FOUNDATIONS FINAL EXAM

procedure for hanging a piggyback

1. assess IV site for patency...

2. CLOSE ROLLER CLAMP on the secondary tubing!!!

3. spike the bag

4. clean port closest to primary IV bag w wipe for 15 seconds

5. connect tubing

6. back-prime the secondary bag by holding it at waist level and releasing clamp

7. hang the secondary bag HIGHER than the primary bag using the secondary set hook

8. program the pump for the secondary bag:

—channel select

—secondary med

—find and choose piggyback med

—choose correct dose and fluid volume

—choose duration (ex: 30 min) to calculate rate

9. unclamp the roller clamp on the secondary tubing and slay

what do you need to check before hanging a secondary bag?

check compatibility of the secondary med with the med/fluids already infusing

infiltration

leakage of non-vesicant fluid into surrounding tissue

s/s of infiltration

area is cool, swollen, and painful

what to do for infiltration?

discontinue IV, elevate arm, may need compresses

infiltration of a vesicant

extravasation

what is a vesicant?

a medication that may cause permanent tissue or nerve damage (including amputation of the limb) if it leaks into tissue and is not treated

s/s of extravasation

pain, burning, change in temp of skin, tightness, blanching of area, slow or stopped infusion

what to do for extravasation?

notify MD stat!!!!

antidote must be given and very short window for treating

examples of vesicants

-chemo agents

-vasopressors

-vancomycin

phlebitis

inflammation of the intimal layer of the vein

-chemical OR mechanical trauma to the vein

s/s of phlebitis

warm, red streak, vein hard and cordlike, painful

what to do for phlebitis?

-stop IV

-restart in another site

-tell MD (possible blood clot)

s/s of IV infection

redness, warmth, drainage, may have pus and a fever

what to do for IV infection?

-remove IV

-start in new area

-notify provider: need antibiotics or sepsis and die

how to check patency of an IV line?

if infusion running: IV site should be free of redness, swelling, coolness, or warmth to the touch. The IV infusion should flow freely.

if no infusion running: flush a bit, pull back check for blood return, flush rest of 10ml syringe... can palpate vein if you want to feel special

air embolism

air enters the circulatory system during tubing change, blood draw, or loss of cap on closed system

-can occur during insertion, maintenance, and removal of a CVAD

is an air embolism chill?

no. its an emergency! can lead to death

s/s of air embolism

-respiratory distress

-cyanosis

-tachycardia

-decreased BP

-decreased LOC

how to prevent an air embolism in central lines?

bend and clamp tubing on CVAD any time you are opening the system

also, have pt hold breath while tubing is changed

what to do if suspect air embolism?

-call a code

-place pt on left side in trendelenberg

-provide O2 and monitor VS frequently

what if the labia closes over the catheter during insertion or if the catheter touches the genitalia before being inserted into the urethra???

the catheter has been contaminated so you MUST START OVER!!! (new kit, new everything)

routine catheter care

-secure catheter

-perineal hygiene

-maintain adequate intake of fluids

-maintain closed system

-prevent pooling of urine in tubing and reflux of urine into bladder

-keep drainage bag below the level of the bladder

best way to prevent catheter-associated urinary tract infections (CAUTIs)

-clean catheter and perineum with soap and water at least BID

-encourage increased PO intake

-dont contaminate drainage spout when emptying catheter

-maintain closed system

-remove catheter ASAP

-change contaminated equipment immediately

-dont place catheter bag above level of bladder, keep off floor, avoid kinks

what indicates a blocked catheter?

pain and bladder distention

NG tube (background info)

40-45in silicone or PUR, bore size 8-12

-short-term!!!! less than 6 weeks

-stomach regulates gastric release to duodenum

-acidic pH secretions protect against infection

-may be easily moved and dislodged

-NO BASILAR FX!

how to measure NG tube

measure from tip of nose to earlobe to between xyphoid process and umbilicus

-put piece of tape on site

-insert tube to this point (taped point)

ways to verify placement of NG tube

1. x-ray

2. compare length each day: measure tube length immediately after insertion and compare (mark w sharpie)

3. pH litmus test of gastric aspirate

what is the only way to CONFIRM NG tube placement?

x-ray

what pH of gastric aspirate indicates correct NG placement?

< 5 (red litmus paper)

when can you begin feedings with an NG tube?

once placement is confirmed by radiology!!!!!!

NEVER before this... unless salem sump

color of gastric aspirate

green, off-white, brown, or colorless and cloudy

when is parenteral nutrition indicated?

when GI tract not functioning

what is TPN?

highly concentrated HYPERTONIC IV solution

what does TPN do?

restore calories and nutrients

TPN is administered via a...

central venous access device (CVAD)

-PICC

-Hickman

-implanted port

not peripheral IV... unless you want phlebitis and bad things!

TPN has a high ____________ concentration, so what should you check regularly?

glucose (dextrose); CHECK BLOOD SUGAR

monitor for hyperglycemia

what does a healthy stoma look like?

pink, moist, "beefy red"

what color do you NOT want to see with a stoma?

pale, black, or blue

notify provider asap please

when to change ostomy appliance?

every 3-7 days or when leaking

how do you change an ostomy appliance?

1. remove appliance by pushing skin away from appliance

2. wash surrounding skin w warm water and soap

3. dry surrounding skin

4. using measuring device, determine correct stoma size

5. trace circle and cut opening of wafer 1/8in larger than stoma

6. apply wafer

7. hold in place with hands for THREE MINUTES at 3&9 and 12&6 to make sure wafer sticks

opening of wafer must be cut _____ larger than the stoma... why?

1/8 inch; prevent stool from accumulating on skin

the closer the stoma is to the rectum, the more ___________ the stool will be

solid

ileostomy stool characteristics

liquid, pt will have liters and liters of output (ENTIRE COLON REMOVED, ZERO WATER REABSORBED FROM STOOL)

DESCENDING/SIGMOID colostomy stool characteristics

solid, normy (CLOSEST TO RECTUM, MOST OF COLON PRESERVED)

what is the #1 complication with an ileostomy?

dehydration

enema

introduction of fluids or meds into large intestine

-distends intestine + irritates mucosa = increased peristalsis

most enemas work within...

15-30 minutes

enema procedure

1. verify order

2. add 500ml of warm water to bag

3. prime tubing, close slide clamp

4. raise bed to waist level, have pt turn on left side

5. pad bed well if you dont hate yourself

6. clean gloves, lubricate tubing 2-3in. from the tip

7. hang bag no higher than 18in. above anus

8. insert tube 3-4in. into the rectum; one hand on pt, one on tubing

9. instill over 5-10 minutes

10. when sol. infused, clamp tubing and withdraw

11. bedpan, bedside commode, or BR (NO FLUSH!)

what if pt cramps during enema instillation?

slow flow by lowering bag

blood transfusions are done only with...

compatible fluid

blood types compatible with A

A, O

blood types compatible with B

B, O

blood types compatible with AB

A, B, AB, O

blood types compatible with O

O

who is the universal donor?

O

how to determine if blood product compatible?

type and screen before surgery

type and cross match to ensure compatibility before infusion

what is the best scenario for a blood infusion?

if a pt can receive their own blood

unit of blood must be hung and running within _____________ of receiving from blood bank

15 minutes

what is the maximum length of time a unit of PRBCs can hang?

infuse over 2-3 hours, must DISCARD after 4 HOURS!

signs of allergic transfusion reaction

hives, itching, anaphylaxis

what do you do for allergic transfusion reaction?

1. stop infusion at once, notify provider stat

2. start NS to keep vein open (KVO)

3. may need antihistamines...

4. DOCUMENT!

signs of febrile transfusion reaction

incr in temperature of at least one degree F within 2 hours of starting transfusion

-fever

-chills

-malaise

-risk incr w multiple transfusions

what to do for febrile transfusion reaction?

1. stop transfusion

2. NS KVO

3. notify provider

4. treat symptoms (blanky)

signs of hemolytic transfusion reaction

wrong blood typed product hung; antigen-antibody response; IMMEDIATE SYMPTOMS

-facial flushing

-fever

-chills

-HA

-low back pain

-signs of shock

what to do for hemolytic transfusion reaction?

EMERGENCY! POSSIBLY FATAL!

1. stop transfusion asap

2. call a code and notify provider

3. send bag and tubing to blood bank

4. draw blood samples and save first voided urine within 2 hours to check for hemolyzed RBCs

signs of circulatory overload transfusion reaction?

incr risk in pts with heart and lung disease

-SOB

-crackles

-cough

-signs of pulmonary edema

what to do for circulatory overload transfusion reaction?

1. stop infusion

2. call provider

3. check VS

4. HIGH FOWLERS POSITION

5. may need diuretics

signs of transfusion-related acute lung injury (TRALI)

usually induced by the transfusion of antibodies against human leukocyte antigens

-non-cardiac pulmonary edema

-hypoxemia

within first 6 hours of product transfusion

what do i dooo for TRALI???

notify provider,,, no specific treatment :D

pre-transfusion requirements

1. type and cross match

2. check IV for patency

3. baseline set of vitals

4. provider gets CONSENT and explains procedure and possible complications (informed)

5. bag of NS and tubing close by in case

stage I pressure injury

NON-BLANCHABLE erythema of INTACT skin

stage II pressure injury

partial thickness SKIN LOSS with EXPOSED DERMIS due to shear

-blister-like

stage III pressure injury

full thickness skin loss, ADIPOSE tissue visible

-granulation tissue, epibole, slough or eschar may be visible

-depth varies, undermining and tunneling may occur

stage IV pressure injury

full thickness tissue loss, exposed FASCIA, MUSCLE, TENDON, LIGAMENT, AND BONE visible!

-depth varies

unstageable pressure injury

full thickness tissue loss with base covered by eschar or slough

deep tissue injury

persistent NON-BLANCHABLE deep red, maroon, or purple discoloration

-may evolve rapidly and reveal subQ tissue, fascia, muscle, etc.

dehiscence

unintentional separation of wound edges, especially a surgical wound

evisceration

separation of wound with protrusion of abdominal contents through the opening

-typ in obese, malnourished, immunocompromised

what to do for dehiscence or evisceration???

1. cover area w sterile moist NS-soaked 4x4s (gauze)

2. return pt to bed (supine) (semi fowler's)

3. call a code and provider immediately!!!

4. monitor LOC and VS

principles of sterile technique

1. Only sterile objects can touch sterile objects

2. Objects remain above waist level

3. Never turn your back on a sterile field

4. Outer 1" of any sterile field is contaminated

5. Open sterile packages away from you

6. Avoid moisture on the field- it is a wick

7. Consider any object contaminated if you have any doubt to its sterility

im assuming this is what she means... you get the idea... dont introduce infectious organisms to wound bed pls

what is the purpose of oropharyngeal and nasopharyngeal airways?

reduces the risk of aspiration and prevents the tongue from obstructing the posterior pharynx (therefore occluding the airway) in a pt who is UNCONSCIOUS but breathing independently!

when is suction applied with a trach?

suction is only engaged as the catheter is WITHDRAWN from the tracheostomy

when do you hyper-oxygenate a pt and how during tracheal suctioning?

hyper-oxygenate beforehand and between suction passes as needed to maintain adequate saturations

use AMBU bag or by incr vent O2 settings

symptoms that tell you a pt needs suctioned

-visible mucus that cannot be cleared from trach tube with a cough

-audible or visible secretions

-desat, difficulty breathing, pale/blue color around mouth or fingernails

-whistling noise from trach

-etc.

three primary chest tube components

1. collection chamber (2500ml)

2. water-seal chamber

3. suction control chamber

assessment of collection chamber function

-regularly measure and document drainage

-check for kinks or folds in the drainage tubing

-no blood please

assessment of water seal function

-ensure and maintain 2cm water level

-TIDALING is APPROPRIATE

-intermittent bubbling is NORMAL

-continuous bubbling is NOT NORMAL

what is tidaling?

the appropriate fluctuation of fluid within the water seal chamber during respiration (rise and fall with inspiration/expiration)

what does tidaling mean?

indicates the chest tube is patent

when does tidaling stop?

-lung has re-expanded

-tubing is kinked

-tubing is obstructed

what does continuous bubbling in the water seal chamber indicate?

an air leak

locate the origin quickly by searching the tubings and connections... drainage system may require replacement

assessment of suction control chamber

continuous gentle bubbling is NORMAL!

suctioning of the chest tube is...

ordered

does vigorous bubbling in the suction control chamber mean increased suction?

no... only causes water to dissipate more quickly

what is crepitus (subcutaneous emphysema)?

coarse, crackling sensation palpable over the skin when air abnormally escapes from the lung and enters the subcutaneous tissue

how to check for crepitus?

palpate the thorax

when do you palpate for crepitus?

as part of the ongoing assessment of a pt with a tension pneumothorax

when do you clamp a chest tube?

ONLY in these situations:

1. per order

2. checking for an air leak

3. changing the full device

4. strongly considering removal

chest tubes placed higher drain...

air (typically)