Marjorie Bontron-
The lack or absence of breathing
apnea
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slow breathing; respirations are fewer than 12 per minute
bradypnea
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a hollow plastic tube surgically inserted into the chest cavity, which allows for the removal of trapped air and the drainage of blood or fluid
chest tube
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allows for the removal of trapped air through a hollow plastic
pneumothorax
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the drainage of blood or fluid through a hollow plastic tube; surgically inserted into the cavity
hemothorax or pleural effusion
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respirations that gradually increase in rate and depth and then become shallow and slow; breathing may stop (apnea) for 10 to 20 seconds
cheyne-stokes
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an abnormal condition, evidenced by bluish color in the skin, lips, mucous membranes and nail beds caused by a lack of oxygenated blood in the visible tissues
cyanosis
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Sterile and pure water that has been boiled and allowed to cool and condense
distilled water
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Normal breathing
eupnea
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A mask used to deliver oxygen that covers the client's nose and mouth.
face mask
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flowmeter a device that regulates the flow of oxygen to the nasal cannula or face mask
flowmeter
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the volume of a substance, such as oxygen or fluids, administered over a prescribed period
flow rate
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bloody sputum
hemoptysis
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Oxygen that contains water vapour.
humidified oxygen
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Respirations that are more rapid and deeper than normal.
hyperventilation
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Respirations that are slow, shallow, and sometimes irregular.
hypoventilation
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a deficiency of oxygen in the cells
hypoxia
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the process of inserting an artificial airway
intubation
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Deep, rapid respiration characteristic of diabetic acidosis or other conditions causing acidosis.
kussmaul respiration
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The use of a ventilator to move air into and out of the lungs.
mechanical ventilation
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A flexible tube inserted into the nares of the nose to deliver oxygen
nasal cannula
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Shortness of breath when lying in a flat or supine position; ability to breathe comfortably only when sitting or standing
orthopnea
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devices that help reduce oxygen wastage
oxygen-conserving deivices
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a harmful chemical or substance in air or water
pollutant
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stoppage of breathing
respiratory arrest
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Slow, weak respirations at a rate of fewer than 12 per minute; respirations are not deep enough to bring enough air into the lungs.
respiratory depression
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mucus from the respiratory system that is expectorated (expelled) through the mouth
sputum
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the process of withdrawing or sucking up fluid
suctioning
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rapid breathing; respirations are 24 or more per minute
tachypnea
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a surgically created openinig through the neck into the trachea
tracheostomy
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A machine used to provide airflow into and out of the lungs.
ventilator
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alcohol, nail polish remover, oils, petroleum jelly, greases
ignite easily
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cigarettes, cigars, pipes, matches, lighters
smoking materials
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direct sunlight, lit cigarettes, candles, lamps, stoves, heating ducts, radiators, heating pipes, space heaters, kerosene heaters
heat sources and open flames
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do not use materials like wool and synthetic fabrics; it could cause what?
cause static electricity
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If a fire occurs, what do you do?
turn off the oxygen then move the client to safety.
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what kind of device that you are not allowed to remove if the oxygen is administered?
cannula, mask
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which part of the body that you check signs of irritation caused by the oxygen therapy device?
check behind the ears, under the nose, around the face and cheekbones
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what do you do if the client's face is dirty and moist while using the mask?
keep it clean and dry
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what do you report to your supervisor as emergency?
If the flow rate is too high or too low, when the humidifier is not bubbling and when there are signs and symptoms of hypoxia, respiratory distress, or abnormal breathing patterns
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Low flow rates
1 to 2 L per min
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oxygen flow rate can range from ?
2 to 15 L/min
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A client in pain will probably not eat or participate in care. Pain may affect your client's breathing and moving, turning, repositioning, and walking. In addition, pain is exhausting and can make the client depressed or irritable. It is important that the client be made as comfortable as possible.
Pain and Comfort
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It is important that you observe your client's skin, especially over the bony prominences, and report any reddened areas. Remember that irritated areas can quickly become pressure sores!
Prevention of Pressure Sores
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Movement is important for everyone because it encourages deeper respirations and better blood circulation, reduces the risk of pressure ulcers developing, increases the body's metabolism, promotes peristalsis, and improves digestion. Clients with painful wounds are often reluctant to move or to ambulate, and those with wounds that are foul smelling may be self-conscious about leaving their rooms, even if they can.
Movement and ambulation
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Depending on the type of dressing that is ordered for your client, the appearance, care, and maintenance of the dressing may vary. Regardless of type, all dressings should be kept clean.
Dressings
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The client's wound cannot heal with a diet that is poor in protein or vitamin C. In addition, the client must have adequate fluid to replace any lost in wound drainage. The client who is anemic will not have enough hemoglobin to bind with oxygen, so the client must also eat an iron-rich diet.
Nutrition and Hydration
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Oxygen is a requirement for healing. On a cellular level, oxygen must bind itself to hemoglobin (part of a red blood cell) and be transported throughout the body.
Oxygenation
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Some wounds, especially those with necrotic tissue (dead tissue), may be very foul smelling, which can embarrass the client and ruin the appetite.
Odour
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Fever is the body's way of fighting infection by increasing white blood cells and blood flow to the area. Not all clients who have an infection will have a fever when you take the temperature. Some clients (such as older adults or clients with immune challenges) may not have a fever in the presence of an infection.
Temperature
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Clean, dry skin is less likely to harbour pathogens than moist, soiled skin. Pathogens can cause skin infections, which, in turn, can lead to skin ulceration and breakdown.
Skin Care
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Intact skin is the body's first line of defense against pathogens. It is important that skin is kept intact, as it is easier to prevent a skin infection than it is to cure one.
Maintaining Skin Integrity
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Delayed healing is a risk for clients who are older or obese or who have poor nutrition. Poor circulation and diabetes also affect healing.
Survivors of violence have many other concerns. Fear of future attacks, concerns about the attacker being found and convicted, and fear for family members are common.
The wound may be disfiguring. Whatever the wound's location or size, the client's body image and self-esteem are often affected.
Amputation of a finger, hand, arm, toes, foot, or leg can affect the client's function, daily activities, and job.
The wound may be large or small. It may be visible to others—on the face, arms, or legs—or hidden by clothing. If the client had surgery, anaesthesia and pain medication can affect eating and elimination.
Complications and Concerns
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who teaches the client and family about administering IV medications at home?
Nurse
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the giving of a solution highly concentrated with nutrients
hyperalimentation
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The giving of nutrients by way of the intestine
enteral nutrition
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A combination device that includes access to both the stomach and the jejunum
gastro-jejunostomy tube
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A surgically created opening that is used to drain wastes or to feed the client.
ostomy
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A combination device that includes access to both the stomach and the jejunum
gastro-jejunostomy tube
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A tube inserted into the intestines through an opening into the middle part of the small intestine
jejunostomy tube
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Weighing and measuring the client
Orienting the client to the room, nursing unit, and hospital
Obtaining a urine specimen if ordered
admission procedures
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Responsibilities Regarding Physical Examinations
Collect linens for draping the client for the procedure, collect examination equipment, prepare the room for the examination, transport the client to and from the exam room, assist with lighting, Do vital signs, position and drape the client, hand equipment and instruments to the examiner, stay with the client for emotional support, label specimen containers, disposed of soiled linen, clean equipment
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a lighted instrument used to examine the internal structures of the eye
Ophthalmoscope
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a lighted instrument used to examine the external ear and the eardrum. Some scopes are combination ophthalmoscopes and otoscopes, with parts for examining both eyes and ears.
Otoscope
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used to tap body parts to test reflexes.
Percussion hammer
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used to open the vagina so it and the cervix can be examined.
Vaginal speculum
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used to examine the inside of the nose
Nasal speculum
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an instrument used to test hearing.
Tuning fork
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used to examine the mouth, teeth, and throat.
Laryngeal mirror
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what to do when the client is worried about having a physical exam?
Be sensitive to the client's feelings and concerns
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who will inform the client for the pre-procedure exam?
Physician or nurse
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If the client may have to remove all clothes, what do they wear?
hospital gown and may covered with a paper drape, bath blanket or sheet.
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surgery that is scheduled but nonurgent
Elective surgery
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surgery that must be done soon to prevent further damage, disability, or disease
Urgent surgery
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surgery that must be done immediately to save a client's life or prevent disability. Clients who have been in accidents often require emergency surgery.
Emergency surgery
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Investigative surgery to determine the cause of a client's symptoms or the extent to which an illness has affected the body. For example, a client who has been unable to conceive a child may require diagnostic surgery to explore why.
Diagnostic
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surgery performed to restore the function or appearance of a body part or organ. For example, a client who has lost several fingers in a farming accident may require skin grafts and digit replacement to regain partial (or full) use of his hand.
Reconstructive
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surgery performed to enhance the quality of the dying client's life, not to cure the client. For example, a client with a large esophageal tumor may need to have the tumor removed or reduced to help her be able to eat.
Palliative
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surgery aimed at repairing (or removing) an injured or diseased body part in order to cure the disease. A client who has sustained abdominal injuries in a car accident would undergo surgery to repair any damaged areas.
Curative
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a surgical procedure in which a donor's tissue or organs(s) is implanted into a recipient's body in order to restore function and save the life of the recipient. Examples of transplanted tissues include skin, eyes (or parts of eyes), organs, bones, and bone marrow.
Transplant
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A drain is placed in the wound and attached to suction. Drains are sutured to the wound and connected to the reservoir
Hemovac
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leaves a wound, for example, and wounds often result from trauma—an accident (such as a fall or vehicular accident) or violent act (such as a gunshot or stabbing) that injures skin, mucous membranes, bones, or internal organs.
surgical incision
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3 days wound healing; Bleeding stops, and a scab forms over the wound, which prevents microbes from entering the wound. Blood supply to the wound increases, and the blood brings nutrients and healing substances. Because blood supply increases, signs and symptoms of inflammation—redness, swelling, heat or warmth, and pain—may appear, and there may be some loss of function.
Inflammatory phase
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day 3 to day 21, Tissue cells multiply to repair the wound
proliferative phase
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day 21 to 1 or 2 years The scar tissue gains strength and appears red and raised but eventually becomes thin and paler than surrounding skin.
Maturation phase
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What is an IV Lines?
An intravenous catheter is a small plastic cannula that is inserted in the vein with the use of a needle. After the plastic cannula is secure within the vein, the needle is removed. they are most commonly inserted in the hand or forearm but can be located in other areas such as the foot. Intravenous catheters are used to supply a client with additional fluids or medications.
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What does an HCA need to do when providing care to a client with an IV?
- Never Remove the IV Bag from the pole it is situated on
- Notify an RN if:
-They observe blood in the IV Tubing or the IV Site is leaking
- the accidently dislodge the IV during care.
- the client is complaining about pain in the area.
- Avoid getting the dressing or insertion site wet during care.
-If available, use an IV gown to dress the client (IV gowns will have snaps on the sleeves of the gown)
-Check with the RN or team leader about specific client information/Instructions before mobilizing a client. Clients who are allowed to be up and walking and have an IV can generally be mobilized.
-There are a few exceptions.
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What does an HCA need to knkow about providing care to a client with oxygen tubing?
Clients may require oxygen therapy as either a short term intervention, clients with pneumonia, for example, or for long term use (such as COPD clients). How much oxygen therapy is required and what method of delivery is used will depend on the client's condition and may change as the client improves or deteriorates. Chronic conditions, such as COPD, will require consistent oxygen therapy at all times.
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What does an HCA need to do when providing care to a client on oxygen?
When providing care to a client on oxygen, the HCA should:
- Never adjust the flow rate of the oxygen.
- Check with the RN or team leader about whether the client requires oxygen before and during mobilization.
- Check with the RN or LPN if you find oxygen tubing laying on the floor in room where there is more than one client, to ensure that the nasal prongs are replaced before being reapplied to the correct client.
- Reapply nasal prongs to a client if the prongs become dislodged during care.
- Check with the RN or team leader about specific client kinformation before mobilizing a client.
- Clients who are ambulatory and on oxy generally can be mobilized.
- There are a few exceptions.
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What is surgical drain?
Surgical drains are:
- External drainage system that are used to collect and drain internal fluids after a surgical procedure.
- there are many different types of surgical drains and HCAs must always confirm instructions with the health care team prior to providing care for these types of clients
- Often pinned to gowns to prevent them from accidentally becoming dislodged.
- often covered by dressings.
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What does an HCA need to do providing care to a client with a surgical drain?
When providing care to a client with a surgical drain, the HCA should:
- Use caution when removing a client's gown, as some drains may be pinned to the gown.
- Safely remove safety pins from the old gown and secure to the new gown when care is complete.
- Never remove a dressing that may be oozing(leaking) HCAs may place a gauze over the site and report it to the RN or team leader immediately.
-Avoid getting the dressing around the drain wet during care. Wash and dr around the dressing site.
- Report any pain or discomfort a client may experience during care and care-related activities.
-read the client's care plan/talk to their RN or your team leader to determine. If the client is allowed to sit/ get up and walk if they have a surgical drain. HCAs should also have the RN or team leader check the client prior to getting out of bed to ensure the drainage system is secure.
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What does an HCA need to know about providing care to a client with a chest tube?
HCAs need to know that:
- Chest tubes are used when a client's lung cannot inflate and deflate on its own. This may be the result of an external trauma such as and accident, or as a result of a fluid build-up in the lung that has caused it to collapse.
-Chest Tubes are secured with a lot of tape.
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What does an HCA need to do when providing care to a client with a chest tube?
When providing care to a client with a chest tube, the HCA should:
- Avoid getting too much moisture around the chest tube dressing, wash around the tape with a moist washcloth.
- Report any drainage that may be observed during care to the RN or team leader.
-Report any pain or discomfort a client may experience during care and care-related activities.
-Always check with the RN prior to mobilizing a client with a chest tube. Accidently dislodging or withdrawing the chest tube may cause the client to go into respiratory distress and requires immediate medical intervention.
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What does an HCA need to know about providing care to a client with a catheter?
HCAs need to know that:
- Catheters in acute care settings are inserted as a short term medical intervention. This may include surgical clients both pre-operatively and post-operatively to facilitate bladder drainage during surgery. Unless otherwise indicated, catheters in acute care settings should only be used for short periods of time.
- Although clients who are allowed to be up and walking and have catheters can generally be mobilized, there are a few exceptions. HCAs must check with the RN or team leader about specific client information.
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What does an HCA need to do when providing care to a client with a catheter?
When providing care to a client with a catheter, HCA should:
- Confirm instructions and gather information regarding anything that may be different in providing care for a specific client with a catheter.
- Report any pain or discomfort a client may experience during care or care-related activities.
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What types of surgical incisions would you expect to see in acute care?
In acute care, you may encounter a wide variety of incisions. Incisions are generally covered with a dressing/bandage.
- Common surgical incisions include:
- abdominal incisions
- Hip/Knee incisions
- Other.
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What does an HCA need to do when providing care to a client with a surgical incision?
When providing care to a client with a surgical incision, the HCA should:
- Confirm instructions with the RN/LPN.
- Gather information and supplies for care
- Seek Permission from the client to look at the bandage over the incision and to perform care
-Notify an RN immediately if there is a large amount of drainage on the bandage over the incision.
- Never remove a dressing that may be oozing. HCAs may place a gauze over the site
- Report any pain or discomfort a client may experience during care or care-related activities
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Strategies For:
-Prioritizing tasks
-Demonstrating flexibility in work assignments
-problem-solving and decision-making regarding care provision.
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What does an HCA need to know to prioritize tasks when providing care in acute care settings?
When providing care in acute settings, HCAs need to:
- Attend huddles/shift reports or seek information from the other members of the health care team about changing priorities throughout the day.
- Seek guidance and direction from the RN or LPN related to their responsibilities
- Communicate clearly with the Health care team to identify what tasks have or have not yet been completed
-Anticipate that they will need to be flexible in their client care assignment based on the client's needs. Although they may have been given assignments, they may be reassigned during their work days due to unforeseen circumstances.
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When teams work interprofessionally:
-Decision-making is shared
-Leadership is shared
-The role of each health care provider is understood and the client and family are included in the process
-Communication on the team is efficient, open, respectful and client-centered and the client and family are integrated into the care process
