Week 5: Inflammation, Infection, Surgical Patient, Pain, BGM

What should you check before opening sterile gloves?

INSPECT that package is intact, dry, not expired, and the right size

What part of the package is contaminated?

Outer 1-inch border

What does the bare hand touch on the first glove?

Inside the cuff

What does the sterile hand touch on the second glove?

Outside the cuff

What is the rule for the second glove?

Glove-to-glove, skin-to-skin

Where should sterile hands stay?

Above waist and in sight

Why are drains used?

Remove fluid, blood, or pus from a wound

What is a JP drain?

Closed suction drainage system

What should you asses with a drain

Amount, color, consistency, odor, and site

What does maintaining suction do?

Helps pull drainage from the wound

What should you document about drainage?

Amount, color, consistency, and odor

What counts as intake?

Oral fluids, IVs, tube feedings, liquid meds

What count as output?

Urine, emesis, stool, drains, NG drainage

What unit is I&O measured in?

mL

What is the net I&O formula?

Intake - Output

What does positive fluid balance mean?

More intake than output

What is the first step before collecting?

Identify the patient correctly

What container should you use?

The correct container for the specimen

How do you prevent contamination?

Hand hygiene and proper technique

When should a specimen be labeled?

Immediately after collection

What should happen after labeling?

Send speciman to the lab promptly

What should you assess on a wound

Size, color, drainage, edges, skin, pain

What is serous drainage?

Clear, pale yellow, watery fluid (serum component of blood).

What is sanguineous drainage?

Blood drainage

What is purulent drainage?

Thick yellow/green drainage; may indicate infection

What are the signs of wound infection?

Redness, warmth, swelling, pain, pus, fever

What is the purpose of a dressing?

Protect wound and absorb drainage

What should you do before BGM?

Identify patient and perform hand hygiene

Where is the fingerstick performed?

Side the fingertip

What should you do with the lancet?

Dispose immediatley in sharps container

What are signs of hypoglycemia?

Shaking, sweaty, confused, weak, hungry

What are the signs of hyperglycemia?

Thirst, frequent urination, fatigue, blurred vision

What pain scale is most common for adults?

Numerical rating scale (0-10)

Who is the Wong-Baker FACES scale for?

Children > 3 years or langauge/literacy barriers

What does PAINAD assess?

Pain in patients with advanced dementia

What 5 things does PAINAD assess?

Breathing, vocalization, facial expression, body language, consolability

Who is FLACC used for?

Young children or patients with severe developmental delays

What does FLACC assess?

Face, Legs, Activity, Cry, Consolability

Who is NCCPC-R used for?

Individuals with severe development/cognitive delays

Who is CPOT used for? (Critical Care Pain Observation Tool) & Comfort

Sedated, nonverbal, or mechanically ventilated ICU patients

What is Comfort used for?

Assessing pain/distress in nonverbal or critically ill pateints

What is the most important rule about pain?

Believe the patientʻs report (they are the most reliable)