Nutrition
BMI Classifications
Underweight: below 18.5
Healthy Weight: 18.5-24.9
Overweight: 24-29.9
Obesity: 30 and above
Minimum hourly urine elimination
30 mL/hr
Serous drainage
clear, thin & watery drainage from a wound site
Nursing interventions for the client who have vision loss
Call clients by name before approaching to avoid startling them, identify yourself, stay within clients’ visual field if they have a partial loss, give specific information about the location of items or areas of the building, explain interventions before touching clients, before leaving, inform clients of your departure
Informed consent
The legal process by which a client or the client’s legally appointed designee has given written permission for a procedure or treatment.
Manifestations of Malnutrition
Dry, brittle hair & nails; poor dental health; weakness & fatigue; flaccid muscles; prominent protrusions in bony areas; loss of appetite; mental status changes
what is CAUTI
catheter-associated urinary tract infection
The Glasgow Coma scale
assessment used to obtain baseline assessment of the client’s level of consciousness and for ongoing assessment.
Rosenbaum test
type of eye examination to screen for presbyopia (impaired near vision or farsightedness)
Maslow’s Hierarchy of Needs
Guides the delivery of nursing care and priority setting when they identify a preferential order of client problems: physiological, safety and security, love and belonging, self-esteem, and self actualization.
Risk factors for obesity
lack of physical activity, lack of sleep, genetics, medications, calorie intake, limited access to healthy foods, easy access to fast food and socioeconomic status
Nursing interventions for constipation
1. increase fiber & water consumption
2. give bulk-forming products
3. administer stool softeners, stimulants, or suppositories as ordered by the physician
4. encourage regular exercise
Negative pressure wound therapy
vacuum-assisted closure system that removes pressure of a injury and aids in healing process
Nursing interventions for sensory overload
Provide a private room, reduce lights and noises, offer the client earplugs and dark glasses if needed, provide orientation cues (calendars, clocks), limit visitors, reduce unpleasant odors, assist the client with stress reduction, ensure pain is adequately managed, schedule sleep to minimize interruptions.
Flow rates for Nasal cannula, Simple face mask, Partial rebreather mask, Non- rebreather mask & Venturi mask
Nasal cannula: 1-6 L/min
Simple face mask: 5-10 L/min
Partial rebreather mask: 10-15 L/min
Non-rebreather mask: 10-15 L/min
Venturi mask: 4-15 L/min
Cultural factors that affect nutrition
Islam: pork, alcohol, shellfish prohibited; Judaism: Kosher diet; Mormonism: alcohol/tobacco, coffee/tea discouraged; Catholicism: avoid meat on Friday's during lent
Client education for fecal occult blood specimen
2. do not contaminate stool with urine
3. do not place toilet tissue in bedpan
4. notify nurse as soon as possible after defacation
Cranial nerve assessment
assessment to determine all 12 cranial nerves functionality
Define decorticate posturing
abnormal posturing that manifests as flexion and internal rotation of upper extremity joints and legs
pH levels of Metabolic acidosis vs. Metabolic alkalosis
Metabolic acidosis: pH > 7.45, loss of bicarbonate
Metabolic alkalosis: pH < 7.35, antacid overdose
Difference between enteral nutrition and parenteral nutrition
Enteral: tube placed into the stomach/small intestine
Parenteral: tube inserted into a vein for nutrients to enter directly into the bloodstream
Steps for obtaining a catheter-urine specimen
perform hand hygiene and don gloves, clean port with alcohol swab, insert needle and withdraw desired urine amount, transfer urine sample to specimen container avoiding contamination, then remove gloves, perform hand hygiene, label the specimen container and transfer to lab
Staging of pressure ulcers
stage 1: non-blanched, intact red skin
stage 2: open, shallow wound with red/moist wound base
stage 3: open wound, visible adipose tissue
stage 4: deep wound with exposed muscle, tendon and bone visible
Patient education for the client with a new hearing aid
1. Use the lowest setting that allows hearing without feedback,
2. To clean the ear mold, use mild soap and water while keeping the hearing aid dry.
3. When the hearing aid is not in use for an extended length of time, turn it off and remove the battery to conserve battery power and avoid corrosion of the hearing aid. Keep replacement batteries on hand.
Requirements for alcohol based waterless antiseptics vs. soap and water
Soap and water: if contamination with spores is suspected, visibly soiled or contaminated with blood or body fluids, c. diff.
Alcohol based waterless antiseptics: preferred unless the hands are visibly dirty, because the alcohol-based product is more effective in removing micro-organisms