Tiêu đề NCM 116 RLE SEMI FINALS ✅

SEMI FINALS COVERAGE Ethico-legal responsibilities in perioperative period Normal ranges of Laboratory tests and Independent Nursing action/health teachings Cardiac drugs and Antibiotics IVF & drug Computations ID, SQ, ID Procedures Management of clients with post- operative peritonitis Care of clients with Penrose drain, JP drain and care to prevent infection on surgical sites. Diagnostics & Treatment of degenerative disorders. Post evacuation of epidural hematoma Acute gastroenteritis, severe dehydration. Neurologic Assessment SEMI FINALS COVERAGE 1 Care of client with JP Drain and Wound Care 1 Jackson Pratt 1 Types Of Dressing 3 Wound Drainage 4 Venous Insufficiency Wound care 5 Burns Wound care 5 IV and Drug Computation 6 CALCULATING DOSAGE USING RATIOS/PROPORTION 8 Ethico-legal responsibilities in Perioperative period 9 Normal ranges of Laboratory tests and Independent Nursing action/health teachings 9 DIAGNOSTIC TESTS (GENERAL) 10 Cardiac Drugs 18 ❖ Drugs Affecting Blood Pressure 18 Antihypertensive 18 Antihypotensive 18 ❖ Cardiotonic Agents 18 ❖ Antiarrhythmic Agents 18 ❖ Antianginal Agents 18 ❖ Lipid-Lowering Agents 19 Antibiotics 19 ID, SQ, ID Procedures 20 Management of clients with Postoperative Peritonitis 22 Diagnostics & Treatment of Degenerative Disorders 28 Post Evacuation of Epidural Hematoma 28 Acute gastroenteritis, severe dehydration 32 Neurologic Assessment 36 The Screening Neurological Examination 41 Essential screening neurological exam for adults and older children 41 Essential screening neurological exam for young children 43 The Traditional Screening Neurological Exam 44 Step-by-Step Guide to the Neurological Examination 44
NCM 116 RLE SEMI FINALS by TONS and MADS Care of client with JP Drain and Wound Care ● Introduction to Wound Care - not transcribed ● Wound Care 1 - not transcribed ● A Day of a Wound Care Nurse - not transcribed Penrose Drain Jackson Pratt ❖ They commonly leave this drain within the abdomen and other cavities after surgery. ❖ It helps drain and collect blood and body fluid after surgery. ❖ This can prevent swelling and reduces the risk for infection. ❖ The tube is held in place by a few stitches. It's covered with a bandage. ❖ A JP drain is a closed system drain that uses bulb suction to prevent wound drainage from collecting around the surgical site. The benefits of a closed system drain are that they decrease the risk for infection and allows you to measure how much drainage the wound is draining. On the other hand, an open drain system (like a Penrose drain), doesn’t allow you to measure drainage and there is a high risk for infection. ❖ Steps on how to do empty a JP Drain ➢ Unplug cap ➢ Turn bulb upside down and squeeze contents into a measuring cup. ➢ Clean plug off with alcohol (decrease chances of infection) ➢ Compress the bulb ➢ Re-cap the bulb (make sure the bulb stays compressed) ➢ Document how much drainage you emptied....very important! *This is so important because surgeons will order for a JP drain to be discontinued when the site is draining less than 30 cc per 24 hours. Hemovac Drain Basic Wound Care ● No hydrogen peroxide, no alcohol; ONLY NSS For irrigation ● Use gauze, not cotton balls (leaving fibers) ● Wound sample: Use uncleanest part (middle) - Ideal after cleaning the wound ● Food: Protein, Iron, Zinc Surgical Wound Dressing Application Adhering to certain procedures when caring for a patient with a surgical wound can help prevent infection by preventing pathogens from entering the wound. In addition to promoting patient comfort, such procedures protect the skin surface from maceration and excoriation caused by contact with irritating drainage. They also enable measurement of wound drainage to monitor fluid balance. The two primary methods used to manage a draining surgical wound care dressing and poaching. Dressing is preferred unless caustic or excessive drainage is compromising the patient's skin integrity. Usually, packing and gauze dressings are sufficient to manage lightly seeping wounds with drains and wounds with minimal purulent drainage. Some wounds, such as those that become chronic, may require occlusive dressings. The color of the wound can help determine which type of dressing to apply. Dressing changes must occur often enough to keep the skin dry. In addition to appropriate dressing, a patient with a surgical wound requires close monitoring. Dressing a wound calls for sterile no-touch technique and sterile supplies to prevent contamination. Always follow standard precautions set by the Centers for Disease Control and Prevention when providing wound care. TAILORING WOUND CARE TO WOUND COLOR Promote healing in any wound by keeping it moist, clean, and free from debris. For an open wound, use wound color to guide the specific management approach and to assess the progress of wound healing. 1
NCM 116 RLE SEMI FINALS by TONS and MADS 1. Red wounds a. Red: color of healthy granulation tissue; indicates normal healing. b. When wound begins to heal, a layer of pale pink granulation tissue covers the wound bed. c. As this layer thickens, it becomes beefy red. d. Cover a red wound, keep it moist and clean, and protect it from trauma. e. Use transparent dressing, hydrocolloid dressing, or gauze dressing moistened with sterileNSS or impregnated with petroleum jelly or antibiotic. 2. Yellow wounds a. Yellow: color of exudate produced by microorganisms in an open wound. b. When wound heals without complications, the immune system removes microorganisms. c. However, if there are too many microorganisms to remove, exudate accumulates and becomes visible. d. Exudate usually appears whitish yellow, creamy yellow, yellowish green, or beige. Dry exudate appears darker. e. Clean and remove exudate using irrigation, then cover it with a moist dressing. f. Use absorptive products or moist gauze dressing with or without antibiotics, hydrotherapy with whirlpool or high-pressure irrigation. 3. Black wounds a. Black: least healthy wound color, signals necrosis. b. Dead, avascular tissue slows healing and provides a site for microorganisms to proliferate. c. Removal of scar is necessary to determine an accurate wound depth. d. Debride black wound using enzyme products, surgical debridement, hydrotherapy with whirlpool or irrigation, or a moist gauze dressing. e. After removing dead tissue, apply dressing to keep wound moist & guard against external contamination 4. Multicolored wounds a. 2-3 colors in a wound. b. Classify wound according to least healthy color present (If both red & yellow, classify as a yellow) Equipment ● Gloves ● Sterile 4" × 4" (10-cm ×10-cm) gauze pads ● Prescribed antiseptic cleaning agent ● Adhesive or other tape ● sterile-tipped measuring device ● Soap and water ● Optional: pain medication; gown and face shield or goggles; acetone-free adhesive remover; sterile NSS; topical medication; sterile container; wound irrigant and irrigation supplies; sterile cotton-tipped applicators; wound culture collection equipment; 2" × 2" (5-cm × 5-cm) gauze pads; sterile forceps; large absorbent dressings Implementation 1. Verify practitioner's order for specific wound care medication and instructions. 2. Review patient’s medical record for history of allergies to tape, topical solutions and medications. 3. Perform hand hygiene 4. Confirm the patient's identity. 5. Provide privacy. 6. Explain the procedure to the patient and family 7. Raise the patient’s bed to waist level when providing care 8. Perform hand hygiene. 9. Screen and assess patient’s pain using facility-defined criteria that are consistent with the patient’s age, condition, and ability to understand. 10. Treat patient’s pain using nonpharmacologic, pharmacologic, or a combination of approaches. Removing the dressing 1. Position patient as necessary to gain access to wound. Expose only the wound site. 2. Perform hand hygiene. 3. Put on a gown and a face shield or goggles, if necessary 4. Put on gloves. 5. Assess the patient's condition. 6. Loosen soiled dressing by holding the patient's skin and pulling tape or dressing toward the wound. Moisten the tape with sterile normal saline. Don't apply solvents to the incision because they could contaminate the wound. 7. Slowly remove the soiled dressing. If gauze adheres to wound, loosen gauze by moistening it with sterile normal saline solution. 8. Observe dressing for the amount, type, color, and odor of drainage. 9. Discard the dressing in an appropriate receptacle 10. Continue with WOUND ASSESSMENT now that old dressing is removed and wound is exposed already: wound drainage, measurement of wound, classifying if wound is acute or chronic, assess the periwound area or the area surrounding the wound 11. Remove and discard your gloves. Caring for the wound 1. Perform hand hygiene. 2. Establish a sterile field with all of equipment and supplies needed. 3. Open and prepare supplies 4. Perform hand hygiene. 5. Put on a new pair of gloves. 6. Saturate sterile gauze pads with the prescribed cleaning agent. Avoid using cotton balls because they can shed fibers in the wound, causing irritation & infection. 7. If ordered, irrigate wound using the specified solution. 8. Pick up moistened gauze pad and squeeze out excess solution. 9. For open wound, clean wound in a full or half circle, beginning in center and working outward. Use a new pad for each circle Clean to at least 1" (2.5 cm) beyond the end of new dressing or 2" (5 cm) beyond the wound margins if you aren't applying a dressing. 2
NCM 116 RLE SEMI FINALS by TONS and MADS 10. For linear incision, work from top of the incision, wipe once to bottom, and then discard gauze pad. With second moistened pad, wipe from top to bottom in vertical path next to the incision. Continue to work outward from the incision in lines running parallel to it. 11. Use each gauze pad for only one stroke. Suture line is cleaner than adjacent skin and the top of the suture line is usually cleaner than the bottom because more drainage collects at the bottom of a wound. 12. Use sterile, cotton-tipped applicators for efficient cleaning of tight-fitting wire sutures, deep and narrow wounds, and wounds with pockets, if needed. Because the cotton on the applicator is wrapped tightly, it's less likely to leave fibers in the wound than a cotton ball. Remember to wipe only once with each applicator. 13. Clean all areas of wound to wash away debris, pus, blood, and necrotic material. Try not to disturb sutures or irritate the incision. Clean to at least 1" (2.5 cm) beyond the end of the new dressing. 14. Check to make sure that the edges of the incision are lined up properly and check for signs of infection (heat, redness, swelling, induration, and odor), dehiscence, and evisceration. If you observe such signs or if the patient reports pain at the wound site, notify the practitioner. 15. Wash the skin surrounding the wound with soap and water and pat it dry using a sterile 4" × 4" (10-cm × 10-cm) gauze pad. Avoid oil-based soap because it can interfere with tape adherence. 16. Apply any prescribed topical medication if ordered. 17. If ordered, pack the wound with sterile 4" × 4" (10-cm × 10-cm) or 2" × 2" (5-cm × 5-cm) gauze pads using sterile forceps. Avoid using cotton-lined gauze pads because cotton fibers can adhere to the wound surface and cause complications. 18. Pack the wound using the wet-to-damp method. Soak the packing material in sterile saline solution and wring it out so that it's slightly moist to provide a moist wound environment that absorbs debris and drainage without disrupting new tissue when the packing is removed. Don't pack the wound tightly (exerts pressure and can damage the wound) Applying a fresh gauze dressing 19. Gently place sterile 4" × 4" (10-cm × 10-cm) gauze pads at the center of wound and move progressively outward to edges of wound site. Extend the gauze at least 1" (2.5 cm) beyond incision in each direction and cover wound evenly with enough sterile dressings (2-3 layers). Use large absorbent dressings to form outer layers, if needed, to provide greater absorbency. 20. Secure dressing's edges to patient's skin with strips of tape to maintain the sterility of the wound site. Completing the procedure 1. Return the bed to the lowest position 2. Dispose of used supplies in appropriate receptacles. 3. Remove and discard your gloves and, if worn, other personal protective equipment. 4. Perform hand hygiene. 5. Reassess and respond to patient's pain by evaluating response to treatment & progress toward pain management goals. Assess for adverse reactions and risk factors for adverse events that may result from treatment. 6. Perform hand hygiene. 7. Document the procedure. Patient Teaching: Teach patient and family about the normal wound healing process. Keep them informed about progress toward healing, including signs and symptoms that they should report. Explain the importance of adequate nutrition and fluid intake in wound healing. Complications: Improper infection control practices during wound assessment can lead to wound infection. Documentation: general appearance of skin and bony prominences; location, size, and appearance of wound site; presence of drains or tubes; presence or absence of drainage. Include color, type, amount, odor of any drainage present. Document date and time of the assessment. Note the patient's tolerance of the procedure. Types Of Dressing 1. GAUZE a.Dry woven or non-woven sponges and wraps with varying degrees of absorbency, based on design. b.Fabric composition may include cotton, polyester or rayon. c. available as sterile or non-sterile, in bulk, and with or without adhesive border. May be impregnated with other products such as hydrogel (to hydrate), sodium chloride (to absorb and draw). 2. TRANSPARENT FILMS a.impermeable to liquid and microbes but permeable to moisture vapor and atmospheric gases like oxygen. b.Visualization is easy since you can see the wound through the dressing. c. comfortable to wear because they can stay firmly on skin for an extended period of time making them both an excellent secondary dressing for long wear time and a good primary dressing for lacerations, skin tears, and I.V. sites. d.Films have been shown to have lower overall infection rates than traditional gauze dressings 3. HYDROGELS - primarily water and/or glycerin in composition. Hydrogels donate moisture to the wound and offer gentle application and removal. 3