What is the function of a bladder scan? When would you use it?
non-invasive measure the volume of urine in the bladder using portable ultrasound technology
Measure PVR
Volume
Retention
How is sleep apnea treated and what is the main priority?
CPAP, positional changes, losing weight, avoiding depressants, ensure an open airway to facilitate breathing
a life-saving medication that rapidly reverses an opioid overdose
What is Narcan (naloxone)?
Eldery population more prone to this BP complication
Orthostatic hypotension
List 3 examples of how to prevent falls
Lock wheels of beds/chairs
Keep room free of clutter
use assistive devices
have pt stand up slowly
assess strength
improve lighting
How do you collect a 24 hour urine?
-Post signs not to discard urine.
-Have patient void-discard first urine-this is start time.
-Collect all urine in the 24-hour period.
-At the end of the 24-hour period ask patient to void-add that to collection.
-If urine is spilt-start again.
-Keep container on fresh ice to keep urine from degrading.
what is parasomnia, examples, and what is the main nursing intervention for this disorder?
activities that can cause you to wake up between NREM and REM, safety is our main priority
What is the nursing responsibility when caring for a patient who has pain?
If pt states they are in pain, we believe the pt report
assess, intervene, reassess, evaluate think ADPIE
pain is not universal, it is individualized
keep pt and family educated and involved
documentation includes rate, rhythm, strength (amplitude), symmetry, site
How would you document a clients pulse?
RACE and PASS what are they for?
RACE: rescue, alarm, contain, extinguish and evacuate
PASS: pull, aim, squeeze, sweep
RACE focusing on safety and evacuation of the fire, while PASS is a tool to extinguish a fire
Signs and symptoms of a UTI in the elderly
First sign of UTI could be confusion in elderly population
–Lower UTI-pain near groin, abdomen, and low back, there is frequency, urgency, blood
–Upper UTI- flank pain, fever, nausea, vomiting
What are some nursing assessments and interventions for insomnia
assessments- evaluating sleep patterns, identifying contributing physical and psychological conditions, reviewing medications and substances, and assessing environmental and lifestyle factors
interventions may include-bedtime routine, refrain from taking naps during the day, exercise, avoid alcohol, avoid caffeine, avoid smoking, take diuretics early in the day
Referred vs radiating pain what is the difference?
Referred pain is felt in a location different from the actual source of the injury or issue
Radiating pain starts in one place and travels directly along a specific nerve path due to compression, irritation, or damage
objective vs subjective data
Subjective data (symptoms) is information based on personal feelings, perceptions, or self-reports
Objective data (signs) is fact-based, measurable, and observable numerical information
Documentation for restraints includes:
Provider orders
Reason/justification
Alternatives
Type and location
Assessments (frequency)
Pt and family communication
What is nocturia? Why does it happen?
Waking up 2 or more times during the night, decrease in ADH, kidney changes
What is cataplexy?
a type of sleep paralysis that results in sudden loss of muscle tone, that can cause a pt to fall asleep, usually triggered by emotion
What is the difference between acute, chronic, and intractable pain?
Acute – pain with short duration < 6 mo.
Chronic - pain lasting > 6 mo.
Intractable – pain that cannot be relieved
Requires the assessment of 2 providers to determine if there is a deficit
What is the apical-radial pulse?
Advocacy vs autonomy
Advocacy: actively supporting, defending on behalf of someone else’s rights, needs, or choices
Autonomy: right of an individual to make independent, informed decisions about their own life, body, and care based on personal values and goals
Catheter surgically placed
Temporary cathether
Catheter left in place
External catheter
Suprapubic catheter
Straight catheter/In & Out
Indwelling catheter
Condom cath, purewick
Type of sleep that promotes memory, brain health, and concentration
What is REM sleep?
Factors that can affect pulse
Age, race, obesity
Exercise, rest, level of hydration
Circadian rhythm
Anxiety, stress, emotions
Medications
Nicotine and caffeine
Hemorrhage, increased intracranial pressure (ICP)
Illness