RN Live Review Fundamentals 2019

NCLEX week 3 - physiological adaptation aquaarina Save RN Live Review Fundamentals 2019 42 terms GiselleG2022Preview Physiological Adaptation Teacher 10 terms Prof_Laura_Garrido Preview Cancer nclex questions 26 terms Sarah_Crum3Preview ATI phy 29 terms Bria Learn1 / 7Study with Learn we want to precent blood clots, pressure ulcers, etc. Choose an answer What are these?

• IJ
• PICC line
• Hickman
• Broviac
• TT

Post-op care: mobility

• why do we encourage early ambulation of possible?

wound drain with increased risk for infection

• penrose drain
• t-tube Used to look at the airway structures or obtain tissue sample

types

• rigid - general anesthesia
• flexible - bedside sedation in the ICU

Preproceudre

• NPO 4-8 hours prior
• May give benzo for light sedation

Posprocesure

What are these?

• IJ
• PICC line
• Hickman
• Broviac
• TT

Central venous catheters

• Way to transfer fluids that are irritating to the vasculature system
• Hypertonic solutons, TPN, rapid blood administration
• Preferred for K and vancomycin administration
• Can also be used for central venous pressure monitoring

Central Line gives continuous and accurate blood pressure readings allows for quick access to gather a blood specimen placed in the artery of radial, brachial, axilalary or femoral terile technique is used arterial line -Ensure gaga reflex intact (nothing to eat or drink until gag reflex has returned)

• Monitor for bleeding/ infection

Don't know?

removes fluid/ air from the pleural space have client lean over the bedside table or place them in semi-fowlers with the unaffected side down procedure

• local anesthesia is. used and may cause a stinging feeling
• have the client hold their breath when the provider is inserting the needle
• no more than 1,000 mL should be removed (if more fliud needs to be removed, a chest tube will be inserted

Risks

• Pneumothorax (pain during inspiration, tachycardia, absent breath sounds on one side)
• Medistinial shift (chest pain/ anxiety)

Infection

• Fever/ increase in WBC

Thoracentesis Used to look at the airway structures or obtain tissue sample types

• rigid - general anesthesia
• flexible - bedside sedation in the ICU

Preproceudre

• NPO 4-8 hours prior
• May give benzo for light sedation

Posprocesure -Ensure gaga reflex intact (nothing to eat or drink until gag reflex has returned)

• Monitor for bleeding/ infection

Bronchoscopy client care for ventilator clients done Q 2 hours

• assess for suctioning needs, how is this done?

check VS listen to lung sounds client care for ventilator clients done Q 2 hours

• this prevents ventilator associated pneumonia and keeps oral mucosa moist

Oral care

client care for ventilator clients done Q 2 hours

• this is done to prevent contractures

passive range of motion client care for ventilator clients done once Q 24 hours (per hospital policy)

• turn the sedation off long enough to check if the client is alert and oriented
• doing this helps improve long term outcomes

Sedation Vacation

• inhale to make the ball rise
• help client sit upright
• have client take a deep breath in through their mout and exhale
• seal lips around mouth piece
• inhale through the mouth and raise the ball as high as possible
• Hold breath for 3-5 seconds
• Exhale
• Repeat for a total of 10 breaths/hour

Incentive spirometer Uses specific positioning and percussion with the hands cupped to help mobilize secretions and help client to clear their airways Chest Physiotherapy Having the client do this Q 2 hours is helpful for preventing pulmonary complications cough, turn, and deep breathe Q 2 hours wound drain with increased risk for infection

• penrose drain
• t-tube

open drainage open drainage

• drainage by gravity

penrose drain open drainage

• insert temporarily into the bile duct
• alllow bile to drain

t-tube