Advanced Interventions Final Exam Study Guide

Module 1: Health History/HEENT

Discuss goals of obtaining a patient health history and physical assessment

Health History Goals

● Gather information
○ Provides the subjective database
● Identify actual & potential health problems
● Identify teaching and referral needs
● Negotiate management
● Support emotional and spiritual needs
● Contract for:
○ Positive behavioral change
○ Disease prevention

Describe content relevant to categories in a traditional health history

Traditional Health History

● Always starts with a general survey

● Review chart/records
● Understand where things go in the chart
● CC ​- Chief Complaint, in pt’s own words
● HPC/HPI​ - History of Present Concern/Illness
● PMH ​- Past Medical History
● FH ​- Family History
● SH​ - Social or Lifestyle History

Discuss the importance of a genogram to developing a patient plan of care

Importance of a Genogram

● Useful if patient is concerned with genetic risk or the interaction of genetic (family
history- FH) and environmental factors
● Helps patient/provider determine the risk for developing a condition, understanding
the reason for developing a condition, understanding if they will pass on the risk to
children
● Contains 3 generations - includes gender, ages and dates of death
● Only contains medical history not social history
Advanced Interventions Final Exam Study Guide

Interpret symbols and drawing conventions used in genograms

Know how to read a genogram (basic symbols covered in lecture) – There will be a genogram on
the exam.
Symbols & Drawing Conventions

● Age & health of family

members
● Reason and age at death
● Male on the left, female
on right (hetero couple)
● Birth order is important
rather than gender
○ Oldest child to
the left
○ Youngest to the
right
● Use abbreviations to
identify relationship:
○ PGM
○ PGF
○ MGM
○ MGF
○ MAunt
○ Muncle
Advanced Interventions Final Exam Study Guide

Identify appropriate techniques to assess cranial nerves

CN I (olfactory) Test ability to identify familiar aromatic ​odors​, ​one nares​ ​at a
Sensory time with ​eyes closed

CN II (optic) Test ​distant ​and ​near ​vision

Sensory Perform ophthalmoscopic examination of fundi

CN III (oculomotor), IV III: ​Allows EOMs to move ​inward, lateral, upward​;​ responsible for upper
(trochlear) and VI eyelid symmetry (Ptosis)
IV: ​Allows EOMs to move eye​ i​ nward and downward ​toward nose
(abducens) VI: ​Allows EOMs to move eye ​laterally​ to ear
Motor Inspect ​pupils’ size for equality​ ​and their direct and consensual ​response to
light​ a​ nd accommodation ​(PERRLA)
Test ​extraocular eye movements (EOM)

CN V (trigeminal) Palpate jaw muscles​ ​for tone and strength when patient
Motor & Sensory clenches teeth
Test ​superficial pain and touch​ ​sensation in each branch (test
temperature sensation if there are unexpected findings to pain
or touch)

CN VII (facial) Inspect ​symmetry of facial features​ ​with various expressions

Motor & Sensory (​smile, frown, puffed cheeks, wrinkled forehead​)

CN VIII (acoustic) Whisper​ near patient’s ear and have them repeat
Sensory If deafness is suspected: Rinne’s Test & Weber’s Test
To test vestibular action: Romberg Test

CN IX Test ​gag reflex ​and ability to ​swallow

(glossopharyngeal) and Inspect palate and uvula for symmetry and gag reflex
X (vagus) If both are fully functioning you will notice the intact gag reflex
Motor & Sensory

CN XI (accessory spinal Have patient ​shrug​ shoulders or turn their head side to side for
nerve) function
Motor

CN XII (hypoglossal) Have patient stick out ​tongue​ and assess for midline
Motor
Advanced Interventions Final Exam Study Guide

Describe components of an external and internal ear assessment

External Ear Exam Internal Ear Exam

Inspection ● Hold the otoscope so the ulnar aspect of

● Note the level of the ear
● Inspect the auricles and move them
around gently to assess tenderness
● Inspect the auditory canal (cerumen,
discharge, redness, tenderness)
Palpation
● Palpate the mastoid process for
tenderness or deformity and the tragus
(tenderness of tragus can be sign of ear
infection)
your hand makes contact with the patient
● Have patient tilt head slightly toward
opposite shoulder
● Pull the ​ear​ ​back and up for the adult
(​back and ​down​ for child​)​ to straighten
ear canal
● Insert otoscope ​under direct vision​ to a
point just beyond the protective hairs
angled toward the nose
● Use the ​shortest and largest ​speculum
that will fit comfortably

Interpret ​ear​ and ​eye​ examination assessment findings

Eye Examination Findings

Conjunctiva should be pink, sclera should be white

Excess tearing can indicate blockage of nasolacrimal duct

Ptosis: ​drooping of upper eyelid

Exophthalmos:​ ​bulging of eyes (indicative of Grave’s Disease)
Xanthelasma:​ ​regular, slightly raised/yellow lesions (suggests lipid disorder)
Anisocoria:​ ​unequal pupils (syndromes cause cat-like pupils)
Presbiopia:​ ​near focus ability is more difficult, hard to see small print clearly, increases with age and
need reader glasses
Strabismus:​ ​cross-eyed

Miosis:​ ​< 2mm (opiates)

Mydriasis:​ ​> 6 mm (cocaine, THC)

Snellen Chart
Record the smallest print successfully read 100%
20/40 vision: ​what the normal eye can read at 40ft, the tested eye can read at 20ft
20/200 = legal blindness
Advanced Interventions Final Exam Study Guide

Eye Examination Findings Cont.

Cataracts:​ progressive clouding of the eye due to age, over age 50

Glaucoma:​ ​Damage to the ocular nerve, can be due to increased ocular pressure. Can cause vision
loss, peripheral vision loss and blindness
Macular Degeneration:​ Macular degeneration causes loss in the center of the field of vision. In dry
macular degeneration, the center of the retina deteriorates. With wet macular degeneration, leaky
blood vessels grow under the retina.
Retinal Detachment:​ ​Retina separates in the back of the eye, retina tear. Lose vision, painless. Can be
corrected with surgery

Ear Examination Findings

Tympanic Membrane​: normally shiny, translucent, pearly gray

Left ear → cone of light at 7 o’clock
Right ear → cone of light at 5 o’clock
Fluid behind the ear can alter where the cone of light is indicating
infection
Note: ​color, any redness, drainage or deformity

Picture:
Upper left is ​cerumen (ear wax)
Upper right is ​bulging​ (significant of​ ear infection​- cannot assess
bony prominences and light is displaced)
Lower left is an ​ear tube
Lower right is a ​perforated​ tympanic membrane
Advanced Interventions Final Exam Study Guide

Accurately identify the location of head and neck superficial peripheral lymph nodes
Head and Neck Superficial Peripheral Lymph Nodes

Discuss characteristics of normal and abnormal lymph nodes

Normal Lymph Nodes Abnormal Lymph Nodes

Movable Large & tender → check area of drainage for

Discrete source of problem
Soft Acute Infection:​ ​enlarged, bilateral,
Non-tender tender/firm, freely movable
Malignancy:​ ​hard, > 3cm, unilateral,
matted/fixed to structures
Advanced Interventions Final Exam Study Guide

Differentiate family history from social history in a health history

Family History Social History

Medical events in the patient’s family Review of patient’s past/current activities

Example: Examples:
Patient’s mother recently died of HTN Patient’s religious preference
Patient’s occupation

Cranial nerves involved in HEENT assessment

HEENT Assessment Cranial Nerves

Facial:
● Cranial Nerve V (Trigeminal, largest)
○ Facial sensation, biting/chewing
○ Assess by asking patient to clench their teeth & palpate jaw
● Cranial Nerve VII (Facial Nerve)
○ Assess by inspecting symmetry of facial expressions (smile, frown, wrinkle
forehead)
Eyes:
● Cranial Nerve II (Optic)
○ Snellen Eye Chart, Rosenbaum Card, Jaeger Card, Confrontation Test

Extraocular Movements:
● Cranial Nerve III (Oculomotor)
○ Allows EOMs to move eye inward, lateral, upward, upper eyelid symmetry
● Cranial Nerve IV (Trochlear)
○ Allows EOMs to move eye inward/downward toward nose
● Cranial Nerve VI (Abducent)
○ Allows EOMs to move eye laterally toward ear
Ear:
● Cranial Nerve VIII (Vestibulo-Cochlear Nerve)
○ Whisper in patient’s ear & have them repeat
Nose & Throat:
● Cranial Nerve IX (Glossopharyngeal nerve)
● Cranial Nerve X (Vagus nerve)
○ If both IX and X are fully functioning you will notice intact gag reflex
● Cranial Nerve XII (Hypoglossal)
○ Inspect tongue for movement side to side/symmetry
○ Inspect nares for deviated septum
Advanced Interventions Final Exam Study Guide

Assessment of lymph nodes /eyes /ears

Lymph Nodes

Gentle​ circular motion​ using finger pads to palpate

Start with preauricular nodes in front of ear
Gentle pressure, use both hands to assess symmetrically (except for submental gland under
chin; easier with one hand)
Deep cervical chain → have patient turn head towards examined side
If palpable, note:
Location (bilateral, unilateral) Mobile, fixed
Size (pathological > 1 cm) Tenderness
Consistency (soft, firm, hard, smooth, Warmth, erythema
nodular) Changes over time
Quantity (discrete, matted)

Assessment: Eyes

Make sure eyelashes evenly distributed

Look for inflammation, drooping, lesions
Use ​Ophthalmoscope → ​enlarges view of eye

Accommodation: ​automatic response when object is brought closer to eyes (eyes should
converge/constrict when object is close then dilate when object is distant)
PERRLA: ​(Pupils equal, round, reactive to light & accommodation)

Assessment: Ears

Light Reflex: ​Left ear will be at 7 o’clock, right ear will be at 5 o’clock (if there is
fluid/infection behind the membrane the area of light may change)
Tympanic membrane​ normally shiny, translucent, pearly gray
Advanced Interventions Final Exam Study Guide

Module 2: Neuro/CVS/PVS

Describe principles of cardiac physiology relevant to a cardiovascular (CV) and peripheral

vascular (PV) assessment
Principles of Cardiac Physiology

● 4 chambers separated by valves; purpose is to prevent backflow of blood

● Right & Left Atria & Ventricles
● 2 Atrioventricular (AV) Valves:
○ Tricuspid & Mitral
● 2 Semilunar (SL):
○ Pulmonic and Aortic
● Valves are unidirectional, open/close passively

Peripheral Venous Disease Peripheral Artery Disease

Build up of blood in legs; blood unable to get Lack of blood to legs

back to heart Caused by atherosclerotic plaque
Damaged or weakened veins due to injury, As the lining thickens from plaque, vess
surgery, inactivity, obesity els are more constricted → reduce blood
First symptom is pain in the area of the clot flow (numbness, tingling, claudication,
Fragile skin that tears easily cool/pale skin, ulcers)
Prone to stasis ulcers Intermittent ​claudication​ of pain when
Edema walking
Pulse NO edema, NO pulse
Dull achy pain Round, smooth sores, black
ELEVATE LEGS DANGLE LEGS OFF BED
*No heating pads for PVD and PAD (pain is worse with vasodilation)
Advanced Interventions Final Exam Study Guide

Identify primary landmarks for conducting a CV assessment

Accurately use techniques of inspection, palpation and auscultation in the performance of a CV

and PV assessment

Inspection Look for scars, prior cardiac surgery, chest deficiencies (barrel/pigeon)
Look for pulsations, lift/heave
Apical Impulse:​ ​pulsation created @ 5th ICS & left mid-clavicular line
(result of L. ventricle moving outward during systole, easier to see in kids)
Displacement:​ ​of apical impulse to the ​left​ i​ ndicates ​enlarged heart
Lift/heave:​ ​pulsation that isn’t apical; considered abnormal;​ forceful
thrusting​ as a result of increased heart workload (ventricular hypertrophy)

Palpation Palpate carotid arteries separately

Note strength & compare with apical pulse
Position patient supine with head of bed/table slightly elevated
Use palm of hand, go from apex to left sternal border to base
Thrill:​ ​palpabile vibration; signifies turbulent blood flow (helps identify
murmur location)

Auscultation Auscultate carotids with bell, listen for ​bruit​ (can be a sign of
atherosclerosis or TIA/ischemic stroke)
Ask patient to hold breath momentarily
3 positions: sitting up, lying on left side, lying on back, head raised 30-45
degrees
Zig-zag pattern starting at base then go downward
S1 loudest at apex
S2 loudest at base
Identify potential causes of cardiac murmurs
Advanced Interventions Final Exam Study Guide

Cardiac Murmurs

The main sign of a valvular heart disease is a murmur

Causes:
Valve Opening Problem Valve Closing Problems

Stenosis​: ​valve tissues (leaflets) are Insufficiency/Regurgitation:​ leaflets ​do not

stiffer/hardened​ which narrows the valve close completely
opening Blood flows backwards
Heart may enlarge to compensate & lose
elasticity/efficiency
Pooling → r/o stroke or PE

Grading Murmurs

Grade I ​- ​Barely audible with a stethoscope in a quiet room

Grade II​ - ​Quiet but clearly audible with a stethoscope
Grade III​ - ​Moderately loud (like S1 or S2)
Grade IV​ - ​Loud, associated with a thrill
Grade V ​- ​Very loud, easily palpable
Grade VI​ - ​Extremely loud​, audible with the stethoscope not in contact with the chest, thrill
palpable​ and ​visible

Heart Murmurs
● Disruption of blood flow through the heart
● Blowing/swishing sound
● Almost always abnormal in adult
● “Innocent Murmur” ​→ healthy children & adolescents
● Described by:
○ Timing ​- where does it occur in cardiac cycle?
○ Loudness​ - intensity?
○ Pitch​ - low medium or high pitch?
○ Pattern​ -
intensify ​(​crescendo​) ​or
decrease ​(​decrescendo​)​ ​ across cardiac cycle?
○ Quality​ - blowing? Musical? Harsh? Rumbling?
○ Location​ - where is it best heard?
○ Radiation
○ Loudness/Intensity
Advanced Interventions Final Exam Study Guide

S1 Heart Sound S2 Heart Sound

● Closure of AV valves → signals ● Closure of semilunar valves → signals

beginning of systole
● Mitral component of first sound (M1)
slightly precedes tricuspid component
(T1)
○ Usually hear these two
components fused as one
sound
○ Can hear S1 all over
precordium, but ​loudest at
apex
end of systole
● Aortic component of second sound
(A2) slightly precedes pulmonic
component (P2)
○ Although heard all over
precordium, S2 ​loudest at
base

Auscultation

Listen in 3 different positions:

1. Pt leaning slightly forward in
expiration
a. Listen with diaphragm at all
5 landmarks
2. Pt supine
a. Listen with diaphragm at all
5 areas
3. Pt rolled to left lateral position
a. Listen with bell at all 5 areas
Advanced Interventions Final Exam Study Guide

Discuss the physiology supporting key differences in the presentation of peripheral arterial and
venous disease
Characteristic Arterial Disease Venous Disease
Skin changes Shiny pale/ dependent rubor Pruritis
Turns brown
Skin temp Cool Warm

Capillary refill > 3 seconds 3 sec or less

Pulses Weak/absent Strong + sym

Hair Absent Present

Edema Absent Present
Necrosis Likely Unlikely

Pain Sharp/stabbing Aching, crampy

State the importance of obtaining an accurate ECG reading

Identify factors to consider obtaining an accurate ECG reading
ECG Reading

**Poor placement can result in misinterpretation**

Importance​: ​ it is displaying the electrical activity of the heart. This can help with diagnoses of
any heart arrhythmias and most importantly can alert the nurse to any ST elevations that
would be indicative of a myocardial infarction
Factors to Consider:
● Warm/dry skin
● Extremity electrodes should point posteriorly
● Patient supine with HOB slightly raised
● Stay still/no shivering
Document: date, time, BP, patient response

Discuss the importance of assessing mental status and level of consciousness.

Advanced Interventions Final Exam Study Guide

Mental Status & LOC

Importance:
A change in either mental status or LOC is the ​first clue​ ​to deteriorating condition
First signs of neurological deterioration are ​subtle​ - can be best detected by family members
& conversation w/ patient
Consciousness is the degree of wakefulness or ability to arouse the patient. Not the same as
orientation, a patient may be conscious but not oriented.

Explore the significance of a motor and sensory assessment.

Motor & Sensory Assessment

Motor Sensory

Significance: Significance:
To note any voluntary/involuntary Majority of neuropathy issues begin distally
movement (tics/tremors) (start assessing at the feet then move to
Movements should be smooth & the hands)
coordinated

Coordination, fine motor skills, balance can Use a safety pin to test superficial pain
only be performed when patient is awake &
alert & can respond to verbal stimuli

Posturing: Deep Tendon Reflexes:

Associated with head trauma
Decorticate Rigidity:​ rigid flexion, preserves
brainstem function
Decerebrate Rigidity:​ arms are pronated
outwards, indicates brainstem damage
Testing for muscle contraction in response
to direct/indirect percussion of a tendon
Clonus:​ foot is dorsiflexed & taps multiple
times (sign of neurological condition)
Advanced Interventions Final Exam Study Guide

Review the importance of a cerebellar assessment

Cerebellar Assessment

Significance:
To test coordination, fine motor skills &
balance
To assess patient’s gait (should have
smooth, rhythmic cadence with equal
amount of time in swing/stance phase,
opposite arm movements)
Coordination:
Rapid alternating movements
Finger to nose to finger test - inability to
coordinate could indicate cerebellar
dysfunction
Heel down shin - loss of coordination is
abnormal

Balance: Gait disturbances could indicate:

Tandem: Spastic hemiparesis (hemiplegic gait)
Heel-toe walking Cerebellar ataxia
Romberg Test: Parkinsonian gait
Feet together, eyes closed
Look for swinging (if there was a lesion,
patient is able to compensate by opening
eyes; removing vision will make patient
sway)

Do not memorize Glasgow Coma scale- if you have a question the scale will be provided.
Glasgow Coma Scale

● Used to quantify LOC/Neurological impairment (usually for patients with trauma and
other hypoxic effects)
● Based on: Eye opening, Motor Response, Verbal response
● Patient receives score for best response in each of these areas (score added together)
○ Score range from 3-15
○ Higher the number, the better
○ <8 usually indicates coma ​– lower scores indicate greater degree of damage
○ Infants and children slightly different
Advanced Interventions Final Exam Study Guide

Module 3: IV Therapy

Discuss patient considerations in the selection of the type of IV therapy

IV Therapy Patient Considerations

Volume of fluid being infused

Long Term/short term therapy
History of drug abuse
Have they had surgery there? Mastectomy on that side
Type of medication

Describe considerations for peripheral venipuncture site selection

Peripheral Venipuncture Considerations

Considerations:
Medical Hx, age, body size, condition of
veins, duration of IV therapy, fluid/med
being infused, level of activity
Start as distal as possible
(if proximal damaged then you can’t use
distal site)
Smallest gauge
Not appropriate for TPN, pH <5 or >9,
osmolality >600 mOsm/L
Supine with head elevated, arms supported
(risk for vasovagal if sitting up)
Apply tourniquet ​5-6 in above site
Bevel up​, 10-30 degree angle
Common sites: cephalic, basilic, metacarpal
Avoid:
Wrist → close proximity to nerves
Legs/feet/ankles → lead to DVT
(In ​emergency​ → use dorsum of foot &
saphenous vein of ankle until central access
gained)
Veins below an area of
phlebitis/sclerosed/thrombus
Skin inflammation/bruising/breakdown
AV shunt/fistula
Lymph nodes removed
Infection
Advanced Interventions Final Exam Study Guide

Describe considerations for central venipuncture access device selection

Central Venipuncture Considerations

Quality of Life and method with lowest risk of complications, nurse is the patient advocate
Choose the most appropriate site for safe therapy
Short term: ​non-tunneled and PICC lines
Long term: ​tunneled and implantable port
Uses: extended hospital stays, poor peripheral access, hypertonic, vesicant or pH extremes,
TPN and chemotherapy

Describe assessment considerations of peripheral and central intravenous sites

https://www.slideshare.net/rajmagbanua/cvad-32922525​ ← really helpful slides on
advantages/disadvantages of CVAD
Assessment Considerations
Peripheral IV Sites Central IV Sites

IV drug user? ● Short term?

Mastectomy/fistula/etc… ○ Non tunneled
Can you find a vein to insert the IV? ○ Picc line
Assess risk for infection, if high risk then ● Long term?
central may be the way to go ○ Tunneled
○ Implantable

Short-Term IVs
PICC Line Non-Tunneled

Duration​: Short-term ​(6 weeks-6 months) Duration​: Short-Term (<14 days)

Uses​: ​IV therapy at home​ & acute care
settings
Placement:
● Upper arm to superior vena cava
● Secured with wound closure strips
● Need X-Ray to confirm placement
Advantages​:
● Eliminates risk of pneumothorax
● Use for ​all ages
● Easier to have labs drawn
● Replaced ​ONLY​ as needed (when site
is infected or when catheter is no
longer patent)
Uses:​ ​patients who are unstable
Placement:
● Inserted in jugular or subclavian
● For subclavian: put pt in
Trendelenburg position
Disadvantages:
Sutured in place → ​High risk of catheter
related bloodstream infections (CLABSI)
Risk of pneumothorax
Advanced Interventions Final Exam Study Guide

Long-Term IVs
Tunneled Implantable Port

Duration:​ Long-Term Duration:​ Long-Term, permanent device

Placement: Placement:
● Jugular or subclavian vein ● Upper chest wall
● Sutured in place but stitches are ● Antecubital area of the arm
removed after 7-14 days ● Need radiology to confirm placement
● Dacron → seal to prevent bacteria Advantages​:
under the skin & prevent ● No visible external porth/lines
dislodgement ● Minimal daily care
Advantages: ● Good for kids & adults (swimming)
● Lower risk CLABSI ● LOW risk for infection
● Allows for ease of movement ● Improved self-image
Disadvantages:
● Discomfort when accessing port

Discuss the etiology of potential complications of peripheral and central intravenous therapy
Peripheral IV Complications Central IV Complications

SYSTEMIC COMPLICATIONS: Pneumothorax/Hemothorax:

Sudden onset of chest pain/SOB due to air
Fluid overload: accumulation in the lungs
Increased BP/HR/RR, crackles, JVD, edema, Give oxygen, monitor vitals, pressure on entry
dyspnea site, remove catheter

Speed Shock: CLABSI or CRBSI:

Foreign substance introduced too quickly, plasma
toxicity/floods organs
Dizziness, chest tightness, dyspnea
Sepsis:
Red, tender IV site, fever, fatigue, tachy, cold
sweat, N/V
Air Embolism:
Air enters central veins, becomes trapped as
blood flows
Respiratory distress, decreased HR, increased BP,
cyanosis, signs of pulmonary edema, change in
LOC, palpitations, weakness, tachypnea
Central line associated bloodstream infection &
catheter related bloodstream infection
If WBC low → will not see drainage or pus, will
see fever/chills
Air Embolism
Thrombosis:
Obstruction of airflow
Catheter Migration:
Occurs when catheter ​moves​ from where it was
placed
Signs: swelling of neck/chest during infusion, pain
during infusion, no blood return, leaking
Advanced Interventions Final Exam Study Guide

Discuss strategies to promote accurate intravenous fluid infusion

Strategies to Promote Accurate IV Infusion

● Aseptic ​technique
● Assess IV site for signs of inflammation/complications
● Select injection port closest to the patient
● Flush IV to ensure patency
● If patient is complaining of pain at IV site, restarting at a slower rate may relieve
discomfort
● Monitor site and infusion for tolerance to fluid volume and complications
● Dressing integrity

Must know filtration vs phlebitis vs. extravasation – this is frequent assessments for you in
practice
Phlebitis Infiltration Extravasation

Inflammation of a vein Leakage of IV fluid into Leakage of vesicant in

Associated w/ acidic/alkaline
solutions w/ high osmolality
Signs:
Warmth, swelling
Risk Factors​:
Mechanical irritation,
chemical irritation,
contamination (bacteria)
Prolonged use of site
surrounding tissue surrounding tissue
Caused by improper (Vesicant: medication that
placement/dislodgement can cause blistering, severe
tissue injury, necrosis:
Signs: chemotherapy agents,
Swelling, pain, Burning, catecholamines, digoxin)
blanching, Signs:
decreased/stopped flow rate Blistering, blanching, swelling

TREATMENT: TREATMENT: TREATMENT:

Remove​ catheter @ first sign
of redness/pain
Warm​ compress
Restart​ using larger vein or
smaller device but not near
phlebitis
Document phlebitis and
treatment
Removal/restart
Elevate
Check cap refill and pulse
Warm compress (pH 8, 9)
Cold compress (ph 5,6)
Document infiltrate and
treatment
IMMEDIATELY stop infusion
Aspirate medication
Notify MD ASAP - estimate
how much was infused.
Elevate
Call pharmacy for antidote
ICE
Document: Medical record
and incident/safety report
Advanced Interventions Final Exam Study Guide

Central vs. peripheral lines – what makes us decide we need a central line? What are central
line complications? Localized complications vs. systemic complications

Central Lines

Uses: Complications:
Extended​ length of therapy (Described above)
Poor peripheral access Air embolism
Total parenteral nutrition Pneumo/hemothorax
Chemotherapy Catheter mitigation
Hypertonic, Vesicant, pH extremes

Module 4: Medication
Advanced Interventions Final Exam Study Guide

Identify methods used to deliver IV medications

IV Medication Administration

● Primary line
○ Primary IV bag (directly attached to patient)
○ Piggyback (medication is piggybacked on primary IV infusion)
○ IV push (through a primary line)
○ Syringe pump (either primary line or piggy backed onto primary line)
○ Volume controlled (primary line or piggybacked onto primary line)
● Saline Lock
○ Intermittent infusion
○ IV push (directly)

Describe principles used to prepare and administer IV medications safely (compatibility is key)
IV Medication: Responsibilities
Assessment: ​physical/lung/bowel sounds, contraindications, baseline data
Compatibility
○ Lexicomp or compatibility chart
○ Incompatibility​ results when 2 or more substances react/interact and change the normal
activity of one or more components; harmful/undesirable effects, loss of therapeutic effects

Physical One ​drug​ is ​MIXED​ with ​another drug​/solution to produce a product

Incompatibility UNSAFE​ for administration
- 2 drugs mixed together that form a precipitate could be harmful
- (Ceftriaxone + Lactated Ringer’s → may form a precipitate &
damage kidneys, lungs, gallbladder​)

Chemical REACTION​ of drug with other drugs/solutions → ​ALTERATIONS​ in ​integrity

Incompatibility and ​potency​ of​ active ingredient

Therapeutic Undesirable effect​ occurring as a result of 2 or more drugs being given

Incompatibility concurrently
- Can have an increased or decreased therapeutic response
Infusion nursing society standard:​ Nurse should verify and chemical,
physical, therapeutic compatibility and stability ​prior​ to administering
infused medications/solutions

6 R’s
○ Patient, Drug, Dose, Route, Time, Documentation
○ Check medication at least​ 3 times ​prior to administration
○ Only administer medications that ​you or a licensed pharmacist​ have prepared
○ Label​ all medications appropriately, accurate dosage calculations
Advanced Interventions Final Exam Study Guide

Discuss infusion guidelines and assessment for the patient receiving a blood transfusion
Blood Transfusion: Assessment

● Pre-Assessment
○ Baseline vitals, taken periodically once transfusion starts based on protocol
○ Kidney function, cardiovascular, lung sounds
○ Evaluate IV site, gauge of needle
■ 18 gauge needle for rapid
■ 20 gauge needle for slow​ (smaller can risk hemolysis)
○ Blood product matches patient
○ RBCs must be ABO and Rh compatible
● Pt identification
○ Identify unit label of blood and patient by ​TWO nurses​ before hanging blood
○ Check for expiration by ​TWO nurses ​(both nurses must document that check
occurred)
● Equipment
○ Y-set filtered
■ 2 drip chambers (1 port with normal saline)
○ Normal saline

Blood Transfusions: Guidelines

Guidelines:
● Pump​ can inform us of phlebitis, easier for 4 hour period
○ Does ​not​ cause hemolysis
● Infuse slowly
○ Large enough dose that can alert the nurse of a reaction but small enough that
it can be successfully treated
○ If pt shows signs of an adverse reaction, transfusion is stopped ​IMMEDIATELY
& hang NS alone in separate tubing
○ After ​15 mins ​have passed safely, flow rate can be increased
○ RBCs should be infused within a ​4 hour​ period
○ RBCs should be hung within ​30 mins​ of obtaining from blood bank

*The only solution you should use to prime the line when hanging RBCs is ​NORMAL SALINE
Advanced Interventions Final Exam Study Guide

AB+ → Universal RECIPIENT

O - → Universal DONOR

Identify signs and symptoms of blood transfusion reactions

Allergic reaction ​can occur immediately or ​within 1 hour ​of the transfusion
Mild reaction Severe Reaction (Anaphylaxis)

Urticaria, localized erythema, facial flushing, Anxiety, hypotension, shock, wheezing,

dyspnea, wheezing urticaria

Nursing Actions: Nursing Actions:

Pause​ transfusion, keep vein open, notify
provider, monitor vital signs, administer
antihistamine orders (or benadryl 30 mins
before)
Discontinue​ transfusion, keep vein open with
just NS, administer CPR, anticipate order for
steroids, maintain BP; prevention using well
washed RBCs where plasma has been
extracted
Advanced Interventions Final Exam Study Guide

Febrile Reaction

Reactions to antibodies directed against leukocytes/platelets

Occurs immediately or 1-2 hours after transfusion is completed

Signs/Symptoms: Interventions:
FEVER most common Discontinue transfusion
Chills Keep vein open with NS
N/V/Headache Notify provider
Tachycardia Monitor VS
Nonproductive cough Administer antipyretic

Prevention:
Use leukocyte-reduced blood components

Acute Hemolytic Transfusion Reaction

Most serious and life-threatening reaction

Occurs after infusion of ​incompatible​ RBCs
● Leads to activation of coagulation system and release of vasoactive enzymes that
result in vasomotor instability, cardiorespiratory collapse, and DIC

Signs/Symptoms: Interventions:
Fever STOP TRANSFUSION
Lumbar, Flank, Chest Pain DISCONNECT tubing completely
Flushing of face Infuse NS
Tachycardia DO NOT GIVE MORE DONOR BLOOD
Call provider ASAP
Prevention: Monitor need for dialysis
Extreme care during identification process
Don’t give the wrong blood!
Advanced Interventions Final Exam Study Guide

Accurately calculate IV medication infusion rates

Accurately calculate intravenous drip rates for infusion via gravity or pump
Calculating Flow Rates - IV Pumps

Calculating IV Drip Rate

IV Flow Rate in mL per hour: Infusion Rate is Less than 1 Hour

Examples:
Advanced Interventions Final Exam Study Guide
Module 5: Surgical Asepsis
Identify factors involved in wound healing
Factors Affecting Wound Healing
Systemic Factors
Age
Children/healthy adults heal rapidly
Infant’s skin and mucous membranes are easily
injured and subject to infection
Older patients have altered hormonal
responses, poor hydration, circulatory
problems; increased r/o skin breakdown
Wound Etiology
Specific condition of the wound affects healing
Circulation & Oxygenation
Adequate blood flow is essential
Obesity → poor blood supply to adipose tissue
Nutritional Status
Requires adequate nutrition
Albumin & prealbumin levels are ​markers for
malnutrition
Protein is needed!
Health Status
Corticosteroids & radiation delay healing
Chronic diseases (CAD, diabetes) delay healing
Immunosuppression can delay healing
Local Factors
Pressure
Internal/external pressure can delay healing
(build up of gas or having tight pants/belt)
Desiccation/Maceration
Desiccation → dehydration
Maceration → overhydration/urinary & fecal
incontinence
Infection
Drainage, exudate, erythema, fever
Take wound culture to identify bacteria
Trauma/Edema
Edema → wounds heal slowly due to ​deprived
blood supply
Necrosis
Necrotic tissue ​must be removed ​in order for
healing to occur
Slough​:​ ​moist, loose, stringy tissue, ​yellow
Eschar:​ dry, thick, leather, ​black
KEY POINTS
Moist​ environment facilitates ​faster​ healing than
a dry environment
Dry​ environment causes a scab formation which
can ​delay​ healing (D = dry/delay)
Advanced Interventions Final Exam Study Guide

Describe the phases of wound healing

Phases of Wound Healing

Hemostasis

Purpose:​ ​to stop bleeding

Duration:​ ​Occurs immediately after initial injury
Involved blood vessels constrict, blood clotting begins (clotting cascade)
Exudate​ is formed → causes swelling and pain
Increased perfusion → results in heat and redness
Platelets stimulate other cells to migrate to the injury to participate in other phases of healing
Fibrin clot → stops bleeding; serves as initial matrix within wound that provides framework for cellular repair;
clot formation happens rapidly (unless bleeding abnormalities)
Larger severed blood vessels → need further measures (tourniquet or manual pressure or suture or
catheterization)

Inflammatory

Duration:​ ​Lasts 2-3 days

WBCs​ (​leukocytes & macrophages​) move to wound
Neutrophils​ are first to respond to wound, remove bacteria from wound through enzymatic activity
Macrophages enter wound and remain for long time; ingest debris and release growth factors that attract
fibroblasts to fill in the wound
Patient has a generalized body response/local inflammation
3rd day: ​macrophages predominant, continue to cleanse wound by removing dead tissue
DECREASED​ level of macrophage is associated w/ ​prolonged or delayed​ wound healing (uncontrolled diabetes
or diabetic wounds)

Proliferation

Lasts for ​several weeks

New tissue is built to fill the wound space through the action of fibroblasts
Acute wounds: collagen production around 5th day of injury (structural tissue protein, provides strength and
support to connective tissue and adequate collagen production is essential) + new blood vessels
A thin layer of epithelial cells forms across the wound
Granulation tissue forms a foundation for scar tissue development; fills the base of an open wound; healthy
tissue contains newly grown blood vessels and should be​ beefy red with uneven surface

Maturation/Remodeling

Final stage of healing; begins about ​3 weeks after​ injury

Can last up to a year after wound occurs
Collagen is remodeled/new collagen tissue is deposited
Scar becomes a flat, thin, white line
Will achieve 80% skin integrity/tensile strength;​ ​will never regain 100% strength
Can make area prone to further wound development
*Note that processes overlap!
Advanced Interventions Final Exam Study Guide
Advanced Interventions Final Exam Study Guide

Identify components of a skin-risk assessment

Braden Risk Assessment Scale

Sensory Perception Ability to respond meaningfully to pressure-related discomfort

Moisture Degree to which the skin is exposed to moisture

Activity Degree of physical activity

Mobility Ability to change/control body position

Nutrition Usual food intake patterns

Friction & Shear Muscle strength/ability to move freely and independently

Advanced Interventions Final Exam Study Guide

The Braden Scale assessment score scale: Very High Risk: Total Score 9 or less. High 
Risk: Total Score 10-12. Moderate Risk: Total Score 13-14. 

Stages of pressure ulcer development

Advanced Interventions Final Exam Study Guide
Advanced Interventions Final Exam Study Guide

Identify appropriate nursing interventions to provide relief or prevent skin conditions

Nursing Interventions

Heat Application

Heat causes vasodilation, ↑ blood flow, ↑ oxygen/nutrients to tissues

Helps with pain, stiffness, aching, reduce inflammation and infection, raises body temperature,
promotes drainage
Aquathermia pad → ​tubes filled w/ water, allows specific temperature control
Bair Hugger → ​Reusable warming agent & single use disposable warming blanket
*​Need an order for any type of heating pad
Moist Heat Dry Heat

Warms skin more quickly, more penetrative Stays at desire temp longer, doesn’t penetrate
than dry heat as deep
Compress, soaps, sitz bath Risk of burns
No longer than 20-30 min Observe for ​pale skin ​(too much heat causes
vessels to ​constrict)​
No longer than 20-30 min

Cold Application

Used to reduce pain, prevent swelling, decrease circulation/bleeding, cool body with high fever
Blood vessels constrict, tissues receive less oxygen/nutrients, used right after an injury
Complications: ​burns, blisters, impaired circulations
Blisters occur from intense cold, when dry cold in direct contact of skin
Prolonged application of cold → blood vessels ​dilate​ (limit to 20 minutes)

Edema Relief

Assist patient with ambulation

Elevation several times a day
Massage toward heart using firm pressure
Protect skin (dry/cracked → r/o infection)
Reduce salt intake (salt can ↑ edema)
Compression socks
Advanced Interventions Final Exam Study Guide

Describe the principles of sterile technique

Principles of Surgical Asepsis

● Sterile items must always be ​above waist or on top of field

○ Don’t drop hands below waist
● Only sterile objects may be placed on a sterile field
● A sterile object or field out of the range of vision or an object held below a person’s waist is
contaminated
○ Never turn your back on a sterile tray or leave it unattended
● Keep movements controlled to prevent airborne pathogen contamination
● Moisture causes contamination
● The edges of a sterile field or container are considered to be contaminated
○ One inch border around the drape and the part of the drape that hangs over the table
edge is considered contaminated
○ Pour off the lip of a bottle of solution
● A sterile object or field becomes contaminated by prolonged exposure to air
○ Never reach across a sterile field, avoid talking/laughing/sneezing, avoid shaken linen
● A sterile object or field becomes contaminated by capillary action when a sterile surface
comes in contact with a wet contaminated surface (avoid spills)
● Fluids flow in the direction of gravity - keep transfer forceps tip down if they are stored in a
disinfectant solution (also applies to surgical scrub)

Module 6: Wound Care

Identify principles of wound care that facilitate healing

Wound Healing Principles

● Remove exudate:
○ Drains, Wound VAC, Irrigation
● Removal of nonviable tissue
○ Cleansing (clean to dirty)
○ Debridement
● Pack wounds loosely
● Nutritional interventions
● Ideal healing environment
○ Moist wound bed
○ Surrounding skin dry
● Red: Protect
● Yellow: Clean
● Black: Debride
Advanced Interventions Final Exam Study Guide

Accurately assess and document the condition of a wound

Wound Assessment

● Location and shape

● Size - measure weekly
● Wound bed - granulation tissue, necrotic tissue, slough tissue
○ Tunneling
○ Undermining (wider below surface)
● Drainage - color, odor, amount
○ Serous
○ Serosanguineous
○ Sanguineous
○ Purulent
● Surrounding tissue
○ Healthy
○ Excoriated
○ Macerated
● Pain - tolerance of dressing change

Wound Drainage - Color, Odor, Amount

Serous:​ ​clean, watery Serosanguineous:​ ​thin,

discharge, usually pink-colored discharge
considered ​normal that is usually part of a
normal wound
recovery

Sanguineous:​ ​dark red Purulent:​ ​a generally

color normally associated thick green or yellow
with ​broken capillaries discharge usually
indicative of infection
Advanced Interventions Final Exam Study Guide

Discuss complications associated with wound healing

Wound Bed Terms

● Necrotic wounds: ​dead tissue, black in color

● Sloughy wounds: ​contain layer of viscous adherent slough, generally yellow or grey in
color
● Granulating wounds: ​significant amounts of highly vascularized granulation tissue,
red or deep pink in color
● Eschar: ​dead tissue that appears black/leathery, impairs healing

Wound Complications

● Infection: ​purulent drainage, pain, redness around

wound, edema, increased temp, elevated WBC
● Hemorrhage: ​large amounts sanguineous drainage
+ other symptoms of hypovolemic shock, check
UNDER clients
● Dehiscence: ​wound edges pulling away
○ Not well-approximated
○ Early sign = increasing serosanguineous
drainage
● Evisceration: ​wound opens revealing internal
organs
○ Emergency, prepare for OR
○ Cover organs with warm NS gauze`
● Fistula: ​abnormal connection between 2 parts of
the body
○ esophagus/windpipe
○ artery/vein
Advanced Interventions Final Exam Study Guide

Discuss assessment of wounds healing by primary and secondary intention

Advanced Interventions Final Exam Study Guide

Describe benefits of wound care dressings and irrigation to the healing process
Dressings for Wounds

Dry gauze Absorbs wound drainage; impregnated with agents to promote healing

Nonadherent Telfa
Gauze

Transparent Tegaderm
Gas exchange between wound & environment but bacteria prevented
from entering; moist healing environment,autolytic

Hydrogels Carrasyn
High water content enhances epithelialization and autolytic
debridement.

Hydrocolloid Duoderm
hydrophilic particles mix with water to form a gel, wound stays moist
DO NOT USE IN INFECTED WOUNDS, auto
Protect against contamination
Provide cushioning

Alginates Calcium Alginate

absorb large amount of exudate
Maintain moist wound environment

Foam Allevyn
Made of hydrophilic material, highly absorbent

Antimicrobials Reduce infection/prevent infection

Saline Moistened Dressings

● Purpose
● Clean from center to periphery
● Pack lightly but completely
○ Unfold the dressing to get better contact with wound bed
Advanced Interventions Final Exam Study Guide

Irrigating Wounds

● Gentle Pressure (4-18 psi)

● Isotonic NaCl
○ Can also irrigate w/ medications and enzymes
● Note:
○ Granulation
○ Necrotic tissue
○ Tunneling/Undermining
○ Drainage
○ Surrounding tissue
● Irrigate until solution flows clear
Advanced Interventions Final Exam Study Guide

Identify how different types of wound debridement methods are used to promote healing

Wound Debridement Methods

Mechanical Moist to wet dressing, manually removed
Causes ​non-selective debridement ​of necrotic tissue & slough → can remove
healthy tissue
Advantages:​ cost effective, simple dressing changes so pt can change own
dressing
Disadvantages: ​removes healthy tissue along w/ necrotic tissue, can be painful

Autolytic Uses body’s ​own processes​, enzymes, moisture to break down eschar & slough
Does not damage healthy skin but breaks down dead tissue over time
Advantages:​ no damage to surrounding skin; it’s selective for necrotic tissue,
easy/effective non-painful
Disadvantages: ​may take days/weeks for healing

Enzymatic Uses chemical agents to breakdown necrotic tissue

Useful for debriding wounds with large amount of necrotic tissue
Advantages:​ works faster than autolytic, minimizes risk to healthy tissue
Disadvantage: ​expensive, can cause discomfort/pain

Surgical/Sharp Uses sharp instruments (scalpel/laser) to remove necrotic tissue

Advantage: ​fastest way to achieve a clean wound bed, can speed healing
Disadvantage:​ not effective if an operating room is required/can be painful for
patient

Maggot Use of maggots that have been grown in a sterile environment

Selective therapy → they only eat necrotic tissue

Describe how wound drainage instruments are used to promote healing

Wound Drainage Instruments

Drain out excess wound fluids to promote healing

Assist & expedite healing process of wounds to prevent infection
Advanced Interventions Final Exam Study Guide

Penrose Drain

Passive drainage
Usually placed through stab wound when excess
drainage expected
Not sutured

Jackson-Pratt Drain
Gentle negative pressure
Empty when ½ full
Holds 50-100 mL
Located along side of wound
Protect from pulling
Usually in abdomen

Hemovac Drain
Negative pressure ppl
Through stab wound
Sutured in place
Large amount of drainage (400-800 mL)

Vacuum-Assisted Closure (VAC)

Negative pressure
Tube embedded in foam
Occlusive dressing
Healing benefits
*LOW risk of infection
Advanced Interventions Final Exam Study Guide

Describe benefits and contraindications for use of pneumatic compression devices

Pneumatic Compression Devices (PCD)

Purpose: Assessment:
Promotes venous return CSM Q 8 hr
Skin integrity
Considerations:
Calf or full leg sleeves Contraindications:
Attaches to air pump DVT
Often used with TEDS
Used until ambulatory

Module 7: Respiratory Skills

Identify tubes used to assist with patient ventilation

Endotracheal Tube Sterile technique
Indications:
Used to administer mechanical ventilation, relieve upper
airway obstructions, protect against aspiration, clearing
copious secretions
Placed through nose or mouth
Short term < 14 days

Tracheostomy Tube Sterile technique

1q
I​ndications:
Replace an ET tube
Mechanical ventilation
Acute or chronic airway obstruction
Copious secretions (use a double lumen)

https://www.youtube.com/watch?v=ULb5q6aBuic&feature=emb_rel_pause​ (wish I
watched this before I took exam 2)

Oropharyngeal Stimulates gag reflex, ​only use for altered LOC

Airway Measure OPA from corner of mouth to the angle of the jaw below the ear

Nasopharyngeal Does NOT stimulate gag reflex, can be used on alert or altered LOC
Airway Measured from nose to angle of jaw
Advanced Interventions Final Exam Study Guide

Discuss factors important to the selection of ventilation assistive devices

● Duration of placement is a big one
○ ET tubes are for only 14 days or less so if its long term you’re going to want a tracheostomy
○ Extremely short term such as an elective surgery you’ll want a laryngeal mask airway
● Whether they are conscious or not → can use the oropharyngeal airway if they have an altered
consciousness level but don't do it if they are alert because it will stimulate the gag reflex, in that case use
the nasopharyngeal airway
● Does the patient have a lot of secretions? If so the tracheostomy might be the way to go because it
promotes suctioning

Describe care measures significant to the care of a patient with an endotracheal,

tracheostomy, or chest tube
Endotracheal Tube

● Check chest for equal expansion

○ If only one side of the chest expands, this could indicate the tube was pushed in too far
○ Auscultate for bilateral breath sounds!
● Monitor o2 sats
● Hook them up to capnography to read CO2
○ Color changes from ​purple​ (oxygen) to ​yellow​ (when exposed to CO2)
● Assess​ ​resp status at least every 2 hours
● Place in​ side-lying or semi-fowler's position​ and ​reposition every 2 hours
● Move tube to opposite side of the mouth every 8 hours​ to make sure you don't mess w the oral
mucosa
● Provide ​oral care every 4 hours ​and get them a bite block
● Tough for them to communicate so get them a whiteboard so they can express their needs

Tracheostomy

● Interventions: Humidify​ to loosen up secretions and prevent the formation of mucous plugs
(patients lose the ability of their natural humidification/filtration system)
● Buildup of mucous and rubbing of tracheostomy tube can irritate skin around the stoma
(should be kept clean and dry, assessed for irritation and infection) – As the stoma heals
post-op, a precut dressing is placed around the stoma/under the face plate. This must be
pre-fabricated split gauze “drain sponge” – you don’t cut with scissors because you don’t
want any loose threads or debris getting in the airway (keeping this clean and dry as well to
prevent maceration)
● When performing trach care: want 2 people changing secure device (tape/Velcro) – patients
can cough and decannulate a trach tube. One person holds the flange secure while the other
replaces the tie. If you’re alone – put new tie on entirely before removing the old one
4
Advanced Interventions Final Exam Study Guide

Chest Tube
● Perform respiratory assessment: RR, breathing, sounds, O2 sats
● Inspect dressing: drainage, assess insertion site for subcutaneous emphysema or tube migration
● Subcutaneous emphysema​: Collection of air in the tissues just under the skin – if a chest tube isn’t
properly placed or dressing isn’t airtight
● Air can leak around tissue at insertion site (can travel in body, causing neck and facial swelling, or even
threatening the airway and possibly causing need for intubation)
● Correcting the chest tube placement usually stops leakage of air into tissues and air is almost always
rapidly reabsorbed
● Keep tubing free of kinks and occlusions – assess, prevent fluid filled dependent loops which can
impede drainage
● Have patient reposition, cough, deep breath, use incentive spirometer

Trach: Emergency Equipment at Bedside

BVM - bag valve mask
Obturator
Suction
Oxygen
2 new tube (same size and smaller)
Always remain with patient if it’s an emergency situation

Identify methods used to suction respiratory secretions

Suction Methods
Closed System Open System
Reusable sterile suction catheter encased in a plastic New sterile catheter for each suction session
sheet Potential risk of:
Attached to vent - ​reduced risk of hypoxia ​and - Infection
infection - Hypoxia
Use for ​24 hours - Stimulation of vagus nerve (causes HR to
Use PPE to prevent contact w/ body fluids (non-sterile drop)
gloves) PPE to prevent contact w/ body fluids - ​sterile gloves
Advanced Interventions Final Exam Study Guide

Describe assessment and care guidelines for safely suctioning a patient

Suctioning
PRN Procedure
- Oropharyngeal (clean technique)
- Nasopharyngeal (sterile)
- Endotracheal (sterile)
- Tracheostomy (sterile)

Pre-Assessment
- Baseline assessment
- Monitor for signs of ​hypoxia​:
- Restlessness
- Adventitious breath sounds
- Decreased O2 sat
- Tachypnea/tachycardia
- Effectiveness of cough
- Hx deviated septum, nasal polyps, epistaxis, nasal injury or swelling
- Assess need for premedication
- Have patient take several deep breaths prior to suctioning to help prevent hypoxemia

Guidelines

Pre & Post Assessment

Procedure considerations:
- Correct catheter size
- Pre-test suction
- Hyperoxygenate per facility
- 3 passes
- 10-15 seconds per pass
- 30 seconds - 1 min between passes
- Set suction at ​80-100 mmHg
Advanced Interventions Final Exam Study Guide

Discuss assessment and care guidelines for providing safe and effective care to a patient with
a chest tube
Care Considerations with Chest Tube
Assess
- Subcutaneous emphysema
- Respiratory status
- Drainage
- Occlusive dressing
- All connections taped
- Tubing free of kinks
- Site for s/sx infection
Semi-Fowler’s
Cough & deep breathing Q 2 hours
Place in pleural space between fifth and sixth rib

Module 8: Elimination Skills

Describe the purposes and benefits of using a handheld bladder scanner

Bladder Scanners

Purposes:
Prevent unnecessary catheterizations
Minimize
- Risk of CAUTI
- Risk of upper urinary tract damage
Allows you to perform a ​noninvasive​ scan of the bladder
Automatically calculates the ​bladder’s volume
Typically take ​3​ ​scans​ & take the average

Identify risk factors for urinary retention

Indwelling & Retention Catheters (Foley)

Causes of Urinary Retention:

Obstruction of urethra (benign prostatic
hyperplasia)
Nerve problems (diabetes/stroke, spina bifida)
Medications (opioids/anesthetics,
anticholinergic, TCAs, antipsychotics)
Weakened bladder muscles (aging)
Advanced Interventions Final Exam Study Guide

Discuss indications for use of a straight or indwelling urinary catheter

Appropriate Indications for Indwelling Inappropriate Indications for Indwelling
Catheter Catheter

Acute urinary retention or obstruction As a substitute for nursing care of patients

Accurate measurement of urinary output in
critically ill patients
Perioperative use in selected surgeries
Assistance with healing stage III or IV perineal
and sacral wounds in incontinent patients
Hospice/comfort/palliative care
Required immobilization for trauma/surgery
with incontinence
For patient or healthcare provider
convenience
For an extended period of time after surgery
Urine Output monitoring that can be
obtained by means other than an indwelling
urinary catheter

Types of Catheterization

Suprapubic Placed through surgical opening in the abdomen

Prone to bacteria, can cause discharge

Replace bandage if it becomes moist

Assess Q 8 Hours

Indwelling Remains in place

(Foley) 2 Lumens - 1 is for the urine drainage, other is for inflating balloon; balloon is what holds
the catheter in the bladder & prevents it from coming out

Intermittent One-time​ use

(straight cath) Removed ​IMMEDIATELY​ after insertion and
drainage of urine
Ex: use for woman during Labor & Delivery

If patient needs to cath themselves at home, it’s easier

to use a stiff tube than latex tube
In hospital: ​Use sterile technique
At home:​ Client would use a clean technique

External For patients who are incontinent externally; place device in perineal region and attach to
(Texas/Purewick suction to collect incontinence & keep patient dry
/Condom)
Advanced Interventions Final Exam Study Guide

Describe situations where a coude catheter is indicated

Urinary Catheters

Coude tip​ - seen in patients with

BPH; curved tip, less flexible,
allows for easier insertion
Three way catheter

Identify appropriate positions for urinary catheterization based on patient assessment

Urinary Catheterization

Usually 14-16 Fr in adult; 5-10 mL balloon

Patient positions
Female Male

Dorsal recumbent Supine (longer urethra)

Side lying
Key Points: Key Points:
Maintain separation of labia until catheter Hold penis shaft until catheter inserted
inserted Insert up to bifurcation
Insert about 2-3 inches until urine return
Advanced Interventions Final Exam Study Guide

Identify measures to ensure accurate and safe placement and irrigation of a urinary catheter
Catheterization

Procedure:
Wear gloves
Perform perineal care
Provide privacy (have another witness)
Use front to back cleansing method for female
Use circular motion from center outward for male (uncircumcised: retract foreskin), clean shaft and
scrotum
Keep the catheter tip sterile!
Don’t test balloon prior to insertion
After catheterization, assess urine for color, odor, sediment, blood, amount, vital signs, fever,
abdominal assessment to determine there’s no longer distention, document

Discuss key documentation requirements for procedures related to catheterization, irrigation

of a catheter, ostomy care
Documentation Requirements
Catheterization

Date & time of catheterization

Type of catheter inserted (straight, indwelling, condom, suprapubic)
Size of catheter
Amount of fluid used to inflate balloon (indwelling)
Urinary output
Catheter patency
Urine quality, quantity, color, odor
Patient’s alertness, orientation, abdominal assessment, skin assessment
Patient & family teaching

Irrigation of a Catheter

Amount & type of irrigant

Characteristics of drainage
Patient tolerance
*Remember: ideal irrigation is NATURAL IRRIGATION (drinking fluids/flushing body)

Ostomy Care

Appearance of stoma (Normal: pink/red/moist)

Condition of peristomal skin
Amount, color, characteristics
Patient tolerance and reaction
Helping patient understand care for this
I&O’s
Advanced Interventions Final Exam Study Guide

Identify and describe various types of urinary and bowel diversion

What is an Ostomy?

● Opening is created in abdominal wall for the elimination of feces or urine

● “Ostomy” → opening into body
● A ​stoma​ is the visible part of a temporary or permanent opening created in the
abdominal wall during a surgical procedure

Three Basic Types

Colostomy Ileostomy Urostomy
(Large intestine) (Small intestine) (Urinary)
Advanced Interventions Final Exam Study Guide

Describe assessment and care of a patient with urinary or bowel diversion

Colostomy

Portion of diseased large intestine (colon) is removed

or by-passed
Remaining portion is brought through the abdominal
wall to form the stoma
Temporary or permanent
End, loop, or double barrel
If temporary, stoma will be necessary until the disease
portion can heal
Requires another surgery to reconnect
The effluent from colostomies is​ thicker and more
formed​ the further down the large intestine (toward
the sigmoid colon) the stoma is placed

Ileostomy

Typically created from the terminal ileum

and the stoma is usually (but not always)
on the right side of the abdomen and has a
smaller diameter than colostomies
The effluent from ileostomies is usually
very ​thin and watery at first
Advanced Interventions Final Exam Study Guide

Module 9: Gastric Decompression

Describe indications for gastric decompression

Gastric Decompression

Indications:
Bowel obstruction, paralytic ileus, surgery on stomach or intestine
Patient is NPO
Functions:
● Allows GI tract to rest (especially for severe vomiting & diarrhea)
● Clears GI tract
○ Promotes healing & allows peristalsis to resume

Identify considerations for the use of a single or double lumen NG tube for decompression

Single Lumen Tubes

Levin
● Sizes 14-18 French and 125 cm long
● Plastic or rubber
○ Several drainage holes near the end
○ Markings on the tube that allow you to make
note of where you’re inserting it
● Used for stomach decompressing, withdrawing
specimens, washing the stomach free of toxic
substances, irrigating stomach, diagnose/treat ​upper
GI bleeds
● Can be used to administer ​meds and/or feedings
● If it were used for suctioning, would use low
intermittent suctioning (don’t want continuous
because it can cause tear of stomach lining)
Advanced Interventions Final Exam Study Guide

Salem Pump (Double Lumen)*

● Most common NG tube

● Clear plastic
● Sizes 14-18
● Used for ​irrigation and tube feeding
● Preferred tube for gastric decompression because it
can be used for continuous suction due to the double
lumen tube
● Blue vent is ​always open ​to air for ​continuous
atmospheric irrigation
● Prevent reflux by having blue vent port ​above the
patient’s waist
● When irrigating the large lumen, want to inject ​20 mL
air into the blue vent to re-establish the buffer barrier
between gastric contents and vent
○ NEVER clamp off the air vent, or connect it to suction, or use it for irrigation
● Larger Lumen is what is connected to suction
● Every shift mark off how much is being collected from contents

Discuss care measures pertinent to the patient with a NG tube

Caring for NG Tubes

Abdominal assessment
Monitor gastric output at least every 8 hours
- Volume, color, type of GI drainage
- GI fluid contains essential body fluids & electrolytes (water, hydrogen, potassium,
sodium, bicarb, magnesium; losing too much fluid can lead to FVD and metabolic acid
base imbalances); ensure patient is receiving adequate replacement fluids by IV or
enteral route,​ report excessive output or signs of FVD to provider
Assess adequacy of suction pressure
- Nausea/vomiting
- Output could be bloody if patient had GI surgery
- Prevent tension/pulling of tube, secure to patient’s gown, ensure enough slack so
they can turn head
- Include ​frequent oral hygiene
Maintain tube patency
- Intermittent irrigation
Advanced Interventions Final Exam Study Guide

Identify best practices for determining correct NG tube placement

Caring for NG Tubes

Proper Placement
● X-Ray* GOLD STANDARD
● Aspiration
○ Aspirate fluid from tube at time of insertion and testing pH
● pH
○ pH 0-5 most likely in the stomach
● Air insertion
○ Check facility policy
● CXR
● CO2 detector
NCLEX DISCLAIMER: NEVER AUSCULTATE OVER THE STOMACH WHILE AIR IS IRRIGATED
THROUGH N-TUBE BECAUSE IT’S NOT A RELIABLE METHOD OF ASSESSING PLACEMENT
In practice of Neonates - check placement by auscultation over stomach due to the fact that
we are putting N-TUBES in them all the time, don’t want to put them through a chest x-ray all
the time, pH is always altered in this population

What is the difference between decompression and gastric lavage?

Gastric Decompression Gastric Lavage

Remove gas/fluids from stomach
Remove ingested toxins other than poison,
to diagnose problems with gastric motility
Gastric lavage should ​NOT​ be used routinely
for patients who have ingested poison - use
polyethylene glycol instead
Advanced Interventions Final Exam Study Guide

Conditions Requiring Drainage

Pneumothorax Hemothorax Pleural Effusion

Air​ between the pleurae Blood​ in the pleural space Transudate​ or ​exudate​ in
pleural space
Advanced Interventions Final Exam Study Guide

Key Points from Exam 1:

● Stereognosis​ is when you place a familiar object in a patient’s hand when they have
their eyes closed, used to test neurosensory assessment
● If you auscultate a patient’s chest and hear a blowing/swishing sound (​bruit​), this is
indicative of blood turbulence
● An IV site is shown to have ​warmth and edema​. The nurse suspects that this could be an
indication of ​phlebitis​.
● Pulmonary Venous Vs. Pulmonary Artery Disease
○ Which one has ruddy skin? Shiny skin? Hairless legs?
● When inserting an IV, you want to insert the​ needle 10-30 degrees, bevel side UP
● PICC lines​ decrease risk of infection and can be kept in place longer
● If a patient covers their eye and uncovers, and their eyes are shifting in gaze, could be
weakness of the ocular muscles
● Which of the following is not a hazard of IV meds? → Insufficient absorption
● What’s the term called when the upper eyelid of one eye droops more than the other?
→ ​Ptosis
● If you suspect a patient is having an allergic reaction to an IV, you want to do a quick
assessment on the patient, ensure emergency medication is available, and call the
provider right away
● Which of the following would you best hear the ​base​ valve closures?
● If a patient’s history says he lives with his wife and 2 children, this would be considered
social history
● If eyes cannot be directed to the same object this is known as ​strabismus
● Which patient would you advocate the use of a central IV catheter? A pt receiving TPN
● Which characteristics of lymph nodes are associated with malignancy? ​Fixed nodes
● A patient would require further teaching if they said they would flush their central IV
catheter with 3 mL
● Older clients are at risk for HTN due to vascular changes and buildup of plaque
● You want to lay a patient on their left lateral side to better hear their heart murmur
● If the right eye is 20/40 and the left eye is 20/30, this means that the left eye is closer to
normal vision than the right eye
● What is presbyopia? → unable to see things up close
● How would you dilate the veins in a patient who has very small veins? Stroke, apply
tourniquet, have the patient clench her fists
● Stiffness​ of the mitral valve indicates ​stenosis
● Where would you best hear S1 and S2? Know where the base and apex are in terms of
intercostal spaces/sternal border
○ Aortic, 2ICS, RSB, S2>S1
○ Pulmonic 2ICS, LSB, S2>S1
Advanced Interventions Final Exam Study Guide

○ Erb’s 3ICS, LSB, S1=S2

○ Mitral (Apical) 5ICS MCL S1>S2
○ Tricuspid 4 ICS LSB S1>S2

Practice Questions

1. The ER nurse is caring for a client reporting dizziness and headache with identified
nystagmus. Which cranial nerves would the nurse plan to assess? ​CN III, CN IV, CN VI
2. What is the correct order of the wound healing process? ​Hemostasis, Inflammatory,
Proliferative, Remodeling
3. How often do immobile patients need to be turned? ​Every 2 hours
4. What are the components of the Braden Assessment? ​Appearance, Wound healing
status, pain, nutrition, activity/mobility, elimination
5. What is cellulitis? ​Infection at IV site
6. What is phlebitis? ​Inflammation of the vein at IV site
7. What is infiltration? ​Seepage of non vesicant solution into surrounding tissue at IV site
8. What is extravasation? ​Seepage of a vesicant into the tissue at IV site
9. What is a vesicant? ​A solution that causes blisters, tissue sloughing, necrosis
10. What is an antibody? ​Immunoglobulin produced by the body in response to a specific
antigen
11. What is an antigen? ​Foreign material capable of inducing a specific immune response
12. What is systolic pressure? ​Highest point of pressure on arterial walls when the
ventricles contract
13. What is debridement? ​Cleaning away tissue/foreign matter from a wound
14. What is dehiscence? ​Separation of the layers of a surgical wound
15. What is dessication? ​Dehydration/being free from moisture
16. What is maceration? ​Softening through liquid/overhydration
17. What is eschar? ​Thick, leathery, necrotic tissue that must be removed in order for
healing to occur
18. What is evisceration? ​Protrusion of internal organs through an incision
19. What is exudate? ​Fluid that accumulates in a wound; may contain serum, cellular
debris, bacteria, and white blood cells
20. What is a fistula? ​An abnormal passage from an internal organ to the skin or from one
internal organ to another
21. What is necrosis? ​Death of cells and tissue
22. What is purulent drainage? ​Comprised of white blood cells, liquefied dead tissue
debris, bacteria
23. What is sanguineous drainage? ​First drainage that a wound produces, red blood
24. What is serosanguineous drainage? ​Drainage that contains blood and yellow serum
Advanced Interventions Final Exam Study Guide

25. What is serous drainage? ​Composed of clear, serous portion of the blood and from
serous membranes
26. The nurse is caring for a client with an indwelling urinary catheter. For this client, the
nurse plays a key role in prevention of which most common complication?
Catheter-associated urinary tract infections (CAUTI)
27. The nurse prepares for insertion of an indwelling urinary catheter for a female client.
Prior to the catheter insertion, what should the nurse do? ​Confirm the medical
prescription for indwelling catheter, assess client’s degree of physical limitations,
question client about allergies to latex/iodine
28. The nurse prepares for insertion of an indwelling urinary catheter for a male client. The
nurse is right-handed. Where should the nurse stand to perform the procedure? ​On the
client’s right side
29. Prior to indwelling urinary catheter insertion for a female client, how should the nurse
cleanse the perineal area? ​Wipe from above urinary orifice downward toward sacrum
30. When placing an indwelling urinary catheter, where should the nurse hold the catheter?
2-3 in from the tip of the catheter
31. The nurse is placing an indwelling urinary catheter for a female client. Once urine drains
into the catheter tubing, what should the nurse do next? ​Advance the catheter an
additional 2-3 in
32. The nurse is inserting an indwelling urinary catheter for a female client. The nurse notes
that no urine flow is obtained and that the catheter appears to be in the vaginal orifice.
What is the next step by the nurse? ​Leave the misplaced catheter in place as a marker
and repeat the procedure with a new catheter.
33. The nurse is caring for a female client with an indwelling urinary catheter. The nurse
notes that the catheter is not draining. What is the correct action by the nurse? ​Check
the catheter tubing for kinks or twisting
34. The nurse is caring for a female client with an indwelling urinary catheter. The client
reports sudden pain and urethral spasm. What is the best action by the nurse? ​Deflate
the balloon, remove the catheter and replace

Coursepoint - Module 19 CVAD Quiz

https://quizlet.com/479827300/​taylors-clinical-skills-module-19-central-venous-access-devices-flash-cards
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