infection
What are examples of medical aseptic skills?
bathing, feeding, repositioning, taking vitals, bed making
What are normal adult vitals?
T 96.8-100.4F. 36-38C
P 60-100 +2 regular
RR 12-20 regular depth
BP 90-119/ 60-79 mmHg
O2 95-100% room air
List immobility complications
atelectasis, pneumonia, Pulmonary embolism, DVT, pressure ulcers, constipation, urolithiasis, orthostatic hypotension, contractures , muscle atrophy, osteoporosis
what are restraint alternatives?
toileting, room close to nurse station, frequent orientation, pain assessment/ medication, frequent rounding (q1hour), distraction
List subjective data
List objective data
subjective- what the client SAYS: pain, fear, anxiety, nausea
Objective- what the RN assesses via palpation, percussion, auscultation, inspection: temp, HR, RR, SPO2, lump, rash, vomit, scar, redness, pallor, capillary refill
What are examples of surgical aseptic skills?
tracheostomy suctioning, tracheostomy cleaning, indwelling catheter insertion
what is pulse pressure?
systolic BP- diastolic BP= pulse pressure
Example:
120/80 BP
120-80= 40 pulse pressure
What does it mean to dangle a patient? what kind of patient would you dangle?
orthostatic hypotension- have client sit on the side of the bed before ambulating for the first time
Why are restraints used?
LAST RESORT! limited control of behavior, prevent harm to client and/or staff
what is critical thinking?
Using reason to guide decisions. Pulling pieces of information together to determine relationship between data. technology combined with nursing judgement
What is the best way to prevent spread of infection?
HAND WASHING!!!
Client has abnormal vital signs. How does the RN prioritize what vital sign to recheck first?
1. ABC-Airway, Breathing, Circulation
2. the most abnormal vital sign
how are cane and Walter measured and used?
For both: height is greater trochanter, elbow angle bend is 15-30 degrees, look up
cane goes on strong side. Cane goes first, then weak leg, then strong leg goes past cane
lift walker forward then take a step toward the walker
How do you assess client on restraints? frequency? document?
q2 hrs remove one restraint at a time to assess skin, perfusion, allow client to move extremity, assess toileting, thirst/hunger, pain, need for restraints.Document every assessment
What is an incident report? Who receives the report? What is reported?
also known as variance report. unusual occurrences are reported to risk management to improve quality of care. do not refer to incident report in client's chart
- sterile only touches sterile, sterile hands above waist, open-away side side closest, never turn back to field, never cross field, sterile water good for 24 hours (lip prior to each use), palm to label of water, drop sterile items from a height of 6 inches
How do you determine how long to count heart rate and respirations for?
If heart rate and respirations are regular and client is not in distress, then count for 30 seconds and multiply by 2
If heart rate/ respirations are irregular OR client is in distress, then count for full minute
crutches: how are they measured and used?
2-4 finger breaths from axilla, look up, 15-30 angle bend
2 point-opposite crutch simultaneously moves with opposite leg (soldier/gangsta walk)
3 point-both crutches move forward then the good leg hops forward
4 point- right crutch, then left leg, then left crutch then right leg
How are soft wrist restraints applied?
cushion on bony prominence, tie in a QUICK RELEASE KNOT to a part of the BED FRAME that moves when the client bed moves (not side rail)
what is the role of documentation and how should it be done?
communication tool. Be descriptive list exact measurements, what you saw, heard, felt, smell. subjective data presented in quotes.
what is nosocomial infection?
infection acquired in a medical facility/hospital
Describe the 2 step blood pressure method
palpate brachial pulse with non dominant hand. Place BP cuff 1 inch above pulse. Inflate bulb with dominant hand while simultaneously assessing brachial pulse. close valve and inflate cuff until pulse disappears (note the number). Inflate 30mmHg more. Then slowly open valve to deflate cuff and NOTE WHEN PULSE REAPPEARS. Should be the same number as when it disappeared.
Describe Gait belt use and client transfers. How do you transfer a client form bed to wheelchair/cart?
stand and pivot
What clients would be at fall risk?
vision impairment, confused, dementia, mobility limitations, sedatives, seizures, orthostatic hypotension