Things You See Over and Over Again Part Deux

Study Guides

ALCOHOL DTs

·        IV fluid replacement

·        Thiamin/niacin

·        Decrease stimuli

·        Orient client

·        Avoid restraint

·        Rest and nutrition

·        Monitor visitor’s

·        Assess for depression and suicidality

BLEEDING TENDENCIES

·        Check for hematuria, tarry stools,  Petechiae, ecchymosis, bleeding gums, coffee-ground emesis

·        Avoid injections where possible

·        Smallest needle possible

·        Maintain pressure to venipuncture for 5 minutes

·        Use an electric razor

·        Avoid contact sports

·        Use a soft toothbrush

·        Check stools and emesis

·        Prevent straining at stool

·        Report S&S shock

·        Avoid rectal temperatures and enemas

·        Monitor platelet count, PT, aPTT

·        Avoid blowing nose

BLOOD PRODUCT ADMINISTRATION

·        Check type, cross match, Rh factor

·        Two nurses should check simultaneously

·        Informed consent

·        Start infusion slowly-5mL/min for first 15 minutes

·        Stay with patient for fist 15-30 minutes

·        Use 19g needle

·        Check VS 15 minutes after infusion started

·        Change entire IV line for each unit

·        Stop if a reaction occurs

·        If phlebitis occurs- remove line and start elsewhere

·        Notify physician immediately of reaction

·        Treat shock or anaphylaxis

·        Send blood and urine sample to lab

·        Send tubing to lab

·        Give O2

·        Vs q1hr until completed

·        Report flank pain

·        Start with NS

BREAST SELF-EXAM

·        Lie down

·        Use finger pads

·        Use three levels for pressure

·        Move in a pattern

·        Examine in mirror for changes, dimpling

·        Perform once a month after menstrual bleeding has stopped

CARDIOVERSION

·        Informed consent

·        Withhold digoxin 4 hours before

·        Discontinue O2

·        Voltage 25-360 joules

·        Monitor EKG

·        Assess after for q15 minutes for 1 hour, q 30 for 2 hours, q1hr

COLOSTOMY/ILEOSTOMY

·        Stoma should be pink or beefy

·        Stoma should be above level of skin

·        Report immediately a stoma that is black or purple

·        Avoid foods that cause gas and odor

·        Irrigate with 500-1500mL/water, insert catheter 8cm and hang irrigation container at shoulder, clamp if patient complains of cramping, should flow in over 5-10 minutes

·        Teach stoma care

·        Burp flange

·        Inspect skin

·        Address altered body image concerns

·        Pouch opening should be 1/8 inch larger than stoma

·        Use skin barriers

·        Pat skin dry-no rubbing

·        Change appliance when 1/3 full

COR PULMONALE

·        Monitor for liver enlargement, dependent edema, anxiety, JVD

·        Weight daily

·        Give Digoxin

·        Give diuretics

·        Give ACEIs

·        Restrict Na

·        I+O

·        Skin care

·        O2 admin

DIETARY CONSIDERATIONS

CLEAR LIQUID

·        Water

·        Broth

·        Tea

·        Gelatin

·        Apple juice

FULL LIQUID

·        Clear liquid +

·        Milk

·        Pudding

·        Custard

·        Creamed soups

·        Ice cream

·        Sherbet

·        Fruit juices

SOFT

·        Pureed vegetables

·        Eggs

·        Tender meats

·        Potatoes

·        Cooked fruits

BLAND

·        Milk

·        Butter

·        Eggs

·        Custard

·        Cottage cheese

·        Strained cereals

·        White bread

·        Gelatin

·        Creamed soups

·        Potatoes

LOW RESIDUE

·        Minimizes intestinal activity

·        No whole rains, corn, beans

RENAL

·        Reduce protein, K and Na

DUMPING SYNDROME

·        No fluids with meals

·        Small, frequent meals

·        Avoid high-salt, high-CHO

·        Lie down 30-60 minutes after meals

·        Monitor for hypoglycemia 2-3 hours after eating

·        Monitor for vertigo, syncope, diaphoresis 5-10 minutes after meals

DVTs

·                     Homan’s sign

·                     Red, tender calf

·                     Difference in calf size bilaterally

·                     Edema and warmth

·                     Early ambulation

·                     SCDs

·                     TED hose

·                     Anticoagulants

·                     Avoid prolonged sitting and crossing legs

·                     Leg exercises q1h

·                     No pillows under knees

·                     Hydration

·                     Elevate foot of be with knees slightly flexed

·                     Signs and symptoms of pulmonary embolism

·                     INR/PT/PTT if on anticoagulants

·                     Peripheral pulses, cap refill, color of extremities

·                     Assess respiratory status frequently

EAR DROPS

·        Ear irrigation— method a. Tilt head toward side of affected ear; gently direct stream of fluid against sides of canal b. After procedure, instruct patient to lie on affected side to facilitate drainage c. Contraindicated if there is evidence of swelling or tenderness

·        Ear drop instillation— method a. Position the affected ear uppermost b. Pull outer ear upward and backward for preschoolers through adults (3 years of age and older) c. Pull outer ear downward and backward for infants and toddlers (under 3 years of age) d. Place drops so they run down the wall of ear canal e. Have patient lie on unaffected ear to encourage absorption

EKG MONITORING

·        QRS 0.04-0.12

·        P wave: QRS= 1:1

·        P-R interval 0.12-0.2

·        HR 60-100

·        Treat client not monitor

·        Check electrode placement

·        Check HR regularity

·        Check for presence of PVCs

·        Check for presence of U wave

·        Placement:

EYES DROPS

·        Eye irrigation— method a. Tilt head back and toward the side of affected area b. Allow irrigating fluid to flow from the inner to the outer canthus c. Use a small bulb syringe or eye dropper to dispense fluid d. Place small basin close to head to collect excess fluid and drainage

·        Eyedrop instillation a. Equipment must be sterile 1) Wash hands before instillation 2) Do not allow dropper to touch eye 3) Do not allow drops from eye to flow across nose into opposite eye b. Tilt head back and look up; pull lid down c. Place drops into center of lower conjunctival sac 1) Instruct client not to squeeze eye 2) Teach client to blink between drops d. To prevent systemic absorption, press the inner canthus near the bridge of the nose for 1-2 minutes

FALLS

·        Orient client

·        Bed in lowest position

·        Side rails up

·        No clutter

·        Have some light in room

·        Call bell within reach

·        Shoes when ambulating

·        Brakes on equipment

·        Braden scale

·        Be aware of sensory deficits

·        Plan for orthostatic hypotension

FLUID VOLUME DEFICIT

·        Check skin turgor

·        Daily weights

·        Check mucous membranes

·        Look for elevated HR/RR

·        Dark urine

·        Look for elevated Hct, Hgb

·        Hourly I+O

·        Replace fluids orally or IV

·        IV fluids will be LR or NS

·        USG

FLUID VOLUME EXCESS

·        Check lung sounds

·        Look for S&S left-sided heart failure

·        Monitor HCT and HGb

·        Weigh daily

·        Restrict fluids

·        I+O

·        Skin care

·        Semi-Fowler’s

·        Low sodium diet

·        Monitor K and EKG

·        Diuretics

·        Monitor edema

HYPERCALCEMIA

·       Watch for dysrhythmias and heart block

·       Watch for diminished LOC

·       IV 0.45% NaCl or 0.9% NS

·       Fluids

·       Lasix

·       Calcitonin

·       Restrict calcium in diet

·       Have patient move around

·       Monitor for calculi

·       Restrict calcium-containing antacids

HYPERKALEMIA

·        Assess EKG

·        Watch for cardiac arrest

·        Assess for muscle twitching and weakness

·        Restrict dietary K

·        Give Kayexalate

·        Have calcium gluconate ready for IV administration

·        Give sodium bicarbonate

·        Give regular insulin and dextrose

·        Diuretics

·        Prepare for dialysis

HYPOCALCEMIA/TETANY

·        Trousseau

·        Chvostek

·        Seizure precautions

·        Tingling

·        Oral calcium gluconate with orange juice

·        IV calcium gluconate

·        Caution with Digoxin- depressed cardiac function

·        Monitor airway for laryngeal stridor

·        Phosphate-binding antacids

·        Calcitrol

·        Vitamin D

HYPOKALEMIA

·        Monitor for muscle weakness, dysrhythmias

·        Watch if taking Digoxin

·        Oral K supplements given with meals

·        Increase dietary intake

·        IV 20-40 mEq, no more than 20 MEq/h

HYPOVOLEMIC SHOCK

·        Modified Trendelenberg

·        Large bore IV (16/18g)

·        Ambu bag

·        O2 admin

·        VS q 5 minutes

·        Monitor I+O

·        Possible drugs: atropine, dopamine, epinephrine, dobutamine, levophed, sodium bicarbonate

·        Monitor CVP

·        Large volume fluid replacement with LR , colloids, plasma expanders

·        Check for patent airway and adequate circulation.

·        Obtain and record the patient’s blood pressure, pulse and respiratory rates, and peripheral pulse rates.

·        Measure the patient’s urine output hourly.

·        Monitor the patient’s ABG and electrolyte levels frequently as ordered.

·        Watch for signs of impending coagulopathy such as petechiae, bruising, bleeding or oozing from guns or venipuncture site.

IICP

·        Watch for early signs: lethargy, stupor, vomiting, HA, pupil changes, diplopia

·        Watch for late signs: Cushing’s triad-widening pulse pressure, irregular/decreasing respirations, bradycardia

·        Prevent Valsalva maneuver

·        Give stool softeners

·        Restrict fluids <1500mL/day

·        Frequent VS checks

·        Neurochecks q2h

·        HOB 30-45

·        Head in neutral position

·        Avoid coughing/sneezing

·        Suctioning only as needed

·        Maintain maximum respiratory exchange

·        Give O2

·        Monitor I+O

·        Avoid opiates and sedatives

·        Give osmotic diuretics

·        Induce hypothermia

·        Reduce environmental stimuli

INFECTION

·        Monitor for heat, redness, swelling, drainage, pain, pus, cellulitis, fever and weakness

·        Monitor WBCs >10,000, elevated ESR and positive cultures

·        Use standard precautions

·        Hand hygiene

·        Use clean gloves when touching bodily fluids

·        Change gloves between procedures

·        Use eye protection and masks when there is a possibility of splashes/sprays

·        Use gown when there is a possibility of splashes or excretions

·        Use mouthpieces for resuscitation

KIDNEY FUNCTION

·        USG (1.010-1.030)

·        Color for urine

·        Urine should be negative for glucose, protein, RBCs, WBCs

·        pH 5-8

·        BUN 7-20

·        Creatinine 0.5-1

·        Uric acid 3.5-7.8

·        Check meds/conditions that could alter kidney function

LIVER FUNCTION

·        Monitor RUQ pain

·        Alkaline phosphate

·        PT time

·        Blood ammonia

·        Cholesterol

·        Bilirubin

·        ALT

·        AST

·        Check meds/conditions that could alter liver function

MASTECTOMY POST-OP

·        Monitor bleeding

·        Operative arm on pillow, slightly elevated

·        No BP, venipuncture in affected arm

·        Avoid injuring affected arm

·        Squeeze ball

·        Encourage to use arm- brush hair etc.

·        Exercise arm

·        Treat psychological issues

·        Refer to support groups

·        Reconstructive surgery

MODIFIABLE RISK FACTORS

·        Alcohol use

·        Diet

·        Smoking

·        Exercise

·        Weight

·        Cholesterol

·        Stress

·        Exposure to sunlight

·        Exposure to pollution

·        Diabetes control

·        BP

·        Hormone therapy

·        Vitamin and mineral intake

NEUROCHECK

·        Check for abnormal posturing

·        Check pupil changes

·        Use Glasgow coma scale

·        Check reflexes

·        Monitor for Cushing’s triad

·        Monitor LOC

·        S&S IICP

·        Assess cranial nerve function

·        VS

·        Hand grips

·        Gait

·        Orientation/alertness

·        Speech

·        Look for ptosis

·        Assess ability to feel and touch

·        Assess for tremors

·        Assess muscle tone

·        Assess for presence of abnormal reflexes

NEUTROPENIC PRECAUTIONS

·        Check skin integrity

·        Check breath sounds

·        Temp q4h- report over 101F

·        CBC

·        Monitor S&S infection

·        Hand hygiene

·        No fresh flowers

·        No standing water

·        Low microbial diet

·        TCDB

·        Meticulous body hygiene

·        Inspect IV sites

·        Keep visitors with respiratory infections away

NON-PHARMACOLOGICAL PAIN INTERVENTIONS

·        TENS

·        Relaxation

·        Meditation

·        Yoga

·        Herbal remedies

·        Acupuncture

·        Therapeutic touch

·        Guided imagery

·        Exercise

·        Distraction

·        Biofeedback

·        Heat/cold

·        Massage

·        hypnosis

O2 ADMINISTRATION

TYPE:

·        Nasal cannula   20-40% 1-6L/min-care of nostril and mouthcare

·        Face mask 40-60% 5-8L/min –skin breakdown

·        Partial rebreather 50-75% 8-11L/min-reservoir bag should be 2/3  full

·        Non-rebreather 80-100%

·        Venture 24-55% 4-10L/min

·        Trach collar 24-100% 10L/min-keep water container full

INTERVENTIONS

·        Watch for infection

·        Change tubing daily

·        Humidify O2

·        Watch for S&S respiratory depression

·        Watch for S&S toxicity and lung damage

·        Watch for congestion, sore throat, substernal discomfort

PAP SMEAR

·        Start at age 21 or after have been sexually active for 3 years

·        Annually until age 39

·        Every 2-3 years if three consecutive normal results

·        >70, stop if 3 consecutive normal results in the last ten years

POISONING

·        Identify poison

·        Save vomitus

·        Teach prevention

·        Stop exposure

·        Give large amounts of fluid

·        ABCs

·        No milk

·        Watch F&E imbalances

·        Cardiac monitoring

·        O2

·        Monitor liver and kidney functioning

·        Gastric lavage-no more than 10mL/kg/in one hour

·        Give diuretics

·        Give chelation

·        Give activated charcoal

·        Induce vomiting unless position is a petroleum derivative or corrosive

·        For aspirin- reduce temperature, vitamin K, IV sodium bicarbonate

·        For lead- BAL, succimer and Desferal

·        For Tylenol-Mucomyst

POST-OP-GENERAL

·        Airway

·        Return of gag, cough and swallowing reflexes

·        LOC

·        Circulation

·        NPO until bowel sounds return

·        I+O

·        Urine quality

·        IV type and fluids

·        Dressings

·        Drainage tubes

·        NG tube

·        Cough/DB q1h

·        Incentive spirometer

·        Semi-Fowler’s unless contraindicated

·        Pain control-teach PCA

·        Cardiovascular status

·        Breath sounds

·        Splint wounds

·        Ambulate ASAP

·        Look for abd distention

·        Monitor for DVTs

·        VS q 15 min X 4, q 30 mins X2 q 1hr x2, as needed

·        Watch for:

v Atelectasis

v Pneumonia

v Hypoxia

v Nausea

v Shack

v Urinary retention

v Hemorrhage

v Wound problems

v Thrombophlebitis

v Infection

v UTIs

POSTURAL DRAINAGE/CHEST PHYSIOTHERAPY

CHEST PHYSIOTHERAPY

·        Do in the morning, 1 hour before meals and 2-3 hours after meals

·        Use cupped hands

·        Have a layer of material between hands and chest

·        Client should cough and deep breath during

·        Oral care after

·        Stop if painful

POSTURAL DRAINAGE

·        Lung segment to be drained is up

·        Positions used: head down, prone, right and left lateral and upright-each position is done 5-10 minutes

·        Remove secretions by coughing or suctioning

·        Do on arising, 1 hour before meals, 203 hours after meals

·        Mouthcare after

·        Monitor VS, cyanosis, ICP

PRURITUS

·        Give antihistamines

·        Baking soda bath

·        Trim nails

·        Use soft linen

·        Keep room temperature moderate

·        Prevent dry skin

·        Apply mittens

·        Turn q2h

RADIATION

BEAM

·        Do not remove markings

·        Avoid lotions, deodorant and perfumes

·        Vitamin D&A ointment permitted

·        Assess skin for redness

·        Assess skin for cracking

·        Antiemetics

·        No tape

·        No sunlight

·        Cotton clothing

INTERNAL

·        Client is NOT radioactive

·        Private room

·        No pregnant caregivers

·        Lead-lined container available

·        Secretions ARE radioactive

·        Wear dosimeter

·        Have ‘caution radioactive materials’ sign on door

·        Limit contact to 30mins per 8hr shift

·        Organize tasks

SEIZURE PRECAUTIONS

·        Airway

·        Turn to side

·        Do not restrain

·        Do not put anything in mouth

·        Loosen clothing

·        Have resuscitation/airway equipment ready

·        Document length

·        Keep safe in post-ictal phase

·        Side rails up and padded

·        Suctioning available

·        Reorient post-ictal

·        Reduce environmental stimuli

SIADH

·        Check LOC, HA, tachycardia, recued UOP

·        Restrict fluids

·        Diuretics

·        Hypertonic saline

·        Declomycin

·        Daily weights

·        I+O

·        Monitor Na levels

SKIN CARE

·        Turn q2h

·        Keep skin dry and clean

·        Ambulate if possible

·        Avoid shearing forces-use draw sheet

·        Proteins and vitamins

·        Special mattresses

·        Protect heels

·        Remove potential irritants

SPUTUM SAMPLE

·        Drink extra fluids nigh before test

·        Rinse mouth with water prior

·        No eating, brushing teeth mouthwashes before

·        Use a sterile container

·        Teach client how to expectorate

·        Early in morning

·        Before first dose of ABX

SUCTIONING

·        Assess need for suctioning

·        Wear protective eyewear

·        Hyperoxygenate before and after suctioning–100% oxygen for 3 min, at least 3 deep breaths

·        Explain procedure to patient (potentially frightening procedure)

·        Elevate head of bed to semi-Fowler’s position

·        Lubricate catheter with sterile saline and insert without applying suction

·        Advance catheter about 16– 20 cm; client will begin to cough; do not apply suction

·        Withdraw catheter 1– 2 cm, apply suction and withdraw catheter with a rotating motion for no more than 10– 15 seconds; wall suction set between 80– 120 mm Hg

·        Hyperoxygenate for 1 to 5 min or until patient’s baseline heart rate and oxygen saturation are reached

·        Repeat procedure after patient has rested, up to 3 total suction passes

·        Endotracheal tube or tracheostomy tube suctioned, then mouth is suctioned; provide mouth care

·        Complications:

a. Hypoxia b. Bronchospasm c. Tissue trauma d. Vagal stimulation e. Cardiac dysrhythmias f. Infection

TESTICULAR SELF-EXAM

·        Start age 14

·        Same time each month

·        After a shower

·        Lumps and swellings are unexpected findings

TPN

·        Chest Xray for placement

·        Check residuals

·        Check placement

·        Elevate HOB

·        Administer at room temperature

·        Initial rate is 50mL/hr

·        Monitor for hyperglycemia

·        Hang 10% dextrose if new bag not available

·        Monitor for FVE

·        Monitor for air embolism

·        Change tubing q24h

·        Do not try to catch up if behind

·        Taper when discontinuing

TRACH/TRACH CARE

·        Tracheostomy care— performed every 8 h and as needed

·        Suction tracheostomy tube

·        Remove old dressings

·        Open sterile tracheostomy care kit 5

·        Put on sterile gloves

·        Remove inner cannula (permanent or disposable)

·        Clean with hydrogen peroxide if permanent inner cannula

·        Rinse with sterile water, dry

·        Reinsert into outer cannula

·        Clean stoma site with hydrogen peroxide and sterile water, then dry

·        Change ties or velcro tracheostomy tube holders as needed; old ties must remain in place until new ties are secured

·        Apply new sterile dressing; do not cut gauze pads

·        Document site of tracheostomy, type/ quantity of secretions, patient tolerance of procedure

TRACTION/CASTS

TRACTION

·        Weights should hang freely

·        Body alignment

·        Pincare q shift

·        Consult PT

CASTS

·        Handle with wet palms

·        Check neurovascular integrity

·        Air dry

·        Ice for pain

·        Elevate on pillow

·        5 Ps-pain, pallor, pulselessness, parasthesias, paralysis

·        Petal edges

·        Skin integrity

·        Do not scratch underneath

·        Teach crutch walking

·        ROM for unaffected extremities

VISUAL IMPAIRMENT

·        Identify yourself when entering room

·        Do not touch unless you let the know you are about to

·        Provide visual aids

·        Call bell within reach

·        Orient to the environment

·        Adequate lighting

·        Provide tools that can help compensate for diminished vision

·        Assist with meals- clock system

·        Assist with ambulation as needed

·        Assistive devices accessible

WOUNDS

·        Document amount and character of drainage

·        MD changes first postop dressing c. Aseptic technique d. Note presence of drains

·        Incision  assessment: edematous, inflamed, excoriated b. Assess drainage: serous, serosanguineous, purulent

·        Note type of sutures

·        Note if edges are well approximated

·        Anticipate infection 3– 5 d postop

·        Debride wound, if needed, to reduce inflammation

·        Change dressing frequently to prevent skin breakdown around site and minimize bacterial growth

·        Check drains

·        Teach splinting

·        Cover evisceration with sterile saline-soaked gauze

Kaplan (2012-05-10). The Basics (Kindle Locations 5082-5086). Kaplan. Kindle Edition.