CDC 4N051_M07_Transcript_20230605(4) PDF

Ensure out-patients are given post-op instructions and know what to do if/when complications arise. C O NT I NU E Incentive Spirometer The incentive spirometer is used to promote voluntary deep breathing. This expands the lungs capacity, allowing them to fill fully with air. The goal is to increase...

Ensure out-patients are given post-op instructions and know what to do if/when complications arise. C O NT I NU E Incentive Spirometer The incentive spirometer is used to promote voluntary deep breathing. This expands the lungs capacity, allowing them to fill fully with air. The goal is to increase the amount of air inhaled and expelled to improve profusion. This exercise is used to prevent or treat atelectasis in postoperative patients. The most common being patients who have undergone thoracic or abdominal surgery, patients who are on bed rest, and those who have neuromuscular disease or spinal injuries. To start, place the patient in the sitting position and explain to the patient to exhale fully. Have the patient place the mouthpiece in his or her mouth. Inhale slowly until the desired goal is reached; hold for three seconds and ensure each ball is raised to the same level. Relax and slowly exhale and explain to the patient this should only be done one time in a minute to allow the patient to relax.  The patient should perform 5-10 breaths per session every hour while awake. C O NT I NU E Diabetic Foot Exam A very important part of your job will be to inspect the condition of the patient’s skin surface, especially pressure points and the feet on a daily basis for admitted patients and routinely for clinical patients. Because of circulatory and healing problems, diabetic patients must be monitored closely for bruises and wound healing. It is very easy for a diabetic to have an injury or wound without knowing it, and they are at high risk for dangerous infections of the lower extremities; severe cases often lead to amputations of the toes, foot, or limb. Nerve damage, known as neuropathy, and poor circulation are the most common causes of diabetic foot problems. The diabetic foot assessment is a key component in the care of a patient with diabetes. The assessment includes risk factor identification in both the diabetic patient's history and physical examination, foot care education, treatment, and referrals as needed. The foot complications related to diabetes such as peripheral neuropathy, foot ulceration, and amputation can be life altering. The American Diabetes Association recommends a diabetic foot examination annually for patients with diabetes with foot care education. Diabetic foot assessment may be recommended more frequently for individuals with risk factors contributing to ulceration, peripheral arterial disease, and peripheral neuropathy. A diabetic foot exam is used to check for foot health problems in people with diabetes. When ulcers or other foot problems are found and treated early, it can prevent serious complications. Monofilament testing is an inexpensive, easy-to-use, and portable test for assessing the loss of protective sensation, and it is recommended by several practice guidelines to detect peripheral neuropathy in otherwise normal feet. The feet should be cleaned at least daily or according to the provider’s orders. You should first look for any damaged skin (report if found) and then press on with hygiene care. Foot care, to include nail care, is explained; however, technicians should not perform nail trimming/care due to the high risk of complications. Most providers will perform nail care themselves because of the high risk. Here are a few tips so you know what to expect when you assist: Inspect the condition of the skin, with a focus between the toes and on the heel. Inspections will be daily for inpatient and routinely for outpatient appointments. Look for any damaged skin, to include: cuts, scrapes or cracks. Look for any bruising or discoloration to the skin. Nail care includes regular trimming, cleaning and cuticle care. Wash feet in warm water; do not soak- this could cause drying. Push cuticles back gently on nails with plastic applicator to prevent hangnails. Toenails are clipped straight across to prevent ingrown nails. Toenail clippings of a diabetic, or one with circulatory disease requires a doctor’s order and is performed by a nurse or physician. Brush a soft nylon fiber called a monofilament over the toes and foot to test the foot's sensitivity to touch. If a problem is found, more frequent testing will likely be recommended, antibiotics to treat infections, and/or surgery to help with bone deformities. Test your knowledge of the pressure points of the feet by using the drag and drop interaction below. C O NT I NU E Endotracheal Care The endotracheal tube is a flexible tube that is inserted through the mouth or nose and into the trachea. This acts as an artificial airway. These are often used for trauma patients, medical emergencies and at times short term for complex patients. This artificial airway provides and maintains a patient airway, it allows for deep tracheal suctioning and removal of secretions, and permits mechanical ventilations. The endotracheal tubes inflated balloon seals off the trachea to prevent aspiration from the gastrointestinal (GI) tract. It is easier to insert in an emergency, however maintaining placement is difficult, therefore it is not recommended for long term use. To start the procedure, verify provider’s orders, verify patient with two patient identifiers. Perform hand hygiene and prior to care, ensure that the patient has equal, bilateral breath sounds throughout the lung fields. Check the marked points on the tube at the insertion level to determine if the tube has moved. Check breath sounds every two hours, suction when needed. Annotate when suctioned, and the color and characteristics of secretions. When the natural humidifying pathway of the oropharynx is bypassed, ensure to provide adequate humidity. Inspect the nose and mouth for any ulcers or pressure areas. Provide oral and nasal care. Oral care will be performed every two to four hours, or by provider orders. Use a soft toothbrush or swab and a prepackaged oral care kit. Prevention of ventilator- associated pneumonia beings with frequent oral care. Ensure to keep the patient’s lips moisturized, preventing them from cracking or becoming sore. Inspect the positioning and stabilization of the tube. Position changes can obstruct the airway and potentially cause tissue erosion and necrosis. Reposition and tape the oral endotracheal tube (ETT) care to the opposite side on a daily basis. Note the tube depth each time. C O NT I NU E Tracheostomy Care Tracheostomy care is vital to establishing and keeping a patent airway. Remember to always keep an eye on your patient to ensure that the tracheostomy has not become blocked with secretions or fluids used for cleaning, or that it has become dislodged. You are working on the patient’s airway, it is vital to ensure you have all the required supplies and equipment prior to starting the performance phase of the maintenance procedure. Never leave. Talk to the patient before the procedure to give him or her an overview of what you will be doing, talk the patient through the procedure as you perform it. Reassess the patient’s airway and respirations upon task completion. PR E PA R AT O R Y PH A SE PE R F O R MA N C E PH A SE You will first need to verify provider’s orders and two patient identifiers. Gather supplies, to include the following: Sterile towel, sterile gauze pads (10), sterile cotton swabs, sterile gloves, hydrogen peroxide, pipe cleaners or brush, sterile water, antiseptic solution and ointment, face shield, tracheostomy tie tapes or tach securing device, oxygen, french suctioning catheter and suction unit. Explain the procedure to the patient. Asses the condition of the stoma. Examine the patients neck, looking for any subcutaneous crepitus. Suction the trachea and pharynx thoroughly prior to care. Wash your hands thoroughly when finished. PR E PA R AT O R Y PH A SE PE R F O R MA N C E PH A SE Assemble equipment: place on sterile towel. Open four gauze pads and pour hydrogen peroxide on them. Open two gauze and pour the antiseptic solution on them. Open two gauze and keep dry. Open the last two gauze and pour sterile water on them. Place the tracheostomy tube tapes onto the field. Put on face shield. Don sterile gloves. Clean the external end of the tracheostomy tube with two hydrogen peroxide saturated gauze. Discard when done. If present, unlock and remove the inner cannula. If a disposable inner cannula is used, using your clean hand replace with a new cannula, touching only the external portion, locking it securely into place. Designate the hand you clean with as contaminated and reserve the opposite hand as sterile for handling sterile equipment. If inner cannula is reusable, remove it with your contaminated hand. Clean with hydrogen peroxide using a brush or pipe cleaners with your sterile hand. When clean, with your sterile hand, drop the brush or pipe cleaners into sterile solution and agitate to rinse thoroughly. Tap gently to dry. Replace with your sterile hand. Clean the stoma Q 4-8 hours with gauze soaked in saline. Use a semicircular motion, moving inward to outward. Note you may use diluted hydrogen peroxide to loosen any crusted secretions. Loosen and remove any crust with sterile cotton swabs or cotton tip applicators. Repeat cleaning using sterile, water soaked gauze pads. Repeat using dry pads. When soiled, change the securement device, per local policy. With assistance to avoid dislodgment, one person will hold the tube, and the second person performs the exchange/ replacement. Carefully remove soiled securement device. Grasp the slit end of the clean tape pulling (threading) through the opening on the side of the tracheostomy tube. Pull the other end of the tape securely through the slit end of the tape. Repeat steps on the opposite side. Tie tapes at the side of the neck in a square knot. You will alternate the knot from side to side, each time the tapes are changed, or secure the securement device. The ties should be tight enough to keep the tube securely in the stoma, but allow two fingers to fit between the tapes and the neck. Place a gauze pad between the stoma site and trach tube, per your local policy. Document procedure and current condition on the stoma and site, to include skin condition, secretions, and any changes. C O NT I NU E Contact Lens Removal It is not uncommon for someone to splash a chemical or have a foreign object blow into an eye. If this happens, the patient will likely go to the emergency room or may show up at the clinic you are working in. You need to know what to do and how to take care of the problem quickly. Delay in care could risk the patient losing eyesight! First, you need to determine whether the patient is wearing contact lenses and if so, which type. If the patient has a chemical in the eye, the provider will most likely want you to remove the contact lens immediately. Leaving a contact lens in place when there is an infection or injury to the eye can compound the damage. You should have the patient sit in a wheel chair and take the patient to a room as he or she probably will not be able to see due to the burning, pain in the injured eye, and both eyes will tear up preventing good vision. If a chemical or foreign object is in the eye, notify the provider immediately and follow his or her directions to splint the object, remove contacts or begin irrigation. You may have the patient remove the contact lenses if he or she is able to or you may need to remove them. The steps are the same whether the patient removes the lenses or you do it. Removal of a Hard Contact Lens – 1. Don clean gloves. 2. Cup your nondominant hand below the patient’s eye. 3. Move the lens directly over the cornea. 4. Pull the upper eyelid up above the edge of the lens. 5. Pull the lower lid down to the lower edge of the lens. 6. Press slightly onto the lower lid, at the edge of the contact lens; the hard lens should slide out between the upper and lower eyelid. 7. Place each contact lens into separate containers with sterile water and label each container with which eye the lens was removed from. Removal of a Soft Contact Lens – 1. Don clean gloves. 2. Place a drop of wetting solution or sterile saline in each eye to moisten the contact surface. 3. Using your non dominant hand, open the eye with your middle finger and thumb. 4. Use the index finger of your dominant hand and place it gently on the lower edge of the contact lens. 5. Slide the lens down toward the lower lid. 6. Gently pinch the lens between your index finger and your thumb, and lift the lens out. 7. If you are unable to remove the contact lens with this technique, get a contact lens suction cup to remove the lens. 8. Place each lens into separate containers with sterile water, and label which eye the lens was removed from. Twist the wand to help release the contact lens Inserting & Removing a Contact Lens in a Clinical Setting When able or available, use a soft contact lens tool to put in and take out contact lenses by focusing on the center of the eye. Place the suction device over the lens and squeeze the wand to help release the contact lens.  Know your patients! Ask them if they wear glasses or contacts. Never allow them to wear their contacts overnight and make sure they have a pair of eye glasses for extended stays. C O NT I NU E Fluorescein Eye Stain First you will need to verify the provider’s orders. Then apply a drop of sterile normal saline to the fluorescein strip; gently pull the lower eyelid down, and gently touch the tip of the strip to the inner aspect of the eyelid. Note: moistening the strip will enhance the release of the dye. Ask the patient to blink several times, allowing for the dye to be distributed. Dye is dispersed over the conjunctiva and cornea. The cornea is viewed through a woods lamp, or other blue light filter in order to illuminate the area of abrasion or ulceration. Apply antibiotic ointment, as directed by the provider and finally, apply a patch if indicated. Apply saline Touch inner eye Utilize woods lamp for viewing C O NT I NU E Ear Irrigation Ear Irrigation Syringe with needle catheter Look for abrasion or ulceration Ear irrigations are used to remove cerumen (ear wax) or any foreign body that occlude the ear canal, thus preventing sound from reaching the tympanic membrane. Ear irrigations are ordered by the primary care provider and should not be performed if there is a chance the tympanic membrane is perforated. S/S to look for prior to ear irrigation include but are not limited to reddening of the tissue, tenderness or white pustules/ secretions. The steps for performing an ear irrigation are listed below. 1 The first step is to verify the provider's orders. 2 Next, gather supplies: one large basin, one kidney basin, sterile 2x2, one 20cc syringe, one 20 gauge IV needle, (remove needle, place in sharps, keep catheter.) hydrogen peroxide, two chux pads, towel, ear curette with light or otoscope, and debrox if ordered. 3 Then you will fill the large basin with warm water and hydrogen peroxide. – DO NOT USE cold water; may cause nausea and dizziness. Fill the 20cc syringe and place the 20 gauge needle onto syringe, remove needle and leave catheter. 4 Now you will place the patient in the sitting position and drape chux pad and towel over shoulder. Have the patient place kidney basin flush to the jaw under the ear and you will gently pull the pinna up and out for adults, down and back for pediatrics, straightening the ear canal. This will allow for irrigation. 5 Place the tip of the syringe at the opening of the ear. Use the otoscope or ear curette w/light to guide the progress off irrigation. Carefully remove any large chunks of cerumen with sterile 2x2 and continue irrigation for prescribed time (or how many ml/ccs provider ordered). Repeat as needed. Have the patient lie on the irrigated side to allow the ear to drain. Inform the provider once irrigation is finished. 6 Document procedure. What the video below and watch how an ear irrigation is performed so you have an idea of what to expect if you have to use this procedure. Ear Irrigation Training Video Transcript.docx 88.4 KB True or False: When performing an ear irrigation, you will fill the large basin with warm water and hydrogen peroxide. DO NOT USE cold water; may cause nausea and dizziness. Fill the 20cc syringe and place the 20 gauge needle onto syringe, remove needle and leave catheter. True False SUBMIT Complete the content above before moving on. Eye Irrigation Eye irrigations are performed when there is the possibility of a foreign body or a caustic substance in the eye. Some examples may range from an eyelash to a scrap of metal or jet fuel. It is an uncomfortable experience for most people and they may be very anxious about future eye damage or loss of eyesight. It is very important you are careful but thorough when irrigating the eye. In some instances, you may go to a scene of a patient with a chemical in the eye. Most areas on base that deal with fuels or chemicals have an emergency eyewash station. If it is available, the patient should use it immediately and then be transported to the hospital for further treatment. You may also have a patient who splashed chemical into their eye walk into your ER or clinic. You should ask if the patient used an emergency eye wash station or running tap water prior to their arrival. Report that information to the provider and they will normally want immediate and thorough flushing with sterile saline or water for 10-30 minutes. In a controlled situation, the provider will normally have you irrigate the eye with an irrigation set. A quick set up is an IV bag with normal saline and IV tubing. Procedure Verify the provider’s orders. Verify patient. Verify correct eye(s) to be flushed. Place patient in a supine position – head should be angled in the direction of the affected eye to prevent runoff into unaffected eye. Position the exam light so that it illuminates the affected eye. Place a chux pad and/or towel on the bed in order to protect the patient’s bedding and clothes. Place an emesis basin close to the patient’s face in order to catch the irrigation solution. Prepare the irrigation set and fluid – fluid should be at room temperature; ensure only sterile normal saline or tap water is used. Don gloves. Remove any crusty discharge from patient’s eyelid with moistened gauze or cotton ball. Moisten with sterile normal saline. Stroke from the inner canthus to the outer edge of the affected eye. Fill the irrigation syringe with the appropriate amount of fluid. With your nondominant hand, gently pull the upper eyelid up and pull the lower eyelid down, which will expose the conjunctival sac. Ask the patient to look down. Hold the irrigation tubing ½ to 1 inch above the eye. Gently depress the plunger of the syringe as to irrigate the eye. Direct the stream from the nasal edge of the eye across the outer edge. You should repeat the irrigation until the desired effect has been reached or the total amount of solution ordered has been administered. If a large amount is prescribed by the provider, allow the patient to rest their eye between washings. Too much fluid pressure may damage the cornea. Allowing the patient to close the eye from time to time can help remove the foreign object by moving it from the upper to lower conjunctival sac. Once complete, dry the eyelid with a sterile gauze or cotton ball. Allow patient to dry off their face by providing a towel. Document the procedure. Include what kind of solution is used and the amount, the appearance of the eye and surrounding tissues, patient’s response to the procedure. C O NT I NU E Complicated Wounds Types of Wounds Wounds can be accidental or intentional. An intentional wound is created for therapeutic reasons, such as during an operation. The different types of accidental wounds include: C O N T USI O N H E MAT O MA A B R A SI O N A MPUTAT I O N This is commonly referred to as a bruise. This type of injury involves the skin and subcutaneous tissue. The skin remains intact, but the underlying tissues are damaged. The extent of the damage depends on the amount of force that was applied to cause the injury. The damage usually includes cell damage and torn blood vessels in the dermis, and leakage of tissue fluid and blood into the damaged tissues. This leakage causes edema and pain and produces a characteristic black and blue discoloration called ecchymosis. C O N T USI O N H E MAT O MA A B R A SI O N A MPUTAT I O N This is a pool of blood that forms beneath the skin when large amounts of tissue are damaged and large blood vessels are ruptured. Hematomas also occur with fractures or when organs are damaged. The extent of the bleeding depends on the force of the injury, size of the damaged blood vessel, and the location of the injury. The femur, for example, is surrounded by large blood vessels. When the femur is fractured, these vessels are usually damaged causing pooling of large amounts of blood. In some cases, this pooling may be enough to cause hypovolemic shock. By contrast, a hematoma can form when you pinch the skin on your finger, but it is so small that it may only be a minor inconvenience. Another common type of hematoma is the subungual hematoma. After a blow or crushing injury to the fingernail, the patient experiences severe and sometimes excruciating pain that persists for hours and may even be associated with a vaso-vagal (sudden loss of consciousness) response. The fingernail has an underlying deep blue-black discoloration which may be localized to the proximal portion of the nail or extend beneath its entire surface. Many times you will assist the physician in performing a trephination (excision) at the base of the nail, using an electric cauterizing lance, or drill. When performed quickly, patients do not feel the heat, just relief from pain. The cautery or drill is rapidly tapped a few times in the same spot at the base of the hematoma until the hole is through the nail. When resistance from the nail gives way, stop further downward pressure to avoid damaging the nail bed. Apply pressure to stop the bleeding and apply antibacterial ointment and bandage accordingly. C O N T USI O N H E MAT O MA A B R A SI O N A MPUTAT I O N This is the loss of a portion of the epidermis as the result of the skin being rubbed or scraped across a rough surface. There may be some bleeding from the capillary vessels in the dermis, but the abrasion usually does not penetrate completely through the dermis. Abrasions are usually extremely painful because multiple pain sensors are normally found in the damaged area. Abrasions are also known as road burns, a strawberry, and rug burn. C O N T USI O N H E MAT O MA A B R A SI O N A MPUTAT I O N This is the surgical removal or traumatic severing of a part of the body. Extremities and its attachments are most subject to amputations. Amputations can be partial or complete. C O N T USI O N H E MAT O MA A B R A SI O N A MPUTAT I O N This is an injury in which a piece of skin is either torn completely loose from all attachments or left hanging as a flap. Avulsed tissues ordinarily separate at normal anatomical planes, usually between the subcutaneous tissue and the muscle fascia. Usually, there is significant bleeding from the bed of the wound. If the avulsed part remains attached by a small pedicle of skin, circulation to the flap may be in jeopardy. C O N T USI O N H E MAT O MA A B R A SI O N A MPUTAT I O N This is a cut produced by a sharp object. The cutting object may leave a torn or jagged wound through the skin and may penetrate into the subcutaneous tissue, underlying muscles, and associated nerves and blood vessels. C O N T USI O N H E MAT O MA A B R A SI O N This is a smooth cut produced by a sharp object. The sharp object in most cases is a knife or surgical scalpel. A MPUTAT I O N C O N T USI O N H E MAT O MA A B R A SI O N A MPUTAT I O N This is an injury caused by a stab with a knife, ice pick, splinter, or any other pointed object, including a bullet. External bleeding is not normally severe because the entrance wound is small, but the penetrating object may injure structures deep within the body causing rapid, fatal bleeding if structures such as the large blood vessels within the chest are involved. Puncture wounds are also highly susceptible to infection because of the depth of the penetration. In some cases, the wound actually penetrates all the way through the body or extremity. Such wounds are called perforating wounds. Regardless the cause of the wound, there are three distinct phases in the healing process, and three basic ways in which a wound heals. We will first go over the three phases. The Healing Process Inflammation Phase The inflammation phase takes place immediately after the injury occurs and typically lasts three to four days. During this phase, blood vessels constrict, platelet aggregation occurs (clumping together) and the formation of fibrin from the action of thrombin on fibrinogen as well as epithelial migration. This is known as hemostasis. From here a scab will begin to form to protect against pathogens, while epithelial cells being to migrate from the margins of the wound to the base of the scab. After roughly 48 hours, you’ll see a thin layer or epithelial tissue forming over the wound. Chemical reactions then occur, releasing histamine and prostaglandin, while small blood vessels then dilate, becoming more permeable. This will cause serous fluid to leak into the traumatized area. Edema, also known as swelling, occurs from the leaking of plasma and electrolytes into the interstitial space. The wound now becomes swollen, red and tender to the touch. Clinical signs of the inflammatory process include: Edema/swelling of the injured area, erythema (redness), heat, warm or increased temperature at the site, pain from pressure on nerve receptors, and lastly, possible loss of function. The Healing Process Proliferation Phase This stage begins on the third or fourth day post injury and can often take two to three weeks. During this phase the wound is filled with new connective tissue, while new epithelium covers the wound. The Healing Process Maturation Phase The final stage of healing, which beings approximately three weeks after the injury. This is the process of collagen lysis (breakdown) and synthesis by the macrophages, producing the strongest possible scar tissue. Stages of Healing     1st Intention Healing It is also referred to as primary union. An excellent example of first intention healing is a surgical closure. There is a minimum of tissue damage, inflammation, or scarring. Of course, closing a wound can only be done when no infection is present; therefore, some few accidental wounds cannot be sutured and healed in this manner.  2nd Intention Healing It is also referred to as granulation. When there is a danger of infection, or when there is an infection already present, the wound is left open to heal from the deeper layers of tissue to the epidermis. This filling in of new pink tissue is called granulation.  3rd Intention Healing It is also referred to as secondary closure. There may be times when the physician may want to delay wound closure due to repeated debridement, irrigations, and excessive drainage. Once the physician ensures that the wound is free of infection, the granulated tissues are approximated (brought together) and then sutured. Another example is when the initial closure breaks open, which is referred to as a wound dehiscence, and is then resutured. Whichever healing process is used, you are responsible for daily dressing changes. Multiple Choice What type of wound is shown in the photo below? Amputation Laceration Incision Avulsion SUBMIT Complete the content above before moving on. WE T-T O - DR Y DR E SSI N G WE T-T O - WE T DR E SSI N G Dressings serve multiple purposes. They prevent microorganisms from freely entering or escaping the wound while also absorbing any drainage. These dressings help debride wounds and encourage cellular growth from the base of the wound to the surface. The frequency of dressing changes depends on the provider’s orders, and amount of necrotic debris that is removed with each dressing change. Verify the providers orders. Asses the old dressing if already in place. Prepare space and supplies. Open dressing package and sterile container (sterile water/solution per Dr. orders). Perform hand hygiene and don gloves. Gently and steadily pull the gauze away from the wound to help debride the necrotic tissue. Do not remoisten prior to removal. Discard soiled dressing and gloves. Perform hand hygiene and pour sterile solution into basin. Don sterile gloves. Place new dressing into the basin with the sterile solution, or moisten the dressing by pouring the solution over it. The dressing should be thoroughly soaked. Wring out each dressing and lightly press the fluffed gauze in the wound, ensure the entire wound is covered. Additional dry dressings may be added as needed to keep the outside surface dry. Remove gloves and discard. Tape edges of dressing and perform hand hygiene and document time of dressing change, type of dressing, appearance of wound and what type of dressing was placed. WE T-T O - DR Y DR E SSI N G WE T-T O - WE T DR E SSI N G Dressings serve multiple purposes. Wet to wet dressing are used to keep a wound moist and promote healing. The main purpose of this dressing is to reduce inflammation; cleanse the skin of the thick exudates, crusts or scales; and to maintain drainage of the affected area. This provides an environment that is warm and moist which can help improve wound healing and increase patient comfort. Verify the providers orders. Asses the old dressing if already in place. Prepare space and supplies. Open dressing package and sterile container (sterile water/solution per Dr. orders). Perform hand hygiene and don gloves. Slowly and carefully remove the gauze. If the dressing is stuck to the wound, add normal saline to loosen it. Discard soiled dressing and gloves. Perform hand hygiene and pour sterile solution into basin. Don sterile gloves. Place new dressing into the basin with the sterile solution, or moisten the dressing by pouring the solution over it. The dressing should be thoroughly soaked. Wring out each dressing and lightly press the fluffed gauze in the wound, ensure the entire wound is covered and cover with a second moist dressing and then a dry sterile 4x8 combined dressing in a single layer on top of the wet dressing. Remove gloves and discard. Tape edges of dressing and perform hand hygiene and document time of dressing change, type of dressing, appearance of wound and what type of dressing was placed. C O NT I NU E Postmortem Care Postmortem Care Procedures Postmortem care is given after the patient is deceased. These procedures occur after the physician pronounces the patient dead. The patient is not legally dead until the physician makes a physical determination. All treatments and procedures continue until the physician makes his assessment and pronounces the patient as “dead.” You will follow local policy in performing postmortem care. Step 1 Final Goodbyes Ask the family if they would like to be alone with the body, to say their last goodbyes. Provide privacy whenever possible, and accommodate any cultural and religious beliefs. Step 2 Begin Gathering Supplies and Prep the Room Gather supplies needed, to include: shroud (sheet used to wrap body) or body bag death care kit gloves bag for personal belongings bathing supplies comb and brush tape and large safety pins body tags or labels valuables list gurney or morgue cart (cookie sheet) Next, verify patient identification. Determine whether an autopsy will be performed or not. Then gather equipment, and prepare working space. Raise the bed to the proper height for you and your partner, and position the over-thebed table for use. Close the door/pull curtains for privacy and dignity. Step 3 Prepare the Body Perform hand hygiene and don gloves. Position the patient in the supine position, place a pillow under the head, and elevate the head of the bed 15-20 degrees. Close the eyelids. If necessary, grasp the eyelashes and gently pull lids down over the cornea. Replace dentures if applicable. Close the mouth. A small rolled towel may be placed under the chin to keep the mouth closed. Closing the mouth and eyes keeps the face in the most natural position during rigor mortis. Remove any jewelry and clothing. List all items on the patient’s valuables list. These will be placed in a bag and returned to the family. Wash all areas of the body that are soiled with blood, feces, urine or any drainage. Place protective pads under rectum, vagina or urethra. After death, the sphincter muscles relax, allowing for loss of bladder and bowl. Comb hair. Deflate any balloons (Foleys etc.) and remove all tubes, to include IVs, catheters, NGs unless otherwise specified. If leaving in place, convert IV catheters to intermittent locks. Secure tubes, remove drainage bag or IV fluid container, cut the tubing and fold over twice. Leaving the IV catheter in place prevents leakage during the coroners embalming process. Change any soiled dressings and remove adhesive from skin. Place small dressing over wounds, securing with paper tape. Step 4 Prepare for Transfer Dress the body in a clean gown. After the family leaves, attach ID tags on the big toe, ankle and wrist. Placed padded ties around the ankles; crisscross the wrists over the abdomen and secure. Place gauze tie or chin strap under the jaw to keep the mouth closed. Place the body on the shroud or in the body bag, while checking placement of drainage bags. Fold the shroud according to instructions. (Follow the numerical order.) Secure the shroud at the chest, waist, and knees and place an ID tag on the outside. Transfer the body to the cart/stretcher. Secure the body with straps. Be careful they are secure but not too tight as to leave marks on the body. Transfer the body to the morgue using the service elevator. Step 5 Document Document the care provided into the patients’ medical record/chart. C O NT I NU E FAST Exam Focused Assessment with Sonography in Trauma, more commonly known as a FAST exam, is performed on trauma patients. It is a rapid ultrasound assessment as a screening tool used to test or look for blood around the heart or free fluid in the abdominal organs after trauma has happened. Previous studies focused on identifying pericardial fluid (fluid around the heart) in blunt trauma patients, however with the advancement of technology comes advanced screening. FAST is now used to also screen or detect for hemothorax, pneumothorax and other cardiac related traumas. Some of the indications for performing the FAST exam include, but not limited to: 1 Chest trauma 2 Blunt or penetrating cardiac trauma Trauma in pregnancy 3 3 4 Pediatric trauma You will need to use a low frequency transducer- ultrasound machine- or a small foot print phased-array (cardiac) probe. There are 10 structures or spaces that are typically viewed/imaged, via the four windows. The patient will be positioned in the supine position, if awake and alert, have the patients place their hands behind their head. Note that placing the patient in the Trendelenburg position can improve the sensitivity of the exam for the patient. You will begin your exam with one of the four regions, depending on the mechanism of injury, and then work through the areas clockwise. Report all findings to the provider, and document in the patient’s chart. These four regions are listed below.      Cardiac This area consists of the pericardium and the heart chambers, especially the right ventricle.  The RUQ- Right Upper Quadrant This area consists of the Morrison’s pouch (hepatorenal recess), liver tip (right paracolic gutter) and the lower right thorax.  LUQ- Left Upper Quadrant This area consists of the subphrenic space, splenorenal recess, spleen tip (left paracolic gutter), lower left thorax.  Pelvic This area consisits of the rectovesical pouch (male patients) and the rectouterine/pouch of Douglas (female patients). Multiple Choice During a FAST exam, what area will you inspect first? Cardiac Right Upper Quadrant Left Upper Quadrant Pelvic SUBMIT E ND O F L E S S O N