Nursing fundamentals
Client eduction sleeping
Exercise regular at least 2 hr before bedtime establish a bedtime routine and regular sleep pattern limit alcohol, caffeine, and nicotine at least 4hr before bedtime limit fluid 2 to 4 hours before bedtime engage in muscle relaxation if anxious or stressed
Nursing considerations for sleeping
Help client establish and follow bedtime routine limit walking clients during the night help with personal hygiene needs CPAP
Fire response
RAce R: rescue and protect clients in close proximity to the fire by moving them to a safer location. A. Alarm: activate the facitlits' alarm C. ontain/confine the fire by closing doors and windows and turning off any sauces of oxygen and any electrical devices e. extinguish the fire if possible using appropriate fire extinguisher
phlebitis or thrombophlebitis
edema throbbing, burning , or pain at the site; increased skin temperature, erythema; a red line up the arm with a palpable band at the vein site, slowed rate of infusion
dehiscence and evisceration require
emergency treatment
How often remove stockings
every 8 hr to assess the redness worms and tenderness
Client eduction for narcolepsy
exercise regulary east small meals that are high in protein avoid activities that increase sleepiness avoid activities that could cause injury should the client fall asleep take naps when drowsy or when narcoleptic events likely take prescribed stimulant
a pericardial friction rub
has a high pitched scratching grating lethargy sound
when doing anything with tracheal want what kind of Clea field
have surgical asepsis
Technique ausculation of abdomen
list with the diaphragm of the stethoscope in all 4 quadrants
enema oil retention
lubricates the rectum and colon for easier passage of stool
graphesthesia
trace a number on the cline ts polar with blunt end of pencil and ask him to identify
Nasogastric intubation
Auscultate palpate assist client to high fowlers position if the client vomits, clear the airway, and provide comfort prior to continuing check placement pirate gently to collect gastric contents. confirm placement with an x-rayif not in stomach advance it 2 inches and repeat clamp the ng tube do not insert ianything in blue pigtail
Three types of wound colors
Red: healthy regeneration of tissue Yellow: presence of purulent drainage and slough Black: presence of eschar that hinders healing and requires removal Red - cover yellow- clean black- debride ,
Cold Therapy
assess the site every 5 to 10 minutes to check for following: redness or pallor, pain or burning, numbness, shivering, blisters, decreased sensation, mottling of this skin, cyanosis (with cold applications) discontinue the application if any of the above occur, or remove the application at the predetermined time usually 15-30 minutes.
Unexpected sound for abdomen
loud, growling sounds (borborygmi) are hyperactive sounds that indicate increased gastrointestinal motility. possible causes include diarrhea, anxiety, bowel inflammation, and reactions to some food s
Cane instructions:
maintain two points of support on the ground at all times keep the cane on the stronger side of the body support the body weight on both legs move the can forward 6 to 10 inches the move the weaker leg forward toward the cane next advance the stronger leg past the cane
Seizure Precautions
make sure rescue equipment at bedside: O2, oral airway, suction equipment and padding, saline lock lower person to floor head flexed slightly forward stay with client and call for help. maintain airway potency and suction PRN. admin meds
Microbes can move by gravity from a non sterile ties to sterile so you should
no reach across or above turn back hold its min of 6 inches an sterile non -waterproff wrapper that coms into contact with moisture becomes nonsteirle
eye irrigation
nurse should hold the irrigate 1 above the eye direct the irrigation solution onto the lower conjunctiva sac the nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating eyes direct inner cantus to outer cantus
FECAL OCCULT BLOOD (GUAIC) TEST
obtain a fecal sample using medical asepsis while wearing gloves. Collect stool specimens for serial guar testing 3 times from 3 different defecations.
sputum collection nursing actions
obtain specimens early in the morning. wait 1 to 2 hours after client eats to obtain a specimen to decrease the likelihood of emesis or aspiration perform chest physiotherapy to help mobilize secretions if a client cannot cough effectively and expectorate sputum into the container, collect the specimen by endotracheal suctioning
Infiltration or Extravesation
pallor, local swelling at the site, decreased skin temperature around the site, damp dressing, slowed rate of infusion
Nursing actions for pulmonary embolism
prepare to give thormbolytics or anticoagulants position client win a high fowler's postion obtain pulse oximetry admin o2
enema soap suds
pure Castile soap in tap water or normal saling acts as a n irritant to promote bowel peristalsis
enema normal saline
safest due to equal osmotic pressure volume stimulates peristalsis
the diameter of the tracheostomy must be
smaller than the trachea
enema tap water or hypotonic solution
stimulates evacuation never repeated due to potential water toxicity
enemas are a last resort for
stimulating defecation
treatment for infiltration or extravasation
stop the infusion and remove the catherter elevate the extremity encourage active range of motion apply a warm or cold compress depending on the solution infusing restart the infusion proximal to the site or in another extremity
Cleansing enemea
the height of the bag above the rectum determines the depth of the cleansing
Fire extinguisher
PASS P. pull the pin A. aim at the base of the fire S. squeeze the handle S sweep the extinguisher from side to sider covering area of the fire
how much fluid should a person consume in a day
2,000-3000 ml of fluid/day
fiber requirement
25 - 30 f/ sY
thermometer when use oral?
4 years old or older
What angle do you inject an IM injection?
90 degrees
Categories of triage during mass casualty events
Class I: highest priority is given to clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized class II: second highest priority is given to clients who have major injuries that are not yet life- threatening and can usually wait *45 to 60 min* for treatmetn Class III: the next highest priority is given to clients who have minor injuries that are not life-threatening nd do not need immediate attention CIV: no expected to live and allow to die naturally. comformeasure can be provided but restorative care is not
A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first?
Remove the sleeve of the gown from the arm without the IV line nurse should slow the infusion using the roller clamp to prevent large volume infusion of IV solution while changing the gown. The nurse should disconnect the IV line form the pump while removing and reapplying he gown quickly to maintain the infusion rate prescribed with the pump.
The signature on the preoperative consent form is the client's
The nurse acts as a witness too attest that it is the client's signature on the
A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions hsouldthe nurse take to ensure proper operation of the device?
The nurse should keep the diaphragm of the device compressed to maintain suction and prevent clotting of sanguineous drainage. This drainage system is not made for irrigating The nurse should cleanse the drain opening with an alcohol wipe after the opening it to decrease entry of microorganisms The nurse should maintain the drainage tubing below the level of the incision to enhance drainage the nurse should collapse the device of the air after emptying the contents periodically to create enough suction to pull fluid exudate into the collection area of the device
A nurse is preparing to administer an intramuscular injection to a client who is overweight. which of the following sites should the nurse select for the injection?
The side hip between the iliac crest and anterior iliac spine forms the boundaries for ventrogluteal injection place a hand on the cline's greater trochanter 9righ hand on left hip) with the first two fingers touching the iliac crest and anterior superior iliac spine forming a V shape
Class of fire extinguishers
classA: combustible such as paper, wood, upholstery, rags and other types of trash fires b. flammable liquid gas fires c electrical fire s
Heat therapy
monitor bony prominences carefully because they are more sensitive to heat applications avoid over metal devices do not apply heat to abdomen to pregnant woman do not put on person who is immobile do not put on first 24 hour after traumatic injury
If pt impaled should you remove object
no
if having heat stroke should you let the pt shiver
no cover with a sheet
Stereognosis
place a familiar object in the client's hadn't and ask him to identify tit
Considerations for PT with trach
two extra tracheostomy tubes, obturator o2 source provide method to communicate with staff provide adequate humidification and hydration to thin secretions and reduce the risk of mucous plugs give oral care every 2 hours 8 provide tracheostomy care every 8 hours 8 to reduce risk of infection and skin breakdown suction tracheostomy tube using sterile suctioning supplies use surgical asepsis to remove and clean the inner cannula *change non disposable trach tubes every 6 to 8 weeks resposion*
Ambulation
walk on affected side
where apply bp cuff
1 inch above the antecubital space with the brachial artery in line with the marking of the cuff inflate the cuff another 30 mm hg and slowly release the pressure to note when the pulse is palpable again release the pressure no faster than 2 to 3 mm hg per second
crutches: 2-point gait (non-weight bearing)
1. Begin in the tripod position, maintain weight on the "unaffected" [weight-bearing] extremity 2. Advance both crutches and the affected extremity [crutches are placed forward 6 - 8 inches] 3. Move the "unaffected" weight-bearing foot/leg forward [beyond the crutches] 4. Advance both crutches, and then the affected extremity 5. Continue sequence making steps of equal length
Cane use
1. Cane is used on the good, "unaffected," side to provide support to the opposite lower limb (6-12 inches) 2. Advance cane simultaneously with the opposite "affected" lower limb 3. The "unaffected" lower limb should assume the first full weight-bearing step on level surfaces
crutches standing up
1. Hold the hand grips of both crutches in one hand. 2. Push off from the chair or bed with one hand, with the crutches in your other hand (see picture at right). 3. Stand, and then check your balance. 4. Place the crutches under your arms, and press them to your side
crutches: 4-point gait (weight bearing)
1. Place right crutch forward a comfortable distance. 2. Shift weight and move left foot forward. Never place foot ahead of crutch that was just moved. 3. Move left crutch forward. 4. Move right foot forward. 5. Repeat steps above
Crutch use sitting dow n
1. With your crutches, back up to the chair or bed until you feel it behind your knees. Take the crutches from under your arms. Put them together, and hold onto both hand grips with one hand. 2. Reach back for the chair or bed with your free hand. 3. Slowly lower yourself onto the chair or bed
Fracture Pan
1. set aside time to defecate 2. rase head of bed to 30 degrees 3. never leave pt lying flat on bedpan 5. have drink plenary of liquids before 5 roll client to side
how big cut opening for stoma?
1/18 to 1/8 inch larger
Enteral feedings what size of a syringe what type of solution
10 - 60 ml sterile or tap water want formula room temp want in fowler's position or elevate head to 30 degrees auscultate sounds of bowels check gastric contests for pH. a good indication of appropriate placement is obtaining gastric contents with a pH between 0 and 4 aspirate for residual volume flush the tubing with at least 30 mL tap water
what angle want to put IV
10 to 30 then move 0.6 inch
IV THERAPY WHERE PUT TOURNIQUET
10-15 MM (46 IN ) ABOVE THE INSERTION SITE TO COMPRESS ONLY VENOUS BLOOD FLOW
how much should a person consume in day
1500 kcal
A nurse is preparing to admin cefixime 8 mg/kg/day PO to divide equally every 12 hr to toddler who weights 22 lb. available is 100 mg/ 5 mL. How may ml should the nurse administer per dose
2.2/1 = 11 lb/ x kg x = 10 8 mg. 10 kg/ 1 day = 80 mg 100 mg/ 5 ml = 40 mg/x ml x = 2
width of blood pressure cuff should be
40% of the arm circumference at the point where the cuff is wrapped. the bladder should surround 80% of the arm circumference of an adult and the whole arm for a child.
wound cleaning which direction?
least contaminated toward the most contaminated never use same gauze to cleanse across an incision or wound more than once do not use cotton ballsand other products that shed fibers
auscultation of heart which way have them lay down?
left side (best position for ausulaten extra heart sounds or murmurs)
when alert provider about urine output
less than 20 mls an hour
Weber test
Technique: place a vibrating tuning fork on top of the client's head. Ask whether the client can hear the sound best in the right ear, the left ear or both Expected finding: the client hears sound equally in both ears (negative weber test)
A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?
The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing Should tilt head forward
A nurse is caring for a client who has an NG tube for intermittent enteral feedings. which of the following actions should the nurse take?
The nurse should auscultate the bowel sounds before each feeding to ensure the client has peristalsis bowel activity fo the digestive stymie to digest or absorb the general nutrition the nurse should elevate the client's head of between between 30 -45 to prevent aspiration
Collecting urine specimen
The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup The nurse should use a fish urein specimen obtain near the indwelling uinary catheter to prevent contamination
Removal of NG tube
The nurse should disconnect the NG tube from the suction apparatus before removal to decrease injury to the gastronisnestinal mucosa The nurse should instill 50 mL of air into the tube to clear the contents of gastric drainage and decrease the risk of aspiration on removal of the tube the nurse should pinch NG tube while removing the tube to decrease the risk of aspiration of any gastric contents the nurse should instruct the client to take a deep breath and to hold it during the removal of the ng tube to close off the glottis and decrease the risk of aspiration of any gastric contents
how clean stoma?
Use mild soap and water to cleanse the skin, then dry it gently and completely. Mositurinzing soaps can interfere with adherence of pouch
Stool for culture parasites and ova
ask the client to collect the specimen in the toilet receptacle, bedside commode, or bedpan don gloves use a wooden tongue depressor to transfer the stool to a specimen container label the container with clients identifying info remove the gloves perform hand hygine transport the specimen to the lab
Romberg test
ask the client to stand with his feet together, his arms at his sides, and his eyes closed. Expected finding: the client stands with minimal swaying for at least 5 seconds
Braden scale
assess risks for developing a pressure ulcer goes up to 18
compared to body what consider contaminated filed
any object held below the waist or above the chest contaminated
thrills (heart)
are a palpable vibration that can accompany murmurs or cardiac malformation
murmurs (heart)
are audible when blood volume in the heart increase so its flow is impeded or alter. sue the bell of the stethoscope to hear the characteristic blowing or swishing can.
suctioning considerations
assist client to high-fowler's position encourage lient to breathe deeply and cough in an attempt to clear the secretions withough artificial suction ;use no larger than a 16 French suction catheter when suctioning an 8 mm endotracheal tube or tracheostomy tube. hyperoxgenate the client using a bag-value may use suction pressure no higher than n120 to 150 mm hg. limit each suction attempt to no longer than 10 to 15 seconds to avoid hypoxemia and vagal response
Auscultation abdomen when most appropriate time?
in between meals
Dullness: (lungs)
in fluid or solid tissue, this can indicate pneumonia or a tumor
Bruits (heart)
blowing or swishing sounds that indicate obstructed peripheral blood flow. use the bell of the stereoscope
hyper resonance lungs
in the presence of air, this can indicate pneumothorax or emphysema
Abdomen order
inspect auscultate, percuss palpate
Sputum collection
collect during coughing whenever possible, encourage coughing.. coughing is more effective than artificial suctioning at moving secretions into the upper trachea and laryngophrynx suction orally, nasally or endotracheally, not routinely
enema medicated
contains medications, such as antibiotics or antihelminitcs, to retain for a period of time
treatment of phlebitis or thrombophlebitis
discontinue the infusion and remove the catheter elevate the extremity apply warm compresses 3 to 4 x a day restart infusion in a different vein proximal to the site or in another extremity obtain a specimen for culture at the site and prepare the catheter for culture if drainage is present
collecting sputum
do it in the morning rinse mouth take a deep breath and cough prior collect 4 to 10 ml
Crutch instructions
do not alter crutches after fitting follow the prescribed crutch gait, support body weight at the hand grips with elbows fixed at 30 degrees. Position the cruches on the unaffected side when sitting or risign from chair
treatment hematoma
do not apply alcohol apply pressure after IV catheter removal use a warm compress and elevation after the bleeding stops
Dropping eye drops
drop the eye medication in the outer third of the lower conjunctival sac nurse should apply gently pressure to the nasolacrimal duct after instilling the ye medication for 30-60 seconds to keep the medication from running down the duct or out of the eye
Hematoma
ecchymosis at the site
Expected sounds for abdomen
high pitched clicks and gurgles 5 to 35 times/ min. To make the determination of absent bowel sounds, you mush hear no sounds after listening for a full 5 minutes
if get exposed to blood
unless. break in skin no reason for more documentation or investigation
Chest Physiotherpy involves
use of chest perfusion, vibration, and postural drainage to help mobilize secretion. chest percussion and vibration facilitate movement of secretions into the central airways. for postural drainage, one or more positions allow gravity to assist with the removal of secretions from specific area of the lung . early morn postural drainage mobilizes secretions that have accumulated through the night
enema low-volume hypertonic
used by clients who cannot tolerate high-volume enema commercially prepared
A nures is planning care for a client who has had a wound infection following abdominal surgery. To promote healing and fight infection which mineral should the nurse plan to increase in the client's diet?
vitamin c and zinc. vitm e aid in skin and wound healing
enema procedure
wam enema solution. pour the solution into the enema bag, allowing it to fill the tubing, and then close the clamp place absorbent pads under the client to protect the bed lines position the client on the left side with the right leg flexed forewar lubricate the rectal tube or nozzle slowly insert the rectal tube 3 to 4 inches for adult 2 to 3 inches for child with the bag level with clean's hip, open the clamp raise the bag 12 to 18 inches above the anus depending on the level of cleansing desired. slow the flow of solution by lowering the containing if the client reports cramping or if fluid leaks around the tube at the anus lubricate. ask client to remain the solution for the prescribed amount of time
ambulating
want to stand toward weaker side instruct pt to lean forward from the hips place the wheelchair at a 45 degree e angel wants wide stance 1 foot apart
How to properly wash hands
wash hands with soap and warm water. rub hands together vigorously, and rinse under running water. Wash for at least 15 seconds to remove transient fora and up to 2 min when hands are more soiled.
