Technical Skills Lab
Technical Skills Lab NURS 241
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This 5 page Study Guide was uploaded by Ludwig Sanford on Monday October 12, 2015. The Study Guide belongs to NURS 241 at Ferris State University taught by Margaret Smith in Fall. Since its upload, it has received 44 views. For similar materials see /class/221611/nurs-241-ferris-state-university in Nursing and Health Sciences at Ferris State University.
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Date Created: 10/12/15
241 Final Exam Review Review restraints application amp considerations 0 Some considerations of using restraints Can only be used with consent of patient and only with a physicians order The order must specify the type of restraint location and the behaviors that justify the use of restraint Orders must be renewed based on time period speci ed by agency Restrained clients can experience a loss of selfesteem fear anger and humiliation The use of restraints requires a psychological adjustment of the client and family Use of restraints must meet the following objectives Reduce the risk of client injury from falls Prevent interruption oftherapies being provided Prevent the confused or combative client from removing vital life support equipment Reduce the risk of injury to others by the client 0 Some considerations in applying restraints Assess placement area of restraint and skin underneath where restraint will be Pad skin and bony prominences Attach restraint to a moving part of the bed not the side rail Secure restraints with a quick release tie Two nger width between skin and restraint Assess proper placement ofrestraint skin integrity pulses color temperature and sensation of restrained body part every two hours Restraints should be removed every two hours Seizures nursing actions amp considerations 0 Assess seizure HX noting frequency the presence of an aura any sensory image experienced before onset of seizure and the sequence of events 0 Assess medication HX 0 Inspect clients environment for any safety hazards if seizure occurs 0 Pad side rails and headboard bed in low position client in a sidelying position 0 If seizure occurs guide client to oor and protect head and turn to the side 0 Do not put anything in the client s mouth 0 Note time that seizure began and stay with client to note the sequence of events 0 For Status Epilepticus put on gloves and insert oral ainNay and use pillows or pads to protect client Preop teaching guidelines know steps amp rationales for the different education we do 0 The information required to make informed decisions needs to be accurate complete and relevant to the client s needs 0 Identify specific learning objectives that are specific to the client Teaching is an interactive process that promotes learning Incentive Spriometry Skin Preparation Coughing and deep breathing 1012X Q H while awake Sterile technique understand the principles amp practice Principles of sterile technique I Prevents contamination of an open wound isolates operative area from the unsterile environment and maintains sterile eld I Surgical asepsis is used in the following situations Procedures that require intentional perforation of the client s skin When the skin s integrity is broken as a result of trauma surgical incision or burns During procedures that involve insertion of catheters or surgical instruments into sterile body cavities I The following principles are important in surgical asepsis A sterile object remains sterile only when touched by another sterile object Only sterile objects may be placed on a sterile field A sterile object or field out ofthe range of vision or an object held below a person s waist is contaminated A sterile object or field becomes contaminated by prolonged exposure to air When a sterile surface come in contact with a wet contaminated surface the sterile object or field becomes contaminated by capillary action Fluid ows in the direction of gravity The edges of a sterile field or container are considered to be contaminated Suctioning and trach care nursing actions and considerations Nursing actions for suctioning and trach care Clients with arti cial ainNays are at high risk for infection and airway injury Suctioning and trach care are sterile techniques Tracheostomy is for clients requiring long term assistance Tracheostomy s have an inner cannula which can either be disposable or not and this main part requires cleaning Review the procedure for sterile catheterization Know what to do for care of an indwelling catheter For example since infection is a major concern with these what precautions do you need to be aware of What questions should you ask yourself before doing a sterile cath on your patient Think about what you need to gather as well as what you need to educate your patient on before insertion and after removal of cath Keeping the insertion technique sterile to reduce risk for infection Is this catheterization necessary Did I assess 1amp0 last void and bladder distension Educate the patient on what it will feel like not fighting the urge to eliminate DON T PULL IT OUT Make sure they have voided 6 to 8 hours after catheter removal Minimum amount they must void after removal is 250 mL in 68 hours Put patient s leg down when strapping catheter to her leg Nasogastric tube understand elements of insertion irrigation amp removal Review Procedure Enteral feeding tube placement and care of Stomach has a pH of between 04 Dark green in the stomach Yellow in the intestines Increase rate every 10 12 hours if patient tolerates feeding Most serious complication is aspiration of feeding into lungs IV starts review the procedure Think about what you would consider when going in to start an IV on a pt Where will you place it Etc Know what would be important in IV insertion and removal for safely performing that procedure Review procedure Where they have had IVs placed before DO NOT place on side of mastectomy skin graft tenderness edema bruises Place in most distal site Nondominant arm Use of the tourniquet and safe removal within one minute of application STERILE Pull tape away from direction of insertion when removing Make sure tegaderm is sealing the hub of the catheter IV push IVP and IV piggyback IVPB meds review these procedures in your book Understand the most important considerations when delivering meds in this way IVP RATE OF INFUSION Open system or saline heparin lock For lock ush with saline heparin before and after medication administration second ush goes at rate of medication IVPB Hang above main bag Prime the secondary line using the primary solution There will be a few questions related to IV therapy as well as a couple math questions related to IV calculations Review the skills in lab that pertain to obtaining specimens COCA Sputum Collect this specimen in the morning recommended 310 mL of specimen Must be sputum Refrigerate within 30 minutes if it cannot be taken to lab 0 Urine Specimen Collect midstream Refrigerate within 30 minutes 0 Wound Specimen Clean the wound first with nonantiseptic solution and let it dry Swab a 1 cm squared area and use enough pressure to express uid from the wound Need to keep the swab sterile until it is used to swab the wound Review stages of pressure ulcers and wound care 0 Know wound care procedure 0 Stages of pressure ulcers I Stage 1 Skin intact with nonblanchable redness usually over bony prominence I Stage 2 Partial thickness skin loss involving epidermis dermis or both The ulcer is super cial and presents clinically as an abrasion blister or shallow crater Stage 3 Full thickness tissue loss subcutaneous tissue may be visible Bone muscle and tendons are not exposed Slough may be present but does not obscure tissue Stage 4 Full thickness tissue loss with exposed bone tendon or muscle Slough or eshcar may be present as well as tunneling 0 Types of Healing I Primary Skin edges are closed I Secondary The wound is left open and takes longer to heal I Tertiary Wound left open for several days most common in wounds that are contaminated and risk for infection is high Wound closed when risk for infection is resolved 0 Phases ofwounds p 1286 I In ammatory 13 days I Proliferative 324 days I Maturation may take more than a year Wettodry dressing changes nursing actions amp considerations 0 Review procedure Review colostomy care education for new colostomy patients etc 0 Review procedures Measure and cut hole as accurate as possible 0 Education Full irrigation takes about an hour Never use an enema set to irrigate Low fiber diet when they rst get an ostomy to reduce risk of blockage Small bowel requires time to adapt to diversion Blood transfusions What are the concerns with administration What guidelines must you follow Review the blood transfusion record used in lab Allergies Low back pain chills temperature increase of 3 degrees Stop infusion if reaction occurs Stay with them for 15 minutes then check on them every half hour Have a second nurse verify patient and blood type Warm the blood to room temperature Begin transfusion rate for 100150 mL per hour Central line care What are the risks How do we care for these What education will you need to do with your client 0 Prevent Air embolism Valsalva procedure turn head away from tubing 0 Sterile insertion 0 Change tubing and dressing 0 Observe strict sterile technique clean gloves Medication administration know nursing actions amp considerations for various routes oral eye ear rectal vaginal inhalation amp injections as well as safety measures associated with each 0 Oral I Assess ability to swallow I Give patient 60 100 mL of uid I Place med in cap I Buccal 7 inside the cheek I Sublingual 7 under the tongue 0 Eye I Conjunctival sac I Avoid cornea and have them look up I Hold lacrimal duct to protect from systemic spread I Close eyes gently and hold for 30 to 60 seconds 0 Ear I Have patient laying in bed or sitting in chair with head tilted I Up and out for adult down and away for child I Massage tragus to promote spread of medication 0 Rectal I Lubricate suppository I Insert 4 for adult 2 for a child I Lay in left side lying position for 5 minutes I Insert along bottom of wall toward umbilicus o Vaginal I Lubricate I Lay in dorsal recumbent or supine for 10 minutes I Wash applicator for cream or foam and save for patient I Insert 34 for suppository 23 for foam applicator
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