1
Q
MA or SA: med administration
A
Typically MA
2
Q
MA or SA: Insertion of IV catheter
A
Peripheral is MA (but prep skin)
Central is SA
3
Q
MA or SA: Dressing change with a decubitus ulcer (bed sore)
A
MA - chronic wounds are considered colonized
4
Q
MA or SA: Urinary catheterization in the hospital
A
surgical asepsis
5
Q
MA or SA: insertion of a NG tube
A
MA
6
Q
MA or SA: simple dressing change of a new surgical incision
A
MA
7
Q
MA or SA: complex dressing change in an abdominal wound
A
SA
8
Q
MA or SA: Assisting witha. surgical procedure at the bedside
A
SA
9
Q
Which aseptic technique is performed to reduce the number of pathogens transferred to the patient?
A
medical asepsis aka clean technique
10
Q
What steps are involved during clean technique?
A
Hand hygiene before procedure
Non-sterile gloving
Procedure using clean equipment
Remove gloves
Hand hygiene after procedure
11
Q
Which aseptic technique is used to promote absence of all microorganisms OR significantly reduce the # of pathogens introduced?
A
surgical asepsis aka sterile technique
12
Q
When do we use sterile technique/surgical asepsis?
A
- When entering a sterile body cavity
- If mucous membranes are damaged in GI tract or mouth (prone to infection)
- During surgical procedures
- If the pt. has a compromised immune system
13
Q
What steps are involved in sugical asepsis/sterile technique?
A
- Hand hygiene before procedure
- Sterile gloves and supplies used during procedure to eliminate new microorganisms from entering the body
- Hand hygiene following procedure
14
Q
Sterile or not sterile: the nurses’ hands after she performs correct hand hygiene
A
Not Sterile
15
Q
Sterile or Not Sterile: your scrub top after it has been washed and dried
A
Not sterile
16
Q
True or False: Skin preparation like hand hygiene and sterile garb eliminates the number of microorganisms that could be introduced to the patient
A
False: it reduces them, but does not eliminate
17
Q
True or False: sterile items may only touch other sterile items
A
True
18
Q
True or False: A patient’s wound is considered sterile
A
True
19
Q
What 4 things do you check to ensure your equipment is sterile?
A
- is it labeled sterile?
- is the package intact?
- is the expiration in date?
- has it been stored properly?
20
Q
Moist paper packaging can transmit organisms through what process?
A
capillary action
21
Q
In regards to a sterile procedure, how do you ensure the comfort of your patient?
A
- Assess their comfort/pain prior to the procedure
- Administer analgesics appropriately
- Identify your patient using a source document
- Explain the procedure and ask about questions or concerns
- Prepare all supplies efficiently
- Place pt. in position only as long as necessary
- Enlist help PRN
22
Q
How do we manage a sterile field to ensure it remains sterile?
A
- Face the sterile field at all times
- Never walk away from the field
- Keep your equipment and hands above the waist
- Remember that the outer 1 inch of a sterile field is nonsterile, as are drapes over the edge of a table
- Reach across the field as little as possible
- Do not cough, sneeze or talk excessively
23
Q
What are the steps in setting up a sterile field on a bedside table?
A
- Clean table
- Wash hands
- Open packaging and prep sterile field area
- wash hands
- put on clean gloves
- remove the old dressing
- Wash hands
- change to sterile gloves
- work in one direction across the table to complete the dressing/packing
- dispose of materials and remove gloves
- wash hands
24
Q
What should you do before donning sterile gloves?
A
- Wash hands
- Assess fit
- Ensure you have your lucky gloves
25
What should you do if you have prepared a sterile field and forgotten something?
Ask the patient to use their call light and ask a colleague to bring it to you OR dispose of sterile field and start again
26
What should you do if you have sterile gloves on and forgot to open an essential item?
Open the item and use your lucky pair of gloves for the procedure
27
What is included on a source document?
Patient's name, DOB and the procedure to be performed
28
How do you use a source document?
Prior to a procedure, compare it to the patient's wristband and confirm out loud.
29
What do you do with a source document after a procedure?
Place in a confidential shredding bin.
30
Why do we perform blood glucose testing?
to monitor patient's at risk of hypo or hyperglycemia and check the effectiveness of insulin or other antidiabetic drug
31
Who is at risk for hypo/hyperglycemia?
1. diabetics
2. patients on steroids
3. patients on TPN
4. patients with other illnesses that require tight glucose control
32
True or False: you need an MD order to perform glucose testing
True
33
What is they typical schedule for doing blood glucose testing?
AC and HS
34
When is it okay to do a blood glucose test w/o an order?
Decreased LOC - crisis situation
35
What do you want to assess in your patient before doing a blood glucose test?
1. Prior results (trends)
2. Any s/sx of hypo/hyperglycemia
3. Risk for bleeding (anti-coags)
4. Tough skin
36
What are the clinical markers of hypoglycemia?
BS < 60 and s/sx
37
How do you respond to hypoglycemia as a nurse?
Give some form of glucose such as OJ or if NPO, give Dextrose IVP
38
How can patient's treat low blood sugar at home?
Give glucagon IM
39
What are interventions for unexpected blood glucose levels?
1. Correlate your values with assessment
2. Use insulin sliding scales to determine dose
3. Contact the lab to confirm critically low or high test results after repeat testing
4. Notify RN promptly
40
What can you use to cleanse the site in FSBG as long as its within your facility policy?
soap and water
alcohol
41
What are the considerations for choosing a puncture site?
use the sides of finger pads
no thumbs
rotate fingers and puncture site
42
What information do you need to have on hand to complete the FSBG procedure?
1. source document
2. operator ID number-badge
3. Patient ID band barcode
43
What equipment do you need for a FSBG?
1. Gloves
2. Sterile lancet(s)
3. cotton balls/2x2s
4. glucose test strip
5. glucose meter
6. soap and water or alcohol swab
44
What procedure should be followed to complete a FSBG procedure at bedside?
1. prepare glucose meter and test strip
2. Explain the procedure
3. ID the patient using source document w/ name and DOB
4. Select finger
5. Cleanse according to policy
6. Position hand in dependent position and warm if needed
7. Don clean gloves
8. Warn patient before stick
9. Perform puncture
10. Apply blood sample to end of stick
11. Provide hemostasis with gauze or cotton ball
12. Note test results and share with patient and RN
13. Enter required comments into meter
14. Turn off meter
15. Dispose of equipment including lancets in sharps and other items in trash
16. Return meter to dock
17. Info is uploaded automatically to EMAR
45
Blood glucose monitoring Cuesta program standards include
1. Cleaning the patient's finger, or site, per facility policy
2. Collecting blood sample and assuring hemostasis
3. Reporting results to RN and clinical faculty
4. Treating results per student scope
5. Verifying documentation
46
What are the six rights of med admin?
right patient
right med
right dose
right route
right time
right documentation
47
What do we as nurses verbalize before administration?
1. name of drug
2. indication
3. therapeutic effects
4. pertinent pre-assessment
5. anticipated side effects
6. drug interactions
7. safe dose range
8. nursing implications
48
When we scan the patient's armband, what are we verifying?
Patient identifiers against the EMAR
49
What is the typical protocol for administering high-risk medications?
Complete dose verifications with two licensed nurses
50
What type of medications do we use specialized knowledge and policies for that cannot be implemented until after learning in second semester?
chemotherapeutic and antineoplastic
51
What are the different med groupings you could have?
Scheduled/routine
Unscheduled/on-hold
PRN
Continuous IV infusions
Discontinued meds
52
What is involved in med research as a nurse?
1. Connect the drug to diagnosis/history to see if it makes sense (Davis -Implentation and Assessment sections)
2. Conduct any pre-assessments including vital signs, lab work, physical assessments
3. Perform any necessary calculations
4. Review order in EMAR and determine acceptable window of time for med admin
5. Check to see when last dose was given
53
54
What is Cuesta's time medication window?
30 mins before or after med is due
55
When withdrawing meds from dispensary machines, what should you verify?
Med, dose, exp. date
56
1. Describe the three checks of med admin
1. Outside of patient room at EMAR to determine if appropriate/indicated
2. After getting meds from dispensary with instructor, compare meds in hand to EMAR using the 5 rights (pt., med, dose, route, time)
3. After entering patient room, verifying name, DOB and allergies, scanning meds, doing education and altering meds, compare to EMAR for final check with 5 rights)
4. Give meds and then click document in system (6th right)
57
How should a patient be positioned in bed when taking meds?
at least 30 degrees (be sure to assess ability to swallow first)
57
When should you dispose of vials and packages?
After the patient has taken their meds and you have documented
58
When completing your third check at the EMAR and scanning your meds, what should you be looking for?
pop-ups on the EMAR screen
59
What are the minimum teaching points you should share during med admin with patients?
What is the med
What is the action of the med
Potential common and life-threatening adverse effects
60
Who sets the standards for patient teaching?
The Joint Commission
61
How would you verify patient identifying info with nonverbal patients?
1. Check the patient's wristband against the EMAR
2. Utilize family
62
63
True or False: It's okay to leave meds at the bedside for your patient to take later if they are asleep
False
64
What is the process for held or refused medications?
1. Document why med was not given
2. Notify RN/physician promptly
65
With liquid medication, how do you measure the dose?
Fill the medicine cup until the mensicus of the medicine reaches the appropriate dose on the cup
66
67
Which type of meds should you not cut or crush?
Enteric coated, sustained release or extended release
(SR, CD, CR, ER, XL, XR)
68
What is the best way to administer crushed meds in applesauce or pudding?
Use the least amount possible - start with one spoonful containing all meds then after they've taken their meds can give more sauce/pudding
69
Which of these is true about sublingual meds?
-They work slowly over time
-They avoid the first-pass effect because the area is highly vascularized
They avoid first-pass effect
They actually work rapidly
70
What is nitroglycerin given for and what type of medication is it?
acute angina; sublingual
71
What is the name of medications given between gum and cheek that avoid first pass effect?
Buccal
72
What is the procedure for giving eye drops
1. Wearing gloves, clean away any drainage and exten the patient's head
2. Give patient a tissue
3. Retract the lower lid and without touching the eye, place the gtts in conjunctival sac
4. Have patient hold eye closed and press on nasal-lacrimal duct for 30 seconds
73
Which direction do you apply eye ointment in?
Inner to outer
74
What is the process for applying ear drops in an adult?
1.Let med stand at room temp for 30 mins if cold
2.Place patient on side with ear to be treated up
3. Grab pinna and pull up and back
4. Direct gtts alon side of canal, not onto eardrum
5. Directly massage tragus to move gtts along canal
6. Lie on side for at least 10 mins
7. Insert cotton ball
75
What is the process for admin nasal spray?
1. Have patient blow nose first
2. Sit the pt. up right if possible
3. Occlude one nare
4. Gently shake the spray and insert tip into nostril
5. Squeeze to give dose
76
What is the process for inserting a rectal suppository?
1. Place pt. in sims position
2. Don gloves and lubricate with water soluble jelly
3. Instruct patient to relax as much as possible
4. Push gently into rectum, 1 in. past anal sphincter
5. Lie on side for 15-20 mins
77
What is the process for administering a transdermal patch?
1. Remove the old patch with gloves and fold on itself
2. Cleanse the skin of old med
3. Check to see if irritated
4. Write date, time and initial on new patch
5. Place new med patch in a new site
6. Don't massage med into skin
7. Dispose of old patch in med waste container
78
What are the steps for administering an inhaler med with a spacer?
1. Remove cap and attach spacer
2. shake canister
3. Ast pt. to take a deep breath out w/ mouth
4. Place the inhaler in pts. mouth and ask them to press the med top
5. Inhale slowly
6. Hold breath
7. Exhale slowly
8. Remove slowly
9. Wait 1 min till next puff
79
What causes wounds?
Pressure, Trauma, Surgery, Burns, Infections, Arterial/Venous Insufficiency
80
Wound care protects patients from the following (3):
1. Mechanical injury
2. Pressure
3. Microbial contamination
81
Wound care includes:
1. Enhancing healing
2. Absorbing drainage
3. Splinting and immobilizing the wound site
4. Preventing premature closure of infected wounds
5. Debriding the wound site
82
What are Cuesta's performance standards for wound care?
1. Follow hospital policy, protocol or orders for type of wound care
2. Use source document
3. Determine clean vs. sterile
4. Apply principles of clean or sterile technique
5. Document per facility policy
83
True or False: we change incision dressings the first time post-surgery
false - typically surgeon unless otherwise ordered
84
What are the 10 observation/documentation points for wounds?
1. location
2. size/shape
3. color/appearance
4. odor
5. approximation
6. sutures/staples
7. drains
8. drainage
9. undermining/tunneling
10. dressing type
85
separation of wound edges
dehiscence
86
abdominal contents protrued through wound opening (involves muscle separation)
evisceration
87
True or False: dehiscence and evisceration are serious complications that require immediate intervention
true
88
results in a hairline scar from a small, clean wound with clear edges that is sutured early
primary intention healing
89
Describe secondary healing intention
occurs when a wound is gaping and irregularly shaped, forms granulation first and then epitheilialization closes the wound
90
Wound is first left open to heal from the inside out - forming granulation tissue. Once healed to a certain degree the remaining opening is sutured together.
Tertiary healing intention
91
What causes pressure injuries?
1. Pressure
2. Compromised blood flow
3. Shearing forces
92
How often is the Braden scale evaluating in Cerner?
q shift
93
What 6 areas does the Braden Scale evaluate?
1. Moisture
2. Activity
3. Mobility
4. Sensory Perception
5. Nutrition
6. Friction and shear
94
What is the range of scores for the Braden scale and at what score are patient's at risk for skin breakdown?
6-23; at risk at <18
95
What are the preventative interventions we would begin if a patient was at risk for skin breakdown d/t Braden score?
1. Turn/reposition patient
2. Protect bony prominences like heels
3. Increase activity
4. Promote nutrition/hydration
5. Manage moisture
6. Use pressure-redistribution surfaces
96
What is an unstageable pressure injury?
1. one that is obscured by slough/eschar tissue
2. involves full-thickness skin loss
97
What are the characteristics of a stage 1 pressure injury?
1. Reddened area
2. Localized
3. Non-blanchable
4. usually over bony prominence
5. Might be painful, hard/soft, warmer/cooler than surrounding areas
98
What are the order of the tissue layers involved in pressure injuries?
1. epidermis
2. dermis
3. fat (subq)
4. muscle
5. bone
98
What are the characteristics of a stage 2 pressure injury?
1. partial thickness loss of dermis
2. open but shallow
3. pink wound bed
99
What are the characteristics of a stage 3 pressure injury?
1. deep crater
2. full thickness skin loss
3. may extend into adipose layer
100
What is a stage 4 pressure injury?
1. Full thickness skin loss
2. Very deep injury that may extend to muscle or bone
3. May see dead tissue like slough or eschar
101
True or False: medical devices can cause pressure injuries
True
102
What are 5 other types of wounds besides pressure injuries?
1. skin tears
2. arterial ulcers
3. venous ulcers
4. diabetic food ulcers
5. incontinence associated dermatitis
103
Who directs wound care?
1. MD order is first
2. Then PT/RN wound specialist
104
What are transparent dressings like Tegaderm typically used for?
IV coverings
105
What are impregnated non-adherent dressings (Adaptic, vaseline gauze or xeroform) typically used for?
Chest tubes
106
What type of procedure is an example of when you would cover the resulting wound with a non-adherent dressing?
hip arthroplasty incision sites
107
Mepilex and duoderm -provide moist healing environment and absorb wound exudate
hydrocolloids
108
Hydrogel (90% water in a gel base) promotes healing through:
-Granulation
Epithelializtion
Autolytic debridement
Rehydration of wound bed
filling in dead space
use during infection
109
True or False: hydrogel should only be applied to dressings and not directly to wound bed
False
110
What types of solutions are used for wound irrigation?
1. Normal saline
2. full or partial strength hydrogen peroxide
3. Dakin's solution
111
What are 4 important wound care prinicples?
1. Move from clean to contaminated areas
2. Pressure injuries are considered colonized so you would use clean technique
3. Wound itself is considered sterile
4. Moist to dry dressings to gently debride area - dressing in wound should be moist (not wet) but dry dressing should be dry as to not break down skin
112
True or False: Removal of outer dressing on a wound is done with clean gloves
True
113
True or False: removeal of (old) inner dressing is done w/ clean tweezers
False - sterile tweezers
114
When do you apply sterile gloves when changing a wound dressing?
After old dressing has been removed from on top of and inside of wound
115
What are the two suture types?
1. Plain interrupted
2. Plain continuous
116
can be applied to skin after staple/suture removal to help skin stay closed and support skin
steri strips
116
hypoallergenic adhesive straps used to facilitate frequent dressing changes and help prevent skin trauma.
Montgomery straps
117
Cyanoacrylate glue is also known as ____ and is used for these types of wounds.
derma-bond; small, clean, simple lacerations
118
allows for open drainage through capillary action to skin surface through tube, drainage absorbed in dressing.
Penrose drain
119
a suction drain that must be compressed; has ___ maximum
Jackson Pratt; 150mL
120
How often are JP drain I/O charted?
at least q shift
121
122
What are the four outcomes of cold therapy?
1. controls bleeding
2. decreases edema
3. pain control
4. anti-inflammatory
123
How do you safely apply cold therapy?
1. Make sure you have an order
2. Do not apply it directly to their skin
3. Discontinue when numb and assess response
4. Usually 15 mins on/off
124
What are the three outcomes of heat therapy?
1. Facilitates soft tissue repair
2. Relaxes skeletal muscles
3. Increases blood flow to area
125
What are the safety steps for heat therapy?
1. Get an order
2. Make sure they have intact sensory function
3. Assess response
126
127
NRAD 201B
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