VS
Expected reference range for oral temperature.
What is 36-38C (96.8-100.4F) with the Average being 98.6F)
Patient Identifiers.
What is name and DOB?
Requires the use of respirator (N95 mask) and negative airflow room.
What is airborne isolation precautions?
Water temperature for bathing.
What is warm, not hot water that is replaced as it cools?
What does this promote? Comfort, relaxation, vasodilation (wound healing, increases oxygen levels and supply to tissues)
Data collected by observing.
What is objective data?
Contraindication for obtaining rectal temperature.
What is coagulation disorders/clients with bleeding disorders, immunocompromised clients, rectal disorders?
Safety in client hospital room.
What is Bed low and locked, call light in reach, bed rails up?
Precautions for an immunocompromised client.
What is protective isolation?
Proper way to clean the eyes.
What is cleaning from inner to outer canthus with a clean washcloth and water?
The first step in preparing to assess a client.
What is gathering needed equipment?
When an apical pulse is indicated.
What is irregular HR or a HR that is out of expected range?
Has to wash with soap and water.
What is Clients with C.Diff
Has a decreased resistance to infection due to factors such as a depressed immune system, malnutrition, presence of a chronic disease, or a smoking history
What is Susceptible host?
Requires placing on the side for oral care.
What is an unconscious client?
Encourages venous return when bathing.
What is washing extremities from proximal to distal?
Blood pressure reading 134/82 mmHg from the right arm with the client in the supine position.
What is Stage 1 Hypertension?
Primary way to stop the spread of infection.
What is Hand Hygiene?
Requires cleaning from front to back.
What is perineal care (specifically with females)?
What is placing in denture cup with warm water or lining the sink with a washcloth when cleaning over the sink?
How do you assist the client in removing dentures and what are you assessing?
The reason older adults have lower body temperatures.
What is loss of subcutaneous fat?
PPE Removal
What is 1) Remove the gloves; 2) Remove the protective eyewear; 3) Remove the gown; 4) Remove the mask. Gloves need to be removed before touching any of the additional PPE?
Pain, swelling, redness, warmth at the site of an injury.
What is a localized infection?
Cannot soak feet with foot care.
Proper nail care for clients.