wounds
clear drainage
serous drainage
blood in the urine
hematuria
< than 12 breaths per minute
heart rate < 60
bradypnea
bradycardia
What terms are used to document bowel sounds if they are slow or faster than normal?
hypoactive, hyperactive
hemostasis
stopping blood flow
bloody, red drainage
sanguineous
Low urine output
oliguria
Name the type of fluid loss occurs when a patient is breathing fast?
insensible fluid loss
In what order do you assess the bowels and why?
Inspection, auscultation, percussion, palpation, RLQ.
leukocytosis
elevated wbc
pink drainage
pus drainage
serosanguineous
purulent
No urine output
anuria
RR >20 in an adult
heart rate >100
How long do you listen to a heart rate prior to giving meds and why?
tachypnea
tachycardia
60 sec because of irregularity potential
How long do you need to listen to bowel sounds to determine if they are absent?
For 5 minutes in each quadrant
What do you assess for with an AV fistula?
hemostasis, bruit, thrill, signs of infection
bruising
erythema
ecchymosis
What is an AV fistula and why is it created?
Connect an artery to a vein usually in the arm, vessels are made wider and stronger by a surgeon for dialysis
no breathing for 10 sec or longer
You have a pt with a nasogastric tube. What precautions do you place your pt on? How do you confirm placement?
Aspiration precautions, aspirate gastric content, air auscultation, and Xray placement.
What is your across the room assessment?
opening of the surgical site
dehiscence
What precautions must be taken for a pt with AV fistula at CMMC
Pink limb alert bracelet, arm precautions, no blood draws, IVS, or lab draws in the affected arm
Clinical presentation of respiratory distress in a child
How long do you watch for a respiratory rate in an infant?
tachypnea, head bobbing, nasal flaring, retractions, color, lethargy
60 seconds because it is irregular
You have a pt. complaining of severe watery diarrhea, leukocytosis, cramping, foul smelling, and was recently on abx. As a nurse what. test do you think should be ordered and why. What precautions and hand hygiene options?
C-Diff testing, GI iso, hand hygiene with soap/water, bleach wipes, gown, gloves
Clinical symptoms of left-sided and right-sided heart failure?
Left- pulmonary congestion
Right- edema