Exam 1
1. Cane :: -Appropriate height (at wrist level when arm is at side)
-Pt strong hand on cane
*MOVE CANE WITH WEAKER LEG*
2. At risk for falls due to :: incontenience
3. Transferring pt to WC :: -Place WC on strong side angled to bed
-Strong hand to armrest, then pivot
4. Safe pt handling:: -Keep pt directly in front of you and as close as possible to prevent back injuries
,5. Skin integrity:: -dont wear restrictive clothing
-WC pt lift themselves off buttock for 10 seconds q1hr
6. Pressure Ulcer stages:: *Stage 2- skin is not intact; open or fluid blister*
7. Wet-to-damp wound care:: mechanically removes necrotic tissue
does more damage than good bc it removes the good tissue as well
8. Informed consent:: -surgeon is responsible for having consent signed
-Pt who can not sign can sign with an ”X” but must be witnessed by two people
-If the pt doesn't understand the surgery, the surgeon has to be notified
-A blind pt can sign the consent, has to be witnessed by 2 people
-Nurses DO NOT clarify orders/procedure/risks, must call the MD to explain to pt
9. Pre-OP:: -Report these to surgeon:
-increased PT/INR/aPTT/Creatinine
-Verify operative permit is signed
,-Side rails up, bed down, call light within reach
1 0. Intra-OP:: -Pts are lifted into position onto the OR table to prevent shearing
-Gel pads are placed on the OR table to prevent pressure ulcers
-Warming blankets are used
-Cover the pts head and feet (decrease hypothermia)
*If saving is necessary, hair should be removed using disposable sterile supplies immediately before the start of the
procedure*
-Sterile scrubbing from fingertips to elbow for 3-5 minutes
1 1 . Post-OP:: -in PACU, nurse immediately assess pt airway, LOC
-RR •:10 may indicate respiratory depression due to anesthesia
-Sanguineous to serosanguineous drainage is normal
-Crusting at incision line and swelling is normal
1 2. Malignant hyperthermia:: -life threatening
-you will see HIGH TEMPERATURE
-early sign is tachycardia, muscle rigidity
-Dantrolene is used to treat
1 3. Pain Management:: *Pain management referral for pts in chronic pain unre-lieved*
, -Pain after abdominal sx is from trapped carbon dioxide, ambulate pt as soon as
possible
-Use FACES scale in pts with dementia
1 4. PCA Pump:: -Lockout interval of 5-15 minutes
-Pt cannot be cognitively impaired
-Only the pt can press the button
1 5. If incision opens:: -cover with wet sterile gauze
-Do not try to reinsert protruding organ
-Reassure pt
-Supine position with knees bent
1 6. IV:: -20G 1-1.5” needle is adequate for most therapies
-Huber needle should be placed at 90 degree angle to access port (chemo pt)
1 7. TPN:: - Check each bag twice
-If TPN is unavailable, hang 10% dextrose/water or 20% D/W until TPN is available
-If TPN not administered on time, do not increase the rate
-Change IV tubing q24 hours when new bag is hung
1. Cane :: -Appropriate height (at wrist level when arm is at side)
-Pt strong hand on cane
*MOVE CANE WITH WEAKER LEG*
2. At risk for falls due to :: incontenience
3. Transferring pt to WC :: -Place WC on strong side angled to bed
-Strong hand to armrest, then pivot
4. Safe pt handling:: -Keep pt directly in front of you and as close as possible to prevent back injuries
,5. Skin integrity:: -dont wear restrictive clothing
-WC pt lift themselves off buttock for 10 seconds q1hr
6. Pressure Ulcer stages:: *Stage 2- skin is not intact; open or fluid blister*
7. Wet-to-damp wound care:: mechanically removes necrotic tissue
does more damage than good bc it removes the good tissue as well
8. Informed consent:: -surgeon is responsible for having consent signed
-Pt who can not sign can sign with an ”X” but must be witnessed by two people
-If the pt doesn't understand the surgery, the surgeon has to be notified
-A blind pt can sign the consent, has to be witnessed by 2 people
-Nurses DO NOT clarify orders/procedure/risks, must call the MD to explain to pt
9. Pre-OP:: -Report these to surgeon:
-increased PT/INR/aPTT/Creatinine
-Verify operative permit is signed
,-Side rails up, bed down, call light within reach
1 0. Intra-OP:: -Pts are lifted into position onto the OR table to prevent shearing
-Gel pads are placed on the OR table to prevent pressure ulcers
-Warming blankets are used
-Cover the pts head and feet (decrease hypothermia)
*If saving is necessary, hair should be removed using disposable sterile supplies immediately before the start of the
procedure*
-Sterile scrubbing from fingertips to elbow for 3-5 minutes
1 1 . Post-OP:: -in PACU, nurse immediately assess pt airway, LOC
-RR •:10 may indicate respiratory depression due to anesthesia
-Sanguineous to serosanguineous drainage is normal
-Crusting at incision line and swelling is normal
1 2. Malignant hyperthermia:: -life threatening
-you will see HIGH TEMPERATURE
-early sign is tachycardia, muscle rigidity
-Dantrolene is used to treat
1 3. Pain Management:: *Pain management referral for pts in chronic pain unre-lieved*
, -Pain after abdominal sx is from trapped carbon dioxide, ambulate pt as soon as
possible
-Use FACES scale in pts with dementia
1 4. PCA Pump:: -Lockout interval of 5-15 minutes
-Pt cannot be cognitively impaired
-Only the pt can press the button
1 5. If incision opens:: -cover with wet sterile gauze
-Do not try to reinsert protruding organ
-Reassure pt
-Supine position with knees bent
1 6. IV:: -20G 1-1.5” needle is adequate for most therapies
-Huber needle should be placed at 90 degree angle to access port (chemo pt)
1 7. TPN:: - Check each bag twice
-If TPN is unavailable, hang 10% dextrose/water or 20% D/W until TPN is available
-If TPN not administered on time, do not increase the rate
-Change IV tubing q24 hours when new bag is hung
