Skin Care
A documented Braden score of what indicates a patient is at risk for skin breakdown
18 or less
Foley care is to be performed how often
During daily hygiene, after stooling or incontinence, and at a minimum once per shift
All specimens should be labeled with what
2 patient identifiers
The water seal is filled with this into the suction port
Provided water
This indicates there is an air leak somewhere in the system
Bubbling
In pressure injury prevention, moisture management is a strategy that involves assessing and managing incontinence, ensuring timely hygiene care and what to protect skin integrity
Using Barrier Creams
How often do you assess indications for continuing a Foley catheter
Each shift
Only two ways to collect a urine specimen for testing
1) Catheter
2) Clean Catch Mid-Steam Void
-80mmHg
Palpate the surrounding skin
Damage to the skin and underlying tissue caused by prolonged pressure
Pressure Injury
When a patient does not meet criteria for continuing a Foley catheter and is greater than 18 years of age, what order should the nurse place and sign per protocol
When collecting a Clean Catch Mid-Stream Void, what should you instruct them to do after they have cleaned with the provided towelettes
Begin urinating into the toilet, then without stopping the stream, insert the container to collect the specimen directly into the container
In the event the chest tube becomes dislodged below the insertion site, you should place the end tubing in what
1-2 inches of sterile water
The up and down movement of the patient pressure float ball in the graduated water seal chamber
Tidaling
This is required for a patient with a Braden Score of 18 or less, regardless of whether there is a physician's order
Turning every 2 hours
List 3 of the 5 actions you should take when a patient refuses Foley catheter removal
1) Completely fill out the Refusal of Care form
2) Outline risks and benefits of refusing care
3) Document the care being refused
4) Notify the physician
5) Obtain signatures
When collecting a urine specimen from a Foley catheter, it is important to do this before clamping, cleaning, and collecting a urine sample from the sampling port
Drain the tubing of all urine
Indicating suction is working, this is what you will see on the Oasis drainage system
Orange bellow will expand beyond the triangle mark
To determine where the air leak is, begin clamping for a few seconds, starting in this direction
At the insertion site and working your way down to the collection device
Despite common assumptions, this evidence-based intervention is more effective than specialty mattresses alone in preventing pressure injuries
Turing and Repositioning
Once you've removed a Foley catheter and the patient can void, what are your next actions
Order bladder scan (NUR374) and check post void residual
What is the order of draw for urine vacutainer collection
1) Gray Rubber Top
2) Yellow/Red Speckled Top
3) Clear Top or Yellow Top
4) Sterile Specimen Cup (Only if urine electrolytes are ordered)
The chest drains dry suction regulator is preset to what
-20cm H20
Typically, will not see tidaling with what
1) Air leak
2) Tubing occlusion
3) Lung fully expanded
4) PEEP