Mobility/Safety
The Braden Scale is used for?
in addition to a skin assessment to determine a patient's risk of skin breakdown. The patient gets a score from a series of questions.
What does sterile mean?
FREE FROM ALL MICROORGANISMS
Bonus: What is sterile once you gown up??
What are VS changes in a patient that is hemorrhaging?
Heart rate increases
BP decreases
RR increases
Abnormal breath sounds may also be called this
Adventitious breath sounds
You are assessing your patient's stoma, what are you looking for and what is expected?
Beefy red stoma, peri skin integrity, drainage/effluent, bowel sounds
What kind of bed is utilized for a patient with a spinal cord injury?
Rotokinetic bed
Bonus: What does it do??
List the operative phases and what do they mean?
preoperative- before surgery
intraoperative- during surgery
postoperative- after surgery
OH NO! Your patient had surgery and now he is calling for you after he coughed a bunch because his abdomen is hurting, the incision opened and it looks like "things" are coming out. What do you expect to find??
Bonus: What do you do?????
List the types of suction and tell me which is sterile and which is not
Oral
ETT
Tracheostomy
Your patient has not been able to void in several hours, they are complaining of some urinary pressure and you have ambulated them in the hallway, ran water in the sink while they attempted to void but they cannot go, what should you do?
Bladder scan patient and reach out to the provider
QUICK! Your patient is in the chair and having a seizure, what should you do????
- assist to safe position on floor
-call a rapid response
- document start of seizure
- protect airway/suction
- monitor length/seizure activity
-protect pt from injury
What is important about preop teaching?
Making sure the patient understands NPO status, what to expect before surgery and after surgery. Importance of early mobility, any post op restrictions, etc. Discuss pain will be managed but not totally eliminated.
List the order of an abdominal assessment
Inspect
Auscultate
Palpate
What is trach care and how is it done?
Performed EVERY shift and prn
HYPEROXYGENATE
inner cannula is removed and disposed, area cleansed with NSS, if not disposable, inner cannula is cleansed with NSS.
Note skin integrity, have second person to assist in holding trach when removing neck collar, place gauze under stoma to collect any drainage
What is included in output?
ANY LIQUID DRAINAGE
Liquid bm, drains, ostomies, voiding, wound drainage
What are some immobility risks?
Skin breakdown, constipation, muscle atrophy, contractures, pneumonia
BONUS: Can you give some signs and symptoms of pneumonia, contractures and muscle atrophy?
What are some complications of general anesthesia?
Mechanical obstruction, retained secretions, laryngospasm, CNS depression, Hypo/Hypertension, Hypovolemia, Cardiac Arrhythmias
Bonus: List some other POST OP complications?
Color, circulation, sensation, and movement
What is a non-rebreather and when is it used?
provides highest oxygen percentage before CPAP, BIPAP or intubation
Used in deteriorating respiratory status
ONE valve, meaning no exhaled air enters reservoir bag
Your patient states "I have had to have a foley put in place before when I couldn't go, can't you just put one in already?" The nurse knows they cannot do this without a doctor's order, why?
It's a dependent intervention
BONUS: Give me an example of a independent intervention
Name the stages of pressure ulcers.
Stage 1--Skin intact, non-blanchable redness, painful.
Stage 2--Partial thickness loss/intact or open blister/shallow crater
Stage 3--Full thickness skin loss/adipose seen, no fascia
Stage 4--Full thickness loss/exposed bone, tendon, muscle, or fascia
Deep Tissue Injury-purple or maroon intact skin
Unstageable-depth wound obscured by slough or eschar
List 2 examples of non-pharmacological pain management and 2 examples of pharmacological pain management?
Massage, relaxation techniques, aromatherapy, heat/cold therapy, music
oxycodone, tylenol, ibuprofen, toradol, dilaudid, morphine, hydrocodone, percocet
What sites can be utilized to assess a patient's blood pressure?
Brachial, radial, popliteal, posterior tibial arteries
Bonus: Give me a NORMAL set of vital signs (T P BP O2)
What is the difference between atelectasis and pneumonia?
Pneumonia- inflammation of alveoli caused by infectious process (3-5 days post op)
DARN, the doctor just ordered a clear liquid diet for your patient and the breakfast trays are heading down the hall, what can your patient have on a clear liquid diet?
Apple juice, broth, jello, water, black coffee/tea, italian ice/popsicles
Bonus: how do we prevent constipation?