PCC exam 3

Transdermal Patch

Skin assessment, hairless area, rotate sites, remove previous patches before applying a new one

Eye administration

Drops are patient specific

Dropper must remain sterile

Instill drops or ointment in conjunctival sac

Drops must be administered before ointment

Punctal occlusion (60 seconds)

Ear administration

Clean procedure unless eardrum is not intact (sterile)

Drops should be room temperature

Pinna positioning: adults up and back, children down and back

Vaginal medications

irrigations (douches), foams, gels, creams, tablets, suppositories

Rectal medication

Irrigations (enemas), suppositories

Insert suppositories

4 inches

Intradermal injection sites

Forearms, upper chest, upper back

Subcutaneous injection sites

back of upper arm, upper back, lower back, abdomen, top of thighs

Intramuscular injection sites

Deltoid, vastus lateralis, ventral gluteal

Ventilation

Inhalation and exhalation

Respiration

Chemical- Internal vs external, exchange of oxygen and carbon dioxide in the alveoli and capillary membrane

Eupnea

Normal breathing

Bradypnea

Slow breathing

Tachypnea

Fast breathing

Kussmauls Respirations

Fast, deep, and labored breathing

Biots respirations

Chaotic, irregular breathing pattern

Oral medications

Pills, enteral, syrups, liquids, elixirs, suspensions

Peds consideration

Topical medications

Lotions, creams, ointments, sprays, powder, patches

What is required for all topical medications?

Gloves

Respiratory medications

Assessment is required before and after administration

Patient specific

Larger needle gauge

Smaller diameter

Standard syringe

1 mL, 5 mL, 10 mL, etc

Insulin syringe

0.3 mL, 0.5 mL, 1 mL

For insulin only

Tuberculin syringe

1 mL capacity

For TB testing

Luer Lock syringe

Twist on needle tip

Pre filled syringe

Single dose, prescribed medication

Safety syringw

Retractable or shielded needle

Labeling for injectables

Date, time, initials, contents

Intradermal injections

Insert 5-15 degrees just below the skin surface, usually only 0.1 mL, uses small 1 mL syringe with a fine 26-28 gauge needle

Subcutaneous injections

Use a 25-30 gauge 3/8-1 inch needle, max amount to be injected is 1 mL at a 45-90 degree angle

Mixing insulin

Clear before cloudy

Intramuscular injections

Use a 21-23 gauge 1-1.5 inch needle, syringe depends on the amount and the maximum amount depends on the site, inject at a 90 degree angle

Cheyne-Stokes respirations

Abnormal cycle of breathing characterized by periods of gradual increase and gradual decrease in depth and rate, followed by a period of apnea

Apnea

Temporary pause of breathing

Hypoxemia

<90% in arterial blood

Early signs of hypoxia in adults

Tachypnea, tachycardia, restlessness, anxiety, confusion, pale skin and mucous membranes, elevated blood pressure, use of accessory muscles, nasal flaring, adventitious lung sounds

Late signs of hypoxia in adults

Stupor (almost unresponsive), cyanotic skin and mucous membranes, bradypnea, bradycardia, hypotension, cardiac dysrhythmias

Nursing interventions for hypoxia

Confirm probe placement

Confirm delivery system is working and the patient is receiving the prescribed amount

Raise the head of bed and encourage pursed lip breathing

Stay with patient to provide support and decrease anxiety

Nasal cannula

1-6 L/min, 24-44%

Advantages of nasal cannula

Safe and easy to apply, comfortable and well tolerated, patient can eat, talk, and ambulate

Disadvantages of a nasal cannula

FiO2 varies with flow rate, and rate/depth of breathing, skin breakdown and dry mucous membranes long term

Nursing actions for nasal cannula

Assess patency and tubing, ensure proper fit, use water-soluble gel to prevent dry nares, humidification for flow rates of 4 L/min and greater

Nasal cannula

Simple face mask

5-10 L/min, 35-60%

Advantages of a simple face mask

Good for mouth breathers, humidified oxygen

Disadvantages of a simple face mask

Flow rates less than 5 L/min can result in rebreathing CO2, anxiety or claustrophobia, eating, drinking, and talking are impaired, risk of skin breakdown, risk of aspiration

Nursing actions for simple face mask

Assess proper fit, client wears nasal cannula while eating, monitor for skin breakdown, use with caution for patients with high risk of aspiration or airway obstruction

simple face mask

Venturi mask

5-10 L/min, 24-60%

Advantages of a venturi mask

Delivers the most precise oxygen concentration with humidity added

Disadvantages of venturi mask

Can be noisy, eating, drinking, and talking impaired, risk of skin breakdown

Nursing actions for venturi mask

Assess equipment and patient frequently to ensure an accurate flow rate, asses proper fit, assess for skin breakdown, ensure the client wears a nasal cannula during meals

Venturi mask

Partial rebreather

10-15 L/min, 60-90%

Advantages of a partial rebreather

Patient can rebreathe up to 1/3 of exhaled air together with room air, humidified oxygen

Disadvantages of a partial rebreather

Complete deflation of the bag during inspiration causes CO2 buildup, FiO2 varies with the client’s breathing pattern, anxiety or claustrophobia, eating, drinking, and talking impaired, risk of aspiration and skin breakdown

Nursing actions for partial rebreather

Keep the reservoir bag 1/3 to ½ full on inspiration by adjusting flow rate, assess proper fit, monitor for skin breakdown, ensure the client uses a nasal cannula during meals, use with caution for clients who have a high risk of aspiration or airway obstruction

partial rebreather

Non rebreather

10-15 L/min, 80-95%

Advantages of non rebreather

Delivers the highest O2 possible (besides intubation), one-way valve between the mask and reservoir allows the client to inhale maximum O2 from the reservoir bag, flaps prevent room air from entering the mask

Disadvantages of a non rebreather

A good seal is required around the face for effectiveness

Nursing actions for a non rebreather

Assess proper fit and skin breakdown, make sure client uses a nasal cannula during meals

Airway clearance

Positioning and postural drainage, incentive spirometer, mobilize secretions

Ways to mobilize secretions

Chest physiotherapy

Turn, cough, and deep breathing

Hydration

Humidification of oxygen

Medications (expectorants, decongestants, bronchodilators, steroids

Oropharyngeal airway

Inserted into the mouth to the pharynx

Nasopharyngeal airway

Inserted in the nostril to the pharynx, patient can tolerate this consciously because it does not stimulate the gag reflex

Endotracheal tube

Tube inserted into the trachea

Orotracheal

mouth to trachea

Nasotracheal

Nose to trachea

Tracheostomy

Directly opened into the trachea

Cuffed

Used for patients who are being ventilated or have trouble swallowing

Chest tube

Inserted into the pleural space to evacuate air or fluid

3 types of chest tubes

Water-seal, dry-seal, or portable

Nursing assessments required for chest tubes

Vitals, spO2, Pulmonary assessment, color, consistency, amount of drainage, pain

Purpose of urination

Waste elimination, maintain fluid balance, maintain electrolytes and acid/base balance, regulate blood pressure

Bladder can hold

500-1000 mL

When does the brain signal the need to urinate

250-400 mL

Pale straw colored urine

Expected

Red urine

Bleeding or diet related

Bright orange or rust colored urine

May be due to medications

Dark amber urine

High level of bilirubin from liver dysfunction, muscle breakdown

Ammonia smell of urine

Stagnant urine

Sweet, fruity odor of urine

Ketones (diabetes mellitus)

Initially cloudy uring

Protein or bacteria

Adults normally void

1500-2000 mL a day; 30 mL/hour

COCA of urine

Color, odor, consistency, amount

Causes of retention

Obstruction, inflammation and swelling, neurological conditions (SCI), medications, anxiety

Risk factors of urinary incontinence

Advanced age, history of UTIs, neuroloigcal disease obesity, smoking/drinking, immobility, perimenopause, childbirth, benign prostatic hyperplasia, diabetes

Complications of urinary incontinence

infection (UTI and/or bacteremia) and inflammation (prostatitis, epididymitis, cystitis, pyelonephritis)

Stress incontinence

Involuntary loss of urine with increased intra-abdominal pressure in the absence of an overactive bladder

Causes of stress incontinence

Pregnancy, childbirth, obesity, chronic constipation and straining, physical activity, laughing, sneezing, coughing, lifting

Treatment for stress incontinence

Kegel exercises, sling/pessary procedure, injection of synthetic materials

Urge incontinence

Inability to stop urine flow long enough to reach the bathroom due to increased bladder pressure

Causes of urge incontinence

Overactive detrusor muscle, UTI

Treatment of urge incontinence

Bladder retraining, medications, neuromodulation (nerve stimulation), botox injection

Overflow incontinence

Frequent loss of small amounts of urine due to overdistension or retention

Causes of overflow incontinence

SCI, MS, impaired detrusor muscle, obstruction (enlarged prostate), or fecal impaction

Treatment for overflow incontinence

Intermittent catheterization, bladder training, medications, surgery, neuromodulation

Reflex incontinence

“unconscious” incontinence, loss of urine when the person does not realize the bladder is full and has no urge to void

Causes of reflex incontinence

CNS disease, SCI, tissue damage from radiation, cystitis, bladder inflammation, radical pelvis surgery