Oxygenation, Comfort, Activity
List appropriate interventions to keep airway clear
What is deep breathe and cough every hour, drink 1100mL to 2L of fluids each day, use bronchodilators as ordered.”
List parameters for normal VS.
What is 12-20 respirations, BP 118/78 & below, temp 96.8-100.4, HR 60-100, sats 95-100%?
What are hand hygiene rules for effective hand washing/ sanitizing?
What is wash hands 15 or more seconds after cleaning stools/diarrhea/ c-diff? What is sanitize when not visibly soiled?
Describe the Gastrocolic reflex
What is the mass peristalsis that occurs after meals?
Client instructions for Foley insertion and removal
What is bear down on insertion and exhale during removal?
Friction & shear definitions and interventions
What is Friction is a force that occurs in a direction to oppose movement. Reduce the surface area of an object or person before attempting to move. Passive, weak, and immobile people are more difficult to move due to greater areas of friction. Shear is a force exerted against the skin when the skin remains stationary and the bony structures beneath it move. Friction and shear can be reduced by using assistive transfer devices.
Describe measures to help maintain skin integrity.
HOB 30 degrees or less, turn every 1-2 h, use drawsheet & assistance when positioning, shift weight in wc every 15 minutes, keep skin clean and use barrier cream, specialty beds
Client conditions that cause prohibit rectal temps
What is clients with oral blood thinners, immunocompromised, diarrhea, hemorrhoids, rectal surgery?
Describe Routes of medication administration and how quickly they work
What is .... IV is quickest onset - 3-5 minutes (See med chart)
Client instruction for NG tube removal
What is hold breath to close glottis and reduce risk of aspiration?
Describe PQRSTU of pain.
P- palliative, provoking
Q-quality
R- radiating/relieving
S- severity
T-timing
U- effect on ur life
List some national patient safety goals.
Use 2 identifiers to identify patient. Patient marks the body site for surgery. Time out before surgery to verify accuracy. Guidelines to prevent infection and increase communication.
Safe PPE removal
What is gloves, then gown only touching inside, then (handwashing if needed) and face mask?
Describe Breathing patterns, definitions
What are eupnea, bradypnea, tachypnea, apnea?
Sterile field directions
What is keep it dry, above waist level, in front of you, sterile only touches sterile, open towards you last?
Describe types of pain
What is acute, chronic, chronic episodic, somatic, visceral, idiopathic, phantom?
What are interventions to prevent blood clots?
Sequential compression devices, compression stockings, low molecular weight heparin SQ into abdomen daily, ankle and foot pump/exercises, activity- ambulation, loose clothing to promote blood return
List and Describe Stages of Infectious Process
What is The incubation stage occurs while the pathogen actively replicates within its host. The prodromal stage is when people are most contagious. The person feels non-specific symptoms such as malaise, fever, myalgia, headache and fatigue. The illness stage occurs when the pathogen is having its maximal impact, the pathogen continues to proliferate (multiply) and spreads rapidly. Fever and chills are common, but less pronounce in the older adult. The convalescent stage is a recovery period. The person has developed antibody against the disease and is getting well.
Angles & needles for injections
What is are 5-15 for intradermal, 27-29, 1/4-1/2 in.
subcutaneous 45, 90, 25-31 g, 3/8- 1 in
IM 90 degrees, 21-25 g 1- 1 1/2 in
Steps in bedside swallowing test & signs of dysphagia
What is give a spoonful of water, then an ice chip, then a sip of water, then a straw to drink water. Call speech pathologist if concerned after this. What are concerning signs? abnormal speech when eating, abnormal mouth movements, gagging, coughing
IM & SQ administration sites
What is vastus lateralis,ventrogluteal, deltoid? What is posterior upper arm, abdomen, top of buttocks, scapular area, anterior thighs?
Describe stages of Pressure Ulcers.
What is 1- intact & non blanching, 2- partial thickness loss of dermis, 3- full thickness loss of epidermis, dermis, and into subcutaneous tissue, 4- full thickness loss through subcu tissue- bone, muscle may be visible. Unstageable- eschar or slough covering tissue. Suspected deep tissue injury- intact with purple discoloration or blood-filled blister.
Describe Isolation Precautions.
What is Standard? What is Contact for MRSA includes gown, gloves, & SOMETIMES mask (if splashing risk)? Contact plus- same with surface cleaning. What is airbourne -N95 respirator? What is droplet includes mask within 3 feet of client? What are Protective Precautions- standard with no fresh flowers, immunocompromised diet, mask for client outside room, no rectal temps.
Types of Urinary Incontinence & definitions/examples
What is functional, overflow, urge, stress, reflex....
Steps of Foley catheter insertion
What are.....