Fundamentals CMA review

Ambulating with crutches

- Axilla crutch should be 1-2 in below armpit - Hold crutches 12 inches in front and 12 inches to the side of each foot. Four point: - R crutch 12 in. Then L foot, then L crutch, the R foot 3 Point gait: - Move affected leg and BOTH crutches forward 12 in. Then move strong leg 2 point gait: - L crutch with R foot together, then R crutch with L foot.

contact precautions

- Gown, gloves - Staph aureus (MRSA) - C. Diff - Norovirus - RSV - VRE

Scope of practice LVN

- Monitor findings and gather data - Reinforce teaching - Perform routine procedures (urinary cath., osteomyelitis care, wound care). - Monitor IV fluids - Place tubes - administer enteral feeding - Perform sterile procedures

Subcutaneous injection

45 or 90 degree angle depending on underlying subcutaneous tissue

Intradermal injection

5-15 degree angle about 1/8 inch under skin.

Simple mask

5-8 L/min equivalent to 40-60% oxygen

Normal blood glucose

70-110 mg/dL

A nurse is assessing a client who has fluid-volume excess. Which of the following findings should the nurse expect? A. Crackles in the lung fields B. Flat neck veins C. Postural hypotension D. Dark yellow urine

A. Crackles in the lung fields Manifestations of fluid volume excess: crackles, dependent edema, full neck veins when the client is upright, elevated blood pressure, and sudden weight gain.

A nurse on a rehab unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? A. Stand toward the clients stronger side B. Instruct the client to lean backward from the hips C. Place the wheelchair at a 45-degree angle to the bed D. Assume a narrow stance with the feet 15 cm (6 in) apart.

C. Place the wheelchair at a 45-degree angle to the bed Allows pt to pivot. Nurse needs to stand in front of the client toward the side that requires the most support.

Lb —-> kg

DIVIDE by 2.2

Administering enteral medications via tubes

Elevate head at least 30 degrees. Pause tube feeding Check placement of feeding tube. Check gastric residual volume. Insert 60 mL syringe into gastric tube and flush with 30 mL of water via gravity. Pour first dose of med into syringe. Flush between each med with at least 15-30 mL of water. Flush gastric tube with 30-60 mL water after last dose.

ISBARR

Identity/Introduction Situation: Client name, age, admitting Dx, chief complaint or urgent need for rapid response. Background: Medical Hx. Current meds. Advanced directives. Assessment: General client impression and significant findings. Labs, vitals Recommendation: Treatment provided and client response. Read back of orders/response

Kg ——> lb

MULTIPLY by 2.2

Apical pulse

Midclavicular, Left 5th intercostal space. Correlates with Mitral valve. Listen for 1 min.

Extension of hand

Pointing fingers toward the ceiling

Flexion of hand

Pointing fingers toward the floor

5 rights or delegation

Right Task Right circumstance (stable pt., situation is appropriate) Right person Right direction & communication Right supervision & Evaluation

pressure injuries

Type 1: - skin is intact - Nonblanchable redness - Swollen - darker skin—-> may appear blue/purple Type 2: - Skin NOT intact - partial thickness loss - No fatty tissue is visible - superficial ulcer Type 3: - Skin not intact - Full skin thickness loss - NO exposed muscle or bone, but ulcer appears as deep crater Typer 4: - Full thickness tissue loss - Tissue necrosis - Bone, muscle, or tendon exposed

IV Flow rate mL/hr

mL of solution/ total hours= mL/hr

Suctioning Trach

- Pour sterile water/saline - Place drape - Don sterile gloves - Connect suction cath to suction tubing. Place the cath tip in the sterile water/ saline basin and apply suction to check function. - Insert cath into trach until resistance or client coughs - Only apply suction while withdrawing. NOT while inserting. - Apply intermittent suction 10-15 sec - ** Discontinue if Heart Rate decreases 20/min or more from baseline. Oxygenate or encourage deep breaths

Airborne precautions

- Private room, door remains closed - Negative pressure preferred. ~12-6 air exchanges each hour - N95 or respirator MTV (measles, Tb, Varicella) - Tuberculosis - Varicella (chicken pox) - Rubeola (measles)

Droplet precaution

- Surgical mask - Private room if possible -Flu - SARS-CoV1 - Adenovirus - Mycoplasma Pneumoniae - Bordetella pertussis - Rhinovirus (common cold)

Ambulating with walker

- Top of walker should be at wrist level - Client should move walker, then step with weaker leg

Ambulating with cane

- With clients arms relaxed at their side, the top of the cane should be level with the wrist. - Elbows should be bent ~15-30 degrees. - Hold cane on stronger side, close to body - Nurse is on the affected side and slightly behind - Advise client to advance cane 6-10 in, then move weaker leg forward parallel to cane.

Scope of practice AP

- obtain vitals - Document I&O - get blood form blood bank - Assist with ADLs

Collection of sputum specimen

-Collect in the morning when pt wakes up, client will be able to cough up the secretions that have accumulated during the night. preferably before breakfast. - should be collected before antibiotic therapy to prevent interference. - Collect 4-10 mL of sputum

Manifestations of fluid volume deficit

-Flat neck veins - Postural hypotension - Dark yellow urine

Conversions

1 tsp= 5 mL 1Tbsp= 15mL 1Tbsp= 3 tsp 1 oz= 30 mL 8 oz= 1 cup 1 gram= 1,000 mg 1 L= 1,000 mL 1 dram= 5 mL LARGE unit to SMall= move decimal 3 place to Right —> SMALL unit to Large= move decimal 3 places to Left <—

Nasal cannula

1-6 L/min Normal O2 for COPD will be low ~90s

Measurement of barrier around stoma

1/8 inch

A nurse is instructing a client about collecting a 24-hr urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure? A. "The next time I urinate will be the first specimen of the collection" B. "I'll make sure to keep the collection bottle in the container of ice they gave me" C. "Once the container is half full, I no longer have to add any more urine" D. "It's okay if a piece of toilet paper gets in the bottle.The lab people will remove it when the do the test"

B. "I'll make sure to keep the collection bottle in the container of ice they gave me" The urine collection must remain chilled to prevent any change in urine composition during the collection. The collection begins after the next time the client urinates. Toilet tissue, menstrual blood, and feces will contaminate the specimen.

Airway suctioning

Oropharynx - Assess need for suction and contraindications -Check SpO2 and heart rate - Semi Fowler position - Fill basin with ~100 ml of water or normal saline. - Connect tubing to suction and the other end to the Yankauer cath. - Turn on suction to 80-120mmHg - Insert cath into mouth along gum line and pharynx. Encourage client to cough. - Rinse cath with water or normal saline Nasopharynx - Semi Fowler - Set suction 80-120mmHg - *Hyperoxygenate or ask client to deep breathe. Remove O2 device if present and keep close to clients face. - Pour STERILE water or saline into basin. Squeeze lubricant onto sterile field. Place drape across chest. - Don STERILE gloves and maintain sterility of dominant hand - Lubricate suction cath lightly - Insert cath into naris as client takes a breath. - Intermittent suction for 10-15 sec as you WITHDRAW and rotate cath. - Reapply O2 prn - Rinse cath and tubing with 0.9% NaCl - Allow at least 20 sec before suctioning again

Braden scale

Sensory perception Moisture Activity Mobility Nutrition Friction & shear Low: 22-23 Moderate: 19-21 High: 18