fundamental skills/procedure

Epinephrine

A critical part of self-care for a person with a history of anaphylactic reaction is the use of emergency epinephrine injection (EpiPen or EpiPen Jr). The client and/or caregiver should be taught the following principles: The EpiPen should always be available for emergency use and so should be taken along (in purse, pocket, backpack) when the client leaves home The EpiPen should be given when the client first notices any anaphylactic symptoms, such as tightening or swelling of the airway, difficulty breathing, wheezing, stridor, or shock The injection should be given in the mid-outer thigh and can be given through clothing The client should receive emergency care as soon as possible by calling 911 or going to the emergency department to monitor for further problems )

lumbar puncture

A lumbar puncture (spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for diagnostic purposes (eg, meningitis). A needle is inserted into the vertebral spaces between L3 and L4 or L4 and L5, and a sample of CSF is drawn. The nurse's role when assisting with a lumbar puncture includes the following: Verify informed consent Gather the lumbar puncture tray and needed supplies Explain the procedure to older child and adult Have client empty the bladder Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table) Assist the client in maintaining the proper position (hold the client if necessary) Provide a distraction and reassure the client throughout the procedure Label specimen containers as they are collected Apply a bandage to the insertion site Deliver specimens to the laboratory

Common causative factors of falsely low SpO2 include:

A pulse oximeter is a noninvasive device that estimates arterial blood oxygen saturation by using a sensor attached to the client's finger, toe, earlobe, nose, or forehead. The sensor (reusable clip or disposable adhesive) contains light-emitting and light-sensing components that measure the amount of light absorbed by oxygenated hemoglobin. Because the sensor estimates the value at a peripheral site, the pulse oximeter measurement is reported as blood oxygen saturation (SpO2). Normal SpO2 for a healthy client is 95%-100%. Any factor that affects light transmission or peripheral blood flow can result in a false reading. Common causative factors of falsely low SpO2 include: Dark fingernail polish or artificial acrylic nails Hypotension and low cardiac output (eg, heart failure) Vasoconstriction (eg, hypothermia, vasopressor medications) Peripheral arterial disease

peripheral vein for laboratory specimens

A tourniquet is applied 3-5 inches above the desired puncture site for no longer than 1 minute when looking for a vein. If longer time is needed, release the tourniquet for at least 3 minutes before reapplying. Prolonged obstruction of blood flow by the tourniquet can change some test results. Pulsating bright red blood indicates that an artery was accessed. If this happens, the needle should be removed immediately and pressure should be applied for at least 5 minutes, followed by a pressure dressing to prevent a hematoma.

An oropharyngeal airway (OPA) is a temporary,

An oropharyngeal airway (OPA) is a temporary, artificial airway device used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. The nurse should ensure the OPA is never taped in place because when the client awakens, the device stimulates the gag reflex and may cause choking and aspiration if it cannot be easily removed

Assessment is the first step in the nursing process

Assessment is the first step in the nursing process that is used to gather information. Lung auscultation is the nurse's initial action with this client. Before intervening, the nurse should assess respiratory status and vital signs to obtain the baseline data that will be compared to subsequent changes.

Calculate the total body surface area (TBSA) burned using the rule of nines

Calculate the total body surface area (TBSA) burned using the rule of nines (anterior torso)+(posterior torso)+(anterior leg)=TBSA burned OR 18%+18%+9%=45% TBSA burned Convert pounds to kilograms to determine body weight (1 kg2.2 lb)(198 lb )=90 kg Calculate the volume needed for infusion 4 mL × body weight (kg)×TBSA burned (%)=infusion volume (mL) OR 4 mL × 90 kg × 45% TBSA = 16200 mL Half of the calculated volume is administered within the first 8 hours.

chest tube client position

Chest tube insertion should be performed with the client's arm raised above the head on the affected side. If possible, the head of the bed should be raised 30-60 degrees to reduce risk of injury to the diaphragm

Enema insertion

Cleansing enemas (eg, normal saline, soapsuds, tap water) relieve constipation by stimulating intestinal peristalsis. When administering an enema, appropriate interventions include: Place the client in a left lateral position with the right knee flexed (ie, Sims position) to promote flow of the enema into the colon . Hang the enema bag no more than 12 in (30 cm) above the rectum to avoid overly rapid administration. Lubricate the enema tubing tip and gently insert 3-4 in (7.6-10 cm) into the rectum. Direct the tubing tip toward the umbilicus (ie, anteriorly) during insertion to prevent intestinal perforation Encourage the client to retain the enema for as long as possible (eg, 5-10 minutes) . Open the roller clamp on the tubing to allow the solution to flow in by gravity. If the client reports abdominal cramping, use the roller clamp to slow the rate of administration When administering an enema, the nurse should place the client in the left lateral position with the right knee flexed, insert the tubing into the rectum with the tip directed toward the umbilicus, and slow the rate of administration if the client reports abdominal cramping. Enemas should be administered at room temperature or warmed.

Net Fluid Balance

Convert all volumes to milliliters (1 L )(1000 mLL )=1000 mL normal saline1 L 1000 mLL =1000 mL normal saline (5 tbsp )(15 mLtbsp)=75 mL vancomycin Calculate intake and output totals Intake: 180 mL+75 mL+240 mL+360 mL+1000 mL+250 mL=2105 mL total intake Output: 150 mL+1300 mL=1450 mL Calculate the net fluid balance Total intake−total output=net fluid balanceTotal intake-total output=net fluid balance 2105 mL−1450 mL=655 mL

During Thoracentesis

During a thoracentesis, a needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. Before the procedure, the nurse places the client in an upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural space through the intercostal spaces, and promotes client comfort.

Extravasation is the infiltration of a drug into the tissue surrounding the vein.

Extravasation is the infiltration of a drug into the tissue surrounding the vein. Norepinephrine (Levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until central venous access is established. The nurse should implement the following interventions to manage norepinephrine extravasation: Stop the infusion immediately and disconnect the IV tubing Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating. Elevate the extremity above the heart to reduce edema . Notify the health care provider and obtain a prescription for the antidote phentolamine (Regitine), a vasodilator that is injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamine)

what to do if extravasation of IV norepinephrine occurs,

Extravasation of IV norepinephrine occurs, the nurse should stop the infusion immediately, aspirate the drug, remove the IV catheter, elevate the extremity, and administer the antidote phentolamine into affected tissues as prescribed. IV access is reestablished on an unaffected extremity or through a central line

For medical procedures, the nurse should ensure that the client:

For medical procedures, the nurse should ensure that the client: Has an empty bladder and is in high Fowler's or a sitting position for paracentesis Is Trendelenburg on the left side for suspected air embolism Has the arm raised above the head on the affected side for chest tube insertion Lies on the right side (for 2 hours) and then supine (12-14 hours) after liver biopsy Is side-lying with the head, back, and knees flexed for lumbar puncture

intervention for transfusion

If signs of a transfusion reaction occur, the nurse should: Stop the transfusion immediately . Using new tubing, infuse normal saline to keep the vein open . Continue to monitor hemodynamic status and notify the health care provider and blood bank. Administer any emergency or prescribed medications to treat the reaction; these may include vasopressors, antihistamines, steroids, or IV fluids . Collect a urine specimen to be assessed for a hemolytic reaction. Document the occurrence and send the remaining blood and tubing set back to the blood bank for analysis

Intramuscular (IM) injections (eg, hepatitis B vaccine, vitamin K) are commonly administered to newborns shortly after birth or before discharge

Intramuscular (IM) injections (eg, hepatitis B vaccine, vitamin K) are commonly administered to newborns shortly after birth or before discharge. The vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred site for IM injections in newborns (age <1 month) and infants (age 1-12 months). The deltoid muscle is an inappropriate injection site for newborns due to inadequate muscle mass .

Key steps when inserting a large-bore nasogastric tube include using clean gloves

Key steps when inserting a large-bore nasogastric tube include using clean gloves; inspecting nares; measuring, marking, and lubricating tube; instructing client to extend the neck back slightly; inserting tube past the nasopharynx and continuing advancement until just above oropharynx; asking the client to flex the head forward and swallow; advancing tube to marked point; and verifying tube placement using abdominal x-ray and anchoring.

Magnetic resonance cholangiopancreatography (MRCP)

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive diagnostic test used to visualize the biliary, hepatic, and pancreatic ducts via MRI. MRCP uses oral or IV gadolinium (noniodine contrast material) and is a safer, less-invasive alternative to endoscopic retrograde cholangiopancreatography to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction. The nurse must assess for contraindications before the procedure, including the presence of certain metal and/or electrical implants (eg, aneurysm clip, pacemaker, cochlear implant) or any previous allergy or reaction to gadolinium (Option 4). A client with a history of rash following prior IV contrast administration should be assessed to determine the type of contrast that caused the reaction. Although allergies to iodine-based contrast material are more common, the nurse must rule out a gadolinium allergy (Option 2). Pregnancy also is a contraindication for MRCP as gadolinium crosses the placenta and may adversely affect the fetus. Delayed/irregular menses may be a normal variation in some clients; however, delayed menses may indicate pregnancy and should be reported for further investigation prior to MRCP

Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade.

Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration.

Nephrotic syndrome is characterized by massive proteinuria and hypoalbuminemia, which results in severe edema most evident in the abdomen, face, and perineum.

Nephrotic syndrome is characterized by massive proteinuria and hypoalbuminemia, which results in severe edema most evident in the abdomen, face, and perineum. Daily dipstick urinalysis determines the presence and pattern of urine protein loss to monitor for exacerbations. To collect a nonsterile urine specimen from a child who is not toilet trained, the nurse can place several cotton balls in a dry diaper and later squeeze urine onto a dipstick. The diaper is checked frequently and the sample collected and tested within 30 minutes of urination for the most accurate result. Children with nephrotic syndrome often have significant edema of the scrotum or labia. Placing a urine dipstick in the child's diaper or applying a standard adhesive urine collection bag around the genital area would cause further irritation and increased risk for skin breakdown

Normal saline (NS) is the only fluid that can be given with a blood transfusion.

Normal saline (NS) is the only fluid that can be given with a blood transfusion. Dextrose solutions may lyse the red blood cells. All other IV solutions and medications may cause precipitation and are incompatible with blood. Blood transfusions should be infused through a dedicated IV line. If a transfusion must be started in an IV catheter currently in use, the nurse should discontinue the infusion(s) and tubing, and then flush the catheter with NS prior to connecting the blood administration tubing. After transfusion, the catheter should be cleared with NS before any other IV fluids are administered.

Two-point gait

One crutch and opposite extremity move together followed by opposite crutch and extremity

orthostatic vital signs

Orthostatic vital signs help assess the body's ability to compensate hemodynamically during postural changes. Changing position normally triggers vasoconstriction in the extremities to promote venous return. Without this response, hypotension and subsequent hypoperfusion of internal organs and the brain occur. Clients with impaired compensatory mechanisms (eg, hypovolemia, sepsis) may exhibit orthostatic hypotension, in which hypotension and/or neurologic impairment (eg, syncope) occur with position change. This increases the client's risk for falls. Orthostatic vital signs involve measuring the client's blood pressure (BP) and heart rate in the supine, sitting, and standing positions. Each measurement should be obtained after maintaining each position for 2 minutes. If any position change produces decreased systolic BP ≥20 mm Hg, decreased diastolic BP ≥10 mm Hg, and/or increased pulse ≥20/min from supine values, the nurse should discontinue assessment, place the client in a recumbent position, and notify the health care provider

Contraindications for kidney biopsy

Percutaneous kidney biopsy is an invasive diagnostic procedure. It involves inserting a needle through the skin to obtain a tissue sample that is then used to determine the cause of certain kidney diseases. The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication for kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well-controlled (goal <140/90 mm Hg) using antihypertensive medications before performing a kidney biopsy

Proper airway suctioning technique includes

Proper airway suctioning technique includes preoxygenation, limiting a suction pass to 10 seconds, and allowing 1-2 minutes between passes to prevent hypoxia. Medium suction pressure should be set at 100-120 mm Hg for adults, with the catheter inserted without suction.

Proper use and care of hearing aids

Proper use and care of hearing aids is essential to the success of hearing aid therapy and is associated with improved outcomes. Proper hearing aid use and care include: Minimize distracting sounds (eg, television, radio) during conversation to enhance effectiveness Turn the volume off prior to insertion, then gradually turn up the volume to a comfortable level . To adjust to the new hearing aids, initially wear them for a short time (eg, 20 minutes) and gradually increase length of wear time. Do not wear the hearing aids when using hair dryers or heat lamps. Regularly check that the battery compartment is clean, the batteries are inserted correctly, and the compartment is shut before insertion . Remove the battery (if possible) at night and when the aid is not in use to extend battery life. Each aid must be cleaned with a soft cloth. Hearing aids should not be immersed in water, as this can damage the electrical components.

signs and symptoms of a blood transfusion reaction typically will occur within the first 15 minutes after initiation of the transfusion.

Signs and symptoms of a blood transfusion reaction typically will occur within the first 15 minutes after initiation of the transfusion. These include shortness of breath, chest tightness, fever, back pain, anxiety, tachycardia, and hypotension. When a transfusion reaction is suspected, the first step is to stop the infusion . An infusion of normal saline is typically started. It is important that normal saline be administered through a different port of the CVC using new tubing or at the closest access point to the client. Flushing the blood in the IV tubing into the client will expose the client to more of the causative agent and increase complications from the transfusion reaction (Option 2). The HCP must then be notified

sputum culture

Sputum culture and sensitivity testing is used to identify infectious organisms in the respiratory tract and determine which antimicrobials are most effective at treating the identified organism. Nurses assisting a client in collecting sputum should instruct the client to: Rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen contamination by oral flora Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of the skin. Inhale deeply several times and then cough forcefully, which promotes expectoration of lower lung secretions and increases sample volume Assume a sitting or upright position before specimen collection, if possible, to promote cough strength during collection

Steps to promote safety and reduce infection risk when initiating IV therapy include the following:

Steps to promote safety and reduce infection risk when initiating IV therapy include the following: Perform hand hygiene using Centers for Disease Control and Prevention guidelines Prepare equipment: Open IV tray, prime tubing with prescribed IV solution for infusion, set IV pump if indicated, prepare tape, and open the over-the-needle catheter (ONC) with safety device Don clean (non-sterile) gloves Identify a possible venipuncture site Apply a tourniquet, ensuring it is tight enough to impede venous return but not tight enough to occlude the artery Select a venipuncture site after palpating the vein. Ask the client to open and close the hand several times to promote vein distension. The tourniquet may need to be released temporarily to restore blood flow and prevent trauma from extended application. Clean the site with chlorhexidine, alcohol, or povidone iodine. Use friction and clean per facility protocol, either back and forth or in a circular motion from insertion site to outward area (clean to dirty direction). Stretch the skin taut using the nondominant hand to stabilize the vein Insert the IV ONC bevel up at a 10- to 30-degree angle and watch for blood backflow as the catheter enters the vein lumen, advancing ¼ inch into the vein to release the stylet. On visualization of blood return, lower the ONC almost parallel with the skin and thread the plastic cannula completely into the vein to the insertion site. Never reinsert the stylet after it is loosened. Use the push-tab safety device to advance the catheter. Apply firm but gentle pressure about 1¼ inch above the catheter tip, release the tourniquet, and retract the stylet from the ONC On removal, guide the protective guard over the stylet for safety and feel for a click as the device is locked. Never try to recap a stylet. Attach a sterile connection of primed IV tubing to the hub of the catheter and stabilize the catheter with tape and dressing using sterile technique. Dispose of the stylet in the sharps container.

The EpiPen is designed to be administered through clothing with a swing and firm push against the mid-outer thigh until the injector clicks.

The EpiPen is designed to be administered through clothing with a swing and firm push against the mid-outer thigh until the injector clicks. The position should be held for 10 seconds to allow the entire contents to be injected (Option 3). The site should be massaged for an additional 10 seconds. Timing is essential in the delivery of epinephrine during an anaphylactic reaction. The nurse should administer the medication immediately on the playground without removing the child's clothing. Any delays can cause client deterioration and make maintenance of a patent airway difficult

air embolism position

The presence of air in the veins, which can lead to cardiac arrest if it enters the heart. The head of the bed should be lowered (Trendelenburg) and the client positioned on the left side; this will cause the air to rise to the right atrium. The health care provider should be notified immediately and the nurse should remain with the client

The procedure for measurement of pulsus paradoxus is as follows:

The procedure for measurement of pulsus paradoxus is as follows: Place client in semirecumbent position Have client breathe normally Determine the SBP using a manual BP cuff Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade.

The protein test pad measures the amount of albumin in the urine

The protein test pad measures the amount of albumin in the urine. Normally, there will not be detectable quantities. Albumin is smaller than most other proteins and is typically the first protein that is seen in the urine when kidney dysfunction begins to develop. Proteinuria is characterized by elevated urine protein and can be an early sign of kidney disease. Occasional loss of up to 150 mg/day of protein in the urine, which may reflect as negative or trace protein on a dipstick, is typically considered normal and usually does not require further evaluation. Common benign causes of transient proteinuria include fever, strenuous exercise, and prolonged standing.

he recommended rates for an intermittent IV infusion of potassium chloride (KCl)

The recommended rates for an intermittent IV infusion of potassium chloride (KCl) are no greater than 10 mEq (10 mmol) over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr (40 mmol/hr) when infused through a central line (follow facility guidelines and policy). If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10 mEq/hr (10 mmol/hr) (ie, 10 mEq [10 mmol] over 30 minutes = 20 mEq/hr [20 mmol/hr]). A too rapid infusion can lead to pain and irritation of the vein and postinfusion phlebitis. Contacting the health care provider to verify this prescription is the priority action.

water seal chamber of chest tube

The water seal chamber of the chest tube drainage system is filled with sterile water and acts as a one-way valve preventing air from entering the client's chest cavity. The water level in the water seal chamber rises and falls with inspiration and expiration, a process known as tidaling. This movement occurs in section B of the water seal chamber and indicates that the system is functioning properly and maintaining appropriate negative pressure. (Section A) This is the suction control chamber, which is usually set at -20 cm H2O to maintain negative pressure in the system. Bubbling will occur when suction is applied. (Section C) The air leak gauge (part of the water seal chamber) allows for assessment of air leaks. Continuous bubbling indicates an air leak in the system. (Section D) This is the drainage collection chamber in which fluid from the client's pleural cavity will collect; the nurse will assess the color and amount and record the output. Educational objective:Tidaling is the fluctuation that occurs in the water seal chamber in relation to the client's respiratory movements. The level of sterile water will rise with inspiration and fall with expiration, indicating proper function of the chest tube drainage system.

Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg, creatinine, protein, uric acid, hormones).

Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg, creatinine, protein, uric acid, hormones). These tests require the collection of all urine produced in a specified time period (a crucial step) to ensure accurate test results. The proper container (with or without preservative) for any specific test is obtained from the laboratory. The collection container must be kept cool (eg, on ice, refrigerated) to prevent bacterial decomposition of the urine. Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning voiding (

to prevent falls after a total knee replacement, clients should use a cane to provide maximum support when climbing up and down any stairs.

To prevent falls after a total knee replacement, clients should use a cane to provide maximum support when climbing up and down any stairs. Clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction. Clients must also keep 2 points of support on the floor at all times (ie, both feet, foot and cane). When descending stairs, the client should: Lead with the cane Bring the weaker leg down next (in this client, it is the left leg) Finally, step down with the stronger leg (Option 1) When ascending stairs, the client should: Step up with the stronger leg first Move the cane next, while bearing weight on the stronger leg Finally, move the weaker leg To remember the order, use the mnemonic "up with the good and down with the bad." The cane always moves before the weaker leg.

infusion of enema

Too rapid infusion of an enema solution may cause intestinal spasms that result in a feeling of fullness, cramping, and pain. If the client reports any of these symptoms, instillation should be stopped for 30 seconds and then resumed at a slower rate. Slow infusion will also decrease the likelihood of premature ejection of the solution, which would not allow for adequate bowel evacuation.

Urinary catherterization (CATH)

Urine could be in the urethra and evident in the tubing even though the tip with the balloon is not in the bladder. It is necessary to further insert the catheter before inflating the balloon to make sure the tip is in the bladder and not the urethra (causing urethral trauma). In the male client, it is recommended that the catheter be inserted 7-9 in (17-22.5 cm) or until urine flows out, due to the longer urethra. The catheter should then be inserted at least an additional 1 in (2.5 cm) or to catheter bifurcation. The client should be told to take slow, deep breaths to help relax the external sphincter and provide a distraction. The catheter needs to be inserted further before inflating the balloon to prevent urethral trauma. Securing the catheter to the leg occurs after the balloon is inflated and placement is assured.

3 point gait

Weight is distributed on both crutches and then on the *unaffected* leg -- then repeat sequence

instruction for lumbar puncture

When assisting with a lumbar puncture, the nurse verifies informed consent, gathers supplies, explains the procedure, has the client void, and then assists the client into position. During the procedure, the nurse provides a distraction, helps the client stay in position (if needed), and labels specimens as they are collected. Afterward, the nurse applies a bandage and ensures that the specimens are delivered to the laboratory.

descending using a cane

When descending stairs: Lead with the cane Bring the weaker leg down next Finally, step down with the stronger leg

how to draw blood procedure

When obtaining blood from a client, insert the needle at 15-degree angle, limit attempts to 2, and avoid the side of a mastectomy. A capillary specimen should be obtained at the side of the finger pad. Never draw a specimen above an IV infusion.

When performing phlebotomy for a laboratory

When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of wrist, position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes.

drawing blood

When performing phlebotomy, clean the site, "fix" or hold the vein taut, and then insert the needle bevel up at a 15-degree angle (no steeper than 30 degree). Some recommend bevel down for children. This will help prevent going through the vein completely. The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. The affected side of a client who has had a mastectomy (especially with lymph node removal) should not be used. It places the client at risk for infection and lymphedema. An arm without IV infusion is preferred. If it is necessary to use the arm with the IV infusion, the specimen should be collected from a vein several centimeters below (distal to) the point of IV infusion, with the tourniquet placed in between. The finger specimen should be obtained from the third or fourth finger on the side of the fingertip, midway between the edge and midpoint. The puncture should be made perpendicular to the fingerprint ridges. Puncture parallel to the ridges tends to make the blood run down the ridges and will hamper collection. A heel stick collection on an infant should be done on the plantar surface.

when performing the suctioning procedure, the nurse follows institution policy and observes principles of infection control and client safety.

When performing the suctioning procedure, the nurse follows institution policy and observes principles of infection control and client safety. Strict aseptic technique is maintained because suctioning can introduce bacteria into the lower airway and lungs. Place the client in semi-Fowler's position, if not contraindicated, to promote lung expansion and oxygenation. Preoxygenate with 100% oxygen (hyper-oxygenate) to prevent hypoxemia and microatelectasis. Alternately, if the client is breathing room air independently, ask the client to take 3-4 deep breaths. Insert the catheter gently the length of the airway without applying suction to prevent mucosal tissue damage. The distance can be premeasured (0.4-0.8 in [1-2 cm] past the distal end of the tube). Withdraw the catheter slightly (0.4-0.8 in [1-2 cm]) if resistance is felt at the carina (bifurcation of the left and right mainstem) to prevent mucosal tissue damage. Apply intermittent suction while rotating the suction catheter during withdrawal to prevent mucosal tissue damage. Limit suction time to 5-10 seconds with each suction pass to prevent mucosal tissue damage and limit hypoxia.

How to use an incentive spirometer

1. Hold in upright position 2. Exhale normally 3. Seal lips tightly around mouthpiece 4. Take in slow deep breaths to elevate the balls or cylinder for 2-6 seconds (start low) 5. Avoid brisk low-volume breaths 6. Remove mouth piece and exhale normally 7. Cough after the incentive effort 8. Relax and take several breaths before using again 9. Repeat the procedure several times and four to five times per hour 10. Clean mouth piece and shake it dry.

incentive spirometer use

1.Assume a sitting or high Fowler position, which optimizes lung expansion, and exhale normally While holding the device at an even level, seal the lips tightly on the mouthpiece to prevent leakage of air around it 2. Inhale deeply through the mouth until the piston is elevated to the predetermined level of tidal volume. The piston is visible on the device and helps provide motivation. 3. Hold the breath for at least 2-3 seconds (up to 6 seconds) as this maintains maximal inhalation 4. Exhale slowly to prevent hyperventilation Breathe normally for several breaths before repeating the process Cough at the end of the session to help with secretion expectoration

Four-point gait

4-point crutch gait is appropriate for a client with leg weakness, who can bear partial or full weight with both legs. It is the easiest gait to use as it resembles normal walking and provides the most stability with 3 points of support on the ground at all times.

Abdominal Paracentesis position

is used to remove ascitic fluid from the peritoneal cavity in end-stage liver disease (cirrhosis). The client should be positioned in high Fowler's or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted. The client should void prior to the procedure to decrease the risk of bladder puncture

apical pulse

the apical pulse is best assessed by placing the stethoscope diaphragm at the apex of the heart/mitral area. This is located at the fifth intercostal space on the midclavicular line. For a client receiving digoxin, the apical heart rate should be assessed for 1 full minute. If the heart rate is <60/min, the nurse should consider holding the dose based on the health care provider's instructions. In addition to the apical heart rate, digoxin and potassium levels should be assessed if available. Digoxin has a very narrow therapeutic range (0.5-2.0 ng/mL), and hypokalemia can potentiate digoxin toxicity (>2.0 ng/mL).

after a lumbar puncture client position

the client is positioned side-lying, with the head, back, and knees flexed. A small pillow may be placed between the legs and under the head for comfort and to maintain the spine in a horizontal position. Following the procedure, the client will be positioned according to the health care provider's prescription (usually supine or with head of the bed elevated 30 degrees)

after a biopsy client position

the client should lie on the right side for a minimum of 2 hours (to apply pressure and splint the puncture site) and then supine for an additional 12-14 hours. The risk for bleeding is increased due to the high vascularity of the liver, but correct positioning reduces this risk.

the steps for administering a continuous enteral feeding include:

the steps for administering a continuous enteral feeding include: Identify the client using 2 identifiers (eg, first and last name, medical record number, date of birth) (Option 4) and explain the procedure to the client. Perform hand hygiene and apply clean gloves. Elevate the head of the bed ≥30 degrees and keep it elevated for at least 30 minutes after feeding to minimize the risk of aspiration (Option 2). Validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the measurement at the time of insertion. The tube should be marked at the nostril with a permanent marker during the initial x-ray validation (Option 5). Check gastric residual volume. Flush the tube with 30 mL of water after checking residual volume, every 4-6 hours during feeding, and before and after medication administration (Option 3). Administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pump

Four-point gait

used when both legs can bear some weight; right foot, left crutch, left crutch, right foot

when performing tracheostomy care, the nurse follows institution policy and observes principles of infection control and client safety. Sterile technique is used to prevent infection of the lower airway. The steps for performing the procedure for a client with a disposable inner cannula include the following:

When performing tracheostomy care, the nurse follows institution policy and observes principles of infection control and client safety. Sterile technique is used to prevent infection of the lower airway. The steps for performing the procedure for a client with a disposable inner cannula include the following: Gather supplies to the bedside, then place client in semi-Fowler's position, if not contraindicated, to promote lung expansion and oxygenation and prevent aspiration of secretions. Don personal protective equipment (mask, goggles, and clean gloves) to maintain universal precautions. Auscultate lungs and suction secretions if necessary. Remove soiled dressing and also remove clean gloves. Don sterile gloves; remove old disposable cannula and replace with a new one. While stabilizing the back plate with the nondominant hand, unlock (unclip) the old cannula with the dominant hand; remove gently by pulling it out in line with its curvature; pick up the new cannula, touching only the outer locking portion (to prevent contamination and maintain asepsis); insert; and lock (clip) into place. Clean around stoma with sterile water or saline, dry and replace sterile gauze pad to remove dried secretions, and dry around stoma well to limit the growth of microorganisms. Some tracheostomy tubes are sutured in place and do not require a dressing. If secretions are copious, apply a dressing.

Wound cultures are used to identify microorganisms

Wound cultures are used to identify microorganisms and select appropriate antibiotics. The nurse should assess and clean the wound, swab from the wound center toward the outer margin, and avoid contamination (eg, hand hygiene, not touching intact skin with swab) to prevent misidentification of microorganisms.

wound culture

Wound cultures identify microorganisms to aid in prescribing appropriate antibiotics and are obtained as follows: Perform hand hygiene, and apply clean gloves. Remove the old dressing. Remove and discard gloves. Perform hand hygiene, and apply sterile gloves. Assess the wound bed. Cleanse the wound bed and surrounding skin with normal saline (eg, flushing, swabbing with gauze) to remove drainage and debris . Remove and discard gloves. Perform hand hygiene, and apply clean gloves. Gently swab the wound bed with a sterile swab, from the wound center toward the outer margin . Avoid contact with skin at the wound edge as it can contaminate the specimen with skin flora. Place the swab in a sterile specimen container; avoid touching the swab to the outside of the container. Apply prescribed topical medication (eg, bacitracin) after obtaining cultures to prevent interference with microorganism identification . Apply new dressing. Remove and discard gloves, and perform hand hygiene. Label the specimen, and document the procedure.