stop procedure immediately, monitor HR and BP and notify physician. * Many pts find that a sitz bath or tub bath after this procedure soothes irritated perineal area. * PCP may order oil-retention enema to be given before the procedure to soften the stool.

(Ent) Med Administration

* Do NOT give meds that might alter gastric pH OR Extended Release/Sustained release meds * Stop feeding 1-2 hrs prior to the med admin if med is incompatible with feeding. · 1 hour prior to medication administration if placement is to be assessed via the pH method. · 30 min. prior to med administration if med should be given on empty stomach. · Immediately before medication administration if medication can be given with food.

(Bowel) Ostomy Appliance Interventions

* Inspect the patients stoma regularly. * Keep skin around stoma site (peristomal area) clean and dry. * Keep the patient as free of odors as possible; * Empty appliance when bag is 1/3 full * Measure the patients fluid intake and output. * Good peristomal care to prevent excoriation. - Teach patient how to care/inspect for appliance. Look at it. - Emotional Support

(HNEE) Lymph Node Assessment

* Using a gentle, circular motion of the finger pads, palpate the lymph nodes. * When symptoms warrant, check for parotid tenderness by palpating in a line form the outer corner of the eye to the lobule of the ear. * Beginning with the peduncular lymph nodes in front of the ear, palpating 10 groups of lymph nodes in a routine order. * Many nodes closely packed so it must be systematic and thorough examination. * Once sequence is established, should not vary or may miss some small nodes. * Using gentle pressure, strong pressure could push nodes into neck muscles. * Best to palpate with both hands symmetrically. * Submental gland under the tip of the chin is easier with one hand. Use other hand to position the patient head. * For deep cervical chin, tip the pt head toward side being examined to relax ipsilateral muscle, then press fingers under muscle. Search for the supraclavicular node by having pt hunch shoulders and elbows forward, relaxing the skin. The inferior belly of the omohyoid muscle crosses the posterior triangle here, not to be mistaken for a lymph node, * If any nodes are palpable, note location, size, shape, delimitation (discrete or matted together) enlarged or tender, check area they drain for source of the problem. (IE) Those in upper cervical or submandibular area often relate to inflammation or a neoplasm in head or neck. Follow up on or refer finding. An enlarged lymph node, particularly when you cannot find the source of the problem, deserves prompt attention. Findings: Palpable lymph nodes, which should be noted. Nodes should feel moveable, discrete, soft, nontender. Might find lymphadenopathy, swollen lymph nodes. If nodes are enlarged or tender, check area they drain for source of the problem. Like those in upper cervical area or submandibular area often relate to inflammation or neoplasm in head and neck

(Urinary) Closed-Irrigation Procedure

*helps maintain patency of draining catheter. *Decrease risk of infection of spreading by preventing introduction of pathogens into the bladder, use self-seal port for access. *If post procedure is at risk for clogging (TURP, cystoscopic exams.) Sterile Saline or Sterile Water is used for intermittent closed catheter irrigation, however a physicians order is required prior to use. Can use up to 30 mL if not ordered, may indicate "until patent." 1. Verify prescriber's order. 2. Assess appearance & amt of pt urine. Measure urine in drainage bag. Assess pt. for bladder distention 3. Determine type of catheter used. Check patency 4. Identify pt. Explain procedure. 5. Perform hand hygiene. Apply gloves. 6. Provide Privacy 7. (Closed Intermittent Irrigation) a. Prepare solution and draw into syringe. b. Clamp indwelling catheter below injection port. c. Cleanse port with swab. d. Connect syringe to port using needle-less system. e. Slowly inject fluid into catheter and bladder. f. Withdraw syringe, remove clamp, and allow solution to drain into bag. 8. When irrigation is completed, reestablish closed drainage system. 9. If solution does not return, have client change position, or gently aspirate solution 10. Re-anchor catheter to client. Assist client to a comfortable position 11. Dispose of supplies. Remove and dispose of gloves.Perform hand hygiene 12. Calculate irrigation fluid used and subtract from total drainage. 13. Record and report type and amount of irrigation, character of drainage, and any unexpected findings.

(Ent) Enteral Tube Interventions

-Check gastric residual (feeding remaining in stomach) before each feeding * or q4-6 hours during cont. feeding (or agency policy) * High gastric volumes (200-250 mL or <) can be assoc. w/ high risk for aspiration and aspiration-related pneumonia. * Making sure pt is as upright as possible during feeding. * If in bed, elevate the HOB at least 30 deg. during feeding + 1 hour after to prevent reflux and aspiration. * Pause feeding if pt has to be repositioned or temporarily laid flat. * Preventing + checking tube from clogs or obstruction. * Use sedatives as sparingly as possible. * Assess feeding tube placement @4 hr interval. * Assess for gastrointestinal intolerance at @ 4 hr intervals.

(Bowel) Procedure: Digital removal of feces.

-wash hands -wear gloves-provide privacy -Sim's position left side - disposable pad under hips -place bedpan nearby -lube well forefinger of dominant hand -insert finger to the level of the hardened mass -move finger about to break up, withdraw segments of stool - allow rest periods, but continue until all removed or significantly reduced -clean the rectal area, perform hand hygiene -slow deep breaths, watch for hemorrhoids

(Assess) Health History and General Survey

1. Biographic Data: Name, address, phone, age, DOB, birthplace, gender, relationship status, race, ethnic origin, occupation, language 2. Reason for seeking care: brief spontaneous statement in pt's own words, like a "title" for story to follow. States 1-2 signs and symptoms and their duration 3. Present Health or History of Present Illness: for well person, short statement of general state of health. For ill person, chronologic record of reason seeking care, from 1st symptom until now. Isolate each reason for care ID'd by pt and say "please tell me all about your headache, from the time it started until now. If long ago, record what occurred to find out why pt seeking care now. PQRSTU Location, Character or Quality, Quantity or Severity, Timing (Onset, Duration, Frequency), Setting, Aggravating or Relieving Factors, Associated Factors, Patients Perception. Understanding 4. Past History: May have residual effects on current health state. Pts Previous experience with illness may also give clues about how pt responds to illness and significance of illness for them. Childhood illnesses, accidents/injuries, serious/chronic illness, hospitalizations, operations, Obstetric history, Immunizations, Last exam date, allergies 5. Medication Reconciliation: Comparison list of current and previous meds done at every hospitalization and clinic visit. Purpose to reduce errors and promote patient safety. For all current meds, note name, dose, schedule and ask "How often do you take it each day, what is it for? how long have you been taking it? any side effects? (or if not taking) "What is the reason you stopped taking it?" 6. Family History: age and health/cause of death of blood relatives such as parents, grandparents, siblings. Age and health of spouse and children. Specifically any fam history of Heart Disease, High Blood Pressure, Stroke, Diabetes, Blood disorders, Cancer, Sickle-cell Anemia, Arthritis, Allergies, Obesity, Alcoholism, Mental Illness, Seizure Disorder, Kidney Disease, TB. Construct fam tree to show this info clearly 7. Review of Systems: General overall health state, present weight (gain or loss, period of time, by diet or other factors) fatigue, weakness, malaise, fever, chills, sweats, or night sweats. Skin, Hair, Nails, Head, Eyes, Ears, Nose and Sinuses, Mouth and throat., Neck, Breast. Resp, CV, Peripheral Vascular, GI, Urinary, Genital, Sexual Health, Musculoskeletal, Neurologic, Hematologic, Endocrine systems 8. Functional Assessment or Activities of Daily Living: measures persons self-care ability in areas of physical health, bathing, dressing, toileting, eating, instrumental activities of independent living such as housekeeping, shopping, cooking, nutritional status, social relationships, resources, self-concept, coping, home environment.

(Urinary) Intermittent Closed Cath Irrigation

1. Confirm the order for catheter irrigation and prescribed solution in the medical record and gather equipment. 2. Perform hand hygiene and put on PPE, if indicated. 3. Close the curtains around the bed and close the door to the room, if possible. Explain to the client what you are going to do, and why. 4. Adjust the bed to a comfortable working height, usually at elbow height of the caregiver. 5. Put on gloves. Empty the catheter drainage bag and measure the amount of urine, noting the amount and characteristics of the urine. Remove gloves. Perform hand hygiene. 6. Expose access port on catheter setup. Place waterproof pad under the catheter and the aspiration port. Remove the catheter from device/tape that is anchoring catheter to the client. 7. Open supplies, using aseptic technique. Pour sterile solution into sterile basin. Draw up the prescribed amount of irrigant (usually 30 to 60 mL) into sterile syringe. Put on gloves. 8. Cleanse the access port on the catheter with antimicrobial swab. 9. Clamp or fold catheter tubing below the access port. 10. Attach the syringe to the access port on the catheter using a twisting motion. Gently instill solution into catheter. 11. Remove syringe from access port. Unclamp or unfold tubing and allow irrigant and urine to flow into the drainage bag. Repeat procedure per provider order. 12. Remove gloves. Re-secure catheter in device or tape to anchor the catheter to the client. 13. Assist the client to a comfortable position. Cover the client with bed linens. Place the bed in the lowest position. 14. Secure drainage bag below the level of the bladder. Check that drainage tubing is not kinked and that movement of side rails does not interfere with the catheter or drainage bag. 15. Remove equipment and discard the syringe in an appropriate receptacle. Remove gloves and additional PPE, if used. 16. Perform hand hygiene. 17. Document procedure, including what solution was used, client tolerance and urine appearance. Also document on Intake and Output (I & O) record.

(Assess) Techniques: Order

1. Inspection 2. Palpation 3. Auscultation 4. Percussion UNLESS Abdominal Assessment (in that case): 1. Inspection 2. Auscultation 3. Palpation 4. Percussion.

(Assess) Interview and Phases

1. Preparatory Phase: review old records, prep environment, prep self, review culture, external factors 2. Introductory Phase: Name and title, confidentiality, purpose and timing of interview and note taking, address patient with surname then ask how they would like to be addressed 3. Working Phase: Ask questions-should be like a conversation not an interrogation, use appropriate communication techniques. Gathers data needed to form the subjective data base 4. Summary and Closure Phase: Summarize information, validate problems, allow patient to add any information not covered in working phase

(HNEE) Equilibrium Test (Romberg test)

1. Remove shoes stand w/ hands close to body 2. Close your eyes 3. HCP observes how well balance maintained 4. May also push pt to test how well balance is regained

(Urinary) Retention Cath Specimen Collection

1. Verify health care provider's order and explain procedure to client. 2. Clamp tubing to collect fresh urine. 3. Wash hands & gather and prepare equipment. 4. Provide client privacy. 5. Apply clean gloves. 6. Swab port with alcohol. 7. Withdraw urine from specimen port using needleless syringe. 8. Place urine specimen in sterile container. 9. Maintain sterility of container, cover and specimen throughout the procedure. 10. Close lid of container, remove gloves and perform hand hygiene. 11. Remove rubber band or clamp from tubing. 12. Label specimen container (date, time, source, and client name). 13. Place in appropriate bag for delivery (According to facility policy). 14. Dispose of materials appropriately. 15. Wash your hands. 16. Document time, date, type of specimen, and client name. Stress Incontinence

(Urinary) Retention Cath Removal

1. Verify health provider's order and explain procedure. 2. Provide for privacy. 3. Using clean gloves, empty catheter bag, measure, perform hand hygiene and record output. 4. Place incontinence pad underneath client. 5. Apply clean gloves and verify the balloon size by looking at the balloon port. 6. Attach appropriate size syringe to the balloon port and allow water to expel (standard is 5 mL balloon or balloon size) 7. Verify that all the water has been removed from balloon. 8. Pinch catheter tubing before and during catheter removal - Have client take a deep breath and exhale when you smoothly pull the catheter out of the client. 9. Dispose of materials appropriately. 10. Give instructions to the client following removal. 11. Maintain medical asepsis throughout. 12. Teach client that they might have burning or dribbling initially and that first void needs to be measured. 13. Maintain organization and efficiency. 14. Document time of removal, amount and characteristics of urine, client's tolerance.

(Urinary) Removal of Catheter

1. Wash hands before/after the procedure, wear gloves. 2. Deflate balloon before attempting to remove catheter by inserting a syringe into the balloon valve and aspirating all of the sterile water used to inflate it. Do not cut the tubing with scissors. 3. Ask pt take several deep breaths, relax while you remove cath, gently. Wrap cath in towel or disposable waterproof drape. 4. Clean perineal area after cath removed. 5. Ensure pts fluid intake is generous and record intake as well as time and amt of fluid output for at least 24 hours (or according to facility policy) following catheter removal. Instruct pt to void into bedpan, urinal or specimen hat. If pt does not void within 8-10 hours of removal of the indwelling catheter, notify provider. 6. Inform pt that it may take a while for the bladder to reestablish voluntary control and that an accident at this time is not unusual. 7. Tell pt might be a slight burning sensation when voiding first few times after cath removal. 8. Observe urine carefully for any abnormalities, document volume of first void to validate adequate emptying of the bladder post removal. 9. Record and report any unusual signs or symptoms, such as discomfort, a burning sensation when voiding, bleeding, or changes in vital signs, especially the pt. temperature. Be alert to any signs or symptoms of infection and report them promptly.

(Asepsis) AWARE

Activity to prevent/halt spread/break chain/minimize threat of infection. Above Waist Water is wick Around 1 inch Sterile Packaging Refrain from Turning Back/Talking over sterile field Ever in Doubt, Throw it Out

(HNEE) Hearing Tests

Air conduction (AC) Normal pathway of hearing. most efficient Bone conduction (BC) • Bones of the skull vibrate and transmit vibrations to the inner ear and acoustic nerve Conductive Hearing Loss Mechanical dysfunction of the external or middle ear. • Results in partial hearing loss • Person can hear if ᛏ amplitude able to reach nerve elements in the inner ear. Sensorineural (perceptive) Hearing Loss • Pathology of the inner ear, acoustic nerve (VIII) or auditory areas of the cerebral cortex. • ᛏ amplitude may not help Whisper Test: having pt place a finger on tragus of one ear. Whisper 2-syllable word 1-2 ft behind the client. Repeat on other ear. Weber Test: using a tuning fork placed on the center of the head or forehead and asking whether the client hears the sound better in one ear or the same in both ears Rinne Test: using a turning fork and placing the base on the client's mastoid process. When the client no longer hears the sound, note the time interval, and move it in front of the external ear. When the client no longer hears a sound, note the time interval.

(Wound) Peri-Wound Assessment

Area of skin around wound bed Redness (Erythemia) Induration (hardening) Smooth, dry Temperature Tenderness Sensation Macerated (soften by soaking) Edematous (edema/swelling) Smooth, Approximation

(Neuro) Geriatric/Pediatric Reflex Findings

Assessment of Child •Unique reflexes •Rooting-turns head to side when cheek stroked •Sucking-to feed •Grasp-touch palm->flexion of fingers •Moro-sudden jarring or noise->extension and abduction of extremities (gone at 3-4 mo) •Babinski-extension and abduction of toes with sole stroking Assessment of Older Adult •Decrease in deep tendon reflexes •Transmission of impulses-delayed reaction time-slower voluntary movement time •Sensory-decrease light touch due to atrophy of nerve endings •Movement (slower gait); decreased fine motor coordination (difficult to button shirts)-cerebellar •Decrease in the 5 senses

(BP) Auscultating Blood Pressure

BP can be measured indirectly by auscultation or palpation. The preferred, and most commonly used, method is *auscultation*; however, palpation is useful in certain situations. Procedure: place stethoscope over an artery, inflate the cuff, and listen for (Korotkoff) sounds cuff deflates.

(IV) Back Priming Secondary (PB)

Back priming is considered best practice and is performed using an infusion pump with primary fluids attached: ◦ Clean, and connect the secondary tubing to the port closest to the drip chamber. Lower the secondary bag below the primary bag, and allow the fluid from the primary bag to fill secondary tubing. * Fill the secondary tubing until it reaches the drip chamber, and then raise the secondary bag above the primary line. Label the secondary tubing near the drip chamber. -Set the infusion rate: Leave both lines open. ◦ For infusion pump: Set the volume to be infused and the rate (mL/ hr) to be administered based on the provider order. ◦ For gravity: Set the roller clamp to appropriate number of drops per minute based on the provider order. To regulate secondary infusion flow rate, wide open roller clamp on secondary tubing and use clamp on primary tubing to adjust flow rate. If the primary infusion's rate differs from that of the secondary infusion, when its completed, remember to adjust the rate as soon as possible after the secondary infusion is complete. If your patient will receive subsequent doses of the secondary infusion, leave the bag and tubing hanging. It can be used for 72 to 96 hours, depending on your facility's policy

(IV) Changing IV Bag

Change solutions without administration set Check 5 Rights/3 Checks Color and consistency

(Wound) Clean no-touch dressing change technique

Changing surface dressings w/out touching wound or surface of any dressing that might be in contact with the wound. To decrease # of m/o's or prevent/reduce the risk of transmission of m/o's. Adherent dressings should be grasped by the corner and removed slowly, gauze dressings can be pinched in the center and lifted off. RN Must: maintain clean enviro w/ hand hygiene, gloves, sterile supplies. Prevent direct contamination of materials + supplies Remember, these wounds are not sterile to begin with AND they are OPEN, so they are already contaminated by microorganisms!

(Wound) Irrigation solutions, technique, and wound packing key points

Cleans tissues + flushes cell debris and drainage from an open wound. -Helps prevent premature surface healing over abscess pocket or infected tract. 19 ga Angiocath w/ 20mL syringe; jets and irrigation set; etc. may be used to irrigate a wound. After irrigation, open wounds are packed to absorb additional drainage. Always follow standard precautions. Check practitioner's order, assess pt's condition and ID allergies. Explain procedure to pt, provide privacy, and position correctly. Place linen saver pad under the patient and place emesis basin below wound so irrigating solution flows from the wound into the basin In lab we can use a chux to catch the irrigant instead of using a basin. -Wash your hands and then put on a gown, gloves and protective eyewear. Remove soiled dressing, then discard the dressing, gloves in trash bag. Establish a clean or sterile field with all the equipment and supplies you'll need for wound irrigation and dressing. Pour prescribed amount of irrigating solution into clean/sterile container (can put irrigating solution container in warm water to warm up the sterile solution prior to use). -New pair of gloves and gown and protective eyewear if indicated. -Fill the syringe with the irrigating solution. -Instill a slow steady stream of solution into the wound until the syringe empties. Make sure irrigating solution flows over tissue from clean to the dirty area of the wound to prevent contamination of clean tissue by exudate. -Also make sure the solution reaches all areas of the wound. -Make sure to irrigate the wound bed only, do not let irrigant flow from peri wound into wound bed. Refill the syringe, and repeat the irrigation Continue to irrigate the wound until you've administered the prescribed amount of solution or until the solution returns clear. Note the amount of solution administered then remove and discard. Cleansing Solutions: Normal saline: Preferred isotonic and used because of lowest toxicity , not as good at cleaning dirty/necrotic wounds Sterile Water Antibiotic preparations Antiseptic solutions 3% Hydrogen Peroxide: Hydrogen Peroxide widely used few studies report its efficacy as an antiseptic Dakin's solution typically used to control infection in pressure ulcers with necrotic tissue. known to be effective against bacteria commonly found in open wounds. cytotoxic to healthy cells and granulating tissues, and not recommended to use for periods longer than 7-10 days Commercial wound cleansers are now widely used for wound irrigation. The surfactant content in cleansers helps to remove bacteria and cellular debris with less force hydrogen peroxide, betadine, and acetic acid should be avoided because these agents can be cytotoxic. Wound Packing: Used to 1. to fill dead space 2. maintain warm moist environment, 3. absorb drainage and to debride, depending on dressing type. Packing helps to prevent the wound closing from the outside in and forming an abscess. Moist wound healing (wet/dry dressings) that fills the wound cavity, used for debridement. Promotes granulation in a moist environment. Like a wick, Soaks up infection/pus/fluids and getting them away from the body. Must be changed min. 3x/day. Requires cover dressing Saline replaced q 24hrs. 3 layers 1. wound bed, 2. peri-wound protection (manyx), 3.cover layer. When packing removed, also removing old unhealthy skin and alllowing the body to heal better. Wound heals from inside out, by layers, keeping top layers from trapping bad tissue or infection. Very important to cleanse/irrigate wound before packing.

(Integ) Colors

Color: Bruising/Contusion (Black/Blue) (aka Ecchymosis) Should be consistent with expected trauma of life. Normally no venous dilations or varicosities, but darker than other areas of skin. Darker-skinned: May appear red or purple at first, then turn blue, brown, green or yellow. Color: Cyanosis (Blue) Bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood. Later sign = older adults. Earlier sign = young. Localized cyanosis does not affect color of mouth. Assess: Lips, nose, cheeks, ears and oral mucous membranes under artificial fluorescent lighting Darker-skinned/Mediterranean: best assessed in conjunctiva & inside of mouth, not gums since skin might appear "dull". Don't confuse cyanosis with common and normal bluish tone on lips Color: Erythema (Redness) Redness of the skin due to capillary dilation. Assess: Palpating areas for warmth or taught or tightly pulleds surfaces that might indicate edema or hardening of deep tissues or blood vessels. Color: Jaundice (Yellow) Yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in blood. Assess: in junction of hard and soft palate in mouth and in under eye sclera. Darker-skinned: Same, but don't confuse normal yellow subconjuctival fatty deposits that are common in outer sclera of darker-skinned people. Sclera yellow of jaundice extends up to the edge of the iris. Color: Pallor (White) Blanching due to emotional stress such as fear, anemia, low blood pressure, impaired blood flow to an area. Assess: Extremities, connective tissue areas. Caused by anemia or shock, decrease in amt of circulating blood or hemoglobin, causing inadequate oxygenation of body tissue. Darker-skinned: Absence of luster of underlying red tones. Brown-skinned individuals show yellow/brown color, black-skinned ind. appear ashen /gray. Observe general pallor in mucous membranes, lips and nail beds.

(HNEE) Extraocular MF Tests

Corneal Light Reflex: By shining a light toward the patient's eyes. The light should be reflected at exactly the same spot in the two corneas. It is used for light perception Cover-Uncover Test: to ID a tropia + differentiate it from phoria,. Occluder is held in front of the eye for a few seconds. When fixing eye is occluded, examiner observes non-occluded eye move to pick up fixation if tropia is present. If no tropia present, non-occluded eye will remain stationary. To assess for a phoria or latent deviation, the examiner observes the eye behind the occlude. If a phoria is present, the uncovered eye does not move, however the eye behind the occlude will deviate and return to a straight position when the occlude is removed. 6 Cardinal Fields: To test extraocular muscle function through a diagnostic positions test. Elicits any muscle weakness during movement. Ask pt to hold head steady, follow mvmt of finger, only with their eyes. Hold finger back about 12in so person can focus on it comfortably. Move to each of six positions, hold it momentarily, then move it back to the center. Clockwise. A normal response is parallel tracking of the object with both eyes.

(Neuro) Cranial Nerves

Cranial III (Oculomotor) Motor: Most Extraocular Movement, Open/Close Eyelids. Parasympathetic: Lens shape Pupil Constriction/Dilation, light reaction Test: Cardinal Points Test Cranial IX (Glossopharyngeal) Motor: Pharynx (Phonation and Swallow ability. Pharynx: Gag reflex. Innervation of tongue, Sensory-taste on posterior 1/3 of tongue, Test: Swallow to test, gag reflex w/ tongue depressor. Cranial X (Vagus) Motor: Pharynx and Larynx: (talking and swallowing) Sensory: sensation muscles of pharynx and larynx. Carotid Sinus, pharynx, viscera. Parasympathetic-Carotid Reflex Movement of soft palate. Test: Say "ah" Cranial XII (Hypoglossal) Movement and Strength of Tongue, (midline, side-side) Movement of food in mouth Test: stick out tongue, move to cheeks

(ENT) Trach Types

Cuffed vs Cuffless •Inflated cuff seals opening around tube to create a tight fit in the trachea- prevents air leakage and aspiration, and permits mechanical ventilation •Always deflate cuffed before oral feedings - can cause difficulty swallowing if left inflated Fenestrated vs Non-fenestrated •Fenestrated has one large or several small openings or windows on its outer curve •Client can remove inner cannula and plug the trach to allow them to speak

(HNEE) Trachea and Thyroid Assessment

Difficult to palpate. Position a standing lamp to share indirectly across the neck to highlight any possible swelling. Tilt head back to stretch skin against thyroid. Give patient a glass of water and inspect neck as they take sip and swallow. Thyroid tissue moves up with a swallow then falls into resting position. To palpate, stand behind patient asking them to sit up straight then bend head slightly forward and to the right. This releases neck muscles on right side. Use the fingers of left hand to push trachea slightly right. Curve right fingers between trachea and sternomastoid muscle retracting it slowly and ask the patient to take a sip of water. The thyroid moves up under palpating fingers with trachea and larynx as the patient swallows. Auscultate thyroid, if its enlarged, auscultate it for presence of a bruit. Soft, pulsatile whooshing, blowing sound, heard best with bell of stethoscope, not present normally.

(BP) BP Documentation

Document and record pt position, size of cuff, extremity used. RA: right arm RL: right leg LA: left arm LL: left leg Ex. 126/80, sitting, LA, Prehypertension

(IV) Documentation

Document ea. dose ASAP after given: The medication record is a legal document. date, time, dose, route, site of administration, and rate of administration. Documented record if any question whether pt received the medication. Do not record meds before given. If not given, the med record would show falsely that the patient received the medication. The name of the med, dose, route, time given, and person administering the med are noted in the record. Record site for an injection. Other specific pt information may be required. -Record pulse rate when admin some cardiac drugs or -Record a desc of effects on pt's pain when administering analgesics. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the primary care provider. This verifies the reason medication was omitted and ensures that the primary care provider is aware of the patient's condition. Sample Documentation of Expected Findings IV catheter on the right hand was discontinued. IV catheter tip was intact. Site is free from redness, warmth, tenderness, or swelling. Gauze applied with pressure for one minute with no bleeding noted. Dressing applied to the site. Sample Documentation of Unexpected Findings IV catheter on the right hand was discontinued. IV catheter tip was intact. Site free from redness, warmth, tenderness, or swelling. Gauze applied with pressure for one minute but bleeding was noted to continue around the gauze dressing. Ongoing pressure was held for five minutes until hemostasis was achieved.

(Ent) Salem-Sump

Double Lumen: Venting system. 1 lumen used to empty stomach, other used to provide a continuous flow of air. The continuous flow of air reduces negative pressure and prevents gastric mucosa from being drawn into catheter, which causes mucosal damage. Anti-Reflux Valve: To prevent gastric secretions from traveling through wrong lumen.

(Wound) Differentiate between different wound care dressing products (Hydrocolloid, transparent film, foam)

Dressings: Alginate Used on partial and full-thickness infected draining wounds such as pressure wounds or venous insufficiency ulcers. Dressings: Contact Layer In contact w/ wound base protecting it from trauma during dressing change *Allow exudate to pass to a secondary dressing *Not intended changed w/ every dressing change *May be used w/ topical medical, wound filler, or gauze dressings Dressings: Hydrocolloid (Duoderm, Comfeel, Tegasorb, Intrasite) gel forming polymer such as gelatin, pectin, and carboxymethylcellulose with a strong film or foam adhesive backing. absorb exudate by swelling into a gel like mass and vary from being occlusive to semi permeable. does not attach to actual wound itself and is instead anchored to intact skin surrounding the wound. Dressings: Sterile Wash hands before change, put on at least one glove, remove dressing and discard with gloves, wash hands again, put on sterile gloves, cleanse wound, cover wound, tape, remove and discard gloves rewash hands Dressings: Transparent Protective covering often used over intravenous insertion sites to allow easy visualization of the site for signs of inflammation(Acu-derm, Tegaderm, Op-site, Bioclusive, Uniflex) Dressings vs Bandages Dressings: prevent additional wound contamination, prevent further injury, apply pressure, absorb drainage, and assist in healing Bandages: keep dressing in place, maintain barrier, provide pressure to control edema, provide support, hold a splint in place, and assist dressing in accomplishing its functions Most to least Moisture-Retentive Dressings: 1. Alginates (Most) 2. Semipermeable Foams 3. Hydrocolloids 4. Hydrogels 5. Semipermeable Films (Least)

(BP) Inaccurate BP reading factors

False High BP: -Manometer not calibrated at zero mark. -BP immediately after exercise/heavy activity -Applying a cuff that is too narrow -Deflating cuff too slowly False Low BP: -Cuff is too wide/too large -Didnt pump 20-30 mmHg above pulse disappearance -Stethoscope earpieces incorrectly placed -kink in tubing

(Assess) Nursing Assessments

Focused Assessment: Nurse gathers data about a specific problem that has already been identified.Helpful questions include:-What are your signs and symptoms?-When did they start?-Doing anything different than usual when they started?-What makes your symptoms better? Worse?-Are you taking any remedies (medical or natural) for your symptoms? Emergency Assessment: Nurse performs when Physiologic /psychological crisis presents to ID life threatening problems.-resident choking in the dining room,-bleeding patient in ED with a stab wound-unresponsive pt in rehab unit,-factory worker threatening violenceare all candidates for an emergency assessment. Initial Assessment: Performed shortly after the patient is admitted to a health care agency or service.The nurse collects subjective data concerning all aspects of the patient's health, past history, allergies, and all pertinent physical findings (skin breakdown) establishing a database and priorities for ongoing problem identification, focused assessments and creating a reference baseline for future comparison and care planning Ongoing Assessment (Time-lapsed): Assessment scheduled to compare a pt's current status to baseline data obtained previously; can be comprehensive or focused; homebound, residential pts often have these

(Ent) Decompression

Gastric Decompression: is removal of unwanted stomach contents, air (aspirate) or fluid. It is performed with a nasogastric tube connected to suction. They may be inserted to decompress or drain the stomach of fluid, unwanted stomach contents, such as poison, medication and air (aspirate) or fluid, allowing it to rest, or before or after surgery, to promote healing. * If for decompression, ensuring gastric output is still being obtained every shift and documented. * Commonly used for post-op pts who have not yet regained peristalsis or pts with a small bowel obstruction to remove accumulation of stomach bile. * Also used in the ER for pts w/ poisonings/OD's and is commonly referred to as "pumping out the stomach." * Also used to remove gastric content. The stomach is drained by gravity or connection to a suction pump to prevent nausea, vomiting, gastric distention or to wash the stomach of toxins. Used on pt's with gastric distention.

(CV) CV Assessment

Gather equipment, explain procedure, pt to gown, ask subjective data. (Chest pain? History of HA? Any heart meds? Place pt in supine position with head of bed up 30-45 degrees, sitting on edge of bed. 1. Inspect: General Appearance (Weight, thin? obese? in distress? anxioud? calm? LOC and orientation) Skin color, texture, fingernails, toenails. Inspect: (a) Neck: JVD, landmarks, symmetrical movements, pulsations, muscle retractions. (b) Chest: pericardial/precordium (portion of body over heart) (c) Thorax: symmetry of movement, pulsations (normal at Mitral) retractions, lifts, heaves, and landmarks. Normal if Apical impulse seen, Abnormal for heave or lift (indicates enlarged ventricle) 2. Palpate Palpate Carotid pulse one at a time, note amplitude, contour, elasticity. APETM for Tenderness, Movements, Pulsations, Using hands palmar surface, w/four fingers held together, gently palpate in a systematic manner, (A)ortic (P)ulmonic, (T)ricuspid, (M)itral, (E)rb's point. Palpate the apical impulse in the mitral area. Note size, duration, force, location in relation to midclavicular line. S1. (diaphragm @ Apex) note strength S2. (diaphrahm @ left upper sternal border/base aortic region) rate and rhythm for 60 sec. If irregular check for pulse deficit S3 (bell at mitral area) for extra heart sounds and murmurs. Note characteristics and location S4. (bell at tricuspid valve) diff positions if cannot be heard in supine. (L)lateral, sitting up, leaning forward, exhaling. •LISTEN FOR 6O SECONDS, noting Rate and Rhythm Abnormal findings include extra heart sounds at any of the cardiac landmarks and abnormal rate or rhythm. Extra heart sounds are often heard when the patient has anemia or heart disease. A wide variety of conditions may alter the normal heart rate or rhythm, including serious infections, diseases of the heart muscle or conducting system, dehydration or overhydration, endocrine disorders, respiratory disorders, and head trauma.

(Neuro) Geriatric Mental Status Tests

Geriatric Depression Scale: Standardized scale-don't use for all geriatrics (0-1)=not depressed, 2 or >further assessment needed Mini-Mental State Examination (MMSE) Brief 30-point questionnaire test that is used to screen for cognitive (intellect) impairment; common use screen dementia.

(Resp) Variations Geri vs Pedi

Geriatric: **Consider starting auscultation at posterior bases and moving towards the apices ▼ thoracic expansion due to calcified cartilage & loss of muscle. Can cause ▼ lung sounds that are harder to hear. ▲ resp rate (compensation for age related changes) •Loss of lung elasticity, ▼ functioning capillaries, resiliency loss •Rigid thoracic wall, weaker muscles, less effective cough; ▲ mucus retention •Kyphosis (thoracic) •Loss of subcutaneous fat, therefore, ribs more prominent ▲ abdominal-diaphragmatic breathing ▲ use of accessory muscles ▲ AP diameter (due to loss of skeletal muscle strength) Pediatric: •Infants have irregular respiratory patterns that get more regular as they age. Periods of apnea normal as long as no other signs of deficient oxygenation present. •Breath sounds are usually louder and harsher due to the thin chest wall-use pediatric stethoscope •Respiratory rates range from 30-60 at birth to 20-40 early childhood 15-25 late childhood, and 14-20 in mid teen years •AP diameter may have increase/transverse (1:1) or equal until age 5-6 •Thin chest wall, bony cartilage and ribs are soft, more horizontal •Respirations unlabored and quiet •Use diaphragm and abdominal muscles to breathe- rise and fall together •Use of accessory muscles, and nasal flaring, grunting is NOT normal and should be investigated immediately.

(Neuro) Level of Consciousness (LOC) Tests

Glasgow Coma Scale (GCS): Assess by observing and asking questions •3 Parameters: 1. eye opening 2. motor response 3. verbal response Scale from 3-15: 3= Coma, ≥14 = Optimal LOC Alert: alert and awake with eyes open and looking at examiner, client responds appropriately Lethargic: opens eyes, answers questions, and falls back asleep Stupor: awakens to vigorous shake or painful stimuli, but returns to unresponsive sleep Coma: remains unresponsive to all stimuli, eyes stay closed. Decorticate: (flexion) -lesions of corticospinal tract Decerebrate: (extension) -lesion of midbrain

(Resp) Respiratory Assessment

Have pt sit up straight, take long slow mouth breaths. Inspect anterior, posterior, lateral thorax for: color, symmetry, position of trachea, AP:T ratio, chest expansion, respiratory rate, depth, rhythm. (-Tachypnea: RR>24/min -Bradypnea: RR<10/min) Palpate for pain, tenderness, crepitus. Wear gloves if lesions are present. (Adv assessment include vocal fremitus and thoracic expansion.) Percuss: Resonance is normal over lung fields. Percussion not a part of basic resp. assess, not inc. in checkoffs Auscultate •Use the diaphragm of the stethoscope to hear high pitched sounds. •Assess for normal bronchial, bronchovesicular, vesicular breath sounds. Staring at apices, compare bilaterally, side to side, progress SOB pt/Elderly: Start @ post. bases, work up towards apices

(Wound) Heat &/or cold therapy indications and contraindications and patient education

Heat: Max use: 20-30 minutes or reflex vasoconstriction+tissue congestion can occur. (vaso)dilates periph blood vessels, increases tissue metabolism, capillary permeability, reduces blood viscosity, muscle tension, and helps relieve pain. Contraindications: do not apply heat to an open wound immediately after the trauma; during hemorrhage; over noninflammatory edema; to an acutely inflamed area, a localized malignant tumor, testes, or abdomen of a pregnant woman; or over metallic implants Cold: Max use 20 min or reflex vasodilation can occur.. (vaso)constricts peripheral blood vessels, increases blood viscosity, reduces flow reduces muscle spasms/tension, metabolism of tissue + promotes comfort. Local anesthetic effect decreases local release of pain-producing substances such as histamine, serotonin, and bradykinin. Reducing formation of edema + inflammation. Contraindications: NOT for open wounds or for patients w/ impaired periph circu or allergy to cold.

(ENT) Tracheal Suctioning Risks

Hypoxia: lack of oxygen. S&S: dyspnea (difficulty breathing) an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis. Anxiety, restlessness, confusion, and drowsiness. Hypoxemia: deficient oxygenation in the blood. when suctioning, oxygen being removed. Damage to mucosa Mucosal irritation with frequent suctioning actually produces more mucous Atelectasis: Collapse alveoli if suction setting is too high Anxiety: It can be frightening; client may feel SOB; may cause severe coughing; may be painful Pain and discomfort: PRE-Medicate for anticipated pain Infection: There is a possibility of introducing pathogens into the respiratory tract Stimulation of Vagus Nerve: Decreases pulse and BP Increase in ICP Cardiac arrhythmias: Irregular HR Stop Breathing: A risk for those clients whose drive to breath is the hypoxic drive If giving oxygen continuously via a trach - warm and humidify

(ENT) Tracheostomy Care

Indications that suctioning is needed to maintain a patent airway and to remove saliva, pulmonary secretions, blood, vomitus, or foreign material from the pharynx. Suctioning of the oropharynx or nasopharynx may be indicated if the patient is able to raise secretions from the airways but unable to clear from the mouth. Assessment •Lung sounds •Skin color •Breathing pattern and rate •Oxygenation (pulse oximeter) •Pulse rate •Dysrhythmias if electrocardiogram is available •Color, consistency, and volume of secretions •Presence of bleeding or evidence of physical trauma •Subjective response including pain •Cough Color, odor, consistency, and amount of secretions, vitals, and respiratory assessment, RR with BP & P Pulse ox, Color pink, LOC, client tolerance Suctioning Suctioning irritates the mucosa and removes oxygen from the respiratory tract, possibly causing hypoxemia (insufficient oxygen in the blood). Thus, it is important to preoxygenate the patient before suctioning. This is accomplished by applying or increasing supplemental oxygen and having the patient take several deep breaths before inserting the catheter. When performed correctly, suctioning provides comfort by relieving respiratory distress. At minimum, it is an uncomfortable procedure and it can be a very painful and/or distressing experience. Individualized pain management must be performed in response to the patient's needs. Anticipate the administration of analgesic medication to a patient who has had surgery or other trauma before suctioning, because the cough reflex will be stimulated. Client positioning and client teaching interventions Semi-Fowlers or lateral position facing me.

(Urinary) Indwelling Catheter Teachings

Indwelling Cath Teaching: Teaching the patient how the indwelling catheter functions and how they can assist with the care of the catheter. Keeping the tubing free of kinks, maintaining a constant downward flow or urine, maintaining an adequate fluid intake, and prompt reporting of any unusual symptoms. If the patient is ambulatory, having them connect the indwelling catheter to a smaller drainage bag that can be secured to the leg. Also, emptying the leg bag at regular intervals, washing hands before and after emptying the bag, and using an antiseptic solution to cleans the connections. Care for the drainage bag daily, using a vinegar solution (1 vinegar/3 water). Cleaning the tubing and bag, allowing them to air dry before using again.

(Urinary) Caths (Male vs Female)

Indwelling M/F Differences: 1. Position is different 2. Cleansing is different 3. Insert in female 2-3 inches after you see urine, then inflate balloon. In male, insert to the bifurcation before inflating the balloon. Male: Check policy (order) regarding a topical anesthetic. --Lubricate catheter if kit does not have a syringe. --Hold the penis upright with nondominant hand and maintain hold throughout procedure. --Retract foreskin if uncircumcised. Clean area at meatus using circular motion, moving from meatus toward base of penis for three cleansings. With lidocaine filled syringe, gently insert tip of syringe with lubricant into urethra and instill 10mL of lubricant (check agency policy). --Insert catheter appropriate distance, until only the drainage port is exposed on the catheter (bifurcation) If it meets resistance, have patient take deep breaths, and rotate catheter, then advance again. Once done inserting catheter, clean then replace the foreskin (if previously retracted), Remove gloves, etc. Female: 1. Lubricate the catheter. 2. Place tray on drape between patients thighs. 3. Retract labia with non-dominant hand, fully expose urethral meatus and maintain separation of labia. 4. Clean each labial fold, (R > L) moving cotton ball from top of meatus towards rectum, discarding cotton ball after each side/stroke. Clean (mid) over meatus moving cotton ball from above toward rectum, discard cotton ball after one downward stroke. 5. Insert cath at appropriate distance. 2-3" until urine flows; then advance cath another 2-3"

(Urinary) Indwelling vs Intermittent Caths

Indwelling vs Intermittent: Indwelling (Retention) catheters like foley catheters have a balloon port to hold the catheter in the bladder for extended periods of time. Intermittent (Straight) catheters are inserted for short periods of time to empty the bladder, then they are removed.

(IV) Systemic Complications

Infection (Site): Localized infection may lead to systemic Infection can occur whenever the skin barrier is broken by the insertion of an IV catheter and bacteria enters the bloodstream. Caused by poor hand hygiene, frequent disconnection of tubing, poor insertion technique. Local S&S: Erythema, edema, induration, drainage (may be purulent) at the insertion site. Systemic S&S: Fever, malaise, chills, other vital signs changes. May lead to sepsis. Erythema, redness, warmth, edema, induration, tenderness, possible fever, drainage (may be purulent) at the insertion site Speed Shock (Systemic): body's reaction to a substance that is infused into the circulatory system too rapidly. S&S: Pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea Nursing Considerations: Carefully monitor rate of fluid flow and use proper IV tubing. Monitor vital signs Sepsis (Systemic): toxic inflammatory condition arising from the spread of microbes, especially bacteria or their toxins, from a focus of infection S&S: loss of consciousness, severe breathlessness, temperature (fever) or low body temperature. Mental state change: confusion/disorientation, slurred speech. cold, clammy and pale/mottled (blue/red lace like pattern) skin. fast heartbeat/ fast breathing. Nursing Considerations: Infection control: All invasive procedures must use aseptic technique after careful hand hygiene. Collaboration w/ other members of the healthcare team to ID site and source of sepsis and specific organisms involved. ••Management of fever. The nurse must monitor the patient closely for shivering. ••Pharmacologic therapy. The nurse should administer prescribed IV fluids and medications including antibiotic agents and vasoactive medications. Monitor blood levels. The nurse must monitor antibiotic toxicity, BUN, creatinine, WBC, hemoglobin, hematocrit, platelet levels, and coagulation studies. Assess physiologic status. The nurse should assess the patient's hemodynamic status, flu Fluid Overload (Systemic): too large a volume of fluid infuses into the circulatory system. Caused by too large of a volume of fluid infusion S&S: Engorged neck veins, increased BP, and dyspnea. Nursing Considerations: Slow rate of infusion, notify primary care provider immediately. Monitor vital signs Air Embolus (Systemic): Air in the circulatory system. Caused by a break in the IV system allowing air into the circulatory system as a bolus S&S: Respiratory distress, increased heart rate, cyanosis, decreased blood pressure, change in LOC This is an EMERGENCY!!! Nursing Considerations: Pinch off catheter or secure system to prevent entry of air. Stop infusion. Place patient on left side in Trendelenburg position. Call for immediate assistance and monitor vitals

(Asepsis) Medical: Clean/Aseptic Technique

Medical Asepsis (clean/aseptic technique): Creating a barrier from microorganisms: Purposeful reduction of pathogens to prevent transfer of microorganisms from one person/object to other during med procedure EX: Administering a parenteral medication, urinary cath, Hand hygiene, wearing PPE

(Neuro) Mental Status Tests

Mental Status Assessment Components: (ABCT) Appearance, Behavior, Cognitive Functions, Thought Process & Perceptions. Determines Frequency and Depth. Examination Factors: Any known illness with Alcohol Use Disorders, or Chronic Renal Disease, Educational and Behavioral Level-Note as Baseline; don't expect exceeding, Response to Personal History Questions indicating Stress, social life, sleep habits, drug/alcohol use Intellect/Cognitive Function: Orientation: to person, place, time and situation Memory (Short + Long Term): lose time > then place > person Thought process: judgement, clarity, concentration, problem solving General Appearance and Behavior: Posture, Dress/Hygiene, Emotional Responses, Attention Span, Judgement, Facial Expressions, Speech (Pattern), Mannerisms, Give's insight into patients self-image. Mood/Feelings: Ask, describe mood, feelings Affect: Facial Expressions, (Flat=void of emotions) Language: (speech) causes for normal and abnormal.

(Wound) Exudate Amount

Minimal: small amount of drainage on dressing, exudate covers less than 25% of bandage Moderate: drainage well-contained in dresssing, wound tissues wet, drainage involves 25-75% of bandage Copious: drainage though dressing or wound dripping. Wound tissue filled with fluid, exudate covered more than 25% bandage

(Ent) Decompression Interventions

Nasogastric tubes may also be used to monitor G bleeding and prevent intestinal obstruction. Removal of unwanted stomach contents,(Aspirate) air or fluid. Performed w/ nasogastric tube connected to suction. * Initial verification of placement with an x-ray to ensure proper placement. Ensuring tube length visible externally, marked + documented. * Aspirating gastric contents, verify basic pH of <5.5 * Assessing patency, flushing tubes 30-60 ml prior to + after admin. * Assessing nares for signs of pressure or injury development. * Using water-based lube on pts nares for comfort. + Irrigating + flushing tube w/ 30-60mL of water/sterile water every 4-6 hours, (also w/ med admin-after verify, between each med, after admin.)

(Inj) Spread Taut Method

Needle: 22-25G vol: 1 mL max • 90 degrees * Decreases Pain, Used to Stretch tissue taut to ease needle into deltoid. * Spread w/ thumb and first finger. * Use based on individual pt. & nursing judgement Adult male 130-260 lbs 1 inch needle. For women under 130lbs, 5/8 needle Women 130-200lbs 1 inch needle Women 200+ 1 1/2 inch needle

(Resp) Breath Sounds

Normal: Resonance (low-pitched hollow sound) predominantly heard over Vesicular lung fields, where air flows through smaller bronchioles and alveoli. Hyperresonance with emphysema Flat sound heard over bony structures like the rib cage Dullness: heart, liver, masses (tumor) fluid (pneumonia, pleural effusion) Adventitious: •Sibilant: high pitched musical sounds mostly during expiration (can also be on inspiration) caused by constricted passages/air being forced through airways narrowed by bronchoconstriction or associated mucosal edema. •Sonorous: low pitched continuous snoring or moaning sound primarily on expiration but can be in inspiration. May clear with coughing; often heard in cases of bronchitis. caused by air passing through or around secretions. •Strider: Harsh, honking wheeze heard only on inspiration. Caused by narrowing of upper airway due to severe broncholaryngospasm or presence of foreign body in the airway. Can be heard without the use of a stethoscope

(Bowel) Stoma Assessment findings.

Normal: Stoma should be dark pink/cherry-red, moist, with minimal bleeding. Abnormal: Pale stoma may indicate anemia, and a dark or purple blue stoma may reflect compromised circulation or ischemia/lack of blood supply

(Urinary) Open Irrigation System

Open irrigation: A. Prepare supplies. B. Apply gloves. C. Position waterproof drape. D. Aspirate 30 ml of solution into sterile irrigating syringe. E. Move collection close to client's thighs. F. Disconnect catheter from drainage tubing, allow urine to flow into basin, and cover open end of tubing with sterile cap. G. Insert syringe, gently instill solution, and withdraw syringe. H. Allow solution to drain into basin; repeat until drainage is clear I. When irrigation is completed, reestablish closed drainage system. J. If solution does not return, have client change position, or gently aspirate solution.

(ENT) Tracheostomy Oropharyngeal, Nasopharyngeal

Oropharyngeal: Semicircular tube of plastic or rubber inserted pharynx through the mouth Nasopharyngeal: Semicircular tube of plastic or rubber inserted pharynx through the nose Tracheostomy Procedure and Tubes A tracheostomy is an artificial opening made into the trachea, usually at the level of the second or third cartilaginous ring. A curved tube, called a tracheostomy tube, is inserted through the opening. It is inserted in the operating room or intensive care unit under sterile conditions using local anesthesia, and can be temporary or permanent. Parts of a tracheostomy The tube is made of semi-flexible plastic (polyurethane or silicone), rigid plastic, or metal and is available in different sizes with varied angles. A tracheostomy tube consists of an outer cannula or main shaft, an inner cannula, and an obturator. An obturator, which guides the direction of the outer cannula, is inserted into the tube during placement and removed once the outer cannula of the tube is in place. Many tubes also have inner cannulas that may or may not be disposable. The outer cannula remains in place in the trachea, and the inner cannula is removed for cleaning or replaced with a new one. Periodic cleaning or replacement of the inner cannula prevents airway obstruction from secretions that have accumulated on the tube's inner surface. A tube with an inner cannula is necessary when patients have excessive secretions or have difficulty clearing their secretions. It also may be recommended for a patient who will be discharged with a tracheostomy tube in place. Tracheostomy tubes may be either cuffed or cuffless. The inflated cuff seals the opening around the tube to create a tight fit in the trachea. This prevents air leakage and aspiration, and permits mechanical ventilation. Newer tracheal cuffs are low pressure, do not require deflating for short intervals every few hours, and can be maintained at lower than tracheal capillary pressure. If a cuffed tube is used, always deflate it before oral feeding unless the patient is at high risk for aspiration. If left cuffed, the balloon can cause pressure that extends through the trachea and onto the esophagus, possibly impeding swallowing or causing erosion of the tissue.

(HNEE) Pupillary Light Reflex Test and Accommodation

PRL: Darken room, ask patient to look straight ahead, bring penlight from side of patient face and briefly shine light on pupil. Observe pupil reaction. If normally rapidly constricts (direct response) Also observe pupil size. Repeat procedure and observe other eyes, it will normally constrict (consensual reflex). Repeat procedure with the other eye Accomodation: Hold the forefinger, a pencil or other straight object about 10 to 15 cm (4-6 inches) from bridge of patient nose. Ask the patient to first look at object, then at distant object, then back to object being held. Pupil normally constricts when looking at a near object and dilates when looking at a distant object.

(CVPV) Peripheral Vascular Assessment

PV ASSESSMENT: Inspection, palpation, and auscultation. Equipment: Stethoscope bell & diaphragm, sphygmomanometer, watch. Prep: Pt Sitting/Supine HOB 30 degrees, if possible. Good lighting for color inspection and for pulsations. Quiet environment for auscultation of heart sounds. Includes measuring BP and assessing the skin and perfusion of the extremities & peripheral pulses Subjective data: Meds? Diuretics? Numbness/tingling? Auscultate BP if not done in gen survey, palpate and auscultate carotid arteries one at a time. ARMS: Check color of skin and nail beds, temp, texture, and turgor of skin and the presence of any lesions, edema or clubbing. Check capillary refill, depress and blanch the nailbeds, release and note time for color return. Should be symmetric in size. Note presence of any scars on hands and arms. Palpate both radial pulses noting rate, rhythm elasticity of vessel wall and equal force. grade force on 3 point scale (3 increased bounding, 2 normal, 1 weak, 0 absent.) Palpate brachial pulses their force should be equal bilaterally. Check epitrochlear lymph nodes in the depression above and behind medial condyle of humerus LEGS: Inspect both legs together noting skin color, hair distribution, venous pattern, size, (Swelling and atrophy) and any skin lesions or ulcers. Temp, moisture, texture, sensations (light and deep, wiggle toes. Lesions, ulcers, Verbalize for edema, unilateral/bilateral pitting/non-pitting 0-3. Presence of superficial veins. Inguinal Lymph Nodes, Peripheral Arteries, Femoral Pulse: Popliteal, Posterior Tibial, Dorsalis Pedis Pulses, verbalize amplitude.nspection, palpation, and auscultation. Equipment: Stethoscope bell & diaphragm, sphygmomanometer, watch. Prep: Pt Sitting/Supine HOB 30 degrees, if possible. Good lighting for color inspection and for pulsations. Quiet environment for auscultation of heart sounds. Includes measuring BP and assessing the skin and perfusion of the extremities & peripheral pulses Subjective data: Meds? Diuretics? Numbness/tingling? Auscultate BP if not done in gen survey, palpate and auscultate carotid arteries one at a time. ARMS: Check color of skin and nail beds, temp, texture, and turgor of skin and the presence of any lesions, edema or clubbing. Check capillary refill, depress and blanch the nailbeds, release and note time for color return. Should be symmetric in size. Note presence of any scars on hands and arms. Palpate both radial pulses noting rate, rhythm elasticity of vessel wall and equal force. grade force on 3 point scale (3 increased bounding, 2 normal, 1 weak, 0 absent.) Palpate brachial pulses their force should be equal bilaterally. Check epitrochlear lymph nodes in the depression above and behind medial condyle of humerus LEGS: Inspect both legs together noting skin color, hair distribution, venous pattern, size, (Swelling and atrophy) and any skin lesions or ulcers. Temp, moisture, texture, sensations (light and deep, wiggle toes. Lesions, ulcers, Verbalize for edema, unilateral/bilateral pitting/non-pitting 0-3. Presence of superficial veins. Inguinal Lymph Nodes, Peripheral Arteries, Femoral Pulse: Popliteal, Posterior Tibial, Dorsalis Pedis Pulses, verbalize amplitude.

(Inj) Lovenox

Packaged prefilled disposable syringes, 30mg each. Air bubble should not be expelled from syringe, it can cause the drug to be expelled as well, which can cause skin irritation. Always admin with patient lying down. Ideal site is cell mass area under skin of anterolateral and posterolateral abdominal wall. Pinch skin between thumb and index finger to make skin fold. Insert full length, then inject slowly, holding the skin fold throughout injection

(HNEE) Vision Tests

Peripheral Vision Confrontation Test: Position self at eye level with patient 2ft away. Pt cover 1 eye w/ opaque card, look straight at you w/ other eye. Hold finger as target midline between you + pt, slowly advance it in from periphery in several directions. Ask pt to say "Now" as wiggling fingertip is first seen, should be just as you also see it. Snellen Chart: Used to assess distant visual acuity -Pt stand 20 ft from chart asked to read smallest line of letters possible. -First with both eyes, then one eye at a time. **Note: Whether patients vision is being tested with or without corrective lenses. * Acquity is then measured by using the standardized numbers on side of chart. Numerator 20 representing distance pt was from chart. Denominator represents smallest line read accurately by pt. * Visual acuity is recorded as fraction and is written as 20 over the smallest line read by the patient with no more than 2 inaccurate readings (such as "20/30-2 with glasses") Thus, the larger the denominator, the poorer the vision. Handheld Snellen: Handheld vision screen w/ varying sizes of print (Jaegercard can be used). The patient holds the card 14 inches from eyes, asked to read smallest line of letters possible, one eye at a time (with opposite eye covered) and corrective lenses in place, if used. Result rec. as fraction, written as 14 over smallest line read by pt. A normal result is 14/14

(Med Admin) Assessment

Pre-Admin: -Check vitals before admin cardiac meds, BP, HR; if parameters too low, hold med, -perform focused resp. assessment: O2, HR, RR, lung sounds should be checked before giving INH resp meds -Review Lab work before giving diuretics like Furosemide, potassium, etc -PQRSTU (Provacative/Palliative, Quality/Quantity, Region/Radiation, Severity, Timing/Treatment, Understanding) During Admin: -Be Cautious and Focused -check and verify allergies -follow agency policies and use 2 verifiers for ID -perform appropriate assessments before med admin. (If didn't check already) -be diligent and perform med calculations accurately •use standard procedures and EBP's •ensure med not expired •always clarify order or procedure if unclear •use available tech to admin meds •be part of safety culture •be alert •Address Pt concerns Post-Admin: Right Response eval Pt after med admin to monitor drug efficacy, adverse effected etc

Integument Assessment · Patient preparation and technique · Identify & describe integument assessment findings that would require follow-up with a physician. · Identify & describe different assessment variations for different skin colors

Prep: Exterior: Removing dentures, jewelry, hair pieces, clothing that interfere with visibility. Interior: Pt sitting in warm, naturally lit private environment Subjective Questions: Skin-related issues, rashes? Meds:currently taking? Hygiene and dietary practices? ADLs? Allergies? History: Personal/Fam. Integ disease/illnesses Chemo/Radiation history? Lifestyle, environmental/occupational exposure. Lesions: Primary: Stage 1 Initial reaction to pathologically altered tissue that may be flat or elevated Macule/Patch: solely color change, flat and circumscribed, < 1 cm. Ex: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever Papule/Nodule/Tumor/Wheal: Palpable Elevated solid masses. Usually < 0.5cm. Ex: mole Vesicle/Bulla/Pustule: circumscribed, superficial skin elevations formed by free serous fluid in a cavity w/in skin layers, > 0.5cm. Ex: Herpes simplex Lesions: Secondary: Stage 2 Result from the changes that take place in the primary lesion due to infection, scratching, trauma, or various stages of a disease. Ulcer: loss of epidermis & dermis, may bleed & scar. Ex. Stasis ulcer Crust: Dried serum residue, pus or blood. Ex: Impetigo Scale: Thin flake of exfoliated dermis, Ex. Dandruff. dry skin Atrophic Scar: Thinning of skin, loss of skin furrows, shiny appearance Scar: Fibrous tissue replaces tissue in the dermis or subcutaneous layer. Keloid: Hypertrophied scar Fissure: Deep linear crack, extends into dermis, Ex: Athletes Foot

(Wound) Psychological Interventions

Psychological: • Pain: Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity, and precipitating factors. Consider cultural influences on response to pain. Explore with patient factors to relieve/worsen pain. Assure patient attentive analgesic care. Attempting to use humor, distractions, music, imagery, or relaxation techniques, if appropriate or encouraged by patient. • Anxiety and Fear : Anxiety and fear are common responses to a wound. Patients are apprehensive about the possibility of the wound opening, how much privacy will be lost as the wound is being cared for, and how they and others will react to the appearance and smell of the wound. When caring for patients with wounds, demonstrating acceptance and empathy, encouraging the expression of feelings, answering questions accurately and honestly, and avoiding excessive exposure of body parts when giving wound care are essential. • Changes in Body Image: Referral to support groups or counselors may be necessary to facilitate coping and acceptance of changes in body structure or function.

(Wound) Assessment and Documentation

RITTA: Area of skin around wound bed Redness (Erythemia) Induration (hardening) Smooth, dry Temperature Tenderness Sensation Macerated (soften by soaking) Edematous (edema/swelling) Smooth, Approximation Exudate Amounts: Minimal: small amount of drainage on dressing, exudate covers less than 25% of bandage Moderate: drainage well-contained in dresssing, wound tissues wet, drainage involves 25-75% of bandage Copious: drainage though dressing or wound dripping. Wound tissue filled with fluid, exudate covered more than 25% bandage Wound Measuring: Standard and/or transmission based precautions Hand hygiene & clean gloves. 1. Insert saline moistened sterile q-tip into site of tunneling note direction q-tip travels +depth. 2. Measure length, width, depth w/ ruler. 3. Measure any wound tunneling or undermining. Take pics

(Assess) MSK Assessment

ROM Assessment: ∙Inspect/Observe Bilaterally: Crepitus, Provide Support, To tolerance Key points such as each joint, how to move it and when to stop moving the limb/joint ∙Degrees: Full/Decreased (Slightly, Moderate, Severe) Smooth rhythmic movements, always return joint to neutral, never push past point of pain. IMPORTANT: Do not force movement of joint if pain, spasm, or resistance. Keep in mind that: Pain, limitation of motion, spastic movement, joint instability, deformity, and contracture indicate a problem with joint, muscle group, or nerve supply.** When performing ROM: SUPPORT Extremeties through all maneuvers from below at the joint. NEVER grab muscles or hold from above. Do NOT perform if client has artificial joints (Be careful). Types: Active ROM (AROM): pt moves all extremities on own for each major joint and its related muscle groups Passive ROM (PROM): Caregiver must completely move all extremeties if limitations assessed with active ROM Active Assistive (AAROM): patient can move joint a small amount but nurse must assist the extremity in moving through full range. Muscle Strength Assessment: •Assess strength by asking pt to move against resistance. •Bilateral equal resistance should be present. •Muscle strength should be bilaterally equal, with a slight increase on the dominant side. 5: Normal Strength, Full ROM against gravity, full resistance 4: Slight Weakness, Full ROM against gravity, some resistance 3: Average Weakness, Full ROM with gravity 2: Severe Weakness, Full ROM w/ gravity eliminated, assited by examiner (passive ROM/Poor ROM) 1: Slight Contraction: severe weakness, slight contract flicker 0: No muscle contraction (Paralysis) Inspection/Palpation: Inspection: Symmetry Structure bone & joint Bony prominences (any deformities?) Muscle Size, Tone, Shape, Strength Mass (w/ Passive ROM) Skin condition (Color, edema) Stance: Base of Support & Weight-bearing ability (during walking) Gait: Position of feet, stride and arm swing Spine Cervical spine- concave Thoracic - convex Lumbar- concave Sacral-convex "Double S Curve" Palpation for tenderness: (Bilaterally) •Muscle Tone: by passive ROM •Muscle Strength: note abnormalities like atrophy, tremors, flaccidity, loss of strength and tone, decreased ROM, uncoordinated movements, swelling and pain. Abnormal findings may indicate MSK disease, trauma, or neurological disease Sensation and Temperature Scoliosis: Abnormal lateral curvature of the spineterm-90 Kyphosis: Hunchback, excessive outward curvature of the spine Lordosis: Abnormal anterior curvature of the lumbar spine (sway-back condition)

(IV) Discontinuing IV Administration

Reasons: Client tolerating oral intake, IV meds discontinued, IV site no longer patent/intact, Pt discharged Process: ◦ Confirm Order. ◦ Hand Hygiene, Check room for transmission-based precautions. ◦ Greet and Confirm patient ID using two patient identifiers (e.g., name and date of birth). ◦ Explain the process to the patient. Ensure the patient's privacy and dignity. ◦ Assess ABCs. 3. Prepare the gauze and tape. 4. Place IV clamp to locked position. 5. Loosen edges of transparent dressing and tape in direction of IV site. 6. Place gauze over IV site and gently pull IV out parallel to the skin. 7. Hold pressure on IV site for 2-3 minutes. If pt is on anticoags may need to hold for 5-10 min. 8. Inspect cath to ensure intact and dispose of it in appropriate container. 9. Remove the gauze pad once bleeding has stopped and assess for any signs of infection at the site, such as redness, swelling, warmth, tenderness, or purulent drainage. 10. Tape the gauze or apply a Band-Aid over the IV site. 11. Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time. 12. Ensure safety measures when leaving the room: ◦ CALL LIGHT: Within reach ◦ BED: Low and locked (in lowest position and brakes on) ◦ SIDE RAILS: Secured ◦ TABLE: Within reach ◦ ROOM: Risk-free for falls (scan room and clear any obstacles) 13. Perform hand hygiene. 14. Document the procedure and related assessment findings. Report any concerns according to agency policy.

(CV) Extra Heart Sounds

S3 (bell at mitral area) for extra heart sounds and murmurs. Note characteristics and location S4. (bell at tricuspid valve) diff positions if cannot be heard in supine. (L)lateral, sitting up, leaning forward, exhaling. •LISTEN FOR 6O SECONDS, noting Rate and Rhythm Abnormal findings include extra heart sounds at any of the cardiac landmarks and abnormal rate or rhythm. Extra heart sounds are often heard when the patient has anemia or heart disease. A wide variety of conditions may alter the normal heart rate or rhythm, including serious infections, diseases of the heart muscle or conducting system, dehydration or overhydration, endocrine disorders, respiratory disorders, and head trauma. Murmur: Extra heart sounds caused by some disruption of blood flow through the heart. Characteristics and grading depend on adequacy of valve function, blood flow rate, and size of valve opening.

(IV) Piggyback (Secondary)

Secondary tubing is a short piece of plastic tubing that connects into the primary IV tubing for administering medications. Infusion device recommended to ensure that it infuses over the prescribed length of time. If not available, use piggyback setup. Referred to as "IV piggyback" (IVPB) medication usually intermittent meds in smaller bags mixed with diluent that infuses at regular intervals (q8h) such as antibiotics. The primary line maintains venous access between drug doses. It is important to remember that not all IV solutions are compatible with all IV medications. It is vital for the nurse to triple check that the secondary medications/fluids are compatible with primary fluids. If medication and fluids are not compatible, a precipitate may form when the fluids mix within the line, posing a significant health danger for the patient. Document the administration of the medication immediately after administration—including date, time, dose, route of administration, site of administration, and rate of administration

(O2) Masks

Simple Mask •Has vents on the side to allow room air to leak in •Dilutes the source oxygen •Allow exhaled carbon dioxide to escape. •Provides low flow 5-8 L/min and FiO2 of 40-60% ** Never apply with flow rate less than 5L/min Simple masks are typically used for when an increased delivery of oxygen is needed for a short period of time (<12 hours). **Because of the risk of retaining carbon dioxide, never apply the simple face mask with a delivery flow rate of less than 5 L/min. (O2) Partial Rebreather Mask •Has a reservoir bag for collection of the first part of the patient's exhaled air. Air in the reservoir is mixed with 100% oxygen for the next inhalation •Patient rebreathes about one third of the expired air from the reservoir bag. •Provides low flow 8-11 L/min and FiO2 50-75% •Permits the conservation of oxygen. •Should deflate slightly with inspiration. If it deflates completely, the flow rate should be increased until only a slight deflation is noted (O2) Venturi Mask •Deliver the most precise concentrations of oxygen. •High flow LPM dependent on adaptor and FiO2 24-40% •Has a large tube with an oxygen inlet. As the tube narrows, the pressure drops, causing air to be pulled in through side ports that are adjusted according to the prescription for oxygen concentration. Be sure that the ports are always open. If these are occluded by linens, clothing, or a patient rolling on the mask, the oxygen delivered might be at an unsafe (too high or too low) concentration. (O2) Positive Airway Pressure (PAP) Help to maintain better carbon dioxide and oxygen levels in blood •Used to treat disorders •Sleep apnea •Obstructive sleep apnea •Heart failure (O2) Nasal Cannula •The most commonly used oxygen delivery device. •Can be High Flow or Low Flow •Low Flow: 1-6 L/min, •FiO2 24-44% •High Flow: 7-60 L/min •FiO2 65-90% •It does not impede eating or speaking and is used easily in the home. •High Flow: aerosolize oxygen and warmed normal saline in order to provide higher flow rates with resulting higher oxygenation concentrations. •The tubing has a larger diameter than low flow to allow for greater oxygen flow. (O2) Non-Rebreather Mask •Delivers the highest concentration of oxygen to a spontaneously breathing patient. •Provides low flow 10-15 L/min and FiO2 80-95% •Has 2 one-way valves that prevent the patient from rebreathing exhaled air. •Reservoir bag is filled with oxygen that enters the mask on inspiration. Exhaled air escapes through side vents. •A malfunction of the bag could cause carbon dioxide buildup and suffocation. Continuous Positive Airway Pressure (CPAP) •Provides continuous mild air pressure to keep airways open Bilevel Positive Airway Pressure (BiPAP) •Air pressure level changes while the patient breaths in and out (O2) Oxygen Concentrator •Commonly used in the home setting •Removes nitrogen from room air and concentrates the oxygen •Portable, cost-effective, easy to use

(Integ) PQRSTU and ABCDE

Size, shape, depth, location, presence of drainage or odor. Nursing Interventions and Teachings P: rovocative/Palliative: What caused it? Q: uality/Quantity: describe pain/discomfort R: egion/Radiation: Where? Does it radiate anywhere else? S: everity: using pain scale T: iming/Treatment: How long have you had it, any treatment that make it better or worse? U: nderstanding and Melanoma Assessment A: ssymetry B: orders (uneven) C: olor (Dark black/multiple colors) D: iameter (greater than 6mm) E: volving (changing in color/size/shape) Assessment: Melanoma

Transmission-Based Precautions

Standard Precautions (Mask, Eye Protection, Face Shield): to protect mucous membranes of the eyes, nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions. Airborne: Known or suspected infection with pathogens transmitted by small respiratory droplets, such as measles. PPE: Fit-tested N95 respirator or PAPR. Airborne infection isolation room, single patient room, patient closed door, restricted susceptible personnel room entry. Droplet: Known or suspected infection with pathogens transmitted by large respiratory droplets generated by coughing, sneezing, or talking, such as influenza, coronavirus, or pertussis. PPE: Mask, goggles or face shield Contact: Known or suspected infections with increased risk for contact transmission (e.g., draining wounds, fecal incontinence) or with epidemiologically important organisms, such as C-diff, MRSA, VRE, or RSV PPE: Gloves, Gown, Dedicated Equipment Use only soap & water for hand hygiene with C-diff patients

(IV) Primary IV Set-Up

Steps taken to ensure no air embolism when starting primary IV line. *Check expiration date. Check patency/light/dark. *Clean the port before attaching the tubing Prime tubing 1. Remove the primary IV tubing from the packaging. ** If administering IV fluid by gravity, note drip factor on package and calculate drops/min. Then calculate for the infusion rate. 2. Move the roller clamp locked clamp it. 3. Remove cover from tubing port on bag of IV fluid. **Maintain Sterility** Keep in eyesight. 4. While maintaining sterility, remove cap from insertion spike on the tubing. insert the spike into the tubing port of the bag of IV fluid. 5. Squeeze the drip chamber two or three times to fill the chamber halfway. 6. Loosen the cap from the end of the IV tubing and open the clamp to prime the tubing over the sink: 7. If using multiple port tubing, invert the ports to prime them and to prevent air accumulation in line. 8. Loosen the cap from the end of the IV tubing and open the clamp to prime the tubing over the sink: 9. If using multiple port tubing, invert the ports to prime them and to prevent air accumulation in line. 10. If the solution is an antibiotic, take care to not waste solution while priming the tubing to ensure the patient receives the correct dosage. 11. Once primed, clamp the IV tubing and check the entire length of the tubing for air bubbles. Tap the tubing gently to remove any air. 12. Replace or tighten the cap on the end of the tubing. 13. Label the primary IV fluid bag with the date and time. Place the tubing label on the tubing near the drip chamber. 14. If the solution is an antibiotic, take care to not waste solution while priming the tubing to ensure the patient receives the correct dosage. 15. Once primed, clamp the IV tubing and check the entire length of the tubing for air bubbles. Tab the tubing gently to remove any air.

(Assess) Abdominal Health Hx Interview

Sub + Obj Questions How is your appetite? Any recent changes to it? Intolerance to any food, pain, nausea or vomiting? Bowel Movements per day? Quality/Quantity? Take any vitamins/OTC supplements? History of Abdominal disease, injury or surgery? Last 24 hr diet?

(Asepsis) Surgical: Sterile Technique

Surgical Asepsis (Sterile Technique): Purposeful attack on Microorganisms: seeking to eliminate every potential microorganism in and around sterile field while also maintaining objects as free from microorganisms as possible. Standard of care for surgical procedures, invasive wound management, and central line care. Requires Combination of meticulous hand washing, creation of sterile field, using long-lasting antimicrobial cleansing agents, such as betadine, donning sterile gloves, and using sterile devices/instruments

(Wound) Drain types & terms

Terms: Serous: clear watery plasma Purulent: thick yellow green tan or brown Serousanguineous: pale pink watery; mix of clear and red fluid Sanguineous: bright red; indicates active bleeding Open Drain: (ex: Penrose) Soft and flexible Does not have a collection devices and empties onto absorptive dressings/skin. Often secured with large sterile safety pin to keep drain from slipping back into cavity. protect skin, if ordered pull drain outward 1-2 inches. Soft, flexible, no collection device, secured w/ large sterile safety pin to keep drain from slipping back into cavity Closed Drain: (Wound Vac): Negative Pressure Therapy. Used to treat a wide variety of acute or chronic wound and wounds that are dry or draining such as: Pressure ulcers, leg ulcers, diabetic foot ulcers, burns. Closed system: Vacuum assisted closure, promotes wound healing and wound closure through application of uniform (Sub-atmospheric) negative pressure on wound bed. Reduces wound bacteria + removal of excess wound fluid/drainage. Neg. pressure results in mech. tension on wound tissues, stimulating cell proliferation, blood flow to wounds, and growth of new blood vessels, pulls together the wound edges. Drainage expected drainage: first 24hrs: sanguinous, 24-72: serosanguinous, more than 72: serous Sponge custom cut to fit inside wound bed Covered with transparent film dressing Tubing compresses sponge + removes drainage. Change ~3x a week Should not be used for Necrosis, Malignancy, Fistulas, Osteomyelitis, Exposed Arteries or veins. Necrotic tissue must be debrided before using wound vac

(ENT) Metal vs Plastic Trach Tube

The condition and needs of the patient determine the selection of either a metal or plastic tracheostomy tube. Although metal tubes are more cost-effective for long-term use, most do not have an adapter at the neck plate that permits connection to respiratory therapy equipment (e.g., an oxygen delivery system, Ambu bag, or mechanical ventilator).

(Bowel) Abdominal Assessment

The patient should be laying down flat and relaxed. They should have an empty bladder 1. Inspect: Symmetry, skin color, integrity, scars, striae, and position of the umbilicus, contour. Look to see if it is flat, rounded, scaphoid, or protuberant 2. Auscultate BEFORE Palpate: Right Lower Quadrant (1600-1800) clockwise. RLQ > RUQ > LUQ > LLQ. Listen 15 sec ea. Then 2 min per quadrant if no bowel sounds. Frequency differences can be due to impending bowel obstructions or a lower GI obstruction Normally should sound tympanic. RUQ will be dull bc of liver 3. Percuss 4. Palpate

(Med Admin) Safety Checks

Three checks: 1. as you take the medication out of the drawer 2. check- before you punch or pour 3. check- as you return it (Place next to MAR again, open place in cup/put dose in cap, then place bottle back in shelf/drawer 5 Rights 1. Right Patient 2. Right Drug 3. Right Dose 4. Right Route 5. Right Time (Unofficial 6th) right documentation Abbreviations to avoid: U, IU, QD, .5mg, MS, SQ, HS, AU, AS, OU, OS, OD

(Urinary) Sterile Specimen Collection from Existing Foley Cath

To decrease the risk of infection by preventing introduction of pathogens into the bladder; using a self-seal port for access. a. clamp the catheter tubing just below the self-sealing port for 10-15 minutes to collect "fresh" urine b. Cleanse the self sealing port with alcohol for 15-30 seconds c. Insert the syringe onto the self sealing port and withdraw 10mL of urine. Sterilely transfer to sterile specimen container. Label container and place in biohazard bag. d. Unclamp catheter tubing. e. The rationale for doing this is to ensure that a sample of urine is taken from the bladder and not the urine bag where urine has been out of the body for a prolonged period of time. Also, it is best not to disconnect the catheter tubing from the catheter to help prevent infection. List two ways to collect a sterile urine specimen. 1. Taking a specimen from an indwelling catheter already in place, from the catheter itself using the special specimen port, not the collecting receptacle. 2. Also can be collected by catheterizing the patients bladder.

(ENT) Trach Supplies at Bedside

Tracheostomy Supplies at Bedside: •Obturator •Suctioning equipment •Oxygen •Ambo bag •Spare tracheostomy tube of the same size •Spare tracheostomy one size smaller

(IV) Site Assessment

Used to maintain site safety and to monitor pt reactions, adverse reactions, overdose, circulatory overload, medication compatibility. 5 rights of med admin, 3 checks Use Sterile Technique to prevent m/o transmissions Frequently. assess for potential complications such as infiltration, extravasation, phlebitis, or infection. If these conditions occur, promptly notify the provider for treatment; IV cath will need to be removed and replaced at an alternative site, and additional meds may be prescribed.

(Inj) Insulin Routes and Mix

a) Abdomen (fastest) large dense muscle, difficult to tense, not near major nerves or vessels, from below costal margin, to iliac crest, more than 2 inches from umbilicus b) Deltoid (fast) outer lateral aspect of upper arm; preferred site, not for repeated injections: c) Vastus Lateralis (above gluteal area) slowest, good size , thigh muscle, well developed in infants and children, no major nerves or vessels easily accessible lying or sitting slightly less rapid absorption than deltoid. many small nerve endings, so don't use irritating meds here "Mixed Insulin: Clear into Cloudy" Regular 1st, then NPH. Roll NPH before using and clean each vial with alcohol swab before each entry into vials 1. Inject mL amt of air into NPH vial. 2. Inject mL amt of air into regular Insulin vial. 3. Draw up Regular Insulin 4. Draw up NPH Insulin

(Bowel) Large Hypotonic Enemas

large volume, warm tap water, distends colon, stimulates peristalsis, softens feces. height of bag controls rate of administration. given over 10-15 min

(Med Admin) Assess

medical history allergies and intolerances, medication history, medication record/orders, diet and fluid orders, laboratory values.

(INJ) Intradermal Injections

needle: 25G-27G, 3/8-5/8" vol: < 0.1 mL syringe: 1 mL calibrated in 0.01 mL Spread taut Inner forearm, free of scars, vasculature, hair.Just below epidermis, (and upper back below scapula) Used for PPD & allergy testing, local anes: Back: longest absorption time of all 3 parenteral routes. Bevel up, barely cover bevel under skin about 1/2 to 1/3 of needle inserted at 5-15 degree angle, NOT near veins, do to side. Inject slowly to see wheal. If no wheal, slightly pull back, not out, try again

(Bowel) Small Hypertonic Enema

small volume, add additional lubricant to tip, administer at room temp, over 1-2 mins, compress bottle to administer solution. Exerts osmotic pressure that pulls fluid out of interstitial spaces. The colon fills with fluid, and the resultant distention promotes defecation. Used for pts who cant tolerate large volumes of fluid

(Neuro) Non-neuro Mental Status Factors

• Age / development • education • culture • language • hearing and sensory deficits • medical conditions • Nurse's articulation/communication of tests • Any known illness with Alcohol Use Disorders, or Chronic Renal Disease • Educational and Behavioral Level-Note as Baseline; don't expect exceeding. • Response to Personal History Questions indicating Stress, social life, sleep habits, drug/alcohol use

(Neuro) Cerebellar Functioning Tests

• Gait: Walk across the room, opposite arms swing • Ataxia: uncoordinated, unsteady gait • Balance (Romberg): walk on toes, heels, then heel to toe, • Strength: muscles tone. Assess muscle strength by asking the patient to move against resistance. Bilateral equal resistance should be present. Observe muscle contraction and determine muscle strength exerted. Muscle strength should be bilaterally equal, with a slight increase on the dominant side. • Coordination: rhythmic movements, finger to thumb, finger to nose, thigh slap; buttoning shirt (fine coordination) Measure arm/leg strength and compare to each side. • Look for clumsy, asymmetrical movements involuntary tremors/unnecessary movements.

(Assess) Comm Techniques Pt history during Interview

• Open-ended: allow pt to speak freely, gives lot of info. Start with: Describe for me, tell me about, how, what are... • Closed-ended: to get facts, narrow in on information, get 1-2 word response. Start with: Do/can/will you, is, are, when... • Laundry List: used to get specific answers, give list of options • Rephrasing: repeat to clarify, encourage more verbalization Describe what observed, ex: "you seem to have difficulty with your left side" **Cues obtained during a general survey assessment are used to guide additional focused assessments in areas of concern.** Nonverbal and Verbal Communication

(Urinary) Interventions

• Wash hands before and after caring for a patient with an indwelling catheter. • Clean the perineal area thoroughly, especially around the meatus, daily and after each bowel movement. • Cleanse the catheter by cleaning gently from the meatus outward. • Use mild soap and water, or a perineal cleanser to clean the perineal area; rinse the area well. Do not use powders and lotions after cleaning. Do not use antibiotic or other antimicrobial cleaners or betadine at the urethral meatus. • Make sure the patient maintains a generous fluid intake, unless contraindicated by other health concerns. This helps prevent infection and irrigates the catheter naturally by increasing urine output. • Encourage the patient to be up and about, as ordered. • Note the volume and character of urine and record observations carefuly. Observe uring through drainage tubing and in collecting container. Note and record the amount of urin on the patient intake-and-output record every 8 hours. Empty the urine into a graduated container calibrated accurately for correct determination of output. • Do not open drainage system to obtain urine specimen or to measure urine. If tubing becomes disconnected, and the sterile closed drainage system has been compromised, replace the catheter and collecting system. When emptying drainage bag, make sure the drainage spout doesn't touch a contaminated surface. • Teach the patient the importance of personal hygiene— especially the importance of careful cleaning after having a bowel movement—and thorough, frequent hand hygiene. • Promptly report any signs or symptoms of infection. These include a burning sensation and irritation at the meatus, cloudy urine, a strong odor to the urine, an elevated temperature, and chills. • Help the patient take a shower bath if possible. Remember to keep the collecting bag lower than the bladder to promote drainage. • Consider evidence-based practice guidelines and facility policy to ensure that the catheter is removed at the earliest time possible, to limit use to the shortest duration possible.

(Neuro) Plantar Reflex

•Normal: toes contract: plantar flexion of toes, sometimes entire foot. •Abnormal: toes dorsiflex (Babinski-normal in infants) With end of reflex hammer, draw a light stroke up the lateral side of sole and across the ball of the foot, like an upside-down J. Infants normal response is dorsiflexion of the big toe and fanning of all toes, which is a positive Babinski sign. This occurs with upper motor neuron disease of the pyramidal tract.

(BP) Orthostatic Blood Pressure

⬇︎ in BP related to positional/postural changes. Significant findings: ⬇︎ in Sys: ≥ 20 OR ⬇︎ in Dias or > 10 w/in 3 min sit/standing, compared to BP from sitting/supine Lying: Lower HOB, pt supine 3-10 min. Take initial BP & Pulse Sitting: Side of bed, legs dangle Wait 1-3 min. Take BP & Pulse Standing: Assist in standing (unless contraindicated, wait 2-3 min, then BP & Pulse