LVN Fundamentals 3 ATI

Heat exhaustion

The most common type of heat injury, this results from prolonged perspiration and the loss of large quantities of salt and water. Observe for signs and symptoms of headache, vertigo, nausea, weakness, and diaphoresis. Mental disorientation and brief loss of consciousness may occur. Nursing interventions: *Cool the victim as quickly as possible; use cold, wet compresses and fan or air conditioner. (if patient starts to shiver, remove cold packs and fan)* Have victim lie down with feet elevated. If alert, give one-half glass of water every 15 minutes for 1 hour. In the clinical setting, IV fluids are given

Heat Stroke

This is a more serious heat injury; death can result. The most common cause is vigorous physical activity in a hot, humid environment. The body becomes overheated, but the cooling mechanism of perspiration does not operate. Assessment: rapidly rising body temperature; hot, dry, erythemic skin; no visible perspiration; pulse rapid initially and then slow and blood pressure falls; breathing deep and rapid; victim complains of headache, dry mouth, nausea, and vomiting Nursing interventions: Cool the victim as quickly as possible; use cold packs around the victim's neck, under the arms, and around the ankles to cool the blood in the main arteries. Establish and maintain an airway. Monitor for chilling as the body temperature falls.

Collecting a Sterile Urine Specimen

Two methods 1) Insert a straight catheter into the urinary bladder and remove urine. 2) Obtain a specimen from the port of an indwelling catheter using sterile technique. Clamp just below catheter port for 30 minutes Insert needle into port at a 30 degree angle and withdraw 5 to 10 mL of urine. Place urine in specimen cup Client will have temporary urinary retention after the removal of an indwelling urinary catheter.

Collecting a Midstream Urine Specimen:

Urine is collected after voiding is initiated (midstream) and before voiding is completed. This is the cleanest part of the voided specimen.

Collecting a urine specimen

Urine specimen is collected for urinalysis Urine specimen is sometimes ordered for culture (to identify the microorganism) and sensitivity (to identify which antibiotic will kill the organism), to diagnose and treat urinary tract infections.

Ear Irrigations

Using a small syringe and solution at body temperature (98.6 F), the nurse can cleanse a patient's external auditory canal of excess cerumen or exudate from a lesion or an inflamed area. The use of solution at body temperature prevents discomfort and vertigo Never occlude the auditory canal with the syringe tip because introducing fluid under pressure risks rupturing the tympanic membrane. Slow, gentle irrigation works best. In infants, pull pinna down and back. For adults, pull pinna up and back. Irrigation is contraindicated when a vegetable foreign body obstructs the auditory. These foreign objects attract and absorb moisture and will swell, causing intense pain and complicating removal of the object.

Heat Application

Vasodilation causes lumen (hollow channel within a tube) of blood vessels to dilate, increasing blood flow to that area of the body. However , if heat applications are applied to an area of the body for more than 1 hour, vessels begin to constrict as the body attempts to control heat loss from the area. Heat application for more than 1 hour sometime cause damage to ephithelial cells, erythema, tenderness and blistering

General Guidelines for Diagnostic Examination

know pt's baseline vital signs. know pt's level of education. determine the patient's awareness of actual or potential medical diagnosis. perform a thorough nursing assessment, including assessment of the patient's cultural background. determine the pt's previous experience with diagnostic testing. Most agencies adhere to standard precautions. Know normal values of the test being performed and causes of deviations from these normal values. Refer to the policy manual for institution's instructions for collection of each specimen during diagnostic examinations. Explain importance of diet restriction. Example: meat free diet before stool specimen. Assess for allergies, especially iodine Many factors have the potential to contribute to dysrhythmias in association with diagnostic exams, including medications such as digitalis and quinidine, hypertrophy of cardiac muscle, alcohol, thyroid dysfunction, coffee, tea, tobacco, electrolyte imbalances, edema, acid-base imbalances, and myocardial ischema.

Discharge against medical advice (AMA)

patient leaves a health care facility without a physician's order for discharge. Notify the physician immediately. the physician will talk to the pt about signing this document. Make sure patient understands that he is leaving against medical advice. Do not detain the patient, this violates his or her legal rights. - false imprisonment

Explain Cognitive domain

style of processing information by listening or reading facts and descriptions

Explain Affective domain

style of processing information that appeals to the person's feelings, beliefs or values.

Explain Psychomotor domain

style of processing information that focuses on learning by doing.

What do you need when admitting a patient?

the admitting department might need information such as the age, name, birth date, social security, etc. but most important the reason for admission. they also provide the wrist band which includes: Patient's name, Age, Admitting number, Physician's name, Room number. Telephone admission consists of: call day before, they give instructions of time, items to bring and not to bring. Emergency Department: People would be admitted directly to a pt care room or special care unit(SCU), intensive care (CCU), Coronary Care unit (CCU), or burn unit. The fam provides necessary info. Greeting the patient by name and making the patient feel welcome is one of the most important aspects of the admission procedure. * The hospital routine should be explained: * When meals are served. When family and friends may visit, etc. Admitting Procedure on the Patient Care Unit: (patient who does not maintain eye contact can indicates signs of stress)Create a plan when planning to provide formal teaching Determine client's level of fluency in their primary language and assess their cultural differences When caring for an older client with ineffective health maintenance regime, begin teaching session with a reference to the client's experience Jewelry, money, and medications should be given to the family to take home. If no family is present valuables must be put in the hospital safe. Follow the hospital policy. Admission assessment must be prepared by a registered nurse (RN).

If Epistaxis is a nosebleed, so what is Epistaxis digitorum ?

trauma from nasal picking. With your thumb and forefinger, apply steady pressure to both nostrils for 10 to 15 minutes.

What is a fracture and what are the types?

A break in the continuity of a bone Types of common fractures: Open or compound fracture- an open wound exists over the fracture site. often affected bone is visible as it protrudes through the skin Closed fracture- the skin overlying he injury is intact. Comminuted fracture- the bone is shattered into two or more fragments or pieces Greenstick fracture- an incomplete break, occurring most commonly in children because of their bones are pliable Spiral fracture- fracture resulting from a twisting force Impacted fracture- fracture suiting from trauma that causes the bone ends to jam together Compressed fracture- fracture to the vertebrae as the result of pressure Depression fracture- results from blunt trauma to a flat bone, causing an indentation in the bone.

Drainage systems

A mechanism is needed to assist gravity in removing exudates from the cavity. Closed drainage: System of tubing and other apparatus attached to the body to remove fluid in airtight circuit that prevents environmental contaminants from entering the wound or cavity. Jackson -Pratt and Hemovac -use a bulb to provide the needed vacuum Open drainage: Drainage that passes through an open-ended tube into a receptacle or out onto the dressing. Penrose drain Suction drainage: Use of a pump or other mechanical device to help extract a fluid Care of the patient with a T-tube drainage system. After surgical removal of the gallbladder, the bile duct is often inflamed and edematous.A drainage tube is frequently inserted into the duct to maintain a free flow of bile.

Sleep and Rest

A patient at rest feels mentally relaxed, free from worry, and physically calm, free from physical or mental exertion Older adults often take medications such as diuretics and theophylline (bronchodilator) that are likely to disturb sleep. Assess time of administration and effect on sleep and modify when possible.

What is a poison? and what would you do first when encountered in a scenario with a pt that has poison?

A poison is any substance (solid, liquid, or gas) that even in small amounts cause damage to the body. Immediately call Poison control center (even if in the emergency room)

Bandages and Binders

A strip or roll of cloth or other material that may be wrapped around a part of the body in a variety of ways for multiple purposes. A binder is a bandage that is made of large pieces of material to fit a specific body part, such as an abdominal binder or a breast binder.

Aquathermia

Aquathermia (Water-Flow) Pads This is used to treat muscle sprains and areas of mild inflammation or edema. The pad is waterproof and works by circulating distilled water through the internal channels of the pad via hoses connected to an electrical unit. Place a thin towel or pillowcase next to the patient's skin so that the pad is not in direct contact with the patient. Applications typically lasts for 20 to 30 minutes.

How can Shock be Assessed?

Assessment (circulatory shock) (hypovolemic shock) Level of consciousness - can become lethargic Skin changes - cool, clammy, pale and ashen Blood pressure - decrease in BP Pulse - tachycardic, weak and thready Respirations - tachypneic, labored, shallow Urinary output - oliguria (decreased) Neuromuscular changes - eyelids close, pupils dilate Gastrointestinal effects - will complain of thirst

What are the assessments and interventions for a fracture?

Assessment: Radiography can determine if a bone is fractured. There is pain and tenderness in the area and pain during movement. Deformity of the limb may be obvious, with edema and discoloration of the area. Fragments of bone may be protruding through the skin. Crepitus: grating sound is heard when the affected part is moved. Nursing interventions: Do not move unless he or she is in danger. ABCs of first aid take priority. Control bleeding if present. Immobilize the fracture but do not attempt to realign the bone. "Splint the part where it lies" Monitor circulation in the limb by assessing color, temperature and pulses below the injury. Apply ice or cold packs to the area. Apply compression bandage Elevate the area

Thoracentesis

Assisst pt to assume the appropriate position (usually sitting) Offer emotional support. No fasting or sedation is necessary. Inform pt to keep movement or coughing to minimum. Administer cough suppressant is pt has torublesome cough. An x-ray film or ultrasound scan is often used to assist in location of the fluid. Flouroscopy may also be used. local ansthetics can reduce pain although there still can be pain felt. monitor vitals. monitor pt for coughing or for hemoptysis. place small dressing over needle site. turn pt on unaffected site for an hour to allow sealing. send specimen promptly. obtain xray to check for pneumothorax. check for subcutanous emphysema or infection. Assess for lung signs is they are diminished.

What are the types of bleeding?

Capillary Most common; results from damaged or broken capillaries and causes oozing of minor cuts, scratches, and abrasions Venous Occurs when the vein is severed or punctured Results in a slow, even flow of dark red blood Embolism may occur if air enters the severed vein. Arterial Least common; usually protected by bones, fat, and other structures Heavy spurting of bright red blood in the rhythm of the heartbeat

Basic Bandage Turns

Circular - used to cover small body regions such as a digit or wrist and are used to anchor bandaging materials Spiral - used to cover cylindric body parts where contour does not vary significantly in size (slender wrist and foreram Spiral-reverse - used to cover inverted cone-shaped body parts such as calf and hip Figure of 8 - used to cover joints and provide immobilization. Recurrent - provides cap-like coverage for scalp or amputation stump

Events necessitating CPR

Clinical Death- The heartbeat and respirations have ceased. Biological Death- This results from permanent cellular damage caused by lack of oxygen.The brain is the first organ to suffer from lack of oxygen.In many cases, CPR can reverse clinical death if initiated before 4 minutes of cardiopulmonary arrest.After 10 minutes without CPR, brain death is certain. Brain Death- This is an irreversible form of unconsciousness characterized by a complete loss of brain function while the heart continues to beat.The usual clinical criteria for brain death include the absence of reflex activity, movements, and respiration; pupils that are fixed and dilated; and absent electric activity of the brain on two electroencephalograms (EEGs) performed 12 to 24 hours apart.

Hematoma

Collection of extravasated blood trapped in the tissues or in an organ resulting from incomplete hemostasis after surgery or injury.

Adhesion

Band of scar tissue that binds together two anatomical surfaces normally separated; most commonly found in the abdomen.

what are Burn injuries?

Burns are a leading cause of accidental injuries, especially among children. Initial management of the burn patient begins at the time of injury. Classified according to the depth or the extent of the body surface burned Complications of all burns are shock from loss of fluids and electrolytes, trauma and infection due to the loss of the skin as a barrier. *Calculate the extent of burns using the rule of nines* Adult: 9%- arms & head. 18%- legs, chest, back. 1% perineal Child: 9%-arms. 18%- head,chest, back. 13.5%-legs. 1%-perineal

Guidelines for Specimen Collection

Consider the patient's need and ability to participate in specimen collection procedures Allow patient to collect their own specimen if they are able to, to avoid embarrassment Collect specimens in appropriate containers, at the correct time, and in the appropriate amount. Properly label all specimens with the patient's identification; complete laboratory requisition form as necessary. Most specimens are transported to the laboratory in a separate outer plastic bag. Deliver specimens to the laboratory within the recommended time or ensure that they are stored properly for later transport ***It is your responsibility as a nurse to notify the physician when laboratory and diagnostic studies deviate from the normal and intervention is necessary.

What is the nursing intervention in DIRECT PRESSURE for bleeding/hemorrhage ?

Direct pressure The most effective general treatment of bleeding is to apply direct pressure over the bleeding site. Raising the bleeding part of the body above the level of the heart will decrease the amount of blood flow and increase the body's ability to clot at this site. Bleeding will usually be controlled in 10 to 30 minutes.

Discharge planning

Discharge Planning is the systematic process of planning for patient care after discharge from the hospital. Ideally, discharge planning begins shortly after admission. Transitional Care: Another approach to discharge planning using transition specialists. Transitional specialists begin discharge planning and usually makes a home visit before the patient is discharged. Following discharge to the home, this specialist is available to patient and family.It has proved to be cost-effective and has improved the quality of care. Discharge Summary: Includes patient's learning needs, how well they were met, the patient teaching completed, short- and long-term goals of care, referrals made, and coordinate care plan to be implemented after discharge A patient may require the services of various disciplines within a hospital. physician order might be needed for these referrals.

What is the nursing intervention in INDIRECT PRESSURE for bleeding/hemorrhage ?

Indirect pressure If direct pressure and elevation do not control bleeding, indirect pressure may be applied to any of the pressure points situated along main arteries. Use your fingers or the heel of your hand to compress the artery against the underlying bone located between the heart and the wound. The most common pressure points are over the carotid, subclavian, brachial and femoral arteries

Cellulitis

Infection of the skin characterized by heat, pain, erythema, and edema

Eye Irrigation

Irrigations - a gentle washing of an area with a stream of solution delivered through a syringe Irrigation should always be done from the inner canthus to the outer canthus to lessen the chances of contaminants being absorbed through the nasolacrimal ducts When caustic chemical enter the eye, gently flush the eye for at least 15 minutes with tap water to prevent burning of the cornea. Eye compress - temperature is no more than 120F or 49C

Promoting Rest and Sleep

Limit interruptions during the night. Perform exercises during the day. Provide a quiet environment with a comfortable room temperature. Limit the number of visitors and duration of visits. Carry out all procedures within a given time frame. Decrease environmental stimuli by dimming the lights and decreasing the noise level. ( tell client not to watch TV until client falls asleep) Wash the patient's back., Gently massage the back., Change the linens., Make certain the patient is warm enough., Offer a caffeine-free beverage such as milk., Change soiled dressings., Have the patient void.

Performing a sterile irrigation

Make sure that the flow of irrigation moves from the area being cleansed to an area that is both distal to and lower than than the wound area.

Changing Dry

Dry Dressings: If a dry dressing adheres to the wound, moisten the dressing with sterile normal saline or sterile water before removing the gauze. Changing a Sterile Dry Dressing:Don clean gloves, remove dressings and discard gloves.Wash hands and don sterile gloves. Cleanse wound, starting from the incision and moving outward (from clean to most contaminated)Dressing tape must be dated and signed.

Liver Biopsy

Explain procedure, obtain written consent. Assess blood coagulation profile; essential that is normal. Keep pt NPO after midnight before examination. assist physician. Send specimens to lab promptly. keep pt on bed rest for 24 hours. keep pt on right side for about 1 to 2 hours. observe for hemorrhage. Apply pressure dressing. Have specimen placed in proper FIXATIVE (any substance used to preserve gross or histologic specimens of tissue for later examination) usually 10% formalin is used. Administer sedative medications as ordered. Moniter vital signs frequently for evidence of hemorrhage and peritonitis. Observe biopsy site. Tell pt to avoid coughing or straining. avoid heavy lifting for 1-2 weeks. evaluate respiration.

Cold Application

Exposure of the skin to cold results in vasoconstriction (the lumen of the blood vessel narrows). The cell's ability to receive adequate blood flow and nutrients results in tissue ischemia (decreased blood supply to a body part or organ often accompanied by pain and organ dysfunction) The skin initially takes on an erythematous appearance, followed by a bluish-purple mottling with numbness and a burning type of pain.

EMS (emergency medical service (EMS)

First Aid is the immediate temporary assistance given to a person who is injured or has become ill. First aid includes assessing the victim for life-threatening conditions, performing appropriate interventions to sustain life and keeping the person in the best possible physical and mental condition until the assistance of emergency medical service (EMS) (a national network of services that provide coordinated aid and medical assistance from primary response to definitive care) is obtained. First aid does not replace medical care but is used to preserve life until medical help is obtained.

How is Adult 2- rescuer CPR handled?

First Rescuer- Determine unresponsiveness. Position the victim. Open the airway. Assess for breathing. If breathing is absent, say "No breathing" and give 2 ventilations. Assess for pulse; if pulse is absent, say "No pulse." Second Rescuer- at the Same Time, Does the Following Finds the location for external cardiac compressions. Assumes proper hand position. Begins external cardiac compressions after the "No pulse" statement is made by the first rescuerSwitching Procedures Switching the positions of the ventilator and the compressor prevents fatigue of both rescuers and allows time for the ventilator to evaluate the effectiveness of CPR. After giving a breath, the ventilator moves to the chest and gets into position to give compressions. The compressor moves to the head and checks the pulse. If no pulse, state, "Resume CPR." Normally, a pulse can be palpable for each compression (2nd rescuer to check effectiveness or CPR)

Irrigation

Gentle washing of an area with a stream of solution delivered through an irrigating syringe. Cleanse in a direction from the least contaminated area to the most contaminated. A handheld shower for wound cleansing, holding the shower spray approximately 12 inches from the wound. Promote wound healing through removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar. Cleanse in a direction from the least contaminated area to the most contaminated area To prevent fluid being retained in the wound, position patient on the side to encourage the irrigant to flow away from the wound

Good Samaritan Laws

Good Samaritan Laws (is a legal stipulation for protection of those who give first aid in an emergency situation) If you follow a reasonable and prudent course of action, the chances of legal problems are small. Victim must give verbal permission. The law assumes that an unconscious person would give consent if he or she were able. Once first aid is initiated, the nurse has the moral and legal obligation to continue the aid until the victim can be cared for by someone with comparable or better training.

Pressure Ulcers

Impaired skin integrity- A patient who stays in one position without relief of pressure can develop a pressure sore. As of Oct 2008, Medicare and Medicaid stopped covering the costs of treating pressure ulcers that developed during hospitalization Pressure ulcers occur when there is sufficient pressure on the skin to cause the blood vessels in an area to collapse. Two mechanical factors play a common role in the development of pressure ulcers. Shearing force: Occurs when the tissue layers of skin slide onto each other, resulting in kinking or stretching of subcutaneous blood vessels; this results in an interruption of blood flow to the skin. Friction: Rubbing of skin against another surface produces friction, which may remove layers of tissue The appearance for pressure ulcers is a major manifestation of impaired skin integrity. Turn patients who are in complete bed rest every 2 hours. Use the 30 degree lateral-incline position. Press the reddened area for blanching.

Triage

In case of multiple injuries, survey patients quickly for severity of injuries to be able to treat life-threatening problems first. This process of classifying a group of patients according to the severity of injury and need of care is called triage. Based on the premise that it is important to treat patients who have a threat of life, vision or limb before other patients. It is a process in which large group of patients is sorted so it is possible to concentrate care and resources on those who are likely to survive. (from the most critical to less critical) Triage - to sort out patients according to who are treatable and untreatable Red - most urgent - life threatening injuries Yellow - second priority - injuries with systemic effects and complication - fractures Green - minor injuries Black - dying or dead - no hope for survival or no treatment Codes: Blue -distress ; Red - fire, Yellow - bomb threat ; Pink - infant abduction, Purple - child abduction ; Orange - hazardous material spill

How is care of incision done?

Incision Coverings: Gauze-Permits air to reach the wound (highly absorbent) Semiocclusive-Permits oxygen but not air impurities to pass Occlusive- Permits neither air nor oxygen to pass. Promotes healing by keeping wound moist Montgomery straps - helps prevent tape irritation of skin when dressings require frequent changing. Remove dressings: An analgesic may need to be given at least 30 minutes before exposing a wound. Sterile technique is followed whenever the wound or dressing is handled.

Obtaining a wound culture

Specimen collected by inserting a sterile swab from the culturette tube into wound secretions, returning the swab to the culturette tube, capping the tube, and crushing the inner ampule so that the medium coats the swab tip. Wipe away pus with a gauze swab prior to culturing the wound.

Collecting a Sputum Specimen:

Sputum is secretions from the lungs. It contains mucus, cellular debris, and microorganisms and may contain blood or pus. It must come from deep in the bronchial tree. Early morning is the best time to collect a specimen, because the patient has not yet cleared the respiratory passages. If patient is not able to expectorate, a nasotracheal or tracheal suctioning can be done to obtain sputum.Apply suction for 5 to 10 seconds collecting 2 to 10 ml of sputum Many tests can be performed on sputum. Culture- Cultivation of microorganisms or cells Sensitivity- Determining the effectiveness of antibiotics Cytology- Study of cells Acid-fast bacillus- Organism responsible for tuberculosis

Stages of Pressure Ulcers

Stage I: intact with nonblanchable erythema of the skin Stage II: partial-thickness skin loss; epidermis, blisters Stage III: full-thickness skin loss, damage or necrosis of subcutaneous tissue Stage IV: full-thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures

Collecting a Stool Specimen

Stool specimens are collected and examined for a variety of reasons. Determine the presence of infection, bleeding, or hemorrhage Observe the amount, color, consistency, and presence of fats Identify parasites, ova, and bacteria Stool to be examined for parasites must be taken to the laboratory immediately in order for the parasites to be examined under the microscope while still alive.

What are strains and sprains and the nursing intervention?

Strains are injuries to muscle tissue from stretching and tearing due to overexertion. Sprains are injuries to joints resulting from stretched or torn ligaments due to twisting of the joint beyond the normal range of motion. Nursing Interventions: RICE Rest the affected extremity Ice should be applied to the part Compression with a compression bandage Elevation above the level of the heart

What are injected poisons?

Minor reactions to insect bites *Remove stinger with a side of a knife or credit card in a scraping motion* Wash the bite with soap and water. Apply cold packs; baking soda paste. Severe reactions to insect bites: Urticaria, wheezing, edema of the lips and tongue, generalized pruritus, and respiratory arrest Nursing interventions: Apply a wide constricting band proximal to the wound; keep affected part in dependent position; transport to the hospital immediately.

What are the factors that affect wound healing?

Nutritional needs. offer 2000 to 2400ml in 24 hours. Rest and activity. If coughing occurs, splint or apply a pillow, a rolled bath blanket or the palms of the hands to the incisional area to lessen intraabdominal pressure

Care of skin

Observe its color, texture, thickness, turgor and temperature Use ample lighting. Natural or halogen lighting is suggested but sunlight is preferred for assessing a patient who has dark skin.

Post-mortem care

Offer the family the opportunity to view the body. Physician is responsible for certifying a death in the medical record. The physician notes the time of death. The physician may request from the family for the autopsy (examination to determine cause of death). Remove, clamp or cut tubes remaining in the body to within1 inch of the skin and tape in place. Never, however, remove tubes, dressings, drains and other equipment on or in the patient when an autopsy is to be performed. Place body in the supine position with arms at the side, palms down or across the abdomen. Prevent discoloration of face ( if blood is allowed to pool) by placing a small pillow or folded towel under the head. Eyelids usually remain closed if gently held down for a few seconds. (ati pg 352-354, 356)

Patient teaching on ear care

Older adults often require ongoing ear care for cerumen removal. Instruct patient to report the following signs and symptoms (which indicate a severe cerumen impaction) to the physician right away: 1.decrease in hearing (progressive hearing loss) 2.progressive ear pain 3.tinnitus (ringing in the ear) 4. crackling noise in the ear *Care of hearing aid - never clean with alcohol (soft cloth only)

Extravasation

Passage or escape into the tissues; usually of blood, serum, or lymph

What are the factors affecting sleep?

Physical Illness, Anxiety and Depression, Drugs and Substances, Lifestyle, Sleep Patterns, Stress, Environment, Exercise and Fatigue, Nutrition NARCOLEPSY- Narcolepsy causes sudden attacks of sleep. Sudden loss of muscle tone and hallucinations might occur.

What is an ingested poison?

Poisoning by mouth is the most common type of poisoning, especially in children. Common substances include household cleaning products, garden and garage supplies, drugs, medications, food, and plants. Nursing interventions: Immediately call the poison control center. Maintain airway. Possible instructions by the poison control center Dilute the poison by giving one or two glasses of water. *Induce vomiting if gag reflex is present and poison is not a corrosive.* Treat for shock and administer CPR if needed.

Electroencephalogram (EEG)

Prepare requisition form. Explain procedure. Make sure hair is clean; administer shampoo as necessary; do not use any oils, sprays, or lotions. Confer with physician reguarding the need to discontinue any medications before examination. Do not administer sedatives or hypnotics, unless ordered. Encourage food intake, but eliminate coffee, tea, and colas. Explain need to patient of remaining still during a test- even blinking will create interference. Instruct pt is sleeping time is to be shortened the night before the test. Assist the pt to remove electrode paste with acetone or witch hazel. Shampoo hair. Ensure safety precautions intil no effects of the sedatives remain; keep side rails up. instruct pt who has had a sleep EEG not to drive home alone.

Bronchoscopy

Prepare requisition form. Explain procedure. Obtain informed consent before pt is premedicated. Instruct pt to be NPO after midnight (4-8hours). Administer preoperative medication as ordered. Do not allow pt to eat or drink after procedure until no effects of anesthesia remain and gag reflex has returned (usually about 2 hours). Observe any sputum for blood; small amounts are normal.

Magnetic Resonance Imaging (MRI)

Prepare requisition form. explain procedure. obtain informed consent. assess the pt for any contraindications to testing. instruct pt to remove all metal objects, such as dentures, partial dentures, jewelry, hairpins, and belts; provide safe storage. motionless pt. antianxiety medications for clostrophobic pts. thumping sound is heard so inform pt. pt can drive and no post op and inform pt results.

What is the process of wound healing?

Process of Wound Healing occurs by primary intention, secondary intention and tertiary intention Primary intention: Wound is made surgically with little tissue loss. Skin edges are close together or directly to each other. Minimal scarring results. It begins during the inflammatory phase of healing. Secondary Intention: The amount of granulation tissue required depends on the size of the wound; scarring is greater in a larger wound. Tertiary Intention: Occurs when a contaminated wound is left open and sutured closed after the infection is controlled or a primary wound becomes infected, is opened, allowed to granulate, and then sutured Patient who has a drain in a surgical wound will heal by tertiary intention

Evisceration

Protrusion of an internal organ through a wound or surgical incision

Dehiscence

Separation of a surgical incision or rupture of a wound closure

Types of wound healing

Serous- Clear, watery plasma Purulent- Thick, yellow, green, tan or brown Serosanguineous- Pale, red, watery, mixture of purulent and Sanguineous- Bright red, indicates active bleeding. Usually the day after surgery

What is Shock ?

Shock is an abnormal condition of inadequate blood flow to the body's peripheral tissues, with life-threatening cellular dysfunction, hypotension, and oliguria. It results from failure of the cardiovascular system to provide sufficient blood circulation to the body's tissues and decreased metabolic waste removal. To maintain circulatory homeostasis, there must be a functioning heart to circulate blood and a sufficient volume of blood.

Sleep Deprivation

Deprivation involves decreases in the amount, quality, and consistency of sleep. When sleep is interrupted or fragmented, changes in the normal sequence of sleep stages occur, and cycles cannot be completed Physiologic signs and symptom: Hand tremors, Decreased reflexes, Slowed response time, Reduction in word memory, Decrease in reasoning and judgment, Cardiac dysrhythmias, Tachycardia Mood swings, Disorientation, Irritability, Decreased motivation, Fatigue, Sleepiness, Hyperexcitability

What is some information to convey in a medical emergency ?

1. Name of the person making the call. 2. location of the emergency. 3. What has happened (either by direct observation or by gathering data) 4. Report whether an immediate threat still exist such as a fire, flood, or physical threat by someone else such as use of a gun or knife. 5. Number of people who need assistance. 6. The victim's or victims' name(s) and age(s). 7. Obvious injuries and the victim's or victims' apparent condition. 8. First aid measures that have already been administered. 9. Presence of medical- alert bracelets ay known history. 10. The physical characteristics of the rescue (stairs, elevators) Note: Always hang up when instructions to do so by the emergency services operator.

Open wounds. name examples as well.

A tetanus toxoid is necessary as a general treatment for all open wounds. It is necessary to readminister the vaccine every 10 years to maintain immunity. Openings or breaks in the mucous membrane or skin Always danger of bleeding or infection Infection is more common in wounds that do not bleed freely, because active bleeding tends to flush microorganisms from the wound. Abrasions - caused by rubbing or scraping of the outer layers of the skin. Rope and carpet burns, scratches, scrapes of knees and elbows Incisions - smoothly divided wounds made by sharp instruments Puncture wounds - piercing wounds of the skin. Can be made by knives, nails, woods, glass. If the object remains firmly in the skin, do not remove it, immobilize wound with dressing and tape and leave it in place for a physician to remove. Lacerations - wounds that are torn with jagged, irregular edges. Bleeding is profuse. Auto accidents, blunt object and heavy machinery accidents are common causes. Avulsions - torn piece of tissue that results in a section being completely removed or left hanging by a flap Chest wounds - extremely dangerous and necessitate immediate medical attention. Air or blood escapes into the pleural space. Normally this space is a vacuum, therefore air (pneumothorax) or blood (hemothorax) entering into this space has potential to cause increase in pressure resulting in collapse of lung tissue. If there is a sucking chest wound (without the penetrating object in place), apply an airtight dressing. Any available material is use. This dressing should be large enough so that it is not sucked into the hole in the victim's chest and as airtight as possible.

Application of a tourniquet

A tourniquet must be used only when the other methods have failed and the victim's life is in danger. Consider using a tourniquet is risking a limb is necessary to save a life It can cause extensive damage to the body part Is often considered beyond the scope of first aid and is usually restricted to professionals such as physicians and paramedics. Never loosen or release a tourniquet once it has been applied.

What is a wound? and what the basic rules for first aid treatment?

A wound is an injury to the internal or external soft tissues of the body. The basic rules for first aid treatment after the ABCs are as follows: 1. Stop bleeding 2. Treat for shock 3. Prevent infection

Common Patient Reactions to Hospitalization

Admission Entry of a patient into the health care facility* Health Care Facility* Any agency that provides health care The first contact with nurses and health care workers is important; anxiety and fears can be lessened and a positive attitude regarding the care to be received can be initiated The nurse can anticipate some common reactions: *Fear of the unknown - most common reaction* Loss of identity, Disorientation, Separation anxiety, Loneliness The nurse may help reduce the severity of common reactions: Have a warm, caring attitude and be courteous, Show empathy, Treat patients with respect, Maintain their dignity Involve them in the plan of care*, Whenever possible, adjust hospital routine to meet their desires Avoid treating these patients differently than other patients; "special" treatment may be interpreted as patronizing. Do not assume they are angry, aggressive, or hostile if they speak loudly or more emotionally than most patients. Learn new patients' names quickly. Use titles such as "Mr." or "Mrs." with the last name. * Older adults sometimes exhibit disorientation or depression when separated from family. * Never attempt to use ethnic dialects with patients. Avoid trying to impress patients by saying you have friends of the same racial background. Be attentive to the patient's nonverbal communication. If you do not understand what a patient is saying, ask for clarification. (ati pg 68)

Bleeding/Hemorrhage

An average adult has approximately 12 pints of blood circulating in his bloodstream. Effects of Blood Loss- Blood loss from internal or external bleeding causes a decrease in oxygen supply to the body. BLOOD PRESSURE DROP SO HEART pumps faster to compensate for the decreased volume and blood pressure. The body will attempt to clot the blood to halt bleeding, usually requiring 6 to 7 minutes. Uncontrolled, bleeding can result in shock and death

What are some types of Shock?

Anaphylactic shock- anaphylaxis( an exaggerated hypersensitivity reaction to a previously encountered antigen) results from a sudden severe, allergic reaction to a foreign substance. Shock occurs because of the sudden decrease in the amount of circulating blood caused by the sudden release of histamine, which creates capillary hyperpermeability, which in turn causes he release of plasma through the capillary walls. Cardiogenic shock- Results from poor heart function caused by various cardiovascular abnormalities. The heart is unable to maintain sufficient BP to all body parts. Hypovolemic shock- (aka hemorrhagic shock) caused by a decrease in fluid volume from bleeding, prolonged vmitting, or diarrhea, or by loss of fluid owing to surgery, trauma, or burns. Neurogenic shock- caused by the nervous system failure to maintain normal contraction of the blood vessels. common causes are spinal anesthesia, quadriplegia, or medications cause vasodilation, which create a condition in which the BP is lower because there is not enough blood fill the dilated blood vessels. Psychogenic shock syncope- caused by the nervous system's reaction to an emotional stimulus. The blood vessels dilate temporarily, decreasing blood flow to the brain, which results in unconsciousness, or syncope. Septic shock- Results from severe infection. Toxins from the microorganisms cause loss of fluid through the blood vessel walls; often seen in people receiving chemotherapy, or in conditions that result in immunocompromised functioning, such as acquired immunodeficiency syndrome (AIDS)

Events Necessitating Cardiopulmonary Resuscitation

Cardia Arrest- most common cause is myocardial infarction (MI). in addition, shock from hemorrhage, trauma to the heart, respiratory arrest, and drugs have potential to precipitate a cardiac arrest. Drowning- Children are the most common. Drunk people can also drown if near water. The low water temp. that produces hypothermia reduces the metabolic rate and decreases oxygen demands. Because of this it is necessary to initiate CPR even when 4 to 6 min are know to have elapse. Electrical shock- accidental electrocution will paralyzee the breathing muscles and cause cardiac arrest by interfering with the normal rhythm of the heart. the rescuer must ensure that the current is de-energized before cpr. Anaphylactic reaction- known allergen or insect bite can produce anaphylaxis, which can cause spasms pr edema of the upper airway and will in some cases progress to cardiovascular collapse. Asphyxiation- or suffocation cause by inhaling a gas other than oxygen. can also be caused by chocking on food or small objects. abdominal thrust are necessary here. Drug overdoes- alcohol and drugs pose a risk. besides treating this as a poisoning emergency, perfumer CPR as necessary. Sudden infant death syndrome (SIDS)- sudden death of an apparent normal and healthy infant that occurs during sleep and with no evidence on physical examination or autopsy. CPR when seen apnea.

Abscess

Cavity containing pus and surrounded by inflamed tissue, formed as a result of suppuration in a localized infection

Changing a wet to Dry

Changing a Wet-to-Dry Dressing:Primary purpose is to mechanically debride a wound. (debridement - removes necrotic tissue from healthy area of wound)

Kübler-Ross stages of grieving/dying

DENIAL and ISOLATION - may refuse to believe or understand loss has occurred ANGER - may strike out at everyone and everything BARGAINING - postpones awareness of reality and may try to deal in overt way (a wedding or graduation) DEPRESSION - withdraws and becomes lonely ACCEPTANCE - accept the loss and looks to the future (ati pg 348, 355)

Heat and Cold application.

Ensure that the physician's order for the therapy is being implemented Excessive heat causes a burning sensation. Cold produces a numbing sensation before pain.

Hematest of stools (Guaiac)- Hemoccult slide test

Explain procedure. assist pt in obtaining specimens, types of materials include cards, tissue wipes, test paper. inform pt of the need for multiple specimens obtained on separate days to increase test accuracy. document specimens sent to lab. instruct not to eat red meat for 3 days prior to test. do not mix urine with stool. some labs reccomend a high residue diet to increase abrassive effect of stool. note any anticoagulans or medications the patient is taking. be gentle when collecting digital rectal examinations. is test positive ascertain whether the pt violated prep. Determining the Presence of Occult Blood in Stool (Guaiac) (Avoid orange juice at least 72 hours prior to exam - can lead to false positive result) The presence of blood in body waste is abnormal. Bright red blood indicates the blood is fresh and that the site of bleeding is in the lower gastrointestinal tract. Black, tarry feces indicates the presence of old blood and that the site of bleeding is higher in the GI tract. Occult indicates blood is present in the stool but cannot be seen without a microscope. Hemoccult test detects occult blood in feces. Take stool from 2 different parts of the stool. Color blue on the smear indicates positive result of occult blood

Foreign Body Airway Obstruction Management

Food is the most common cause of choking or airway obstruction in the adult. Foreign objects are the most common cause of airway obstruction in children. If the air exchange is good and the victim is able to cough forcibly, do not interfere. The victim should be monitored closely, because he or she may regress to a state of poor exchange. Poor Air Exchange- Weak, ineffective cough. High-pitched, "crowing" noise while inhaling. Increased respiratory difficulty. Cyanosis. Complete airway obstruction: cannot speak, breathe, or cough and may clutch the neck Ask the victim, "Are you choking?"

Frostbite

Freezing and damage of body cells Commonly affected area are ears, nose, fingers, and toes. Assessment: initially, skin takes on a red flush with numbness, tingling, and pain; progressively, the part becomes hard and loses all sensation; color turns to grayish white; if thawing occurs, may change to blue-purple or black; edema may develop, followed by blisters. Nursing interventions: Treat the victim for shock and hypothermia; establish and maintain an airway. Warm part by immersion in warm water at 104 to 110° F for 20 to 45 minutes. If tub is not available, may use a hot moist towel. *Be very careful not to rub the part.* The thawed part is wrapped in clean towels or bulky dressings and elevated.

What are the phases of Wound healing?

Hemostasis - termination of bleeding. Begins as soon as the injury occurs. As blood platelets adhere to the injured vessels wall, a clot begins to form called fibrin (a substance that holds the wound together) and bleeding subsides. During the inflammatory phase, an initial increase in blood elements (antibodies, electrolytes, plasma proteins) and water flow out of the blood vessel into the vascular space. This process causes cardinal signs and symptoms of inflammation: erythema, heat, edema, pain, and tissue dysfunction As the inflammatory phase ends, new cells and capillaries fill in the wound, seals the wound and protects it from contamination (proliferation phase) Reconstruction phase Collagen formation occursa glue-like protein substance that adds tensile strength to the wound and tissue. Appearance changes to an irregular, raised, purplish, immature scar. Wound dehiscence most frequently occurs during this phase. Maturation phase: Fibroblasts begin to exit the wound.. The wound continues to gain strength, although healed wounds rarely return to the strength the tissue had before surgery. Keloids may form during this phase.

Obtaining throat specimen

Instruct the patient to tilt head backward. Ask patient to open mouth and say "ah" to permit exposure of the pharynx. If pharynx is not visualized, depress tongue with tongue blade and note inflamed area of pharynx and tonsils. Gently but quickly swab tonsillar area side to side, making contact with inflamed or purulent sites.

What are the guidelines for applying a bandage or binder?

Position body part to be bandaged in a comfortable position of normal anatomical alignment. Bandages cause restriction in movement. Immobilization in position of normal function reduces risks of deformity or injury. Prevent friction between and against skin surfaces by applying gauze or cotton padding. skin surfaces in contact with each other (e.g., between toes, under breast) will likely rub against each other and cause impairment of skin integrity. Apply bandages securely to prevent slippage during movement. When bandaging extremitites, apply bandage first at the distal end and progress towad the trunk (heart). Gradual application of pressure from the distal toward the proximal portion of the extermity promotes venous return and keeps the risk of edema or circulatory impairment to a minimum. Apply bandages firmly, with equal tension exerted over each turn or layer. avoid excess overlapping of bandage layers. approx. 1/3 to 1/2 of previous layer shhould be covered by successive layers)Proper application prevents unequal pressure distribution over bandaged body parts. Position pins, knots, or ties away from wound sesitive skin areas. remove and reapply elastic bandage at least once ever 8 hours, unless otherwise directed by a physician. Remove elastic bandage whenever necessary to readjust wrinkles, looseness, or tightness. because of patient discomfort. Apply bandages to the lower extremities before pt sits or stands. ex. when pt is laying down. Use increasingly wider bandages as size of are to be covered increases. Use adhesive tape rather than lose clips or pins to fasten bandages on small child or infant. Safety pins are the most effective. but most facilitie use tape. Pt with tubes or drains who have binders will require frequent assessment to ensure patency of tubes for drainage.

General Guidelines for Care of Pressure Ulcers

Practice Surgical Asepsis when caring for the pressure ulcer to prvent a secondary infection. Sterile techniqus include the use of sterile dressings, sterile gloves, and sterile irrigation. never massage reddened area. nutritional support promotes repair. observe patients hydration. I&O. turn ever 2 hours in bed and reposition pts on wheelchair ever 15 min. place pt's on risks for skin impairment on pressure relieving mattresses. place a rolled bath blanket under the distal extremities to raise heel of bed. soughnut type cushions are not advisable. USe pressure relieving devices such as low-air-loss bed. (kinair) the use of topical agents to help healing can be used.

How is Pediatric CPR Child/Infant done?

The basic steps of CPR and foreign body airway obstruction management are the same whether the victim is an infant, a child, or an adult. For the purpose of life support Infant: younger than 1 year Child: between the ages of 1 and 8 years Airway- Unresponsiveness should be determined Gently shake the child; tap the heels of an infant. Call for help- If the rescuer cannot immediately activate EMS, perform BLS for 1 minute before going to activate EMS.Position victim on a firm, flat surface for effectiveness of CPR.Open the airway; do not hyperextend in infants. Breathing- Look for movement of the chest, listen for breath sounds, and feel for exhaled airflow. If there is no breathing, inhale and seal the mouth and nose of the infant.Two breaths are given, with a pause between each breath; the volume of air in the infant's lungs is smaller than that in an adult's; adjust to allow for appropriate rise and fall of the chest. Circulation- Assessment of pulse: Carotid artery of the child Brachial artery of the infant If there is a pulse, rescue breathing should be continued at a rate of 1 breath every 3 seconds. If there is no pulse, external cardiac compressions must be performed.The breastbone is compressed to a depth of 0.5 to 1 inch at a rate of at least 100 times per minute.

INFANT - Foreign Body Airway Obstruction Management

The infant is straddled over the rescuer's arm with head lower than the trunk, with the face down. With this arm resting on the rescuer's thigh, the other arm delivers five back blows between the shoulder with the heel of the hand. The rescuer places his or her free hand on the infant's back so that the victim is sandwiched between the two hands. The rescuer turns the infant and places the infant on the rescuer's thigh with the head lower that than the trunk. Five chest thrusts are performed with the hands in the same position as when performing external cardiac compressions.

What is a close wound?

The underlying tissue of the body is involved; the top layer of skin is not broken. Ecchymoses (bruises) and contusions ( injuries that do not break the skin, caused by a blow and characterized by edema, discoloration and pain)occur. Signs and symptoms: Edema, discoloration, deformity, shock, pain and tenderness, and signs of internal bleeding Nursing interventions: Small wound: ice packs and elastic bandage Large wound: treat for shock; cold compresses and pressure bandage

Once CPR is started, it may not be discontinued except for the following reasons.

The victim recovers. The rescuer is exhausted and cannot continue CPR. Trained medical personnel (paramedics) arrive on the scene and take over CPR. A licensed physician arrives on the scene, pronounces the victim dead, and orders CPR to be discontinued.

Patient Evaluation for Iodine Dye Allergies

possible allergic reactions to iodinated dye vary from mild flushing, itching, itching, and urticaria to severe, life-threatening anaphylaxis. In unusual event of anaphylaxis, treatment consists of administration of drugs such as diphenhydramine, steroids, and epinephrine. Always have oxygen and endotrachial equipment on hand for immediate use. asses pt for allergies before and inform the radiologist so they can prescribe Benadryl and steroid preparation before testing. Usually hypoallergenic contrast media will be used. see pt reaction to dye after, usually within 2-6 hours after test. treat with antihistamines or steroids. Iodine is absorbed systematically, and it is necessary to consider all body secretions, such as urine. Dye is injected into the vein in forearm to show better image