lab review

• 1. provide immobilization of body part
• 2. prevent or reduce swelling by allpying pressure
• 3.
• hold a dressing in place on a limb
• 4. secure limb to a slpint
• 5. retain warmth

• ace bandage
• clips or tape

apply dressing (observe for any abrasions)

5 cm (2in)

2.5 cm (1in)

7.5 cm (3-4in)

pad bony prominences and separate skin surfaces that would other wise  touch

by two thirds the width with each turn

• Circulation
• Movement
• Sensation
• check for pallor or cyanosis
• check for color BEFORE to establish baseline

slightly flexed

upward

• distal to proximal
• medial to lateral

even firm pressure

distal part to check circulation

for holding dressing in place. or cover cylindrical part of body. two cicrular turns to anchor, and two circular turns to complete process

for elbow, knee, or ankle.  anchor w two circular turns below joint then go above then below in figure 8 and end w 2 circular turns above joint. (over lap by 2/3's)

used for straight arms and legs. bandage ASCENDS distal to proximal in a spiral manner so that each turn overlapsthe proceeding one by 2/3's

for head, stump or hand.  anchor w 2 circular, around proximal body part then fold bandage back on itself brought centrally over distal end to be covered. and so on

for iron IM and heparin sub-Q.  To give solutions that are highly irritating to the skin

• 1. injetion given w/o complications
• 2. painless as possible
• 3. med enters blood stream and is used by tissues
• 4. minimize damage to sub-q and skin tissues

surgical

you may need to check it with another nurse

usually 90 depending on pt size

TB syringe (3/8-5/8 inch, 25-27 gauge)

1 1/2 to 3 inch 19-20 gauge needle

• chart
• MAR
• 1 1/2 to 3 inch 19-20 (iron) gauge needle
• 3cc syringe w needle
• vial
• alcohol pledget
• 2x2 gauze
• gloves

change it to prevent irritating substance from getting on skin

ventro gluteal and dorso gluteal (dorso gluteal for iron)

use abdomen and its sub-q 1-2 inches from umbilicus and above iliac crest

1-1 1/2 inches

never aspirate for heparin, for all else 5-10 seconds

10 seconds per ML and leave in skin 10 seconds afterward before withdrawing

massage site

NO!!!

tiht clothes and exercise

25-27 gauge 3/8 to 5/8 inch needle

PTT (60-70 sec) and APTT (30-40 sec)

protamine sulfate

thrombocytopenia

• wound granulates and healing process occurs
• wound is free of pathogenic microoragnisms
• sterility is maintained

• sterile dressings, ABDs, 4x4's drain sponge
• tape or montgomery ties
• clean gloves
• sterile gloves
• cleaning solution or normal saline
• plastic bag
• chux

Shellfish

• set up sterile field
• put on disposible (not sterile) gloves
• remove old dressing (pull tape toward wound while holding down skin) toss in trash, remove dirty gloves
• (put on sterile gloves)
• note ACCO of drainage and how many sponges used
• clean wound if ordered by pouring sterile solution over gauzes
• clean wound holding gauze by 4 corners cleanist to dirtiest area (inward to out)
• apply 4x4's
• apply ABD pad
• secure with tape or montgomery straps
• label

with initials, date and time

• to maintain or restore pt's fluid balance (electrolyte and acid base)
• to admin meds
• to provide access for meds
• to maintain nutritional status
• to admin blood products

• sterile iv solution
• sterile iv tubing
• iv pole
• iv label
• tape
• antiseptic solution (alcohol or iodine)
• transparent dressing or 2x2 gauze
• gloves

• pt name and room #
• IV solution amount
• dosage and any additives
• absorbtion time
• drip rate
• time hung
• container number
• signiture

• hang bag on pole
• clamp tubing closed
• spike bag
• connect tubing to bag
• fill drip chamber
• release tubing clamp and let fluid run thru tubing (prime it)
• check for bubbles (air)
• attach to saline lock
• anchor with tape

• put amout of solution on top
• (i.e. 1 liter=1000mls)
• put time on bottom (i.e. 8 hours)

• 1000mls 
•  8hours
• (125 mls/hour)

• take volume (how many mls in bag i.e. 1000) and break down into mls/hour
• (need to know how many hours for infusion to do so, we will assume 8
• hours) 1000/8 = 125mls/hr
• so 125mls goes on top and 60 (time in mins) goes on bottom multiply that by gtt factor on top then
• divide by time on bottom...do math short cut if applicable

• infusion rate*gtt factor
•        time in mins

• 125mls*15 gtt/ml
•        60 mins

• put volume in mls (i.e. 1000 mls)
• over mls per hour (ex 125mls/hr)

•  1000mls
• 125mls/hr

ans (8 hours)

when you don't know the mls per hour figure that out first. or to get infusion rate break down the problem to a mls per hour problem. ex 1000mls to go over 8 hours would be 125mls per hour, now you can figure out drops per min cuz 125 mls * gtt/mls over 60 mins

• hematoma
• infiltration
• site infection
• phlebitis
• clotting
• circulatory overload
• air embolism
• catheter embolism
• systemic infection
• speed shock
• allergic reaction

• raised discolored area caused by leakage of blood at venepuncture site
• tenderness and bruising
• remove IV apply compress
• warm soaks
• document
• prevent by not advancing needle past point of resistance, choose right sized needle

• leakage of iv fluid into tissue
• S/S blanched skin, swelling, decreased skin temp, slow flow
• cause, needle dislodged from vein
• remove IV, warm soaks, elevate extremity restart IV document
• prevent by checking site frequently

• irritation along vein
• S/S vein hard and cordlike when palpated
• sore, red and tender
• causes
• hypertonic solutions
• repeated use of same vein
• catheter too large
• clotting at tip of catheter
• remove IV, warm soaks, notify doctor, restart IV, document
• prevent by using central line for irritating solution, rotate site per policy, limit movement w stabilization

• local contamination of insertsion site
• S/S redness, warmth, tenderness, swelling at site, possible exudates of infectious material
• causes: failure to maintain aseptic technique during insertion, IV longer then recommended time
• nursing action: remove IV, warm soak, notify MD, restart IV, document

• blockage at end of device in pt vein
• S/S unable to flush, tenderness at site, sluggish flow rate
• causes: IV too slow, hep lock not heparinized (no flush) IV bag runs dry
• remove IV, warm compress, document
• prevent by maintaining constant flow as ordered, use non dominant side, don't use force when flushing IV

• More fluid than circulatory system can manage
• S/S Discomfort, neck vein distention, high blood pressure, fluid in lungs, SOB, dyspnea
• causes: infusion rate too fast, miscalculation, never play catch up, positional IV
• slow infusion to KVO, elevate HOB, notify MD, administer meds, O2, monitor vital signs, document
• DO NOT REMOVE IV
• prevention: know cardiovascular history
• monitor lung/breath sounds
• monitor I&O
• maintain and monitor infusion rate
• assess frequently

• air in circulatory system
• S/S sudden chest pain, SOB, lightheadedness, decreased BP, weak rapid pulse, anxiety, pleuritic pain, decreased or loss of consciousness, cyanosis
• causes: loose connections in the IV system, intro of air during catheter placement, air pumped into the circ system via electronic device, IV tubing not purged of air
• hang new solution at KVO rate, position pt in lateral left trendelenberg (allows air to enter right atrium and be dispersed via pulmonary artery) administer oxygen, vital signs, notify MD, reassurance, documentation
• prevention: prime tubing, clamp central line catheters before removing caps or change tubing. do not use scissors near IV tubing

• a sudden adverse physiologic reaction to IV meds that are administered too quickly. Some signs of speed shock are a flushed face, headache, a tight feeling in the chest, irregular pulse, loss of consciousness, and cardiac arrest.
• discontinue drug infusion, begin infusion of dextrose 5% in water at KVO rate, notify MD
• prevent by following manufactures guide lines before giving any meds

• S/S itching, rash, SOB, generalized body edema, increased blood pressure, decreased pulse and respirations
• cause: sensitivity
• change IV to dextrose 5% and slow to KVO, notify MD
• prevent by asking questions about history and allergies, check chart, wristband, stay for 10-15 mins when infusing a new med for the first time

• introduction of microoganisms into the circulatory system
• S/S rapid _________ elevataion, chills, shaking, nausea, vomiting, malaise
• causes: contaminated IV device, or solution, failure to maintain asepsis, immunosuppression, device in vein longer than recommended
• notify MD, ID possible causes, remove IV per policy, culture tip, document
• prevention: examine fluid and tubing, moniter VS, maintain asepsis, change site and tubing

• all or part of IV device shears off into venous system
• S/S related to specific location of embolism, discomfort, decreased BP, cyanosis, thready pulse, respiratory distress, unconsciousness, possibly no signs at all, chest pain
• causes: use of scissors near IV, movement on insertion or removal, device not secured effectively
• apply tourniquet, notify MD, stop IV infusion, restart IV in opposite extremity at KVO rate, document that catheter intact

• maintain sterility
• maintain patency of site
• prevent complications of IV therapy such as phlebitis and infiltration

• secondary tubing
• antiseptic wipes
• neddles syringe
• appropriate med/solution
• gloves

date, drug, dosage, IV solution name

hang primary solution on secondary hanger lower than secondary solution, hang secondary solution on other side of pole higher than primary solution, spike tubing (and proceed as you would with any IV solution)cleanse upper Y port on primary tubing from primary IV, and insert secondary tubing into primary tubing thru Y port, open secondary tubing flow clamp

keeps flow of secondary solution from going into primary bag. located on primary tubing, the secondary solution hangs higher than primary, as piggyback solution empty backcheck valve moves downward which allows primary solution to begin infusing

• maintain sterility
• maintain patency of saline port
• prevent complications
• safely administer medication
• understand SASH method

• needles injection cap with primed extension tubing and port (hep/saline lock)
• 2 normal saline needless syringes or one
• med syringe or IVPB w primed primary tubing
• antimicrobial swabs
• clean gloves
• gauze
• band aid

yes

flush again

close slide lock on port on IV, flush using SASH method then reattach

clamp port or pinch tubing, attach syringe, inject med intermittently allowing IV solution to flow

• relieve discomfort due to bladder distention
• asses amount of residual urine
• obtain urine specimine
• empty bladder completely prior to surgery

• Deltoid (arm)
• ventragluteal (side of thigh by greater trochanter)
• dorsal gluteal
• rectus femoris (top of thigh)
• vastus lateralis (side of thigh)

• mask
• goggles
• gown
• gloves

• gloves
• mask
• gown
• goggles

• Attach 5ml syringe
• aspirate
• flush with 3-5 mls of saline
• attach IVPB med
• when infusion complete disconnect med
• flush again slowly with with 3-5mls
• document

• make sure med can be given on unit
• check IV fluid compatibility
• use port closest to patient
• close slide lock above port
• if incompatible
• Flush
• attach med syringe to port and inject med
• flush again
• then undo slide lock to allow IV to continue infusing
• if compatible
• pinch tubing (or use slide lock)
• clean port
• no need to flush
• attach med syringe to port and inject med
• allow IV fluid to flow intermittently while giving med (med/IV/med/IV) 
• remove syringe and make sure IV slide lock is open to allow IV fluid to flow
• Document

• sterile catheterization kit
• gloves (sterile)
• betadine
• drapes
• cotton balls
• forceps
• water soluble lubricant
• appropriate size catheter
• a receptacle for the urine
• a specimen container
• a flashlight
• disposable gloves

on your dominant side

• frog position
• supine with knees flexed and thighs externally rotated (dorsal recumbant)

750 mls, don't want to cause hypovolemic shock

from the inside

non-dominant

between patients thighs

poor antiseptic solution over cotton balls

• drape pt for privacy
• do perineal care
• set up sterile field (including gloving)
• pour antiseptic over cotton balls
• lube cath tip
• separate labia or pull back foreskin (if applicable) this becomes "dirty hand"
• wipe with cotton ball (swipe/drop/new cotton ball/swipe/drop)
• place drainage end of cath tip in receptacle
• then with sterile hand pick up cath tip and insert
• (5cm) 2inches in for adult and 2.5 cm/1inch for child
• collect urine specimen if req (30 ml)
• empty bladder up to 750mls
• remove
• dry pt remove equip
• document A.C.C.O

firm but steady pressure at 90 degree angle

• to provide route for
• lavage (big tube to clean out)
• gavage (tube feed)
• decompression (ng suctioning)

• appropriate tubing
• large syringe
• emesis basin
• tissue
• tape
• towel
• stethoscope
• glass of water with straw
• water soluble lubricant
• suction equipment
• hoffman clamp (gum band)
• nonsterile gloves
• flashlight
• tongue blade
• rubber band and safety pin

• high fowlers
• (may be inserted in side lying or supine position)

measure from nose to earlobe and from ear to xiphoid process (for child same except go to middle of xiphoid process and umbilicus)

non sterile

4-6 inches

Nostril with most airflow (non stuffy side)

towards ear on the same side as nostril you are entering and twist 180 degrees as you advance

oropharynx

• place stethoscope over stomach and pust 5-20ml of air and check for "whoosh" sound
• aspirate gastric content and check PH
• xray verification
• (observe for resp distress)

time, tube type, what procedure was done, how pt tolerated procedure, and position of the tube

• place pt in high fowlers
• turn off suction if applicable or stop feeding
• inject 30cc of air to clear tube of contents
• clamp tube to prevent aspiration
• tell pt to take deep breath and exhale slowly as you pull tube out

hold feeding and call doctor

room temp (to prevent cramping or GI upset)

no more than 18inches above pt

high fowlers

check for residuals in stomach (by aspirating contents of stomach), if more than 100 (or 50 depending on policy) then hold feeding...always return aspirated residuals

20-35 mins unless continuous

flush with water (check order for prescribed flush amt)

• amount of residual
• time of feeding
• total cc over period
• name of formula
• how pt tolerated feeding
• amount of H20 given

0.8-5 (normally 2-3)

7.4

7.5-8

• NG 30-60mls
• Gtube 30ml (use sterile water if new GT for 2weeks)
• air auscultate
• 5-20mls of air

• do initial flush of 30ml
• then give med
• then 10mls of water between each med
• then flush with 30mls of water to clear tubing

• completed without complications
• painless as possible
• exact dosage is given allowing it to be absorbed promptly and utilized by the tissues
• injection sites are rotated to avoid tissue damage

• correct vial of insulin based on prescription
• correct syringe
• alcohol swabs

you want to try to give it at the same time each day (usually 15-30 mins before breakfast and evening meal) *remember lispro must be given at the time food arrives and first bite is about to be taken*

gently roll between fingers

push in amount of air equivalent to amount you are going to withdraw

first draw up amount of air for cloudy (NPH) then inject it, then draw up amount of air for clear and inject it, then withdraw amount of clear then go back and withdraw amount of cloudy...so order is clear then cloudy

have another RN check your dose

within one inch of navel or belt line

scapular site (if enough sub-q fat is there)

thin person with 1/2 inch needle go in 90 degrees..."fluffy person" 1/2inch needle go in at 45 degrees

yes (smh)

once every two months

a one inch square

what site was used (may use site chart if available)

• remove secretions that obstruct the airway
• facilitate ventilation
• obtain secretions for dx purposes
• prevent infection that may result from accumulated secretions

• towel
• wall or portable suctioning unit
• sterile disposable container for fluids
• sterile norm saline or water
• sterile gloves
• sterile suction cath kit
• water soluble lube
• Y-connector
• trash bag

• infant 50-95
• child 95-100
• adult 100-120

• infant 2-5
• child 5-10
• adult 10-15

semi-fowlers with head turned for oral and neck hyperextended for nasal

dominant hand which will hold suction catheter

100mls

test to see that suction cath is working by testing a small amount of the sterile water

increase O2 to 100% or what ever is ordered by physician

measure from pt's nose to ear lobe without touching cath to pt

do not apply suction going in, only coming out and do intermittently as you pull out cath for no longer than 10 seconds

can cause cardiopulmonary compromise, from hypoxia or vagal overload

1-2 mins to allow oxygenation

nasal first (considered sterile) then rinse with sterile water, then oral

detach from wall or portable unit, roll catheter in glove and dispose

• gastric = yellow
• intestinal = yellowish green cuz of bile

80-100mg

open items farthest away first to prevent contamination by reaching over items

in drug book

piggyback should hang higher than primary IV

dial it to 2

for one minute or 30 sec times 2

NEVER REMOVE FIRST SURGICAL DRESSING

anti coagulant that comes in pre-filled syringe, DO NOT EXPEL BUBBLE FROM SYRINGE BEFORE INJECTION AND DO NOT ASPIRATE

thrombocytopenia

PTT & INR

• bleeding gums
• epistaxis
• petechiae
• ecchymosis
• severe headache
• abdominal and or back pain
• dark red urine and or stools
• decrease in BP
• and or decreased hematocrit