NUR 311 Final Exam (UAB NUR 311 Final Exam)
What is sterile?
anything ABOVE the waist
Doffing sterile gloves
- using gloved dominant hand, grasp outside cuff of
nondominant hand and remove the nondominant glove by
slowly inverting it as you pull it off your hand
- hold soiled glove in dominant hand and use ungloved
nondominant hand to slide 2 fingers betw. wrist and glove and
slowly remove glove off dominant hand balling both gloves
together in a ball w/ contaminated side on inside
- dispose of all materials and return room to pre-procedure state
Assessing wounds
- appearance
- pressure ulcer stage
- size (length, depth, tunneling)
- drainage
- temp
- pain
- prescene of sutures, drains, tubes
- evidence of complications
Pressure injury stages
4 stages
Stage 1
,- intact skin w/ non-blanchable redness
Stage 2
partial-thickness lost, red-pink wound bed
Stage 3
full-thickness loss, sub q fat may be visible
Stage 4
full-thickness tissue loss, exposed bone, tendon, or muscle
Wound measure
- length
- width
- diameter (if circular)
- depth
- tunneling
Cleaning Wound
- top to bottom
- center to outside
- use new gauze each wipe
- loosely pack wounds if ordered
- dry surrounding skins
Dry dressing
wick for drainage, may be used as secondary dressing
Wet to dry dressing
allows debridement of wound
, Non-adherent dressing
should not be used when wound debridement is desired
Labeling dressings
- time
- date
- initials
Phlebitis
inflammation of vein
Nursing considerations to do for phlebitis
- discontinue infusion immediately
- apply warm, moist compresses to affected site
- avoid further use of vein
- restart infusion in another vein
Infiltration
leakage of intravenous fluid into extravascular tissue
(nonvesicant), edema
Nursing considerations to do for infiltration
- check infusion site every hr for signs/symptoms
- discontinue infusion if symptoms occur
- restart infusion @ diff site
- use site-stabilization device
Extravasation
- IV becomes dislodged and medication infuses into tissue
(vesicant), blackened tissue
What is sterile?
anything ABOVE the waist
Doffing sterile gloves
- using gloved dominant hand, grasp outside cuff of
nondominant hand and remove the nondominant glove by
slowly inverting it as you pull it off your hand
- hold soiled glove in dominant hand and use ungloved
nondominant hand to slide 2 fingers betw. wrist and glove and
slowly remove glove off dominant hand balling both gloves
together in a ball w/ contaminated side on inside
- dispose of all materials and return room to pre-procedure state
Assessing wounds
- appearance
- pressure ulcer stage
- size (length, depth, tunneling)
- drainage
- temp
- pain
- prescene of sutures, drains, tubes
- evidence of complications
Pressure injury stages
4 stages
Stage 1
,- intact skin w/ non-blanchable redness
Stage 2
partial-thickness lost, red-pink wound bed
Stage 3
full-thickness loss, sub q fat may be visible
Stage 4
full-thickness tissue loss, exposed bone, tendon, or muscle
Wound measure
- length
- width
- diameter (if circular)
- depth
- tunneling
Cleaning Wound
- top to bottom
- center to outside
- use new gauze each wipe
- loosely pack wounds if ordered
- dry surrounding skins
Dry dressing
wick for drainage, may be used as secondary dressing
Wet to dry dressing
allows debridement of wound
, Non-adherent dressing
should not be used when wound debridement is desired
Labeling dressings
- time
- date
- initials
Phlebitis
inflammation of vein
Nursing considerations to do for phlebitis
- discontinue infusion immediately
- apply warm, moist compresses to affected site
- avoid further use of vein
- restart infusion in another vein
Infiltration
leakage of intravenous fluid into extravascular tissue
(nonvesicant), edema
Nursing considerations to do for infiltration
- check infusion site every hr for signs/symptoms
- discontinue infusion if symptoms occur
- restart infusion @ diff site
- use site-stabilization device
Extravasation
- IV becomes dislodged and medication infuses into tissue
(vesicant), blackened tissue
