엔클렉스 최신 기출 기본간호

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2개월 공부 하고 6/25합격했습니다.
문제 복원 및 해당 개념 정리

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본문내용

[VAD 혈관접근]
① Verify order(solution type, volume rate, dosage, route, medication, Transfusion)
② Experience : 부작용, 혈관 잘 터지는지...
③ OP, procedure 계획되어 있는가(수술 예정인 부위 접근 피하기 위함)
④ Ask Dominant hand (non-dominant hand로 혈관 잡기 위함)
⑤ Risk factor : heart failure, kidney failure, anticoagulant 복용
⑥ condition of both arm(mastectomy..)
⑦ Lab, allery 확인
⑧ clinical condition(dehydration, weight)
⑨ medication history, OTC medication(약국약)

[VAD remove] ★순서
① check the primary health care provider’s prescription ans explain the procedure to the client; ask the client to hold the extremity still during cannula or needle removal
② turn off the IV tubing clamp and remove the dressing and tape covering site
③ apply light pressure with sterile gauze with draw the catheter using slow, steady movement Keeping the hub parallel to the skin(=laterally) - No lift cathether line
④ apply pressure for 2 to 3 min, use dry sterile gauze
⑤ Inspect the site for redness drainage or swelling; check the catheter for intactness
⑥ apply a Dressing as needed per agency policy
⑦ Document the procedure and the client’s response
* No cut tape with scissor
* VAD cath tip 일부가 빠지면 그 위 부위 tourniquet 묶고 의사에게 notify

[Central cathether]
⦁ Superior Vena Cava(SVC) 상대정맥 vein 에 catheter tip 위치 -> right atrium
⦁ Lumen은 single or multiple
⦁ insertion 시에 skin 소독은 30sec friction scrub & 30 sec dry (insert site는 2min dry)
⦁ insert 시 position은 trendelenberg (10도 정도 head down) + head away from insertion site
┗ head down contraindicationty0 제외(Resp Dz, Head injury, IICP)

참고 자료

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