Quiz 2, Medication, Respiratory, Wounds

Why is it important to take initial and serial pictures of wounds

To safe yourself as you weren’t in charge of waht happened before

To document progress

What are the characteritiscs of Gauze Pads

Layers of gauze to absorb exudate

What are the characteristics of Non Adherent Guaze (Teifa, Petrolatum)

NON stick surface to stop furhter injury

Used for seal around chest tube

What are the characteristics of ABD pads

Heavy and Thick to absrob lots of stuff

What are the chracteritsics of Transparent pads

Semipermeable membrane to act as a second skin

What are the characteristics of roller guaze

Long Strips supplied in rolls

Explain how age is a factor that can impact wound healing

As we age we produce less collagen

Explain why protein is important for wound healing

Protein is needed to synthezie collagen, extracellular matrix, antibodies

Ganulation Tissue

Explain why Vitamin C is important for wound healing?

Vitamin C is needed for collagen synthesis

Why is Albumin important for wound healing?

Tissue Repair

Why is zinc importnat for wound healing

Zinc is involved with DNA and RNA polymerse needed for cell multiplcation

What does periwound mean

The immediate surrounding area of a wound

Whats the differnce between skin tear and abrasions

Skin Tear: Epidermis seperates from dermis, causing a flap

Abrasians: Only Affects the epidermis, a scrape

What is the main population affected by skin tear, and the suprising cause of skin tears

Geriatric, or paitent on immunotherapy like steroids

Removal Of medical Device

What are the signs of an infection at a surgical incision

Erythemia

Warmth

tenderness

What is wound dehiscence?

Surgical wound seperate and loose approximation

What is wound eviseceration

Wound edges seperated as well as organ pertruting out the body

Why is normal saline prefered for wound care cleaning and irrigation

Its isotonic (same osmolarity) to blood and body fluids meaning it won’t harm body tissues

What does COCA mean for drainage description

Color

Odor

Consistancy

Amount of output

What is Sanguineous Drainage and what does it indicate

Fresh Red Blood

Appears quickly after surgery

Good Sign if its a light consistant draining

What is Sero-Sanguineous Drainage and what does it indicate?

Mixture of Serous and Sangienous Drainage

Pink

Couple Days after surgery,

What is Serous Drainage? What does it indicate

Straw Colored Older Drainage

No RBC only blood plasma serum

It happens after Sero-Sanguinous Drainage

What is Purulent Drainage, what does it indicate

Thick Opque viscous draining

Infection

Not normal

What is this

Penrose Drain

Open Drain

Does a Jackson Pratt (JP) drain provide low or high suction

Low suction

What is the expected output in mL over 24 hrs for a JP drain

100-200 ml

If a JP drain is draining fast and a lot is that normal

No it’s supposed to be low suction

Is a hemovac drain low or high suction

low suction

What is the expected mL drainage amount of a Hemovac drain over 24 hrs

drain up to 500ml

What is the mechnism that both the JP and Hemovac use to drain

Compression of the device to acheive a constant suction

When dealing with staples wound closure when should it be removed after surgery

7-10 days

What is nursing care for staples

Assess the surroudning skin for irregular things like pain erythema

Infection

What type of surgery is staples usally used on

Abdominal

Orthopedic

What type of surgery are sutures seen in

Tissue closure for deep stuff

What are steri strips

Sterile medical tape for skin tears or removal of staples/sutures to keep the incision area closed

Should steri strips be peeled off

no they should fall off naturally

When removing sutures what are the important items to remeber when removing

Lift the knot upward away from skin

Cut at the base of the knot

What are the methods to collect a urine sample sterilely

Clean Catch/ Midstream

Sterile Catherile sample site

24 Collection ( Void the first one)

When collecting stool samples what is the point?

Test for Occult (Hidden Blood) Ova, parasites

How is stool sample collected for testing

Using a comode Hat

Tounge Blade is used to transfer stool to container

If stool is mixed with urine when collecting specimen what should be done

It’s considered contaminated and should be dumped

What is the point of collected throat and sputum samples

To check for microbes

When is the best time to obtain throat or sputum samples

Early Morning

What is the point of getting wound speciman samples

To check for specific microbes

What are the steps for obtaining a wound culture

1) Select either aerobe or anarobic swab based on waht u need

2) Irrigate the surface exudate

3) Swag in a zig sag order

4) Place swab into container

When you have a speciman container what should you label on it

Date

Time

Initial

Location of wound

Room Number

When would you use an aerobe swab for wound sample

on the surface of wounds that are exposed to air

When would you use an anaerobic swab for wound sample

In tunneling or undermining

When handling an oxygen tank what precautions should be in place

Held Upright in a tank holder

Kept away from flames

Is oxygen a medication?

Yes therefore an order needs to be in place for oxygen

When giving oxygen to COPD paitents what is important to note

Their target oxygen saturation range is 88%-92%

Trigger to breathe is low oxygen instead of high CO2

What is the unit measurement for flow rates

Liters Per Minute

What does this green flow meter use for

Oxygen Adminsitrtion

Uses the Christmas tree swivil

What is this yellow flow meter used for

Medical AIr for breathing treatments

What is the Fi02 of room air

21%

What is the normal ranges for oxygen saturation

95-100%

What is the normal ranges for oxygen sautration for COPD paitent?

88-92%

Besides on the finger where can a pulse oximeter be used?

Toenail Earlobe

What are some early signs and symtoms of respiratory distresss?

Increase RR, HR

Pursed Lip Breathing

Anxiety

Increased Restlessness

What are some late signs and symtoms of respiratory distresss

Tripoding

Increase CAp refill time

Cyanosisi

Lathargic

COnfused

Accesory muscle use

What is the Fi02 of room air

21%

Every liter you add of oxygen how much more % does it add to the FIo2 Value

4% more to the Fi02 Value

1 L = 4% o2

What is the liter range of o2 for nasal cannula?

1-6L/min

What is the Fi02 range for nasal cannula?

FiO2= 25-40%

What is a End Tital CO2 with reservoir attatched?

Special attatchment that prolongs deliverty of oxygen to the nose

Measures CO2 paitent is blowing out

used for procedures

Where are the the sites for risk of pressure injury for nasal cannula

Nose

Face

Skin Behind Ear

Place Foam on ears

How do you prevent dry nares and nosebleeds for a paitent using a nasal cannula

Use a humidifier

What is the L/min range of o2 for a simple face mask

6-12 L/min

What is the Fi02 range of someone reciing oxygen from a simple face mask

35-50%

When would you not give someone a simple face mask

If they have facial injury

What is the L/min o2 range for a non rebreather mask

10-15 L/ min of o2

What is the fi02 range of a non rebreather mask

60-90%

When are Non-Rebreather masks used

Emergency situations

Respiratory distress

How does a non rebreather mask work

Filled bag of 02 is used to breathe

One way valve allowing no co2 to be present in mask

What is vital when giving a paitent a non rebreather mask

Make sure the reservoir bag is attached to o2 and fully filled with it

What is the L/min flow rate of a high flow nasal cannula

2-60 L/M

What is the FI02 of a high flow nasal cannula

Up to 100%

How does a High flow Nasal Cannula work

Like Nasal Cannula that provides heating and humidifcation at body temp

How does a biPAP machine work. Bilevel Positive Airway Pressure

High Pressure during inspiration to help paitent breathe in easier

Low pressure during exhalation to allow paitent easily exhale

A paitent is put on BiPAP to avoid being ______ ?

Mechnically Ventilated

Non Invasive

What is the FiO2 Range for BiPAP?

21-100%

What is Continuous Positive Airway Pressure (CPAP)

A single unchanged pressure to keep airways open and not collapsing

What is the main reason why CPAP is used

Obstructive Sleep Apnea

Helps keep the tounge and pharyngeal soft tissue from relaxing and obstructive airflow

What are the early signs of respiratory distress

Increase HR, RR

Restlessness

Cyanosis

Pursed Breathing

Increase Anxiety

What are the late signs and symptoms of respiratory distress

Tripoding

Cyanosis

Accessosry muscle use

Lethargic

Confused

What is the purpose of the Incentive spirometer

To promote deep slow inhalation in order to fully expand alveoli and preventing Pulmonary complication

How would you teach a paitent to use the incentive spirometer

Inhale with the mouthpiece hold for 3 seconds

Keep the yellow ball over the best line

How often should a paitent use the incenstive spirometer per hour

10 times

What is Atelectasis

Collapse of Alveoli

What is the most common cause of Atelectasis in the hosptial

Anasethia from surgery

Cillia moves slower causing shallow breaths mucus accumulutes in airways causing mucus

If a paitent says they cough after using the incentive spirometer what should a nurse say in respopnse

That means its working

Why should you promote sleeping with a pillow/blanket for a paitent with atelectasis

It works as a barrier to allow for their coughing to be less painful

Deep Breaths will be less painful

Stops them from taking shallow breaths

Why is it important to promote deep breathing for a paitent to sotp respiratory complications

To allow for them alveoli to fully expand and mucus to clear to stop atelectaiss from happening

How often shoudl you change paitent position to stop respiratory complciation

1-2 hrs

What does Fine Crackles mean?

Sticky Deflated Alveoli are popping back open on inhale

High pitched

What do fine crackles sound like

Air is inhaled through small airways

High Pitched

What does medium Crackles mean

Air moving thorugh moist secretions in larger airwyas like bronchioles

What do medium crackles sound like

Lower pitch compared to fine crackles

MOist sound

What does coarse crackles mean

Air moving through the bronchi and trachea and getting caught in the mucous and stuff

What do corase crackles sound like

Loud Bublling

Gurgling