Surgical Nursing
List the sites for intramuscular injections (include name the muscles used). -
ANS-Ventrogluteal- 0-4mls
Vastus lateralis- 5mls
dorsogluteal- not used
Deltoid- not over 4 mls
The 3 principles of pain control are - ANS-3 principles of chronic pain management
Give the client as much control as possible
Use a preventative approach, give before pain is bad
Titrate to effect, desired effect with as few side effects as possible
Intramuscular sites are - ANS-Intramuscular Sites
Ventrogluteal site- preferred site- has fewer blood vessels, even fat distribution and remains
relaxed even if patient is tense.
Location: Right palm over left greater trochlear, index finger over anterior superior iliac spine,
middle finger spread dorsally over iliac crest. Injection site is in the middle of triangle created.
Vastus lateralis site- preferred site for infants and children. Located in middle two thirds of thigh.
Dorsogluteal
Deltoid
Subcut sites are - ANS-Abdomen, buttocks, front and side of thigh
Out and upper arm
Dysuria - ANS-painful urination
:
Enteral Tubing - ANS-Used when the patient is unable to ingest food but is still able to digest
and absorb nutrients.
Feeding tubes can be inserted through:
Nose (nasogastric or nasointestinal)
Nasogastric- stomach nasointestinal -jejunum
Short term - less than 4 weeks
Dyspnoea: - ANS-shortness of breath or uncomfortable awareness of breathing
Dysmenorrhoea: - ANS-Pain during menstruation that limits normal activity
Nursing Interventions for nutrition - ANS-Nursing Interventions
, Help stimulate appetite: minimise odours, oral hygiene, position, manage symptoms i.e.
antiemetic, analgesia
Adhere to preferences or restrictions
Replace % fluid loss via oral, IVT, SCT
Assist: meals/drinks, use special aids
Provide alternatives/varieties, small versus large
Identify or eliminate food intolerance, allergy
Ensure adequate intake with activity
Monitor weight, food/fluid intake and output (FBC), BGL for diabetes
Health promotion with education
Enteral Tube Complications - ANS-Aspiration - displacement, regurgitation or lying flat
Diarrhoea - change in diet, mal absorption,
Constipation- lack of movement or fibre
Tube occlusion, Tube displacement- blockage, kink
Abdominal cramping/nausea/vomiting- delayed emptying, fast feeds, antibiotics or bacterial
infection
Care of Clients Stage 3 Students can give - ANS-Oral care, Securing NGT, GT or PEG, Monitor
bowel sounds
Fluid Balance Chart (input/output) Monitor gastric drainage (colour, consistency, odour and
amount)
Skin integrity, Education and reassurance
Peripheral IV Assessment Scale - ANS-Pain, Redness, Swelling, Hardness, Discharge
Haematoma- - ANS-Localised collection of blood outside of a blood vessel
Phlebitis - ANS-inflammation of a vein
Characterised by redness traveling along the vein, heat, pain, low grade fever
Extravasation- - ANS-leaking of medication into the surrounding tissues of a cannula site
Pain, burning, stinging, heat, redness
Infiltration - ANS-accidental administration of IV fluid into the surrounding tissues
Characterised by swelling, discomfort, tightness
BODY FLUIDS (60 to 70%% body weight)
(Average adult require 2.5 to 3L/day) - ANS-Fluid Gains (mL) Fluid Losses(mL)
Oral fluids 1100-1400 Kidneys 1200-1500
Solid foods 800-1000 Skin 500-600
Metabolism 300 Lungs 400
GIT 100-200
List the sites for intramuscular injections (include name the muscles used). -
ANS-Ventrogluteal- 0-4mls
Vastus lateralis- 5mls
dorsogluteal- not used
Deltoid- not over 4 mls
The 3 principles of pain control are - ANS-3 principles of chronic pain management
Give the client as much control as possible
Use a preventative approach, give before pain is bad
Titrate to effect, desired effect with as few side effects as possible
Intramuscular sites are - ANS-Intramuscular Sites
Ventrogluteal site- preferred site- has fewer blood vessels, even fat distribution and remains
relaxed even if patient is tense.
Location: Right palm over left greater trochlear, index finger over anterior superior iliac spine,
middle finger spread dorsally over iliac crest. Injection site is in the middle of triangle created.
Vastus lateralis site- preferred site for infants and children. Located in middle two thirds of thigh.
Dorsogluteal
Deltoid
Subcut sites are - ANS-Abdomen, buttocks, front and side of thigh
Out and upper arm
Dysuria - ANS-painful urination
:
Enteral Tubing - ANS-Used when the patient is unable to ingest food but is still able to digest
and absorb nutrients.
Feeding tubes can be inserted through:
Nose (nasogastric or nasointestinal)
Nasogastric- stomach nasointestinal -jejunum
Short term - less than 4 weeks
Dyspnoea: - ANS-shortness of breath or uncomfortable awareness of breathing
Dysmenorrhoea: - ANS-Pain during menstruation that limits normal activity
Nursing Interventions for nutrition - ANS-Nursing Interventions
, Help stimulate appetite: minimise odours, oral hygiene, position, manage symptoms i.e.
antiemetic, analgesia
Adhere to preferences or restrictions
Replace % fluid loss via oral, IVT, SCT
Assist: meals/drinks, use special aids
Provide alternatives/varieties, small versus large
Identify or eliminate food intolerance, allergy
Ensure adequate intake with activity
Monitor weight, food/fluid intake and output (FBC), BGL for diabetes
Health promotion with education
Enteral Tube Complications - ANS-Aspiration - displacement, regurgitation or lying flat
Diarrhoea - change in diet, mal absorption,
Constipation- lack of movement or fibre
Tube occlusion, Tube displacement- blockage, kink
Abdominal cramping/nausea/vomiting- delayed emptying, fast feeds, antibiotics or bacterial
infection
Care of Clients Stage 3 Students can give - ANS-Oral care, Securing NGT, GT or PEG, Monitor
bowel sounds
Fluid Balance Chart (input/output) Monitor gastric drainage (colour, consistency, odour and
amount)
Skin integrity, Education and reassurance
Peripheral IV Assessment Scale - ANS-Pain, Redness, Swelling, Hardness, Discharge
Haematoma- - ANS-Localised collection of blood outside of a blood vessel
Phlebitis - ANS-inflammation of a vein
Characterised by redness traveling along the vein, heat, pain, low grade fever
Extravasation- - ANS-leaking of medication into the surrounding tissues of a cannula site
Pain, burning, stinging, heat, redness
Infiltration - ANS-accidental administration of IV fluid into the surrounding tissues
Characterised by swelling, discomfort, tightness
BODY FLUIDS (60 to 70%% body weight)
(Average adult require 2.5 to 3L/day) - ANS-Fluid Gains (mL) Fluid Losses(mL)
Oral fluids 1100-1400 Kidneys 1200-1500
Solid foods 800-1000 Skin 500-600
Metabolism 300 Lungs 400
GIT 100-200
