UWORLD FUNDAMENTAL

Ictal Phase

period of active seizure activity.

Prodromal & Aural Phase

pre-seizure periods; client may experience visual or other sensory changes (warning signs!) ^both phases can go undetected

Blood Compatiability

RhD Positive = BOTH Positive AND Negative RhD Negative = ONLY Negative A = A,O B = B,O O = O (Universal Donor) AB = AB, A, B, O (Universal Receiver)

Which PORT of a triple lumen Central Venous Catheter (CVC) is used for Central Venous Pressure (CVP) monitoring?

DISTAL PORT. ***The largest lumen is used to monitor RIGHT ATRIUM monitoring (CVP)

LOW PRESSURE ALARM on MECHANICAL VENTILATOR

-Disconnected Tubing -TUBE CUFF LEAKAGE! -Extubation -HYPOTENSION (ASSESS FOR BLEEDING!!!!!!)

What is the easiest to use and resemble normal walking in terms of GAIT on CRUTCHES?

4-Point Crutch Gait Has 3 points of support on the ground at all times and is the most advanced gait.

Position for Chest Tube INSERTION

ARM RAISED ABOVE HEAD ON AFFECTED SIDE & HOB 30-60 DEGREES (Fowler's) to reduce risk of injury to diaphragm

Fine Crackles

Distinct, discontinuous, and high-pitched snapping sounds usually heard on inspiration; EXPECTED atelectasis & post-abdominal surgery d/t pain-caused shallow breathing

CAST

(eg, fiberglass, plaster) are applied to immobilize fractured extremities during healing. INTERVENTION: -Report foul odors or hot areas (hot spots) in the cast -Avoid getting the cast wet -Elevate the affected extremity above heart level for the first 48 hours to reduce edema -Regularly perform isometric and range of motion exercises to prevent muscle atrophy -Use cool air from a blow dryer to relieve itching under the cast DO NOT SCRATCH UNDER CAST OR PUT LOTION/POWDER UNDER IT OR "EXPECT NUMBNESS" = COMPARTMENT SYNDROME!!!!

Peripheral IV ASSESSMENT that REQUIRE SITE CHANGE:

***Sites should be changed usually no more frequently than every 72-96 hours unless signs of complications develop COMPLICATIONS: -Phlebitis: erythema, edema, warmth, pain, and palpable venous cord. -Infiltration: edema in DEPENDENT AREAS and cold to touch at insertion site. -Extravasation

Transurethral Resection of the Prostate (TURP)

*Excision of benign prostatic hyperplasia (BPH).* Performed via a resectoscope inserted through the urethra EXPECT CATHETER PLACEMENT POST-OP & *MAINTAIN PATENCY OF THE URETERAL CATHETER* d/t risk of infection & sepsis if clots form and are retained in the bladder

Q: A client is receiving an infusion of total parenteral nutrition (TPN) with 20% dextrose through a central line at 75 mL/hr. The nurse responds to the client's IV pump alarm, which indicates that the bag is empty. The new bag is not expected to arrive from the pharmacy for an hour. What is the most appropriate nursing action?

*Hang 10% DEXTROSE IN WATER and infuse at the SAME RATE until the new bag arrives, then RESUME TPN at 75 mL/hr* *HANG IN WATER!!!!!!!!!!!!!!!!!!!!!!!!*

STROKE (Cerebrovascular Accident [CVA])

*REMEMBER: RIGHT-sided cerebrovascular accident will affect LEFT side of the body (unilateral weakness and neglect) = can result in visual and perceptual deficits depending on which part of the brain is affected* INTERVENTION: -Approach client with visual impairment (HOMONYMOUS HEMIANOPSIA = loss in half of the visual field on the same side) from the UNAFFECTED side ^RISK FOR SELF-NEGLECT on the AFFECTED SIDE -Don clothes on the AFFECTED side first -Teach client to turn their heads to scan the environment -Assess for VISUAL IMPAIRMENTS such as HEMIANOPSIA (less vision or blindness in half the visual field)

WOUND IRRIGATION

*Review immunization history to determine if Tetanus Vaccination is needed for INJURY -Administer the analgesic 30-60 minutes before the procedure -Don a gown and mask with face shield to protect from splashing fluid and sterile gloves -Fill a 30- to 60-mL (LARGE VOLUME) sterile irrigation syringe with the prescribed irrigation solution. -Attach an 18- or 19-gauge needle to the syringe and hold 1 in (2.5 cm) above the area. -Use CONTINUOUS PRESSURE to flush the wound, repeating until drainage is clear. -Dry the surrounding wound area to prevent skin breakdown and irritation. *Cleanse from LEAST to MOST contaminated area.

IM Injection

*Z-track technique prevents tracking (leakage) of the medication into the subcutaneous tissue! 1. Pull the skin 1-1 ½" (2.5-3.5 cm) laterally away from the injection site . 2. Hold the skin taut with the nondominant hand, and insert the needle at a 90-degree angle. 3. Inject the medication slowly into the muscle while maintaining traction at 90-DEGREE ANGLE. 4. Wait 10 seconds after injecting the medication and withdraw the needle while MAINTAINING traction on the skin. 5. Release the hold on the skin. 6. Apply gentle pressure at the injection site, but do not massage!

Crutches

-30-degree bend at the elbow when walking -LOOK FORWARD; not down at feet -crutches & injured foot moved simultaneously in a 3-POINT GAIT -3 finger-width space noted between the axilla and axillary pad -ASSESS FOR Hand & Wrist Weakness (damage to Radial Nerve) INTERVENTIONS: -Keep clear path to bathroom & remove scatter rugs -Use a small backpack/shoulder bag to hold personal items -Wear rubber-soled shoes; preferably without laces -Keep crutches rubber tips dry

LIVER BIOPSY

-Assess coagulation status is checked before the liver biopsy using PT/INR & PTT -Type & Crossmatch Blood in case of hemorrhage -POSITION: SUPINE with RIGHT ARM OVER THE HEAD & HOLD BREATH -After the procedure, frequent vital sign monitoring is indicated as the early signs of hemorrhage are rising pulse (Tachycardia) and respirations (Tachypnea), with hypotension occurring later -Place on RIGHT SIDE for a minimum of 2-4 hours to apply pressure to biopsy site & bed-rest for 12-14 hours

INSUFFICIENT OUTFLOW DURING DIALYSIS? INTERVENTION:

-Assess for abdominal distention & CONSTIPATION -Examine the *catheter for kinks and obstructions* -Place the client in a side-lying position -Administer prescribed medications (eg. stool softeners) & FIBRINOLYTICS (eg. alteplase = to prevent fibrin clots) -MAINTAIN DRAINAGE BAG BELOW THE ABDOMEN = promote gravity flow MOST OFTEN d/t *Constipation*

PREVENTION of ASPIRATION during ENTERAL TUBE FEEDING VIA NG TUBE

-Assess gastrointestinal intolerance to feedings EVERY 4 HOURS by monitoring gastric RESIDUALS and assessing for: abdominal distension, abdominal pain, bowel movements, and flatus. -Assess for GASTRIC RESIDUAL EVERY 4 HOURS in intubated clients -Assess feeding tube placement at regular intervals -Keep head of the bed at ≥30 degrees -Maintain endotracheal cuff pressure at about 25 cm H20 for intubated clients; LOW PRESSURE = ASPIRATION RISK ***Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is necessary *Use caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex *Avoid bolus tube feedings for clients at high risk for aspiration

NASAL SPRAY ADMINISTRATION

-Assume a high Fowler's position with head slightly tilted forward -Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger -Point the nasal spray tip toward the side and away from the center of the nose (AWAY FROM SEPTUM) -Spray the medication into the nose while inhaling deeply -Remove the nozzle from the nose and breathe through the mouth -Repeat the above steps for the other nostril *Blot a runny nose with a facial tissue, but avoid blowing the nose for several minutes after instillation

Promoting Sleep: Nursing Interventions

-Cluster/schedule nursing care to avoid interrupting sleep. -Create a comfortable/restful environment. -Dim the lights at night -Support bedtime rituals/routines. -Offer foods that help promote sleep. -Maintain safety of the client. -Teach about sleep hygiene. DO NOT: leave television on, turn off equipment alarms, or increase dose of sedation medication

Sputum Culture/Sensitivity

-Collect in MORNING -Rinse the mouth with water before collecting sample -Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of the skin -Inhale deeply several times and then cough forcefully -Assume a sitting or UPRIGHT position

Administered medication via Nasogastric Tube (NG Tube)

-Crush/Dissolve all medication separately *Determine if medication is available in LIQUID form -Administer separately -Flush the tube with sterile water before/after medication administration *CONTRAINDICATED: Any enteric-coated, extended-release, or slow-release tablets or capsules (crushing these types of medication to administer via NG Tube would disrupt barrier coating and cause stomach irritation & potentially clog the small-bore tube)

RESTRAINTS

-DO NOT TIE STRAPS TO BASE OF BED OR SIDE RAILS; attach to areas that move with the bed fame using a QUICK RELEASE KNOT. -AVOID SUPINE POSITION; Place in side-lying or semi-fowler position to decrease aspiration risk. -NEVER RE-RESTRAIN CLIENT WITHOUT A NEW ORDER -Perform HOURLY neurovascular checks (pulses, color, skin temperature, sensation, movement) -Brief RELEASE EVERY 2 HOURS: Assess skin integrity and neurovascular status of restrained extremities & provide skin care and range-of-motion exercises & ensure basic needs are met (eg, fluids, nutrition, elimination/toileting) -Pad bony prominences under restraints, if necessary, to protect skin. -Restraint straps should be attached to areas that move with the bed frame *-Seek discontinuation of restraints ASAP*

Tracheostomy Care

-Gather supplies to the bedside ***POSITION: Semi-Fowler's position -Don personal protective equipment (MAKS, goggles, and CLEAN gloves) -Auscultate lungs -Remove soiled dressing THEN remove clean gloves. -Don STERILE gloves; remove old disposable cannula and replace with a new one. -While stabilizing the back plate with the nondominant hand, unlock (unclip) the old cannula with the dominant hand; remove gently by pulling it out in line with its curvature -Pick up the new cannula, touching only the outer locking portion and then insert then lock-in to place -CLEAN around stoma with sterile water or saline -Dry and replace sterile gauze pad & Dry around stoma

CHEST TUBE DRAINAGE

-INSPECT collection chamber EVERY 8 HOURS -50-500 mL for the first 24 hours ******REPORT >100 mL PER HOUR (may require surgical repair/suture) -Sanguineous (bright red) drainage for several hours *Rush of dark bloody drainage from the chest tube if client was turned following a period of minimal drainage is most likely related to retained blood due to a partial blockage in the tube. *REPORT EXCESS BRIGHT RED BLOOD* IF DRAINAGE STOPS: -REPOSITION -Instruct client to cough and deep breathe -AUSCULTATE BREATH SOUNDS *X - DO NOT MILK OR INCREASE SUCTION!!!!!!!!!!* ***CONTACT HCP IF: -EXCESSIVE bright red/frank red drainage (Sanguineous) after several hours; active bleeding -Continued increased drainage (>100 mL/hr) -Changes in the client's vital signs and cardiovascular status that could indicate ACTIVE BLEEDING (eg, hypotension, tachycardia, tachypnea, decreased capillary refill, cool and pale skin)

HIGH PRESSURE ALARM on MECHANICAL VENTILATOR

-Kinked Tubing/Biting on Tubing -Obstruction (eg. excessive secretions, condensation) -Increased airway resistance -Decreased lung compliance -Ventilator Dyssynchrony (anxiety, pain, coughing)

DRAWING BLOOD VIA Central Venous Catheter (CVC):

-Meticulous hand hygiene -Use of disposable gloves during collection and handling of specimen -Appropriate antiseptic (eg, 70% alcohol) scrub of the catheter hub prior to use -Discard the first blood drawn to prevent an inaccurate lab result -Place in BIOHAZARD BAG; reduce risk of transmission of infection -Cleaning the specimen bag with a disinfecting wipe -Proper and immediate transport of specimen to the lab -Avoiding placing specimen in clean areas (eg, nursing station)

Use/Care of HEARING aids

-Minimize distracting sounds (eg, television, radio) during conversation -Turn the volume off prior to insertion, then gradually turn up the volume to a comfortable level -To adjust to the new hearing aids, initially wear them for a short time (eg, 20 minutes) and gradually increase length of wear time. -Do NOT wear the hearing aids when using hair dryers or heat lamps. -Regularly check that the battery compartment is clean, the batteries are inserted correctly, and the compartment is shut before insertion -CLEAN hearing aid with soft cloth; NOT WATER!!! -Remove the battery (if possible) at night and when the aid is not in use to extend battery life. -STORE in safe, dry place when not in use (eg. NOT on food trays)

Pain Relief

-Most ACCURATE level of pain is ACCORDING TO THE PATIENT *Perception of Pain is dependent on the patient. -BEST determinant of pain relief: improvement of clients' SELF-REPORTED PAIN SCORES (objective and measurable)

CONTRAINDICATION for venipuncture in UPPER EXTREMITIES:

-Paralysis -Infection -Arteriovenous fistula or graft (used for HEMODIALYSIS) -Impaired lymphatic drainage (i.e - prior MASTECTOMY) ***If it is necessary to draw blood (perform phlebotomy) from an arm with an IV infusion, collect from a vein several cm BELOW (or DISTAL) to the point of IV infusion

CLEAN CATCH URINE SPECIMEN

-Perform hand hygiene -open the specimen container, leaving the sterile side of the collection lid positioned UPWARD -Spread the labia using the index finger and the thumb of the nondominant hand; hold specimen cup with dominant hand -Cleanse the vulva in a front-to-back motion with provided antiseptic wipes, using a new towelette -Initiate the urinary stream to flush any remaining microorganisms from the urethral meatus -PASS the container into the stream for the collection of 30-60 mL of urine & Remove the specimen container from the stream before the urinary flow ends and the labia are released -Replace the sterile cap without contaminating it and repeat hand hygiene.

PREPARING INJECTION

-Perform hand hygiene and don clean gloves prior to handling medication -Cleanse the vial top with alcohol and let it dry -Withdraw an AMOUNT OF AIR from the vial equal to the prescribed amount of diluent to create negative pressure that will be equalized when the diluent is injected into the vial (*Withdraw air from vial-inject air into diluent-pull up diluent) -Inject the appropriate diluent (eg, sterile saline, sterile water) into the vial -Roll the vial between the palms of the hands to gently mix the solution. *Avoid shaking the vial! -Withdraw the reconstituted medication from the vial into a sterile syringe. -Verify the dosage by checking the prepared medication against the medication administration record and medication label. -Label the syringe with the medication name and dosage to prevent medication errors at the bedside.

Wound Culture

-Perform hand hygiene, and apply CLEAN gloves -Remove the old dressing -Remove and discard gloves. -Perform hand hygiene, and apply STERILE gloves -Assess the wound bed -Cleanse the wound bed and surrounding skin with NORMAL SALINE (eg, flushing, swabbing with gauze) to remove drainage and debris -Perform hand hygiene, and apply CLEAN gloves -Gently swab the wound bed with a sterile swab, from the wound center toward the outer margin -Avoid contact with skin at the wound edge -Place the swab in a sterile specimen container; avoid touching the swab to the outside of the container. -Apply prescribed topical medication (eg, bacitracin) AFTER obtaining cultures to prevent interference with microorganism identification -Apply new dressing -Remove and discard gloves, and perform hand hygiene -Label the specimen, and document the procedure ***DO NOT: obtain sample of the drainage accumulated since the last dressing change d/t drainage likely contains skin flora different from the pathogen(s) responsible for the infection

Fall Risk Factors

-Poor Vision -Positive orthostatic vital signs (eg, rise in pulse of ≥20/min); Orthostatic hypotension -Osteoarthritis of the knees limits joint mobility -Rooms congested with furniture -Improper Bed Height; Difficulty getting in/out of bed/chair -The use of an ambulatory aid such as a cane, walker, or crutches -Impaired gait or balance and difficulty walking -Urinary frequency or receiving diuretics -Weakness from disease process or therapy -Current med regimen that includes sedative, hypnotics, tranquilizers, narcotic analgesics, and diuretics -Cognitive dysfunction (confusion, disorientation, impaired memory/judgement) -Carbidopa/levodopa (Sinemet) is an antiparkinson medication; Parkinson disease increases the risk of falls due to gait abnormality (eg, shuffling gait). Carbidopa/levodopa (Sinemet) may also cause dizziness, involuntary movements, and orthostatic hypotension.

LIQUID MEDICATION FOR INFANTS/CHILD

-Position SEMI-RECLINED -Disposable oral syringes are the preferred tool to administer oral medications. -Direct liquid medication toward the inside of the infant's cheek CHILD: -Encourage child to assist preparation for medication -Provide positive-encouragement ***DO NOT GIVE ANOTHER DOSE IF INFANT OR KID VOMITS; may be sign of overdose.

Ventrogluteal Site Injection

-Position the client supine, prone, or side-lying with the knee and hip flexed *Flexing the knee and hip reduces muscle tension, improves access, and promotes client comfort *SITE SHOULD NOT BE USED FOR IM INJECTIONS IN INFANTS AS THIS AREA DOES NOT HAVE ENOUGH MUSCLE MASS FOR USE; recommended that VASTUS LATERALIS be used until at least age 3.

Position for CHEST TUBE REMOVAL

-Pre-medicate the client with analgesic 30-60 minutes prior to removal (eg. IV opioid, NSAIDs - Ketorolac) & Gather supplies (*Petrolatum Gauze & Sterile 4 x 4 Gauze* to cover insertion site) -Place in SEMI-FOWLER'S POSITION or on the unaffected side to promote comfort -Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed; RISK OF PNEUMOTHORAX -Apply a sterile airtight occlusive dressing to the chest tube site immediately! -Perform a chest x-ray within 2-24 hours after chest tube removal; risk of post-procedure pneumothorax or fluid accumulation

What should be done if patient is having an allergic reaction during IV infusion of a medication?

-STOP THE MEDICATION IMMEDIATELY -Begin normal saline transfusion -DO NOT DISCONTINUE THE IV LINE; medication to reverse allergic reaction will be required

PREVENTION of Urinary Tract Infections (UTIs) with Indwelling Urinary Catheter

-Wash hands -Perform routine perineal hygiene with SOAP AND WATER each shift and after bowel movements or AS NEEDED -Keep drainage system off the floor or contaminated surfaces & Keep the catheter bag BELOW the level of the bladder -Ensure each client has a separate, clean container to empty collection bag and measure urine -Use STERILE technique when collecting a urine specimen -Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or backflow into the bladder -Avoid prolonged kinking, clamping, or obstruction of the catheter tubing -Encourage oral fluid intake -Secure the catheter in accordance with hospital policy (tape or Velcro device) -Inspect the catheter and tubing for integrity, secure connections, and possible kinks *DO NOT PERFORM: Routine irrigations or routine cleansing with antiseptic

TRANSDERMAL PATCH

-Wash the area with soap and water, then rinse and wipe with a clean, dry tissue & Wash hands with soap and water before and after applying the patch -Replaced every 72 hours and used patch must be removed before applying a new one; ROTATE SITES of patch application with each new patch -Place patch on area of flat, intact, dry, hairless skin (commonly on chest and upper outer arm) -Fold the used patch in half so the edges adhere and IMMEDIATELY DISCARD -DO NOT: apply heat over the patch or cut the patch in any way -DO NOT: SHAVE area prior to applying patch *Unlike TOPICAL ANALGESIC PATCHES (lidocaine, capsicum) that deliver drug locally and are placed near the site of pain, transdermal patches have a SYSTEMIC EFFECT. ***USED FOR CHRONIC PAIN; NOT USEFUL IN ACUTE SITUATIONS SINCE IT CAN TAKE UP TO 17 HOURS TO REACH FULL EFFECT!

Palliative Care

-managing symptoms, providing psychosocial support, coordinating care, and assisting with decision making to relieve suffering and improve quality of life -focused on improving quality of life and can be provided at ANY time (can be given CONCURRENTLY with life-prolonging treatment) -provided by multidisciplinary team

BLOOD TRANSFUSIONS

1. *-COLLECT HEART RATE & BLOOD PRESSURE FIRST! (baseline; assess for anaphylactic shock)* 2. Verify two client identifiers (eg, first/last name, medical record number, date of birth), the prescription, and the blood products with another licensed health care provider 3. Ensure that blood type and Rh type are compatible ***An Rh-positive client can safely receive Rh-positive or Rh-negative blood (i.e - AB-positive client is infused O-negative blood) However, Rh-negative can ONLY receive Rh-negative blood. A 4. *Administer the blood via FILTERED TUBING with normal saline on a DEDICATED IV LINE*; prevent clumping ^if previously used line must be used, line must be FLUSHED WITH NORMAL SALINE *5. Monitor VITAL SIGNS BEFORE & DURING transfusion per facility-specific protocol (eg, BEFORE transfusion & FOR 15 minutes after transfusion begins)* *6. Transfuse blood products within MAXIMUM 4 HOURS due to the risk for bacterial growth* REMEMBER: -RN MUST STAY AND MEASURE VITAL SIGNS WITHIN FIRST 15 MINUTES OF TRANSFUSION; cannot be delegated -DOUBLE CHECK; TWO RN must check identification of the client and the blood product ****IF NEGATIVE REACTION (Acute Hemolytic) IS SEEN (red urine, hypotension, itching, wheezing): STOP INFUSION IMMEDIATELY Disconnect tubing at the catheter hub Maintain IV access USING NEW TUBING Collect Urine Specimen to check for HEMOLYZED RBCs

SKIN

1. *PURPURA* = Reddish-purple blotches on the skin that do not blanch with pressure due to bleeding underneath the skin (i.e - blood dyscrasia) 2. *ERYTHEMA* = redness of the skin; d/t -Fever -Vasodilation -Inflammation -High Environmental Temperature

INSTILLING EYE DROPS (Ophthalmic Medication)

1. Perform hand hygiene and don clean gloves 2. Place client in the supine or sitting position with head tilted back toward side of the affected eye. 3. Remove dried secretions with moistened (warm water or normal saline) sterile gauze pads by wiping from the INNER to OUTER canthus. 4. Rest hand on client's forehead and hold dropper 1-2 cm above the conjunctival sac & pull lower eyelid down to expose the conjunctival sac. 5. Instruct client to look upward and then instill drops of medication into the conjunctival sac. 6. Instruct client to close the eyelid and move the eye around (if able). **Apply pressure to the lacrimal duct for 30-60 seconds if medication has systemic effects. 7. Remove excess medication from each eye with a new tissue or gauze pad to prevent cross-contamination *Wait 5 minutes before instilling a different medication into the same eye OINTMENT/LUBRICANT: -apply at bedtime -tilt head back, pull lower lid down, and look upward during administration -squeeze thin strip of ointment on lower eyelid (conjunctival sac) from inner to outer edge -gently close the eyes for 2-3 minutes; DO NOT RUB!

INSTILLING EAR DROPS

1. Perform hand hygiene and don clean gloves 2. Position the client side-lying with the affected ear up 3. Warm ear drops to room temperature 4. Pull the pinna UP AND BACK to straighten the ear canal in clients >4 years old and adults. *Pull the pinna DOWN AND BACK in clients <3 years old. 5. Instill the prescribed number of drops by holding the dropper 1 cm (1/2 in) above the ear canal. *DO NOT OCCLUDE THE EAR CANAL DURING INSTILLATION 6. Apply gentle pressure to the tragus (fleshy part of external ear canal) if it does not cause pain, which facilitates the flow of medication into the ear canal 7. Instruct the client to remain side-lying for at least 2-3 minutes to facilitate medication distribution and prevent leakage 8. Place a cotton ball loosely in the client's outermost ear canal for 15 minutes, only if needed, to absorb excess medication. Perform this with caution and avoid in infants or very young clients as it is a choking hazard

POSITIONING:

1. Position for *ACUTE BLOOD LOSS*: SUPINE & LOWER HEAD OF THE BED ^maintain blood perfusion to the brain & other vital organs 2. Position for *DEMENTIA*: SIDE-LYING or SEMI-FOWLER; ^do NOT lay SUPINE = ASPIRATION RISK d/t inability to reposition if vomiting occurs 3. Position for *DYSPNEA*: RAISE HEAD OF BED; usually the FIRST intervention to implement 4. Position for *Nasogastric BOLUS ENTERAL FEEDINGS*: SEMI-FOWLER POSITION (elevate the head of the bed to 30-45 degrees) AND THEN keep it elevated for 30-60 minutes POST-FEEDING ^ASPIRATION RISK 5. Position for *SECRETION REMOVAL*: FOWLER'S POSITION (sitting upright with the head of the bed at 45-60 degrees) ^used to relieve SHORTNESS OF BREATH = facilitate oxygenation (Breathing) & promote lung expansion (airway) OR POSITION ON THE GOOD LUNG IN DEPENDENT POSITION (ON THE GOOD LUNG SIDE) 6. Position for *RHEUMATOID ARTHRITIS (RA)* & *Post-Total Knee Replacement*: SUPINE (FLAT) ^Knee: avoid CONTRACTURE (eg. placing pillow behind knees) 7. Position for *Buck's Skin Traction*: SUPINE (FLAT) or SEMI-FOWLERS ^*DO NOT RAISE HOB HIGHER THAN 30 DEGREES)* 8. Position for *Paracentesis*: SEMI-TO-HIGH FOWLER 9. Position for *THORACENTESIS*: UPRIGHT SITTING POSITION on the SIDE of the BED, LEANING FORWARD over the bedside table with arms supported on pillows. 9.1 Position *POST-THORACENTESIS*: *TURN ONTO UNAFFECTED SIDE* for 1 hour to FACILITATE LUNG EXPANSION 10. Position during/post *LUMBER PUNCTURE*: During: SIDE-LYING FETAL POSITION or hunched seated position to separate the vertebrae. 10.1 Post-Puncture: SUPINE in bed for 4-12 hours to minimize the risk of a post-punctured headache from the loss of cerebrospinal fluid. *ASSESS FOR CLEAR FLUID LEAKAGE ON DRESSING; Cerebrospinal Fluid!* 11. Position for Post-Liver Biopsy: Positioned on the SURGICAL SIDE (RIGHT SIDE) ^pressure prevents hemorrhage 12. Position for PNEUMONECTOMY: Positioned on the SURGICAL SIDE ^promote adequate expansion and ventilation of the remaining lung.

Peripheral IV INSERTION/CLEANSING/MAINTENANCE

1. Select an IV catheter site on an upper extremity, preferably the hand or forearm (*DISTAL preferred*) *^DO NOT LEAVE TOURNIQUET MORE THAN 1 MINUTE WHEN LOOKING FOR A VEIN* 2. Site should be cleaned with antiseptic solution using friction (preferably chlorhexidine, using a back-and-forth motion) and then allowed to air-dry completely 3. STRETCH SKIN TAUT & ANCHOR VEIN 4. Insert *ONC bevel up at 10-30 degrees angle (ID)*; observe for blood return. 5. Advance catheter hub while retracting stylet for eventual removal; *stylet should be advanced UNTIL blood return is seen (approx. 1/4 inches)* 6. Attach extension or infusion set 7. After insertion, the catheter hub should be secured with a narrow strip of sterile tape & a sterile, transparent, semipermeable dressing (eg, Tegaderm) 8. Port should be cleansed with an alcohol swab to kill externally colonized microorganisms BEFORE EACH ACCESS. 9. Replace line every 72-96 hours unless signs of complications occur *DO NOT SHAVE AREA chosen for IV insertion!* *DO NOT KEEP ARM IN DEPENDENT POSITION = EDEAM!!* *AVOID ANTECUBITAL SPACE/REGION (location where flexion occurs) unless it is an EMERGENCY!!!* ***PULSATING RED BLOOD = signs of ARTERY PUNCTURE.* ^Remove needles immediately and apply pressure for at least 5 minutes.

What SIZE SYRINGE should be used to flush the lumen of a Central Venous Catheter (CVC)?

10-mL SYRINGE

Nasogastric tube (NG tube)

A feeding tube that goes through the nose, through the pharynx, and into the stomach. -Measure/Mark from tip of the nose to the ear lobe to the XIPHOID process or midepigastric area -PLACE small piece of tape at the point of measurement -Lubricate Tube -Head tilted slight FORWARD to facilitate insertion (instruct client to EXTENDED neck back slightly) *-Gently insult just past NASOPHARYNX & Advise client to SWALLOW as the tube passes through the oropharynx & Advance tube to the marked point* *^If client begins to cough and experience difficulty breathing during insertion: PULL BACK ON THE TUBE & WAIT until client is breathing normally* -VERIFY TUBE PLACEMENT (Chest X-Ray) -Post-Verification: Remove STYLET to allow tube feeding -Irrigated with NORMAL SALINE (0.9% NA); NOT WATER (H20 is a hypotonic solution) *-REPORT: dark red DRAINAGE 24 hours post-surgery; drainage should be changing colors to green (bile) or yellowish-brown drainage* **No need for rubber clamps, extending tape measures, or folding tubes ********CONTRAINDICATED: -Post Bariatric & Gastric Surgery d/t risk of potential disruption of surgical site and risk of HEMORRHAGE

Positive end-expiratory pressure (PEEP)

A form of POSITIVE PRESSURE VENTILATION (PPV); Pressure APPLIED at the end of EXPIRATION during mechanical ventilation; counteracts small airway collapse and keeps alveoli open so that they can participate in gas exchange. *Higher level of PEEP = for acute respiratory distress syndrome (ARDS) ^RISK OF BAROTRAUMA TO THE LUNGS (d/t overdistension) = can lead to PNEUMOTHORAX ^^ RISK OF HYPOTENSION d/t increased intrathoracic pressure during inspiration = reduced venous return, ventricular preload, and cardiac output

Pulse Oximeter (SaO2)

A noninvasive device that estimates the arterial blood saturation (SaO2) by using a sensor attached to the adult client's finger, toe, earlobe, nose, or forehead The sensor relies on adequate tissue perfusion, so low blood flow or decreased perfusion can decrease SpO2 readings (commonly d/t heart failure, hypovolemic shock, HYPOTENSION, vasoconstriction) FALSE READING: -Nail Polish -Cold Extremities (Hypothermia) -Vasoconstriction -HYPOTENSION -Low CARDIAC OUTPUT (Heart Failure) -Peripheral Arterial Disease

Peripherally Inserted Central Catheter (PICC)

A venous access device that is inserted via the cephalic or basilic vein and terminates in the superior vena cava. ^Indicated for administration of noxious medications (eg, parenteral nutrition, chemotherapy), for long-term IV therapy, or in clients with poor venous access. *Long-Term IV Therapy & Follow-Up Lab Work can continue AT HOME if needed to be discharged! INTERVENTION: -inspect the insertion site for signs of infection (redness, drainage). -inspect dressing integrity -STERILE dressing changes every 48 hours with a gauze dressing or 7 days with a transparent semipermeable dressing (biopatch) OR immediately if dressing is loose/torn, soiled, or damp. -The line should be flushed before and after medication administration -Blood pressure and venipuncture should NOT be performed on the affected arm. -All infusing medications & parenteral nutritions (except vasopressors; Norepinephrine & Epinephrine) MUST BE PAUSED before drawing blood from the PICC to prevent false interpretation of the client's serum levels. -"Scrub the hub" with alcohol or chlorhexidine/alcohol FOR 10-15 SECONDS ^done before flushing, drawing blood, or administering medication. ***FOR Dressing/Tubing/Injection Cap Change: -Place in SUPINE POSITION *TRENDELENBURG POSITION ON LEFT SIDE IF AIR EMBOLISM IS SUSPECTED -Turn head AWAY from insertion site (d/t risk of site contamination by the client's respiratory secretions) -Wear STERILE GLOVES and SURGICAL MASK when changing the dressing -HOLD BREATH or EXHALE during tubing or injection cap change

Central Venous Catheter AIR EMBOLISM INTERVENTION

AIR LEAKAGE (eg. client gasping for air, writhing?) RISK OF AIR EMBOLISM -Clamp catheter tubing (prevents air embolizing into venous circulation) -Place the client in TRENDELENBURG POSITION on the LEFT side -Administer O2 as needed -Notify HCP -Stay with the client and provide reassurance

What size gauge IV catheter is required for BLOOD TRANSFUSIONS/BLOOD INFUSION?

AT LEAST 20-gauge; but 18-gauge is PREFERRED. *If 20-gauge is already established, it can be used in SURGERIES

LATEX ALLERGY?

AVOID: -Balloons -Latex gloves -AVOCADOS, BANNAS, TOMATOES

IODINE ALLERGY?

AVOID: -SHELLFISH

Benign Prostatic Hyperplasia (BPH)

Abnormal prostate enlargement; most commonly affects male clients age >50 ***RISK OF UTI (Urinary Tract Infection): burning sensation with urination and cloudy/foul-smelling urine SYMPTOMS: -urinary urgency/frequency/hesitancy/retention -dribbling urine after voiding -nighttime frequency (nocturia) INTERVENTION: -AVOID CAFFEINE AND ANTIHISTAMINES! -Implement a fixed voiding schedule -USE VALSALVA maneuver (ie, "bearing down") & CREDE maneuver (ie, gently applying pressure to the lower abdomen) to help facilitate bladder emptying -Assess the perineal area for skin breakdown -Measure postvoid residual volumes -Instruct the client to wait 20-30 seconds after voiding and then attempt to void a second time (ie, DOUBLE VOIDING) ***Surgical prostate resection may be required

Pneumothorax

Air in the pleural cavity caused by a puncture of the lung or chest wall. ENCOURAGE PATIENT TO BREATHE DEEPLY AND COUGH REGULARLY! SYMPTOMS: -Ventilation-perfusion (V/Q) mismatch. -Shortness of Breath/Tachypnea/Hypoxemia -Respiratory Acidosis. -Decreased tidal volume. -DECREASED BREATH SOUNDS & Distant Heart Sounds -SHARP CHEST PAIN with movement on AFFECTED SIDE/ASYMMETRICAL chest expansion -Coughing -CYANOSIS -jugular vein distention (JVD) -Tachycardia

Negative Pressure Wound Therapy

Application of negative pressure to a wound to enhance bacteria and exudate removal. This STERILE procedure creates negative pressure through a sealed dressing and vacuum-assisted closure unit -Administer prescribed pain medication prior to procedure -Apply skin barrier cream to intact skin surrounding the wound -Ensure that the foam dressing shrinks (compresses) after the device is activated -Foam dressing is cut to the size of the wound bed using STERILE technique

Pressure Injuries/Ulcers

Areas of localized skin injury and underlying tissue caused by external pressure. ASSESS HEELS, ANKLES, HIPS, and TAILBONE! Clients at greatest risk: -advanced age -older adults with limited movement and long bone (femur) or hip fractures -quadriplegic/clients with deficits in mobility and activity (spinal cord injury) -incontinence/edema/excessive moisture/dry skin -inadequate nutrition/weight loss/protein deficiency -chronic & critical illness (i.e - AIDS)/immune deficiency -renal failure -Anemia -problems with oxygenation/hypoxia -infection/fever -surgery -Norepinephrine (Levophed) infusion Intervention: -Apply moisture barrier cream & emollients to dry skin -Clean perineal area after incontinent episodes (keep skin clean and free of excessive moisture) -Place foam-padded seat cushions on chairs & provide proper support surfaces -Turn EVERY 2 HOURS

GUAIAC FECAL OCCULT BLOOD TEST

Assess for microscopic blood in the stool as a screening tool for colorectal cancer. STEPS: -Assess for recent ingestion (within last 3 days) of red meat or medications (eg, vitamin C, aspirin, anticoagulants, iron, ibuprofen, corticosteroids) = MAY RESULT IN FALSE POSITIVE -Obtain supplies, wash hands, and apply NON-STERILE gloves -Open the slide's flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the slide. Collect from 2 different areas! -Close the slide cover and allow the stool specimen to dry for 3-5 minutes. -Open the back of the slide and apply 2 drops of developing solution to the boxes on the slide -Assess the color of the Hemoccult slide paper within 30-60 seconds; POSITIVE = BLUE COLOR! -Dispose -Document

*STROKE = FAST*

Assessment for STROKE (CVA) F - Facial Drooping A - Arm Weakness or Drifting of one arm when raised/extended to shoulder level S - Speech Difficulties; slurring, incomprehensible, inability to comprehend T - Notation of the time of SYMPTOM ONSET!

Decerebrate Posture vs Decorticate Posture

BOTH are sign of severe brain damage (likely d/t Cerebrovascular Accident; interruption in blood flow to the brain either d/t bleeding or occlusion of a blood vessel). DECEREBRATE Symptoms: -arms and legs straight out -toes pointed down -head/neck arched back DECORTICATE Symptoms: -Arms FLEXED at the elbow -Hands raised to chest -Legs Extended

SEIZURE

Before: -Remove potential sources of injury -Identify seizure triggers & assess therapeutic level of antiepileptic drugs -Keep O2 at bed side -Provide FULLY PADDED SIDE RAILS & PREPARE O2 SUPPLEMENTS (eg. bag valve mask) and SUCTIONING KIT at BEDSIDE During: -PROTECT HEAD if possible; guide client to the floor and gently cradle the head -Place client in RESCUE POSITION (LEFT LATERAL) *-NEVER EVER PLACE ANYTHING IN MOUTH (eg. ORAL AIRWAY & TONGUE BLADE)* -DO NOT RESTRAIN LIMBS OR TORSO -Stay with seizing patient & document length and symptoms of seizure After: -Perform neurological assessment -Assess for physical injury

Jackson-Pratt (JP) & Hemovac Drains

CLOSED WOUND DRAINAGE-suction devices (evacuator unit) that is connected to a drain that is inserted into or close to a surgical wound; purpose is to DRAIN FLUID BUILD UP in a closed space. Commonly seen post abdominal & breast reconstruction surgery. EMPTYING: -Perform Hand Hygiene (d/t risk of INFECTION) -Pull the PLUG ON THE BULB to open the device & pour drainage into a small, calibrated container; RECORD ACCURATE DRAINAGE OUTPUT -Empty the device every 4-12 hours or AS REQUIRED -Compress Empty bulb until collapsed to restore NEGATIVE pressure -Clean spout on the bulb with ALCOHOL and replace the plug once totally collapsed

What should be done after discontinuing the continuous IV normal saline?

CONVERT to a SALINE LOCK

Postmortem Care

Care typically performed immediately following the pronouncement of death to allow visitation of the deceased by the family. -MAINTAIN PRECAUTIONS IN PLACE -Gently Close Eyes -Remove Tubes & Dressing (per policy) -Straighten & Wash the body & Change lines/gowns -LEAVE DENTURES IN PLACE -Place a pad under the perineum & a pillow under the head -Give belonging to a family member or send with the body *AUTOPSY NOT PERFORMED UNLESS REQUESTED OR UNUSUAL DEATH Delayed if: -Certain cultural or religious beliefs require that care be performed by the family or clergy -Family also may want religious ceremonies performed or last rites given before the body is cleaned or disturbed in any way -Accordance with state law and agency policies. These situations include deaths that are considered non-natural, traumatic, or associated with criminal activity (i.e - Murder, SUICIDE)

Arterial lines (A-lines)

Catheter inserted into an artery; most commonly used to monitor blood pressure directly and in real-time + obtains samples for ABG analysis INSERT IN: -Radial (eg. Transradial Cardiac Catheterization) -Brachial -Femoral (eg. Visualization of Coronary Arteries via Cardiac Catheter = CORONARY ANGIOGRPAHY & ANGIOPLASTY) ASSESS for COMPLICATIONS: -Hemorrhage -Infection -Thrombus formation -Circulatory/neurovascular impairment (eg. one extremity cooler than the other)

Epilepsy

Chronic seizure activity. Usually requires life-long anticonvulsant therapy (eg. Phenytoin); do NOT abruptly STOP medication. ASSESS FOR AURA (premonition that occurs prior to complex or generalized seizure). INTERVENTION: -Identify/avoid seizure triggers (eg. alcohol) -Encourage REST -Teach relaxation techniques (eg. biofeedback) -Encourage client to wear an epilepsy medical identification bracelet in case of emergency -Reduce environmental stimuli (eg. loud noises, bright lights) ***GO TO EMERGENCY ROOM IN THE CASE OF STATUS EPILEPTICUS (eg. prolonged, repeated seizures) *ER not necessary for every seizure; but ADMINISTER IV BENZODIAZEPINES (Diazepam, Lorazepam) IF EXPERIENCING STATUS EPILEPTICUS Symptoms: -GRUNTING -Dazed Appearance

INFILTRATION

Complication that occurs when solution or medication infuses into the surrounding tissues of the infusion site. Intervention: -DISCONTINUE THE IV LINE IMMEDIATELY and begin a new IV; preferable on the opposite extremity -Continue to monitor the infiltration site for swelling or other abnormalities -ELEVATE AFFECTED EXTREMITY -Notify Physician *Cold or Warm Compress may be used but is not a priority!

Confirming correct placement of a left subclavian central venous catheter?

Confirmed via X-Ray: CVC tip is in the client's superior vena cava.

T-piece (Brigg's adapter)

Connects to the Client's ARTIFICIAL AIRWAY; gradually weans client from ventilator use. -Disconnect client from ventilator for short periods of time -Connect T-Piece to Artificial Airway -Provide supplemental O2 at a FIO2 that is 10% higher than ventilator setting

Rhonchi

Continuous, low-pitched wheezes usually heard on expiration that sound like moaning or snoring d/t air moving through mucus congested bronchi; EXPECTED in clients with Chronic Bronchitis, SECRETIONS IN THE LARGER AIRWAYS.

Blind Patient

Create a therapeutic and safe environment while fostering as much independence as possible: -Offer client an elbow for guidance and walk slight ahead while describing movement (SIGHTED GUIDE TECHNIQUE) -Announce room entry and exit -Describe the location of items using a CLOCK-FACE orientation -Instruct the client to use a cane with the dominant hand and to sweep areas in front from side to side for orientation. -Orient the client to the room and maintain this orientation -Ask client DIRECTLY about room arrangement

Deaf/Heard-of-Hearing Patient

Create a therapeutic and safe environment while fostering as much independence as possible: -Visibly gain the client's attention before speaking and DIRECTLY FACE the client so the speaker's face can be seen clearly -Speak at NORMAL VOLUME -Turn on room light to allow lip reading -Ensure functional hearing aids are in place before attempting to speak to the client -Post hearing impairment sign on the client's door

Dehiscence & Evisceration

Dehiscence: Edges of a surgical wound fail to approximate and separate (ie, partial or total separation of the skin and/or tissue layers) & Evisceration: Protrusion of internal organs through the wall of an incision Avoid: Coughing, Sneezing, Vomiting, Getting up from sitting position, or straining! Intervention: -PLACE IN LOW FOWLER'S POSITION WITH KNEES BENT********** (reduce tension on open wound) -COVER wound with sterile saline & gauze -Administer STOOL SOFTENERS (i.e - Docusate) to prevent straining and constipation -Administer ANTIEMETICS (i.e - Ondansetron) for nausea to prevent straining during vomiting -Application of ABDOMINAL BINDER -Tight monitoring of blood sugar (< 140 mg/dL) to decrease infection risk *-SPLINTING THE ABDOMEN by holding a pillow or folded blanket against the wound for support when coughing or moving or deep breathing* -ADEQUATE CALORIC and PROTEIN and VITAMIN C INTAKE

Canes

Descending Stairs: -Lead with the cane -Bring the weaker leg down next (in this client, it is the left leg) -Step down with the stronger leg Ascending Stairs: -Step up with the stronger leg first -Move the cane next, while bearing weight on the stronger leg -Move the weaker leg

Appropriate method to TRANSFER a client safely?

Determined via: -Whether the client can bear weight -Whether the client is cooperative If both criteria is met: clients should be encouraged to do as much as they can for themselves, anticipating discharge in the near future. It is appropriate to transfer this client with 1 person standing by for safety with walker.

External Fixator

Device used to stabilize broken bones; metal pins are placed through the tissue into the bone and connect to a frame outside the skin INTERVENTION: -Assess for signs of neurovascular compromise and pin site infection (new, increased, and/or purulent drainage and checking the skin surrounding the pins for erythema, warmth, pain, or breakdown); risk of osteomyelitis -Assessing for signs of compartment syndrome (eg, decreased pulses, coolness, pain, numbness, tingling) -Performing pin site care with a sterile cleaning solution (eg, chlorhexidine, sterile normal saline) and gauze -Monitoring pins and device for loosening and reporting to the health care provider (HCP) if they are loose DO NOT MANIPULATE PIN BY YOURSELF!!!!

Salem Pump Tube

Double lumen (large lumen attached to continuous suction, smaller lumen within the large lumen is open to the atmosphere) NASOGASTRIC tube; has "pigtail" blue air vent to allow air to freely be exchanged. ^CONTINUOUS SUCTION can be applied to decompress the stomach if a double lumen Salem sump tube is in place Intervention: -PLACE in Semi-Fowler's Position -KEEP AIR VENT (Blue Pigtail) OPEN! DO NOT PLUG! -KEEP AIR VENT ABOVE THE LEVEL OF STOMACH TO PREVENT REFLUX -Inspect drainage system for patency -Turn off suction briefly during auscultation (Suction can be mistaken for bowel sounds) -Provide mouth care every 4 hours X - no need to check for residual; Salem Sump is attached to continuous suction for decompression. NOT FOR ENTERAL FEEDING!

Hemodialysis

FASTER in cleaning in blood of toxins compared to Peritoneal Dialysis; REQUIRES LESS TIME TO FILTER but require patients to travel to nearby dialysis centers! INTERVENTION: -Assess the client's fluid status (weight, blood pressure, peripheral edema, lung and heart sounds) -Assess vascular access (arteriovenous fistula, arteriovenous grafts) -Assess vital signs ***ASSURE PATECY via Palpate the fistula in the arm for a THRILL and Auscultate for a BRUIT -IV Heparin is added to the blood after client is connected to dialysis machine BEFORE dialyzing fluid is instilled -DO NOT GIVE PO MEDS BEFORE DIALYSIS *RISK OF HYPOTENSION *-DECREASE PROTEIN & POTASSIUM & SODIUM INTAKE if there is RENAL PROBLEMS (eg. chicken - protein, tomato - potassium, mayonnaise - sodium)* CONTRAINDICATED: ACETYLSALICYLIC ACID d/t client on Heparin concurrently if on Hemodialysis

BARIUM ENEMA

Fluoroscopy; visualizes colon outlined by contrast to detect polyps, ulcers, tumors, and diverticula. CONTRAINDICATED: -DIVERTICULITIS (may cause RUPTURE of inflamed diverticula = PERITONITIS) Pre-Op INTERVENTION: -Administer cathartic (eg, magnesium citrate, polyethylene glycol) to empty stool from the colon. -CLEAR LIQUID DIET day before the procedure -Do NOT eat or drink anything 8 hours before the test -Teach client to expect being placed in various positions & may experience abdominal cramping/urge to defecate POST-OP INTERVENTION: -Expect the passage of chalky, white stool -ADMINISTER LAXATIVE (eg, magnesium hydroxide [Milk of Magnesia]) -INCREASE FLUID INTAKE & FIBER-INTAKE x prevent constipation

Romberg Test

Focused neurologic examination; assesses client's perception of head and body in space. ***POSITIVE = loss of coordination (ATAXIA)

SPIRAL FRACTURE

Fracture in which the bone has been twisted apart; occurs often as a result of CHILD ABUSE. PRIORITY: REPORT THE INJURY PER FACILITY PROTOCOL; suspicions of child abuse.

VENTURI MASK

High-flow device that delivers a guaranteed oxygen concentration regardless of the client's respiratory rate, depth, or tidal volume (TV). The adaptor or barrel can be set to deliver 24%-50% oxygen concentration. COLORED BARRELS; used in unstable clients with COPD *rapid changes in inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with COPD, so the VENTURI MASK is the best choice.

BURNS

INTERVENTION: -*Emergency care - Immerse in cold water (gradual temperature change; do not put ICE on burns or any ointment or neutralizing solution) -Cover area with clean, dry cloth to prevent contamination -DO NOT remove charred clothing; but remove clothing if NOT stuck to skin, around the burn *-ADMINISTER analgesics via IV; poor reaction to IM, SQ, and PO medications* -Insert Foley Catheter; measure hourly urine output accurately *-ASSESS for HYPERKALEMIA!* *-1% silver sulfadiazine = ointment applied to burns; can cause LEUKOPENIA (assess WBCs) & Arm Burns are difficult to care for d/t muscle contractures & risk of deformity* -Assess adequacy of fluid resuscitation: LEVEL OF CONSCIOUSNESS (alterations in sensorium) capillary refill (burns can cause LOSS OF PERIPHERAL PULSES) URINE (anuria, oliguria = lack of fluid). **18-24 hours post burn: ELEVATED HEMATOCRIT d/t hemoconcentration from Hypovolemia; but eventual ANEMIA later on d/t blood loss and hemolysis **48-72 hours post burn: assess for FLUID VOLUME EXCESS (Hypervolemia) d/t fluid resuscitation and restoration of capillary permeability; symptoms = distended jugular veins, edema. ^^^Signs of ADEQUATE Fluid Resuscitation: -Adequate urine output (DIURESIS) -Alteration in sensorium = back to baseline -Respiratory rate and capillary refill = all normal REHABILITATION: -Gentle massage with water-based lotion to alleviate itching -Range-of-motion exercises daily -SUNSCREEN & avoid direct contact with sunlight -Encourage TUBULAR SUPPORT/Pressure garments (i.e - JOBST GARMENT) = decreases hypertrophic scar formation via applied tension. -Prepare to administer TETANUS TOXOID (prevent tetanus) *-ADMINISTER VITAMIN D (^same for Osteomalacia)*

Hypertonic IV solutions causes nausea, vomiting, or diarrhea. INTERVENTION?

INTERVENTION: SLOW DOWN THE RATE of administration! Hypertonic IV Solution causes these symptoms d/t gastrointestinal tract pulling fluid from the surrounding intra- and extravascular compartments; causes symptom similar to dumping syndrome and may cause temporary diarrhea with cramps, nausea, and vomiting.

Allen's Test

Identifies vascular compromises; identifies radial and ulnar artery PATENCY!!!!!! (wrist)

Extravasation

Infiltration of a VESICANT (agent irritating to the human tissue) into the tissue surrounding the vein; CAUSES HARM! -STOP the infusion immediately and disconnect the IV tubing -Use a syringe to aspirate the drug from the IV catheter; REMOVE the IV catheter while aspirating. -ELEVATE the extremity above the heart to reduce edema -Notify the health care provider -Obtain a prescription for the antidote if available (eg. Phentolamine - vasodilator for adrenergic agonists such as norepnephrine, dopamine)

PERITONITIS

Inflammation of the PERITONEUM (membrane lining the abdominal cavity and surrounding the organs within it) Symptoms: -Abdominal Tenderness/Pain; worsens with motion or touch -Abdominal bloating or distention -Nausea/Vomiting/Diarrhea OR Constipation -Minimal Urine Output -Low Grade Fever & Chills RISK OF: HEPATIC ENCEPHALOPATHY HEPATORENAL SYNDROME (progressive kidney failure) SEPSIS/SEPTIC SHOCK Can be caused by: -Perforated Colon -Peritoneal Dialysis -Infection -Appendicitis/Pancreatitis Perforation (REBOUND TENDERNESS!!!!!!) -Cirrhosis of the liver/Liver disease -Pelvic inflammatory disease (PID) -Crohn's Disease -DIVERTICULITIS rupture d/t Barium Enema -Abdominal wound/injury

Cellulitis

Inflammation of the subcutaneous tissues that is typically caused by bacterial infection; causes reddening, inflammation, and EDEMA. Intervention: ***ELEVATE AFFECTED EXTREMITY to reduce edema -Apply warm compress -Mark & Date the reddened areas; assess for spreading -DON gown and gloves while in contact or potentially in contact with body fluids (eg. urine, stool, baths)

Paracentesis (abdominocentesis)

Insertion of needle or catheter into the peritoneal cavity (ascites) to obtain ascitic fluid for diagnostic or therapeutic purposes (decreases intra-abdominal pressure & fluid volume). ^RISK OF HYPERVOLEMIA d/t high volume peritoneal fluid removal (> 5 L) Pre-Op Intervention: -Obtain baseline vital signs, abdominal circumference, and weight -Place in SEMI-TO-HIGH FOLWER POSITION -EMPTY BLADDER PRIOR TO INSERTION!!! *x NPO is NOT REQUIRED & doctor obtains informed consent*

Position for Central Venous Catheter INSERTION/Maintenance/REMOVAL

Insertion: -Place in TRENDELENBURG POSITION (supine on 15-30 degree incline with feet elevated above the head) with head slightly turned to the LEFT Dressing Change/Tubing Changes: -Place in SUPINE position Removal: -Place in SUPINE position -BEAR DOWN/EXHALE (VALSALVA MANEUVER) during removal of the line xDO NOT INHALE (risk of air embolism). ^Apply air-occlusive dressing to the site after line

Oxygen Administration AT HOME

Interventions: -AVOID VASELINE, SYNTHETIC/WOOL FABRICS, and NAIL POLISH (Acetone) and ANY OTHER FLAMMABLE SUBSTANCE -Keep at least 5-10 feet from any gas stoves or open flames -DO NOT INCREASE LITER FLOW; should be used as prescribed. *Higher rates in COPD can decrease drive to breathe.

INJECTION ANGLES

Intramuscular (IM) = 90 degrees *Acceptable in: Deltoid, Vastus Lateralis, and Ventrogluteal site (preferred) **Vastus Lateralis = MOST OPTIMAL FOR INFANTS Subcutaneous (SQ) = 90 degrees (if 2 inch of skin can be grabbed) or 45 degrees (if only 1 inch of skin can be grabbed) *massage site for INSULIN Intradermal = 5-15 degrees *DO NOT MASSAGE SITE Peripheral IV Insertion = 10-30 degrees

Central Venous Catheter (CVC)

Intravenous access device with MULTIPLE LUMENS (can administer incompatible drugs simultaneously, perform blood draws, deliver PARENTERAL nutrition, and do hemodynamic monitoring) inserted into large veins such as the subclavian, jugular, or femoral veins in the center of the body. -Require form of HEPARIN flush to maintain patency and prevent clotting when not in use; 10-100 units/mL = standard dose for flushing CVC. ^1000-10,000 units/mL = given for VENOUS THROMBOEMBOLISM; not for maintenance. -Change occlusive dressing every 7 days

Cheyne-Stokes respiration

Irregular breathing pattern characterized by alternating deep and shallow respirations followed by periods of apnea (10-20 seconds); associated with certain neurologic conditions (eg, stroke, increased intracranial pressure) and END OF LIFE!

Phlebostatic Axis

Level of Atria at 4th ICS, 1/2 Anterior-Posterior (AP) diameter when client is in SUPINE position. ^To measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the transducer system must be placed at the phlebostatic axis.

Coarse Crackles

Loud, low-pitched bubbling heard during inspiration and are not cleared by coughing; EXPECTED in Pulmonary Edema, Pulmonary Fibrosis, Left Ventricle Heart Failure, Chronic HEART FAILUR *Anticipate FUROSEMIDE IV PUSH; diuretics used to increase fluid excretion by the kidneys

BUCK'S SKIN TRACTION

Maintains proper alignment of an injured body part by using weights to apply a continuous pulling force. -PLACE supine (FLAT) with FOOT OF BED RAISED or in semi-Fowler's position (maximum of 20-30 degrees) & Limb in NEUTRAL POSITION -Regularly assess the neurovascular status and skin integrity of the limb in traction -Loosen/Tighten Velcro straps of boot as needed & reassess neurovascular status in 30 minutes -Provide a fracture pan -Weights should be free-hanging at all times and should never be placed onto the bed or touch the floor *A staff member should support the weight while the client is repositioned up in bed to prevent excessive pull on the extremity -Ensure adequate DO NOT elevate the head of the bed past 30 degrees; SLIDING DO NOT perform side-to-side position change with WEDGE pillow *DO NOT EVER REMOVE WEIGHTS! CAN CAUSE DEATH!*

NON-REBREATHER MASK

Mask that can deliver 60%-95% oxygen concentrations and is usually used short term. ***HAS A BIG BAG ATTACHED (RESERVOIR BAG; keep OXYGEN FLOW HIGH ENOUGH to keep bag at least 2/3 inflated during inhalation) Used often for: SHORT TERM = asthma, pneumonia, trauma, and severe sepsis. ***CAN BLUNT drive to breathe in patients with COPD d/t over-oxygenation

Vastus Lateralis (ANTEROLATERAL MIDDLE PORTION OF THIGH)

Most recommended IM injection site for infants and newborns ***(eg. HEP B Vaccine & VITAMIN K) For Infants: Use a 1-INCH (25-mm) needle to administer medication in the muscle to reach the IM tissue and minimize local reactions.

Jehovah's Witness

NO BLOOD PRODUCTS or BLOOD TRANSFUSIONS in ANY Form (Plasma, RBCs, Whole Blood, Platelet Transfusions, WBCs)

Electroencephalogram (EEG)

NON-INVASIVE Diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the brain; commonly done post seizure. TEACHING: -Wash hairs to remove oils and hair care products & Wash hair post-procedure -Remove accessories such as ribbons or barrettes -Avoid caffeine (coffee, cocoa), stimulants, and central nervous system depressants prior to the test

What is the ONLY Fluid that can be given with a BLOOD TRANSFUSION/BLOOD INFUSION

NORMAL SALINE (NS) DO NOT INFUSE DEXTROSE SOLUTIONS. *****DISCONTINUE DEXTROSE INFUSION, FLUSH LINE WITH NS PRIOR TO ADMINISTERING BLOOD!!!!!!!!!

MYOPIA

Nearsightedness; reduced visual acuity when viewing objects at a distance -SQUINTS -MUST GET CLOSE TO SEE (eg. books, television)

Requirement for AIRWAY SUCTIONING (tracheostomies, endotracheal tubes, aspiration risk, acute respiratory distress)

PERFORM FOR: -Decreased oxygen saturation -Altered mental status (eg, irritability, lethargy) -Increased heart rate -Increased respiratory rate -Increased work of breathing (eg, flared nostrils, use of accessory muscles) -Adventitious breath sounds (eg, crackles, wheezes, rhonchi) -Pallor, mottled, or cyanotic skin coloring Intervention: PSOA -Position (eg. high Fowler's Position for ARDS, Semi-Fowler for artificial airway suctioning) *-Pre-Oxygenate for Tracheostomy Suctioning* -Perform oropharyngeal suctioning -Administer 100% oxygen by nonrebreather masks -Assess lung sounds -Notify the primary health care provider (HCP)

Hemorrhagic Stroke

Occurs d/t blood vessel ruptures in the brain & bleeding into the brain tissue or subarachnoid space; can lead to increased intracranial pressure (ICP) SYMPTOMS: -ICP -Dysphagia (Aspiration risk!) INTERVENTION: -Remain NPO until a swallow function screen is performed -Perform neurological assessments (eg, level of consciousness, pupillary response) at regular intervals & REPORT! -Reduce stimulation -Administer stool softeners to reduce strain during bowel movements -Reduce Exertion (coughing) -Maintain strict bed rest & assist with ADLs *-Maintain HEAD in MIDLINE position to improve jugular venous return to the heart* -DO NOT ADMINSITER ANTICOAGULANTS (eg. Enoxaparin) = INCREASED RISK OF BLEEDING

Administering BOLUS Enteral Feedings via Nasogastric Tube (NG Tube)

POSITION: -Elevate the head of the bed to 30-45 degrees (SEMI-FOWLER POSITION) *Keep HOB elevated for 30-60 minutes afterwards -Assess Gastric Residual Volumes (GRVs) every 4 hours or BEFORE EACH BOLUS FEEDING; hold feeding if GRV is too high d/t aspiration risk -Aspirate GRV to assess for Gastric pH (should be ACIDIC; pH < 5) & GRV should be returned to the stomach -Flush before and after feedings [*Enteral (Tube) Feedings:] given during critically ill times; MAINTAINS gut integrity & helps prevent stress ulcers + lower risk of infections compared to TPN!

Administering CLEANSING ENEMA

POSITION: LEFT LATERAL position with the right knee flexed (ie, SIMS position) -Hang the enema bag no more than 12 in (30 cm) above the rectum to avoid overly rapid administration. -Lubricate the enema tubing tip and gently insert 3-4 in (7.6-10 cm) into the rectum. -Direct the tubing tip toward the umbilicus during insertion -WARM UP ENEMA prior to administration -Encourage the client to retain the enema for as long as possible (eg, 5-10 minutes) -Open the roller clamp on the tubing to allow the solution to flow in by gravity. ****If the client reports abdominal cramping, use the roller clamp to slow the rate of administration

DYSPHAGIA/ASPIRATION RISK

Placed on Dysphagia diet: -Modification of food consistency (pureed, soft but NOT TOO THIN) -Thickened liquids -Place client in UPRIGHT position at 90-degree angle -Tilt the neck slightly to assist with laryngeal elevation and closure of the epiglottis

Central Venous Access

Placement: sites in the upper body (internal JUGULAR or SUBCLAVIAN) are preferred to minimize the risk of infection. *Access sites in the inguinal area (femoral) are easily contaminated by urine or feces. Intervention: -Assess daily for signs/symptoms of infection (eg, redness, swelling, drainage) -Duration of CVC placement based on clinical need and judgment that there is no evidence of infection ^Peripherally inserted central catheter (PICC) lines can be left in for weeks or months. The occlusion of one lumen does not necessitate removal of the catheter.

Postictal Phase

Post-active seizure; client may experience confusion/headache/disorientation while recovering from the seizure. headache.

REFEEDING SYNDROME

Potentially fatal complication of nutritional rehabilitation in chronically malnourished clients (eg, anorexia nervosa, chronic alcoholism). ^The LACK of PO intake has resulted in pancreas making less insulin = when feeding is introduced, pancreas INCREASES INSULIN secretions, leading to phosphorous, potassium, and magnesium shifting intracellularly. Symptoms: -Phosphorus deficiency (Hypophosphatemia) (eg. muscle weakness, RESPIRATORY FAILURE) ******Hypokalemia & Magnesium Deficiency (eg. risk of CARDIAC ARRHYTHMIAS) -Thiamine Deficiency Intervention: -Monitor ELECTROYLTE CLOSELY for the first few days of NUTRITIONAL REPLENISHMENT (TPN, Enteral Feeding)

Peak Expiratory Flow Meter

Provides peak expiratory flow rate (PEFR) or the peak velocity of exhaled air during forced exhalation. Green Zone = > 80% of personal best Yellow Zone = 50-79% of personal best; intervention needed (eg. short-acting bronchodilator like Albuterol or treatment modification) Red Zone = <50% of personal best; EMERGENCY!!!

IF CVC (Central Venous Catheter) is DISLODGED?

RISK OF AIR EMBOLISM = LIFE THREATENING COMPLICATION! -Administer oxygen via non-rebreather mask -Apply an occlusive dressing over the insertion site -PLACE IN LEFT LATERAL TRENDELENBURG POSITION (promote venous air pooling in the heart apex) -Continuously monitor vital signs and respiratory effort -Notify the HCP IMMEDIATELY!

TELETHERAPY

Radiation therapy administered by a machine positioned at some distance from the patient. Intervention: -PHOTOSENSITIVITY (protect skin from SUN EXPOSURE) -Wash treatment site with lukewarm water & mild soap -Wear soft, loose-fitting clothing (DO NOT rub, scratch, scrub skin) -Pat skin dry after bathing -AVOID BANDAGES OR TAPE TO THE TREATMENT AREA -ONLY USE creams approved by HCP -AVOID HEATING PADS/ICE PACKS [IF RADIATION IS TO THE HEAD/NECK:] -Avoid irritants such as acidic, spicy foods -Encourage liquid intake -Perform oral hygiene multiple times throughout the day -Use ARTIFICIAL SALIVA to control dryness

BRACHYTHERAPY

Radioactive Implant to the cancerous site or tumor for a short time; usually 24-72 hours. INTERVENTION: -Cluster Care; limit spent time in room to *30 MINUTES MAX A SHIFT* (rotate daily responsibility, wear dosimeter film badge, stand at the entrance of the room to communicate with the client when possible) ^INCLUDING VISITORS -Keep door to the room CLOSED (NO PREGNANT WOMEN OR CHILD UNDER 18 ALLOWED IN) *-STRICT BEDREST* -MAINTAIN AT LEAST 6 FEET FROM CLIENT (Private Room/Private Bath, Put up "RADIATION" sign) -SHIELD WITH LEAD APRON during care -Low-Fiber Diet may be initiated to prevent frequent bowel movements

Kussmaul breathing

Rapid, deep respirations; associated with METABOLIC ACIDOSIS (eg, renal failure, diabetic ketoacidosis, shock). Is a compensatory action by the lungs to excrete excess acid from the body by hyperventilating, thereby blowing off carbon dioxide

Dialysis Disequilibrium Syndrome (DDS)

Rare but potentially life-threatening complication that can occur in clients during the initial stages of hemodialysis (HD) d/t creating a concentration gradient that can lead to excess fluid in the brain cells and increased intracranial pressure. SLOW DOWN THE RATE OF DIALYSIS! ASSESS FOR: -Nausea/Vomiting -CHANGE IN MENTATION -Seizure RISK -Restless -Disorientation -Headache *CONTACT HCP IMMEDIATELY

INCENTIVE SPIROMETRY

Recommended in postoperative clients to prevent atelectasis associated with incisional pain, especially in upper abdominal incisions (close to the diaphragm) INTERVNETION: -Provide ADEQUATE PAIN RELIEF PRIOR -Assume a sitting or high Fowler position, which optimizes lung expansion, and exhale normally -While holding the device at an even level, seal the lips tightly on the mouthpiece to prevent leakage of air around it -Inhale deeply through the mouth until the piston is elevated to the predetermined level of tidal volume. The piston is visible on the device and helps provide motivation. -Hold the breath for at least 2-3 seconds (up to 6 seconds) as this maintains maximal inhalation -Exhale slowly to prevent hyperventilation -Breathe normally for several breaths before repeating the process -Cough at the end of the session to help with secretion expectoration -RECOMMEND 5-10 BREATHS PER SESSION EVERY HOUR WHILE AWAKE

TRANSFUSION REACTION to Blood Transfusion

Remain with the client for 15 minutes after starting a blood transfusion to monitor for signs of a reactions ^Symptoms: fever, chills, nausea, vomiting, pruritus, HYPOTENSION, decreased urine output, back pain, and dyspnea. INTERVENTION: -Stop the transfusion immediately! -Using NEW tubing, infuse normal saline *DO NOT FLUSH OLD LINE; introduction to more causative agent (blood!) -Continue to monitor hemodynamic status & ASSESS BREATH SOUNDS -Notify the health care provider and blood bank. -Administer any emergency or prescribed medications to treat the reaction; these may include vasopressors, antihistamines, steroids, or IV fluids. -Collect a urine specimen to be assessed for a hemolytic reaction. -Document the occurrence and send the remaining blood and tubing set back to the blood bank for analysis.

EXTUBATION

Removal of a previously inserted tube (eg. Endotracheal Tube) RISK OF ASPIRATION & AIRWAY OBSTRUCTION BEFORE REMOVAL: *-SUCTION THE ET TUBE!* THEN cuff is deflated & tube is removed d/t risk of secretion leading to ASPIRATION! INTERVENTION: *-NPO (NO ORAL MEDS or WATER or ICE CHIPS)* -Place in HIGH FOWLER POSITION -Administer warm, humidified oxygen via Face Mask -Provide oral care with oral sponges -ENCOURAGE INCENTIVE SPIROMETER USAGE & Cough/Deep Breathe

Modified Radical Mastectomy

Removal of axillary lymph nodes that are involved in lymphatic drainage of the arm. -DO NOT start an IV line in the arm that was operated on; RISK of Lymphedema -Place a SIGN above the client's bed notifying hospital staff of MASTECTOMY PRECAUTIONS -Insert IV line in the most DISTAL site of the UNAFFECTED SIDE

Peritoneal Dialysis

Removes excess waste products from blood when kidneys can no longer function adequately; via the abdominal lining (ie, peritoneum) as a semipermeable membrane to dialyze a client with insufficient renal function ***DURING instillation & dwell portions: monitored closely for indications of respiratory distress (eg, difficulty breathing, rapid respirations, crackles) POST Dwell time: catheter is unclamped and the fluid drains out via gravity. INTERVENTION: -Assess the client's fluid status (weight, blood pressure, peripheral edema, lung and heart sounds) -Assess vascular access (arteriovenous fistula, arteriovenous grafts) -Assess vital signs -Check client's medical records to determine the last post-dialysis weight -Obtain vital signs & current weight -Palpate the fistula in the arm for a THRILL and Auscultate for a BRUIT -WARM dialyzing fluid prior to instilling: helps DILATE peritoneal blood vessels -IV Heparin is added to the blood after client is connected to dialysis machine BEFORE dialyzing fluid is instilled -DO NOT GIVE PO MEDS BEFORE DIALYSIS ***REPORT CLOUDY OUTFLOW, LOW-GRADE FEVER, TACHYCARDIA = signs of PERITONITIS (infection of the peritoneal cavity)*

Position after MASTECTOMY

SEMI-FOWLER'S POSITION with affected side's arm and hand elevated to promote drainage and prevent venous and lymphatic pooling & promote ease of breathing. *NOT high-Fowler's as anesthesia from operation could result in HYPOTENSION and dizziness.

What are SR or XL Tablets?

SR = SUSTAINED RELEASE XL = EXTENDED RELEASE DO NOT CUT OR CRUSH UP OR GIVE VIA NG TUBE!!!!!!!!

Urinary Incontinence/Overflow Incontinence

SYMPTOMS: -Incomplete bladder emptying & urinary retention -Overdistension and overfilling of the bladder -Frequent involuntary dribbling of urine INTERVENTION: -Implement a fixed voiding schedule -USE VALSALVA maneuver (ie, "bearing down") & CREDE maneuver (ie, gently applying pressure to the lower abdomen) to help facilitate bladder emptying -Assess the perineal area for skin breakdown -Measure postvoid residual volumes -Instruct the client to wait 20-30 seconds after voiding and then attempt to void a second time (ie, DOUBLE VOIDING)

Urinary Tract infections (UTIs)/CYSTITIS

SYMPTOMS: -urinary frequency/urgency, dysuria, foul-smelling urine, and a sensation of bladder fullness INTERVENTION: -Take all antibiotics as prescribed -Increase fluid intake -Wipe from front to back -AVOID synthetic fabrics (eg, nylon, spandex) -Void after sexual intercourse -AVOID DOUCHING & using feminine perineal products (eg, deodorants, powders, sprays) -AVOID spermicidal contraceptive jelly & DIAPHRAGM use temporarily (until symptoms subside) ***REPORT MENTAL CHANGES ***If cystitis goes unreported or untreated, the infection may ascend to the kidneys and cause pyelonephritis ***********PRIORITY assessment = rule out indicators of PYELONEPHRITIS (type of UTI = one or both KIDNEYS become INFECTED) (eg, FLANK PAIN, NAUSEA/VOMITING)

Glass Ampule

Single-dose medication container with a scored area on the neck that must be broken to withdraw the medication -Flick the upper stem of the ampule with a fingernail several times to ensure removal of medication from the ampule neck -Using sterile gauze to break the ampule neck AWAY from the nurse's body to prevent injury from glass shards -Set the ampule on a flat surface or inverting it to withdraw the medication via FILTER NEEDLE **do NOT inject air into the ampule -Ensure filter needle does not touch the outer rim -Dispose ampule in a sharps container

Halo External Fixation Device

Stabilizes a cervical or high thoracic fracture when there is insignificant damage to the ligaments or spinal cord. Intervention: -Monitor sensory and muscle function -Clean pin sites with sterile solution (eg, chlorhexidine, water) -Keep the vest liner clean and dry (eg, changing weekly or when soiled, using a cool blow-dryer to dry) to protect the skin -Place foam inserts under pressure points to prevent pressure injury -Place a small pillow under the client's head when supine to reduce pressure on the device -Keeping the correct-sized wrench available at all times in case of emergency DO NOT MANIPULATE PINS OR GRAB THE DEVICE FRAME!!!

Tracheostomy

Surgical procedure to create opening through the trachea to provide an airway (aka TRACHEAL INTUBATION) ************Interventions: -CHECK the tightness of ties and ADJUST IF NECESSARY; ALLOW 1 FINGER TO FIT -CARRY TWO TRACHEOSTOMY TUBES; ONE OF THE SAME SIZE AND ONE A SIZE SMALLER -IF EXPERIENCING RESPIRATORY DISTRESS = 1. DEEP-SUCTIONING (risk of injury! only done during respiratory distress!) 2. IF ALL FAILS = change the tracheostomy tube at once; high-risk procedure -IF TRACHEOSTOMY TUBE IS FOUND DISLODGED = INSERT A NEW TRACHEOSTOMY TUBE USING BEDSIDE OBTURATOR! -If able to tolerate oral intake: PARTIALLY OR FULLY DEFLATE THE CUFF & position UPRIGHT BEFORE FEEDING -KEEP tracheal cuff INFLATED for the first 24 hours post-surgery; avoid ANY manipulation of the tracheostomy including cuff deflation to minimize bleeding & DO NOT change inner cannula within the first 24 hours UNLESS tube is found dislodged *RISK OF PNEUMOTHORAX: assess for HYPOTENSION and HYPOXIA - AUSCULTATE LUNG SOUNDS BILATERALLY!

INFILTRATION SYMPTOMS vs EXTRAVASTION SYMPTOMS

Swelling, pallor, COLDNESS, or pain around the infusion site; significant decrease in the flow rate! VS BURNING STINGING PAIN, redness, blistering, tissue necrosis/ulceration around the infusion site

Position for Air Embolism

TRENDELENBURG (head down) on LEFT SIDE (traps air in the right atrium) *Notify physician & stay with client

Oropharyngeal Airway (OPA)

Temporary, artificial airway device; prevents tracheal obstruction in clients who are sedated or unconscious. -Measure OPA size prior to insertion; measured with the flange next to the client's cheek. WILL REACH JAW ANGLE -Ensure that the device is easily removable from the client's mouth *DO NOT TAPE!!!!!!! -Insert with the DISTAL END pointing upward toward the roof of the mouth (curved end pointing upward) -ROTATE the tip downward toward the esophagus once the OPA reaches the soft palate (eg, back of the mouth)

Indwelling Catheter (FOLEY catheter)

Thin, sterile tube inserted into the bladder to drain urine ***************Recommended that the catheter be inserted 7-9 in (17-22.5 cm) or until urine flows out THEN be inserted at least an additional 1 in (2.5 cm) or to catheter bifurcation. ^ENSURE THAT THE TIP IS IN THE BLADDER and NOT THE URETHRA; in Females, insertion into the vagina HAPPENS. -Perform hand hygiene -Apply sterile gloves -Use NON-DOMINANT hand to spread the labia or hold up the penis -Cleanse with antiseptic swab -Advise patient to take slow, deep breaths to help relax the external sphincter -Insert catheter until the urine is visualized -Secure the catheter to the leg occurs after the balloon is inflated and placement is assured. -Cleanse area around the meatus TWICE a day -Empty drainage bags every 8 HOURS -Maintain fluid intake at 2000-2500mL range *****HYPOTENSION & HEMATURIA RISK post-obstructive diuresis = RAPID DECOMPRESSION

How is Total Parenteral Nutrient (TPN) given?

Through Central Venous Catheter (CVC); d/t its viscosity and high glucose, lipids, electrolytes, vitamins and minerals, it is safest when administered through a CVC or peripherally inserted central catheter.

How is Enteral Nutrient given through?

Through GI TRACT (PO or through a feeding tube; commonly NASOGASTRIC TUBE)

CHEST TUBE

Tube placed into the intrapleural space to act as a drain. Insertion & re-insertion of the tube is a MEDICAL procedure; which requires a physician. **If pulled out accidentally - apply a STERILE OCCLUSIVE/petrolatum dressing over the site TAPED ON 3 SIDES; prevent further air leaks or in a emergency: PLACE A CLEAN GLOVED HAND TO OCCLUDE; PREVENT AIR EMBOLISM. ***DO NOT CLAMP DURING TRANSPORT! Left To Right: 1. Suction Regulation 2. Air Leak Gauge 3. Water Seal Chamber 4. Collection Chamber 1. SUCTION CONTROL CHAMBER: Maintains negative pressure in the system. GENTLE CONTINUOUS BUBBLING will occur when suction is applied & DOCUMENT gentle bubbling = chest tube functioning properly 2 & 3 WATER SEAL CHAMBER: Composed of a AIR LEAK GAUGE + WATER-SEAL CHAMBER. ^CONSTANT BUBBLING in air leak gauge = AIR LEAK IN THE SYSTEM Filled with sterile water and acts as a one-way valve preventing air from entering the client's chest cavity (PLEURAL SPACE) upon INSPIRATION *Risk of Tension Pneumothorax! ^TIDALING = rising and falling of water in water seal chamber that rises and falls with inspiration and expiration (indicates proper functioning and maintains appropriate negative pressure). 4. COLLECTION CHAMBER: Collection of fluid from the client's pleural cavity will be collected. *NOTIFY physician if the output is above 200 mL!

Endotracheal tube (ET tube)

Tube placed via endotracheal intubation into the trachea & connected to a ventilator (pushes air into the lungs and allows it to come back out) to deliver O2 to the lungs. Intervention: -Endotracheal tube cuff pressure should NEVER exceed 20 mmHg; risk for tracheal erosion -Cuff pressure should NEVER be under 10 mmHg; risk for ASPIRATION ***Assess for: MAINSTEM BRONCHUS INTUBATION (symptoms similar to pneumothorax, pneumonia = absence of/decreased breath sounds); wrong entry of tube d/t insertion of the tube too far; can occur in EITHER LEFT OR RIGHT!

RECTAL SUPPOSITORY IN CHILDREN/INFANTS/NEWBORNS

UNDER 3 YEARS OLD: -Position SUPINE with KNEES AND FEET RAISED -Lubricate the tip of suppository with water-soluble jelly -Guide Suppository against rectal wall (to remain in contact with rectal mucosa; not buried inside stool) -Gloved Fifth Finger for insertion PAST the external AND internal sphincters -Hold buttocks firmly after insertion OVER 3 YEARS OLD: -Position on SIDE with KNEES FLEXED -Lubricate the tip of suppository with water-soluble jelly -Guide Suppository against rectal wall (to remain in contact with rectal mucosa; not buried inside stool) -Gloved INDEX FINGER for insertion PAST the external AND internal sphincters -Hold buttocks firmly after insertion

Open endotracheal (ET) SUCTIONING

Used to clear secretions and maintain airway patency; ***DONE ONLY WHEN CLINICALLY INDICATED (eg. adventitious breath sounds, coughing) -Perform hand hygiene and don STERILE GLOVES & STERILE TECHNIQUES ***-SUCTION the oropharynx and perform ORAL CARE before SUCTIONING the tracheostomy OR EVEN BEFORE OXYGENATING*** -Preoxygenate with 100% oxygen & REOXYGENATE between suctions passes AND after suction -Advance catheter into the trachea until resistance is met & retract 1 cm before applying suction; DO NOT suction while advancing (inserted WITHOUT suction) -Apply suction ONLY while withdrawing the catheter -Suction at MEDIUM PRESSURE (100-120 mmHg for adults, 50-75 mmHg for children) -Expect coughing; helps loosen secretions -Use sterile technique; sterile glove if client does NOT have a closed suction system ***Wait AT LEAST 1 minute between suction passes to VENTILATE & encourage deep breathing & coughing ***Limit each suction pass to ≤10 seconds. -Small crepitus is expected; but report EXPANSION of the area of crepitus . *If feeding is found in the TRACHEA during suctioning = ASPIRATION has occurred

Boston Brace/Wilmington Brace/Milwaukee brace/Thoracolumbosacral Orthosis (TLSO) Brace

Used to diminish the progression of deformed spinal curves in scoliosis DOES NOT cure the existing spinal deformities but do prevent further worsening, INTERVENTION: -Wear a cotton t-shirt under the brace ALWAYS; prevent skin breakdown -Assess Psychosocial issues (eg, body image, sense of control, socialization) -Perform spinal strengthening exercises -DO NOT USE LOTION OR POWDER UNDER BRACE -Worn for 18-23 hours per day; REMOVED for bathing/showering and exercise

SLINGS

Used to support the shoulder after a fracture, dislocation, injury, or surgery. -Elbow is flexed at 90 degrees -Hand is held SLIGHTLY ABOVE the level of the elbow -Bottom of the sling ends in the middle of the palm with the fingers visible, to be able to assess circulation -Sling supports the wrist -Assess for Skin IRRITATION

Tension Pneumothorax

a pneumothorax with rapid accumulation of air in the pleural space causing severe high intrapleural pressures with resultant tension on the heart and great vessels. ***Risk for patients with rib fractures and a chest tube. SYMPTOMS: -Diminished breath sounds on the affected side -Rapidly deteriorating ABGs in the presence of an open airway -SHOCK! ***Mediastinal Shift (deviation of the mediastinal structures towards one side of the chest cavity) occurs primarily d/t TENSION PNEUMOTHORAX, results in tracheal deviation and deviation of the heart's point of maximum impulse. ^Mediastinal Tissue and Organ shifting are UNIQUE to Tension Pneumothorax!

Pleural Effusion

abnormal accumulation of fluid in the pleural space (between they layers of the pleura outside the lungs); causes compression of the lungs & diminished/absent breath sounds if auscultated over the area. Require DIURETICS or THORACENTESIS

HYPOTONIC IV solution

i.e - 0.45% sodium chloride (½ NS) Solution with lower osmolarity; creates a concentration gradient and shift fluid OUT OF the intravascular compartment INTO the interstitial tissue and cells (Causes CELLS TO EXPAND) CONTRAINDICATED FOR: Gastroenteritis

ISOTONIC IV solutions

i.e - 0.9% Sodium Chloride (Normal Saline), Lactated Ringer's Solutions that have the same osmolality as plasma and are administered to expand intravascular fluid volume. These solutions replace fluid losses commonly associated with vomiting and diarrhea, burns, low urine output, tachycardia d/t hypovolemia, and traumatic injury. GIVEN FOR: *-Acute Gastroenteritis* -Fluid Resuscitation -Dehydration -Vomiting -Hypovolemic Shock CONTRAINDICATED FOR: -Fluid Overload *-Renal Failure (d/t Risk of Exacerbating Fluid Overload)* -Hypertensive Crisis

HYPERTONIC IV solutions

i.e - 3%, 5% Sodium Chloride, ANY DEXTROSE SOLUTION Solution with higher osmolarity; creates a concentration gradient and shift fluid INTO the intravascular compartment and OUT of interstitial tissue and cells (Causes CELLS TO SHRINK) ***can sometimes cause NAUSEA, VOMITING, and DIARRHEA; slow down rate of administration if this occurs; can be gradually progressed to established goal rate GIVEN FOR: *-Cerebral Edema/Increased Intracranial Pressure (reduces pressure via pulling fluid out of cells and decreasing ICP)* -Hyponatremia (pulls sodium back into the intravascular system along with fluid)

Thoracentesis

insertion of a large-bore needle through an intercostal (pleural) space to remove excess fluid; done for 1. Diagnostic - analysis of fluid to diagnose the underlying cause of the pleural effusion (eg, infection, malignancy, heart failure), including cytology, bacterial culture, and related testing 2. Therapeutic - removal of excess fluid (>1 L) improves dyspnea and client comfort Complications: -Pneumothorax (Decreased chest expansion with inspiration and breath sounds on the affected side, tachypnea, tracheal deviation to the opposite side, and hyperresonance (air) on the affected side)**** -Hemothorax -Pulmonary Edema -Infection Post-Procedure: -Assess level of alertness, Lung Sounds, O2 Sat, Respiratory Pattern, Pain, Vital Signs -Observes for changes in respiratory rate and depth, symmetry of chest expansion, and breath sounds