~Important~
Asepsis Principles & Sterile Technique
● Major mode of transmission for pathogens identified in health care settings is unwashed
hands of a healthcare worker
● Asepsis: prevention of infection or breaking the chain of infection
○ Medical asepsis: clean technique, involves procedures and practices that reduce
the number and transfer of pathogens
■ Ex. hand hygiene, wearing gloves, giving a flu shot, nasogastric tubes
○ Surgical asepsis: sterile technique, practices used to keep objects and areas free
from microorganisms THINK: surgeries require STERILE environment
■ Ex. urinary catheter, IV catheter, sterile dressing change
○ Proper hand hygiene includes
■ Moment 1 – before touching patient
■ Moment 2 – before clean or aseptic technique
■ Moment 3 – after body fluid exposure risk
■ Moment 4 – after touching patient
■ Moment 5 – after touching patient surroundings
○ If hands are not visibly soiled → use alcohol based hand rubs for 15 seconds
■ Saves time, more accessible, and reduces bacterial count on hands
● Medical asepsis (clean technique) → reducing number of organisms present and
preventing the transfer of organisms
○ Good hand hygiene techniques https://www.youtube.com/watch?v=G5-Rp6FMCQ
■ Scrub for at least 20 seconds with 1 tsp of soap
■ Do not let your clothes touch the sink
■ Soap and water is the best technique!!
● Use when:
○ Hands are visibly dirty
○ Soiled with blood or bodily fluids
○ Before eating
○ After using the toilet
○ Exposure to spore-forming organisms
○ Start and end of shift
○ Carry soiled items away from the body to prevent touching
○ Do not place any soiled linen or other items on the floor – increases
contamination
○ Avoid allowing patients to cough, sneeze, or breathe directly on others “cough
etiquette”
■ Maintain separation of 3+ feet from person with respiratory infection
(unless wearing PPE)
○ Dispose of soiled or used items directly into appropriate containers
~Important~
■ Feces and urine → toilet
■ Contaminated items, such as blood → biohazard bag
○ Sterilize items that are suspected of pathogens
● Surgical asepsis (sterile technique) → the absence of all microorganisms “surgery
requires sterile” https://www.youtube.com/watch?v=lumZOF-METc
○ The 7 principles of sterile technique
■ Sterile objects remain sterile only when touched by another sterile object
■ Only sterile objects may be placed on a sterile field
■ A sterile object or field out of range of vision or an object held below a
person’s waist is contaminated (do not leave sterile environment)
■ Sterile objects become contaminated by prolonged exposure to air
■ When a sterile surface comes in contact with a wet, contaminated surface,
the sterile object or field becomes contaminated by capillary action (think
of what happens with a paper towel in water)
■ Avoid spilling fluids on a cloth or paper sterile field
■ The edges of a sterile field or container are considered to be
contaminated (~1 inch)
○ Open sterile packages AWAY from you
■ Prevents accidental contamination
○ Consider an object contaminated if you have any doubt as to its sterility
○ Avoid talking, coughing, sneezing, or reaching over a sterile field
PPE & Isolation Precautions
● Standard precautions
○ Standard use in the care of all hospitalized patients regardless of diagnosis;
prevent and control infection
○ Applies to blood; all body fluids, secretions, and excretions, non intact skin, and
mucous membranes
○ Protects patients AND healthcare worker
○ Follow hand hygiene (SOAP & WATER = BEST)
○ Wear clean, nonsterile gloves; change gloves between tasks on the same patient,
as necessary, and remove gloves promptly after use
■ When encountering body fluids, mucous membranes, etc.
○ Wear PPE = mask, eye protection, face shield, gown
■ Use goggles with invasive procedures that may result in splattering of
blood or bodily fluids
■ Remove PPE before leaving the room
○ Avoid recapping needles; always place needles, sharps, and scalpels in
appropriate puncture-resistant containers after use
○ Follow respiratory hygiene/cough etiquette
○ Keep the room clean
~Important~
■ CLEAN TO DIRTY
○ Use safe injection practices
● Transmission-based precautions https://youtu.be/EknQ4CudbEw
○ Used in addition to standard precautions for patients with suspected infection that
can be transmitted by airborne, droplet, or contact routes
○ Airborne precautions: prevent transmission of pathogens through air via
moisture or dust particles
■ THINK “MTV is on the Air” – Measles, Tuberculosis, Varicella (chicken
pox) + COVID
■ Place patient in a private room that has monitored negative air pressure;
keep door closed and patient in room
■ Transport patient out of room only when necessary and place surgical
mask on the patient if possible
■ Healthcare workers wear a respiratory mask (N95 or higher)
○ Droplet precautions: prevent transmission through coughing, sneezing, talking,
etc. by an infected person, creating large droplets that are inhaled by others
■ Diphtheria, Rubella, Adenovirus, Pneumonia (DRAP)
■ Private room required
■ Transport patient out of room only when necessary and place mask on the
patient if possible
■ Keep visitors 3ft away from the infected person, must also wear a mask
○ Contact precautions: prevent transmission of infectious agents that are spread by
the direct or indirect contact with the patient or the patient’s environment
■ For patients who are infected by MRSA, C. diff, VRE, etc.
■ In the presence of excessive wound drainage, fecal incontinence, or other
discharges from the body
■ Place patient in private room if available
■ Wear gloves and a gown whenever you enter the room for all interactions;
wash hands with an antimicrobial or antiseptic agent when leaving the
room
● Use disposable equipment
■ Limit movement of the patient out of the room → patients MUST wear
correct PPE when leaving
● Protective precautions: to protect the patient when they are immunocompromised
○ Positive-pressure airflow, no fresh flowers or plants, no sick visitors
○ PPE depends on the individual patient
○ Ex. transplants, chemotherapy
● Personal Protective Equipment (PPE)
https://www.youtube.com/watch?v=iwvnA_b9Q8Y
○ Applying/Donning PPE (GowMaGoGlo)
~Important~
■ 1. Gown
■ 2. Mask
■ 3. Goggles
■ 4. Gloves
○ Removing/Doffing PPE (GGGM)
■ 1. Gloves
■ 2. Goggles
■ 3. Gown
■ 4. Mask
Type of
Precautions
PPE Required
Gown
Mask
Airborne
X
X (N95)
Droplet
X
X (surgical)
Contact
X
Goggles
Gloves
X
X
X
X
Safety
● Risk factors
○ #1 risk = history of falls
○ Primary cause of unintentional injuries throughout life → older adults (65+) and
children are at highest risk
○ PRIMARY CAUSES OF FALLS
■ Age 65+
■ History of falls
■ Impaired mobility
■ Cardiovascular changes (orthostatic hypotension)
● Dizziness, weakness, might pass out
■ Vision impairment
■ Confusion
■ Anesthesia
■ Toileting !! most falls occur here
● Factors affecting safety
○ Developmental considerations
■ Neonate → infection, falls, and SIDS
● Never leave infant unattended
● Use crib rails
~Important~
■
■
■
■
■
● Choking hazards → toys, pillows, etc. in cribs
● Use car seats properly → rear facing car seats in the back seat
Toddler → falls, cuts, burns, suffocation/drowning, and inhalation or
ingestion of foreign bodies
● Childproof environment
● Poison prevention control – always call PPC FIRST
● Use car seats properly
School-aged child → burns, drowning, broken bones, concussions,
inhalation/ingestion, guns and weapons, substance abuse
● Interventions for safety at home, school, and neighborhood
● Bicycle safety
● Child abduction awareness
● Wear seatbelts
● Accidents and injuries are COMMON
Adolescent → motor vehicle accidents, drowning, guns and weapons,
inhalation/ingestion
● Safe driving skills
● Avoidance of tobacco and alcohol
● Risk of infection with body piercing
● Guns and violence
Adult → stress, domestic violence, motor vehicle accidents, industrial
accidents, drug and alcohol abuse
● Unsafe health habits and coping strategies
● Effects of stress on lifestyle and health
Older adult → falls, motor vehicle accidents, elder abuse, sensorimotor
changes, and fires
● Accident prevention
● Orient person to their surroundings (call bell, restroom, etc)
● Safe home environment and medication safety
● Interventions
○ Assess your patient
○ Fall risk band (yellow)
○ No-skid socks
○ Keep room clear and clean
○ Call light and personal belonging need to be within reach
○ Beds locked and in lowest position
○ Use of side rails and assisted devices
● Fire Safety (RACE)
○ R – rescue anyone in immediate danger
○ A – activate the fire code and notify appropriate person
~Important~
○ C – confine the fire by closing doors and windows
○ E – evacuate patients and other people to a safe area
● Seizure: an alteration in sensation, behavior, movement, perception, or consciousness
that may be noticeable as abnormal, involuntary contractions and rapid shaking with loss
of consciousness
○ RISK OF hypoxia, vomiting, and pulmonary aspiration
○ Reduce environmental stimuli (sound, light intensity)
○ Bed in lowest position – lowers risk for fall
○ Bedside equipment
■ Suction equipment
■ Oral suction
■ Bite block or oral airway
■ Oxygen
■ Padded rails
○ Monitor therapeutic drug levels
○
○ Safety precautions
■ Always provide a safe environment
■ Do not restrain the patient or put anything in their mouth
■ Support the head and place something soft under them
● Place them in side-lying position
■ Stay with the patient and CALL FOR HELP
● Physical restraint: any manual method, physical or mechanical device, material, or
equipment that the person cannot remove easily, which immobilizes or reduces the
person’s freedom of movement
○ LAST RESORT ONLY; all other alternatives must have been implemented and
failed; must be documented
■ Encourage family visitation, offer distractions or a calm environment,
move patient room near nursing station, games, TV, music
○ Must have an order from the primary care provider; last for 24 hours
○ Must remove restraints every 2 hours and perform ROM
■ Assess circulation and need for fluids or urination
○ Bed rails
~Important~
■ 2-3 side rails up = safety
■ 4 side rails up = restraint
■ If patient asks for bed rails to be up → not a restraint
○ Extremity restraint (hands, wrist or ankles)
■ Ensure two fingers can be inserted between the restraint and patient’s
extremity
■ Use a quick-release knot to tie the restraint to the bed frame, not side rail
■ Keep the call bell within reach
■ Steps for apply restraints
● Explain rationale for use to the client and the family
● Pad bony prominences
● Wrap the restraint around the client’s ankle and secure it with the
hook-and-loop fastener
● Ensure that two fingers fit between the restraint and the client’s
skin
● Position limbs in normal anatomic position
● Secure restraints to the bed frame with quick-release knots
■ SPECIAL CONSIDERATIONS
● Do not position patient with wrist restraints flat in a supine
position due to an increased risk of aspiration
● Check restraints for correct size before applying
● Keep a pair of scissors for quick removal of restraints
○ Risks associated with restraints
■ Falls
■ Pressure ulcers
■ Delirium
■ Contractures and skin breakdown
■ Incontinence
■ Respiratory difficulties
● Assisted devices
○ Walker → improve balance by increasing support
■ Specified by arm strength and balance
■ Top of the walker should line up with the patient’s wrist
■ Elbows should be flexed about 30 degrees
■ Rubber tips should be intact to prevent slipping
○ Canes → widen support, providing improved balance
■ Held on the STRONG side
■ The cane’s tip is 4in to the side of the foot
■ Elbow should be flexed 15 degrees
■ Move cane and weak side together, then move strong side
~Important~
■ Stairs
● Good leg goes up first
● Bad leg goes down first
○ Crutches → to help strengthen one or both legs
■ 2-3 fingers of space between axilla and rest pad
● Support needs to be on the hands and arms, not in the axillary areas
→ nerve damage and skin abrasion
■ Hand grips should be even with the hip-line; elbow flexed at 30 degrees
■ Stairs
● Crutches always go first
● Good leg goes UP the stairs
● Bad leg does DOWN the stairs
○ Considerations
■ Nurse stands on patient’s weak side to protect them
■ Use a wide stance when helping patients
■ Use hips and knees to assist
■ Keep heavy objects close to your body
■ Keep the bed at waist level
● Activity
○ Isotonic exercise: muscle shortening and active movement
■ Carrying out ADLs
■ Independently performing ROM exercises
■ Swimming, walking, jogging, and bicycling
○ Isometric exercises: muscle contraction without shortening
■ Contractions of quadriceps and gluteal muscles
■ Encouraged for patients with limited mobility
○ Isokinetic exercise: muscle contractions with resistance
■ Rehabilitative exercises for knee and elbow injuries
■ Complete ROM (max degree of movement)
● Graduated compression stockings = used for patients at risk for deep vein thrombosis and
pulmonary embolism and to help prevent phlebitis
○ Increase velocity of blood, promoting venous return to the heart
○ An order is required for use
● Effects of immobility on the body systems
○ Increased cardiac workload
○ Increased risk for orthostatic hypotension
○ Decreased rate of respiration
○ Impaired gas exchange
○ Altered digestion and utilization of nutrients
○ Increased urinary stasis
~Important~
○ Decreased muscle size, tone and strength
○ Decreased joint mobility and flexibility
● Safety principles
○ Always work CLEAN to DIRTY
○ Expose only one section of the body at a time, maintain privacy, and ensure
patient comfort
○ Bathing is a great opportunity for assessment and building trust and rapport
○ Encourage patient independence
○ Keep all dirty/soiled material away from your body
○ Do not put anything on the floor
Medication Administration
● No medication can be given to a patient without a medication order from a licensed
practitioner!!
○ The medication order MUST include (never guess!):
■ Patient’s name and date of birth
■ Date and time the order is written
■ Name of drug to be administered
■ Dosage of the drug
■ Route by which the drug is to be administered
■ Frequency of administration
■ Signature of the prescribing provider
○ If anything is missing → you cannot give the medication & you must call the
provider
● Use medicines safely
○ Properly label medicines
○ Take extra care with patients on anticoagulants
■ Increased risk for bleeding!!
○ Give correct information about a patient’s medications
○ Give written information about medications the patient needs to take
○ Educate the patient on bringing an up-to-date list of medicine when going to the
doctor
● Before giving medication ALWAYS KNOW
○ The action and purpose
○ Safe dose range
○ Contraindications
○ Drug to drug interactions
○ Precautions before administering
○ Nursing implications
○ Proper administration technique
● Rights of Medication Administration “DR. T.R.A.M.P”
~Important~
○ (1) right Patient
○ (2) right Medication
○ (3) right dosage/Amount
○ (4) right Time
○ (5) right Route
○ (6) right Documentation
○ (7) right Reason
○ (8) right assessment (allergies, complications, ability to swallow)
○ (9) right response from patient
○ (10) right to education
○ (11) right to refuse (assess the reason & address the concern)
● Nursing considerations
○ Three Checks
■ (1) In the med room: read the eMAR and select proper medication
■ (2) After retrieving medication: compare medication label with the
eMAR
■ (3) At bedside: recheck labels after identifying patient and before
administration
○ Check for allergies
○ Specific parameters
■ Blood pressure drugs
○ Check for 2 patient identifiers
■ If patient is in a coma – check their wristband
○ Insulin is a 2 nurse check ALWAYS
○ Do not open meds until at the bedside
○ Pull medications for one patient at a time
○ Assess the patient
○ Education
● Drug administration
○ Children → difficulty swallowing tablets and capsules; most medications are
available in liquid form
■ Use a dropper for infants or very young children
■ Crush uncoated tablets or empty soft capsules and mix the medication
with soft foods
○ Older adults
■ Allow extra time to administer medications
■ May have difficulty swallowing medications; easier to take it in liquid
form or crushed
■ Assist in setting up a schedule for at home use
■ Monitor for adverse reactions
~Important~
■ Teach the name of the drug, not just the color
● Process for drug administration
○ Perform assessments prior to administration
○ Provide effective medication teaching
■ Verify the medication is okay with the patient
○ Position the patient and assist as needed
■ Oral medications → high fowler’s position
○ Never leave the medications at bedside
○ Document medication administration on MAR
■ Always be detailed!!!
○ Medication refusal
■ Assess the reason why & educate
■ For time sensitive medications → encourage patient to take and explain
the importance
○ Prepare medications for ONE patient at a time
○ Always review patient’s chart for allergies and contraindications before
administration
■ Verify with the patient
● Oral Medications
○ More prolonged, less toxic effect
○ Know the purpose and adverse effects
○ Verify allergies
○ Assess the patient’s ability to swallow
○ CANNOT CRUSH enteric coated, extended release, capsules
● Topical Medications
○ Used for local effects; wear gloves
○ Patches
■ Assess patient’s skin for placement
● Do not place on hairy skin
■ Rotate the site to avoid irritation
■ Use palm to place firmly for 10 seconds
■ Initial and write the date on medical tape
○ Eye Drops
■ Pull down the lower lid to administer in conjunctival sac
● Avoids damage and pain to the eye
■ Avoid touching the eye with the dropper
■ Apply pressure to ensure proper administration
■ Don’t let the patient rub their eye after
■ Eye ointment → inner to outer corners of the eye; do not get tube into eye
○ Ear Drops
~Important~
■ For adults – pull the ear up and back
■ For children – pull the ear down and back
○ Suppositories
■ Position patient in left-lying sim’s position
● Only expose the body part you are assessing
■ Wear gloves and lubricate suppository and finger
■ Tell the patient to take a deep breath
■ Insert suppository into anus
● 4 inches for adults
● 2 inches for children
● Inhalation medications
○ Inhalers
■ Metered-dose (MDI)
● Handheld uses aerosol spray to administer medication into the
lungs for localized and systemic effects
○ Used primarily in children or patients with decreased lung
capacity
● Educate the patient on how to use it properly
● Assess lung sounds and respiratory rate before administration
○ Provides baseline data for later assessment
● STEPS
○ Shake it
○ Place the spacer mouthpiece into mouth
■ Especially for children if they are unable to hold
the inhaler
○ Release one puff and inhale slowly and deeply
○ Hold for 5-10 seconds
○ Exhale slowly
○ Wait 1-5 minutes between each puff
○ Rinse mouth after using – avoid accumulation of bacteria;
yeast
● Injection medications
○ Intradermal injection: into the dermis, longest absorption time
■ Used for allergy tests, local anesthesia, tuberculosis
● Avoid massaging or putting pressure on the site
■ 25-27 gauge ⅜-⅝ in, less than 0.5 mL, 5-15 degrees
■ Pull skin taut, bevel UP, inject slowly
■ Most common in in forearm, scapula
○ Subcutaneous injection: into the adipose tissue, slow and sustained rate of
absorption into the capillaries
~Important~
■ Used for insulin and heparin
■ Insulin → must be double checked by 2 licensed nurses; high-risk
drug
○ Check the order, blood glucose level, correct dose, and
correct insulin
○ Use the insulin syringe with units
○ Mixing regular insulin (R) and NPH insulin (N) “clear to
cloudy”
■ NPH = long acting (cloudy)
■ Regular = short acting (clear)
■ Rapid = rapid acting (clear)
● Food must be at bedside to avoid
hypoglycemic shock
○ Check the name and expiration date on the vial before
mixing
○ NPH needs to be “rolled” in the palms of the hands
○ Wipe the tops of both vials with an antimicrobial swab and
allow to dry
○ “Clear into Cloudy”
■ Apply air into the NPH (cloudy) vial FIRST
● Same amount as units prescribed
● Injection of air → prevents vacuum
■ Apply air into the regular (clear) vial NEXT
● Same amount as units prescribed
● Keep the needle in the vial and invert the
vial
■ Withdraw the units prescribed from the regular vial
■ Withdraw the units prescribed from the NPH vial
■ 25-27 gauge, ⅜-⅝ in no more than 1 mL, 45-90 degrees
● Pinch the skin, inject, release the skin
● Angle depends on amount of fatty tissue
■ Do not massage the site or apply pressure
■ Injections in the abdomen > arms > thighs > gluteal
■
~Important~
○ Intramuscular injection: into the muscles; slow, sustained release over hours,
days, or weeks
■ Fastest rate of absorption due to larger and more blood vessels
● Good route for irritating medications
■ Used for antibiotics, hormones, vaccines
■ Z track technique prevents leakage of medication into the needle track
■ 18- to 25-gauge needle, up to 3 mL, 90 degree angle
●
●
Kids, elderly = up to 2mL
Infants = up to 1 mL
■ Locations for IM route
● Deltoid → fast absorption, less pain
○ 25 gauge 1 inch
○
● Vastus Lateralis → large muscle, easily accessible (common for
<2 years)
○
● Ventrogluteal → tolerates large amounts, less painful (Z-track
method)
○ 22 gauge 1 ½ inch
○
Skin Integrity
● Developmental considerations
○ Children
■ <2 years – skin is thinner and weaker
■ Skin and mucous membranes are injured easily
~Important~
■ Becomes increasingly resistant to injury and infection
○ Older adults
■ Structure changes as a person gets older
■ Easily damaged skin
■ Circulation and collagen are impaired → increased risk for tissue damage
■ Healing time is delayed
● Wound = break or disruption in the integrity of the skin and tissues
○ Phases of wound healing (HIP Man)
■ Hemostasis → blood vessels constrict & blood clotting to control
bleeding
● Occurs immediately after initial injury
● Exudate (fluid) is formed
■ Inflammatory → leukocytes and macrophages move to the wound and
clean to allow healing
● Lasts 2-3 days
● Leukocytes ingest bacteria and debris
● Macrophages release growth factors and fibroblasts
● Characterized by pain, heat, redness, and swelling
● Patient may have elevated temperature, leukocytosis, and
discomfort
■ Proliferation → new tissue fills wound space through the action of
fibroblasts “new life” = “new tissue”
● Lasts for several weeks
● Capillaries bring oxygen and nutrients
● Blood flow is reinstituted
● Granulation tissue is formed
■ Maturation → final stage of healing
● After 3 weeks of healing
● Scar tissue begins to heal and is less elastic
○ Wound classification
■ Intentional (surgery) or unintentional (injury: increased infection &
bleeding)
○ Factors affecting wound healing
■ Local factors
● Pressure (disrupts blood flow)
● Desiccation (dehydration, cells become dry)
● Maceration (softening of skin due to moisture)
● Trauma
● Edema
● Infection
~Important~
● Excessive bleeding
● Necrosis
● Biofilm (decreases effectiveness of antibiotics and normal immune
response; delays healing)
■ Systemic factors
● Age
○ Very young and old patients have sensitive skin
● Circulation and oxygenation
○ Inadequate nutrients needed for removal
○ Ex. diabetics – more likely to be chronic, poor circulation
● Nutrition (often forgotten)
○ Malnourished or NPO patients are at risk for wound
complications
○ Zinc → proliferation of cells
○ Vitamin B → enzymes
○ Vitamin K → clotting
○ Calories and protein → build skin and tissue
○ Fats → creating cell membrane
○ Vitamin A & C → promote collagen synthesis; wound
healing
● Wound cause
● Medications
○ Corticosteroids decrease inflammatory response
○ Radiation depresses bone marrow function
● Immunosuppression
○ AIDS, lupus, chemotherapy
○ Wound complications
■ Infection
● Signs & symptoms
○ Increased purulent drainage, pain, redness, swelling,
increased body temperature, increased WBCs, odor
● Can lead to chronic wounds, bone infection, and sepsis
■ Hemorrhage (highest risk after surgery)
● Check dressing frequently; including UNDER the patient
● If uncontrolled bleeding occurs → APPLY PRESSURE
● Can lead to a hematoma = internal blood clots
■ Dehiscence & Evisceration
● Most serious wound complications !!
● Dehiscence → muscle intact; due to increased abdominal pressure
~Important~
● Evisceration → bowels protruding from wound; due to increased
drainage; requires immediate surgery “something giving away”
○ Position patient in low Fowler’s
○ Cover area with saline moistened sterile gauze
○ NPO for surgery
●
■ Fistula
● Abnormal passage from an internal organ or vessel
● Can be purposeful or accidental
● Often results from an abscess (infected fluid that has not drained)
● Can lead to increased infection and skin breakdown
●
● Pressure injury: localized damage to the skin and underlying tissue that usually occurs
over a bony prominence
○ Acute or chronic
○ Occur in older adults due to aging skin, chronic illness, immobility, malnutrition
○ Important to reposition patients every 2 hours
○ Factors in development
■ External pressure compressing blood vessels
● Occur mainly over the tailbone, heels, and hip bones
● Leads to ischemia (deficiency of blood in an area), hypoxia
(inadequate oxygen to cells), edema, inflammation
■ Friction and forces that tear and injure blood vessels
● The skin over elbows and heels are affected
○ RISK FACTORS
■ Immobility
■ Nutrition and hydration
■ Moisture (incontinence, drainage)
■ Mental status
~Important~
■ Age
○ RISK ASSESSMENT → Braden Scale (0-24) *will be provided on exam*
■ MANSS
● M: moisture = skin exposure to moisture
● A: activity = degree of physical activity
● N: nutrition = usual food intake pattern
● S: sensory perception = ability to respond to pressure, discomfort,
and pain
● S: shear and friction = shear is one layer of tissue sliced over
another layer; friction is two surfaces rubbing against each other
■ Score less than 12 = increased risk
■ Score 13+ = decreased risk
○ Prevention
■ Turn every 2 hours
■ Adequate hydration and nutrition
● Protein, fatty acids, vitamins and minerals
■ Keep skin DRY
○ Stages
■ Stage 1: Erythema of skin = red skin, changes in sensation, temperature,
or firmness
■ Stage 2: Partial-thickness = partial loss of skin with exposed dermis;
looks almost like a blister
■ Stage 3: Full-thickness = loss of skin, adipose tissue is visible
■ Stage 4: Full-thickness and tissue loss = exposed fascia, muscle, tendon,
ligament, or bone in the ulcer
■ Obscured/Unstageable= tissue damage is obscured by eschar (necrosis)
● Remove necrotic tissue before staging
■ Deep tissue injury = purple, maroon area indicating tissue injury
~Important~
○
● Wound assessment
○ Assess old dressings – look for drainage, measure the size, determine location
○ BYR scale for color
■ Black (necrotic) = debri BAD – call provider
■ Yellow (sloughy) = cleaning
■ Red (granulating) = protect GOOD
○ Assess the color, odor, consistency
○ Palpate for firmness, temperature, and swelling
○ Assess for pain
○ Assess for signs of infection
● Types of wound drainages
○ Serous → clear and watery
○ Sanguineous → fresh bleeding, or darker old bleeding
○ Serosanguineous → serum and red blood cells; light pink to red
○ Purulent → thick, foul odor, may be yellow or green
■ Contains white blood cells, dead tissue, and bacteria
~Important~
○
Bowel Elimination + Skills
● CONSIDERATION
○ Valsalva cardiac effect → trouble defecating
■ Increased blood pressure, low HR
■ Take laxatives to help
○ Fecal impaction → breaking up fecal mass and removing it from the impaction
■ Usually seen in spinal cord injuries
■ Requires an order – invasive
■ Risk of triggering valsalva – monitor patient
○ Bowel incontinence
■ Requires proper cleaning to avoid skin breakdown
■ Educate on scheduled toileting and proper squatting
● Peristalsis: contraction and relaxation of GI smooth muscles facilitates in moving
contents down GI tract
○ Patients may lose this ability due to:
■ Opioids, anesthesia, nerve/muscle damage, immobility
● Vili: increased surface area = greater nutrient uptake
○ Decreased absorption could be due to:
■ Celiac disease, IBS, necrosis, GI surgery, age
● Factors influencing bowel elimination
○ Age = aging → decreased
○ Diet = increase fiber intake – whole grains, dry peas and beans, fruits and veggies
■ Constipating food → processed cheese, meat, eggs, pasta, rice, white
bread, iron and calcium supplements
■ Foods with laxative effect → prunes, dairy, fruits and veggies, spicy
foods, alcohol, coffee
■ Gas producing foods → certain veggies, milk, carbonated drinks
○ Fluid intake = water and electrolytes ~2-3L a day
~Important~
○
○
○
○
○
○
○
○
○
Physical activity = increase mobility
Psychological factors = stress and anxiety → decreased
Personal habits = patients in a new place are hesitant → decreased
Position = squatting
Pain = increased pain → decreased
Pregnancy = increased hormones and pressure on abdomen → increased
Surgery & anesthesia = slows down motility
Medications = ALWAYS ASSESS MEDICATIONS
Diagnostic tests
■ Fecal occult test – measures blood in stool
● Detects GI bleeding, ulcers, colon cancer
● Assess for hemorrhoids
● BLUE = POSITIVE
● Avoid vitamin C
■ C. diff – increased diarrhea, request an order
● Nasogastric tube: used to relieve pressure or drain unwanted contents in the GI system
due to some type of blockage
○
○ Correct way to measure
■ Nostril – tip of earlobe – xiphoid process
■ Check patency of nasal – looking for deviation
● Find the one they can breathe out better
○ Connected to suction or to gravity bag
○ Large bore is for gastric decompression – suction out extra content
■ Can be continuous or intermittent
■ Do not put gastric content back, test pH
■ Usually for overdose, after surgery, no bowel movements
○ Small bore for enteral feeding ONLY
■ Assess the tubing before feeding
● Aspirate for gastric secretions (note the amount and color)
● Flush with 30-50mL to avoid blockage
○ Would you suction and feed a patient through a NG tube at the same time? NO!
Turn off suction for 30 minutes
○ When inserting the tube, always have water for the patient to swallow
~Important~
●
●
●
●
○ Determine placement by aspirating and testing for pH
■ Gastric levels <5.5
■ Intestinal levels <7.45
■ X-ray is needed to CONFIRM proper placement
Enteral tube feeding = preferred method of meeting nutritional needs if a patient is
unable to swallow or take nutrients orally
○ Requires a functioning GI tract
○ COMPLICATIONS → risk of aspiration due to food getting into the lungs
■ Must position patient in proper position (high-fowler’s)
○ Nasogastric, jejunal, gastric
○ When inserting the tube:
■ Tell the patient to keep swallowing while inserting
■ To assure proper placement, get an x-ray
○ Surgical/endoscopic placement (long-term)
○ Continuous feedings (feeding pump)
○ Intermittent feeding (regular intervals or through a syringe)
Parenteral nutrition = nutrients are provided intravenously for patients unable to digest
or absorb nutrition
○ Requires consistent evaluation
○ Crohn’s disease, short-bowel syndrome
○ Total parenteral nutrition → large veins, more nutrients
■ At risk for infection and increased glucose levels
○ Peripheral parenteral nutrition → peripheral veins, nutrients (more common)
Constipation
○ Identify and manage contributing factors
○ Use laxatives, if appropriate
■ Only for short-term use
○ Enemas – inserting fluids into the rectum to influence bowel movement
■ PURPOSE
● Cleansing = before colonoscopy/surgery for a better visualization
● Oil retention = becomes slippery for the stool to come out
● Carminative = relieves gas
● Kayexalate = clears extra potassium from body
○ Educate about diet/fluid intake
○ Promote ambulation/exercise
Ostomy: surgically created opening of part of an organ to the surface of the body to
discharge wastes
○ Created when contents are unable to pass through normally
○ Ex. cancer – cancer and part of colon is removed
○ Stoma = the opening at the surface of the body
~Important~
■ Should be beefy red, moist
■ Purple/blue color – NECROSIS
○ Ileostomy → part of small intestine is removed
■ Secretion will be liquidy and thin
■ EFFECT: loss of nutrients; dehydration
■ No control
○ Colostomy → part of the large colon is removed
■ More consistent with normal excretion
■ EFFECT: dehydration
■ Some control
○
○ Ostomy care
■ Not sterile
■ Assess newly creates ostomies frequently
● Color, frequency, output
■ Report any complications immediately
■ Monitor nutritional, electrolyte and fluid balance
■ Educate patient on care of the ostomy when he or she is ready
● Can be emotional or embarrassing for the patient
● Consider how it affects the patient
○ Inform the patient about certain foods that cause odor/gas and increase fluid
intake
○ Patients with ostomies can still have constipation and diarrhea
Urinary Elimination + Skills
● Factors affecting urination
○ Food and fluid intake
■ Increased sodium → decreases urine formation
■ Alcohol → diuretic effect, increasing urine production
○ Developmental considerations
■ Child – toilet training 2-3 years old
● Enuresis → incontinence of urine past the age of toilet training
■ Aging
● Nocturia
~Important~
● Increased frequency (due to decreased muscle tone)
● Urine retention and stasis
● Voluntary control affected by physical problems (weakness)
● AT RISK FOR DEHYDRATION
○ Pathologic conditions
■ Renal impairment affects urine output
○ Medications
■ Diuretics → increased urine production
■ Pyridium → turns urine orange
■ Nephrotoxic → toxic to the kidneys (analgesics)
○ Psychological variables
■ Stress → decrease in urination
■ Level of comfort – make sure patient has privacy
○ Activity and muscle tone
■ Exercise is GOOD for the bladder
■ Decreased muscle → increased urine in the bladder → increased infection
● Frequency of urination
○ Amount In = Amount Out
○ Measuring intake and output (mL)
○ Frequent intervals – void at first early urge to urinate, usually measured every 3-4
hours
○ Infrequent intervals – greater risk of UTI and kidney disorders
● Common Urinary Elimination Problems
○ Urinary retention – due to medications, muscle tone, enlarged prostate; when
urine is not completely excreted from the bladder
■ Causes
● Enlarged prostate
● Urethral stricture
● Kidney stones
● Stroke or spinal cord injury
○ Urinary tract infection (UTI) – may be caused by indwelling catheters, urinary
retention, urinary/fecal incontinence, poor hygiene practices increase risk
■ S&S
● Dysuria, cystitis, urgency, frequency, incontinence, foul-smelling
cloudy urine, hematuria
● Flank pain (more serious) – pain in the kidneys
■ Patients AT RISK for UTI
● Women
● Sexually active
● Women who use diaphragms for contraception
~Important~
● Postmenopausal women
● Individuals with indwelling urinary catheter
● Individuals with diabetes mellitus
○ Why? Increased glucose in urine → attracts bacteria
● Older adults
■ Catheter-associated UTI
● Usually from hospital procedures; most common
● IMPORTANT TO USE STERILE TECHNIQUE
● Regular perineal and catheter care is required
● Never let the drainage bags get full, empty when half full
○ Why? Urine will backtrack leading to infection
● Check for kinks or occlusions
● Keep drainage bag below the bladder to work with gravity
● Do not let tube or bag touch the floor
○ Urinary incontinence
■ Overflow = signal to empty bladder underactive or absent resulting in
overdistention and overflow of bladder
■ Urge = strong urge to urinate when bladder is not full (i.e. overactive
bladder)
■ Functional = aware of the need to urinate, but cannot due to factors
outside the urinary tract (i.e. inability to reach toilet, environment,
physical limitations, memory loss)
■ Reflex = emptying of the bladder without sensation of need to void (i.e.
spinal cord injury)
■ Stress = involuntary loss of urine related to an increase in intra-abdominal
pressure (i.e. coughing, sneezing, exercise)
■ Total = continuous, unpredictable loss of urine (usually a result of
surgery, trauma, anatomic abnormality)
■ Transient = appears suddenly and lasts 6 months or less
■ Mixed = urine loss with features of two or more types of incontinence
● Nursing Process
○ Assess data about voiding patterns, habits, past history of problems
○ Physical examination of bladder; assessment of skin integrity and hydration; and
examination of the urine (can also assess pain in the kidneys)
■ Kidneys – any flank pain or tenderness?
■ Urinary bladder – palpate and percuss the bladder for distention or use a
bedside bladder scanner
● Bedside bladder scanner = uses ultrasound technology to
determine how much urine is in the bladder or how much urine has
been retained
~Important~
○ No order is required
○ Do this BEFORE catheterization
○ If there is no urine present → problem with kidneys
■ Urethral orifice – inspect for signs of infection, discharge, or odor
■ Skin – assess skin breakdown and exposure to moisture, skin turgor for
hydration status
● Incontinence-associated dermatitis = infection from lack of skin
care
○ Correlation of findings with results of procedures and diagnostic tests
● Urine assessment
○ Assess for amount (intake and output), color, odor, clarity, and sediment
■ Certain medications can affect the color of urine
○ Specific gravity = density of urine NORMAL 1.015-1.025
○ Presence of abnormal constituents = sign of infection or kidney problem
■ Glucose
■ Protein
■ Ketone bodies
■ Bacteria
■ Blood, pus, casts
● Assessing a problem with voiding
○ Examples of questions to ask:
■ Do you urinate at regular times throughout the day?
■ Do you drink water?
■ Are you limiting your sodium intake?
■ Is your urine volume constant?
● Indwelling/foley catheter = double lumen; extracts urine and injects saline to inflate
balloon
○ Used for continuous urinary drainage
○ Monitor intake and output, volume, and character of urine
○ Empty the bag at HALFWAY
○ Keep drainage bag below the bladder and off the floor at all times
○ Insert catheter until urine is seen and then continue to insert
■ No urine? Advance the catheter
○ Avoids blocking/damaging the sphincter with the balloon
~Important~
○
● Straight/intermittent catheter = single lumen; drains bladder for urine
○ Used for a one time use
○ Lowers risk of CAUTI and complications
○ Patients can use clean technique at home
○ Used for patients with spinal cord injuries or other neurological conditions
○
● Condom catheter
○ Patients who are at high fall risk or unable to hold a urinal
○ 1-2 inches away from the tip of the penis; leave flexible room around the penis
(not too taught)
○ Assess the skin often!!
● Patient goals
○ Maintain fluid, electrolyte, and acid-base balance
○ Empty bladder completely at regular intervals without discomfort
■ Consequence = infection
○ Provide care for urinary diversion
○ Develop plan to modify factors contributing to current or future urinary problems
○ Correct unhealthy urinary habits
● Promoting normal urination
○ Promote fluid intake
○ Strengthening muscle tone
■ Pelvic floor exercise for urinary incontinence
■ Practice urinating and stopping (kegels)
○ Assisting with toileting
■ EMPOWER
■ ENSURE PRIVACY
● Maintaining normal voiding patterns
○ Regular schedule
~Important~
○ Urge to void
○ Privacy
○ Position
○ Hygiene
● Patient education for UTI
○ Increase fluid intake
○ Promote good hygiene – wiping from front to back
○ Urinate after sex
○ Urge to urinate – GO RIGHT AWAY
○ Drink cranberry juice
○ Wear loose, breathable underwear
○ Increase activity
○ Take antibiotics as prescribed
● Reasons for catheterization
○ Used as a last resort!!
○ Straight catheter FIRST before indwelling catheter
○ Relieving urinary retention
○ Prolonged patient immobilization
○ Obtaining a sterile urine specimen when patient is unable to void voluntarily
○ Accurate measurement of urinary output in critically ill patients
○ Assisting in healing open sacral or perineal wounds in incontinent patients
○ Emptying the bladder before, during, or after surgical procedures
○ Providing improved comfort for end-of-life care
Nutrition
● ADPIE
○ Assessment – nutritional screening
■ Ask for 24 hour diet recall
■ Alcohol consumption, food allergies
○ Diagnosis – imbalanced nutrition
○ Planning – nutritional education and counseling
○ Implementation – meal planning, educating
○ Evaluation – effectiveness of interventions
● BMI
○ Underweight = less than 18.5
○ Healthy = 18.5-24.9
○ Obese = 30-34.9
● Therapeutic diets
○ Consistent-carbohydrate diet = type 1 and type 2 diabetes, gestational diabetes,
impaired glucose tolerance
■ High-fiber and heart-healthy fats are encouraged
~Important~
■ Sodium intake is limited
○ Fat-restricted diet = cardiovascular disease to help prevent atherosclerosis
■ Intended to lower the patient’s total intake of fat
○ High fiber diet = prevent or treat constipation; IBS, diverticulosis
○ Low-fiber diet = before surgery, ulcerative colitis, Crohn’s disease
○ Sodium-restricted diet = hypertension, heart failure, renal disease, liver disease
■ “Heart-healthy” diet
○ Renal diet = nephrotic syndrome, kidney disease, diabetic kidney disease
■ Reduces the workload on the kidneys to delay or prevent damage
● Post-surgery diets (diet progression)
○ NPO – nothing, sips of water with meds may be allowed
○ Clear liquid – clear broth, coffee, tea, fruit juice, gelatin
○ Full liquid – cream soup, custard/pudding, vegetable juice, yogurt
○ Pureed – scrambled eggs; pureed meat, vegetables, fruit; mashed potatoes
■ For patients who can chew, but cannot swallow
○ Mechanically altered – pasta, casseroles, tender meat, cooked fruit/vegetables
■ Makes it easier for the patient to consume
○ High fiber – fresh fruit, oatmeal, dried fruit
■ Patient needs LOTS of fluids!!
● Enteral tube feeding = preferred method of meeting nutritional needs if a patient is
unable to swallow or take nutrients orally; short-term
○ Requires a functioning GI tract
○ COMPLICATIONS → risk of aspiration due to food getting into the lungs
■ Must position patient in proper position (high-fowler’s)
■ Ensure proper placement with x-ray
○ When inserting the tube:
■ Tell the patient to keep swallowing while inserting
■ To assure proper placement, get an x-ray
○ Types of feeding administration
■ Continuous = feeding into intestines to avoid dumping syndrome
■ Intermittent = feedings delivered at regular intervals
○ Enteral tube bags must be changed every 24 hours
● Diabetes
○ Type 1: the body makes little or no insulin
■ Glucose monitoring
■ Insulin dependent
■ Exercise
○ Type 2: the body is resistant to insulin
■ Diet, exercise, weight management
■ Glucose monitoring
~Important~
○ Gestational: high blood sugar that develops during pregnancy
Oxygenation, Circulation, Perfusion
● Gas exchange is made possible by:
○ Ventilation = movement of air into and out of the lungs
■ Contraction → inhaling
■ Relaxing → exhaling
■ Factors
● Condition of the musculature
○ Weak muscles = less effective inhalation and exhalation
(OLDER ADULTS)
○ Signs of difficulty breathing
■ Nasal flaring
■ Retractions
■ Use of accessory muscles
● Compliance of the lung tissue
○ The ability of the lungs to distend or expand
○ Decreased compliance = decreased oxygenation
○ Surfactant = decreases surface tension, prevents alveoli
from collapsing
○ Conditions that decrease compliance
■ Emphysema and fibrosis
■ Older adults have decreased surfactant
■ Premature babies do not have enough surfactant to
breathe on their own
● Airway resistance
○ When the diameter of an airway decreases, the airway
resistance increase and limits the amount of oxygen
delivered to the alveoli
○ Conditions that increase resistance
■ Asthma
■ Sleep apnea
■ Edema
■ Increased secretions
■ Obstruction
○ May hear wheezing, high pitched sounds, crackling
○ Respiration = exchange of oxygen and carbon dioxide between the atmospheric
air in the terminal alveoli and blood in the capillaries
■ Moves from high pressure/concentration to low pressure/concentration
■ Factors influencing diffusion
● Change in surface area
~Important~
○ Removal of the lung, emphysema
○ Reducing the surface area, reduces diffusion
● Thickening of the alveolar-capillary membrane (Pneumonia)
● Partial pressure
○ Increased altitude pressure, decreased respiration
■ Atelectasis → collapse of the alveoli; prevents normal gas exchange
● Usually due to hospitalization/post-op complication
● Nursing interventions
○ Deep breathing exercises
○ Ambulation – better circulation
○ Semi-fowler’s position
○ Perfusion = process by which oxygenated capillary blood passes through the
body tissues
■ Factors
● Amount of blood flowing through lungs
● Activity level
○ Increased activity → increases demand for O2 → increases
perfusion
● Adequate blood supply and proper cardiovascular functioning
● Medulla oblongata regulates respiration
○ Chemoreceptors sense changes in concentration of O2, CO2, and pH
○ Proprioceptors – sensory receptors in the muscles; help increase ventilation
○ What effect would a CNS injury (stroke) have on respirations?
■ Respiratory depression, hypoxia
● ABG normal values for ventilation
○ PaO2 (partial pressure O2) = 80-100 mm Hg
■ Measures pressure of oxygen moving in and out of the body
○ PaCO2 (partial pressure CO2) = 35-45 mm Hg
■ Measures pressure of carbon dioxide moving in and out of the body
○ SpO2 (peripheral O2 saturation) = 95-100%
■ Measures concentration of oxygen in circulation
● Alterations in respiratory functioning
○ HYPOventilation = decreased respirations; body retains CO2 and can lead to
respiratory acidosis
■ Can occur with atelectasis, sedation, and drug overdose
■ S&S: changes in mental status, low respiration rate, potential cardiac
arrest, death
■ Intervention: give O2, encourage deep breathing and coughing, may need
respiratory treatment
~Important~
○ HYPERventilation = increased rate/depth of respirations; lungs remove CO2
faster than it is produced and can lead to respiratory alkalosis
■ Can occur with severe anxiety
■ S&S: lightheadedness, loss of consciousness
■ Interventions: patient breathe into brown paper bag, help calm anxiety
○ Hypoxia = inadequate tissue oxygenation; life threatening condition
■ S&S: restlessness, anxiety, tachycardia, bradycardia, extreme restlessness,
dyspnea “RATBED”
■ Causative factors
● Decreased O2 carrying capacity (anemia, carbon monoxide
poisoning)
● Hypovolemia – decreased circulating blood volume (shock, severe
dehydration)
● Decreased O2 concentration (airway obstructions, decreased
environmental oxygen from high altitude, hypoventilation)
● Increased metabolic rate – demanding more O2, persistent fever
(needs O2 to fight infection), exercise
■ Give O2 ASAP
● Cardiovascular system
● https://www.youtube.com/watch?v=ruM4Xxhx32U
● https://www.youtube.com/watch?v=GVU_zANtroE
●
○ Cardiac output = stroke volume X heart rate
○ Stroke volume is affected by:
■ Preload – volume of blood in ventricles at the end of diastole
● Stretching of ventricles
● Conditions increase preload
○ Heart failure, renal failure, hypervolemia
● Conditions decrease
○ Low blood volume, hypovolemia
~Important~
■ Afterload – resistance/pressure of left ventricles to pump blood to the
body
● Increase
○ Hypertension, vasoconstriction
● Decrease
○ Low BP
■ Contractility – strength of the heart’s muscles
○ Regulation of the cardiovascular system
■ Conduction system
●
■ Alterations in conduction
Rhythm
HR
SV
CO
BRADYCARDIA
<60bpm
↓
↑
↓
TACHYCARDIA
>100bpm
↑
↓
↓
ATRIAL FIBRILLATION
100-175 bpm
↑
↓
↓
VENTRICULAR
FIBRILLATION
>175 bpm
↑
↓
↓
● Atrial fibrillation is at risk for blood clots
○ Deep vein thrombosis – swelling, erythema, warmth
● Ventricular fibrillation is deadly
■ Blood flow to the cardiovascular system
● Myocardial ischemia = decreased blood flow to the heart
○ Stable angina – temporary imbalance; often due to an
increase in myocardial oxygen demand
■ Often relieved with rest and vasodilators
■ Reduce alcohol, no smoking, activity is limited
~Important~
○ Myocardial infarction – medical emergency; usually due
to decrease in O2 blood flow
■ Accompanied by chest pain
■ Can only be relieved through surgery
■ Factors affecting the function of the heart:
● Nervous system
● Hormones
● Drugs
○ Heart failure → inability to pump sufficient blood leading to inadequate
perfusion and oxygenation of tissues
■ Causes
● Chronic HTN – heart was to work harder
● Coronary artery disease
● Incompetent valves
○ Deep Vein Thrombosis (DVT): blood clots form in the deep veins, usually in the
legs
■ Requires IMMEDIATE attention → can lead to pulmonary embolism
■ Risk factors: impaired circulation, decreased motility, prolonged bed rest,
smoking, obesity
■ Symptoms: swelling in legs/calf, inflammation, redness, pain, warmth
■ Intervention: ambulate!!!!!!, encourage hydration, ROM, compression
stockings
■ DO NOT massage the leg
● Factors affecting cardiopulmonary functioning
○ Level of health
○ Development
■ Infants-adolescents → immature immune system
● At risk for upper respiratory infection
■ Older adults → cardiac output decreases, cannot handle stress
○ Nutrition
○ Exercise
○ Smoking
○ Substance abuse
○ Stress
○ Environmental factors
● Nursing process
○ Assessment
■ Health history
■ Physical assessment
■ Vital signs
~Important~
○
○
○
○
■ Diagnostic tests
■ Pulse oximetry monitoring
● Assess and read the patient FIRST, not the number
● COPD/chronic lung disease O2 level 88%-92% is normal
Diagnoses
■ Ineffective airway clearance
■ Impaired gas exchange
■ Decreased cardiac output
Planning
■ Demonstrate improved gas exchange
■ Preserve cardiopulmonary function
■ Demonstrate coping methods and self-care behaviors
Implementation
■ Promote healthy lifestyle
■ Maintain good nutrition
■ Adequate hydration
■ Promote lung expansion
● Breathing exercises !!
○ Pursed lip breathing for COPD
● Ambulation → preventative for DVT
● Incentive spirometer → inhaling deep and slow
● Semi-fowlers, high-fowlers
■ Promoting and controlling cough
● Effective coughing – helps clear the airway clear of secretions
■ Loosen and mobilize secretions
■ Meeting oxygen needs with medication (inhalers)
■ Providing supplemental oxygen
● Humidifier requires an order → DO NOT HOLD IN
EMERGENCY
● In patients with COPD, the administration of excessive oxygen
causes them to hypoventilate
○ Can lead to respiratory acidosis
■ Suctioning
■ Thoracentesis (removal of fluid in pleural space)
■ Chest tubes
● Never clamp the tubing
Evaluation
■ Ask about improvement
■ Auscultate lung sounds
■ Evaluate pulse oximetry changes
~Important~
■ Use diagnostic results
● Oxygen delivery devices – least invasive to most invasive
https://healthandwillness.org/oxygen-delivery-devices-and-flow-rates/
○ Nasal Cannula
■ 1-6L/min 24-44%
■ Can dry mucosa and needs humidification
■ Patients can eat with this
○ Simple face mask
■ 5-8L/min 40-60%
■ Contraindicated for patients who retain CO2, may induce claustrophobia
○ Venturi mask
■ 4-6L/min 24-60%
■ Has flow-control meter on the mask
○ Partial/non-rebreather mask (emergency use)
■ 10-15L/min 80-95%
■ Should never be deflated
○ Always assess the skin
○ Humidify at 4L and above
■ Can dry out mucosa
○ Administering oxygen greater than 28% can damage patient’s stimulus to breathe
deeper with COPD
● Complete Blood Count
● Coagulation
~Important~
● Patients on anticoagulant therapy should expect longer bleeding times → takes longer to
build clots
● In emergency situations:
○ Maintaining an airway is a priority
○ Administer oxygen
○ Interventions will vary
○ Always have emergency supplies ready
○ Activate appropriate emergency response
● Cardiopulmonary resuscitation
○ Permanent heart, brain, and vital organ damage occurs within 4-6 minutes
○ CPR
■ Maintain circulation
■ Establish airway
■ Initiate breathing
■ Early defibrillation
JUST FOR REVIEW
~Important~
○ Sitting position = evaluation of head, neck, lungs, vital signs
■
○ Supine position = flat on back, head slightly elevated; anesthesia, surgery,
abdomen exam
■
○ Sims’ position = rectal, perineal, and pelvic exams; rectal temperatures, enemas
■ Left-lying – rectal and vaginal area
■ Alternative for elderly patients
■
○ Dorsal recumbent position = best for patients with pain in back or abdomen
■
○ Standing position = posture, balance, gait, male genitalia
■
○ Prone position = hip joint, back exams; cardiac and respiratory problems cannot
tolerate
■
○ Knee-chest position = rectal, vaginal exams
■ Small pillow for comfort
■ Embarrassing for patient – reduce time
~Important~
■
○ Lithotomy position = female genitalia, reproductive tracts, and rectum
■
○ High-fowler’s position = head, neck, and upper body (60-90 degrees)
■
○ Fowler’s position (30-45 degrees) = promotes lung expansion
■