Hygiene, Precautions & Oral Meds & Misc
What is extended-release, slow-release, enteric-coated medications?
Nursing interventions to promote urinary elimination
Encourage fluid intake, encourage voiding, assist up to the toilet, sit upright, turn Q2H
An interdisciplinary team member that assists with ambulation:
Assists with grooming, feeding self
Physical therapist
Occupational therapist
Characteristics of pain
What is
Palliative/provocative
Quality
Radiation
Severity
Temporal Factors
Steps to collect sputum
Collect early in the morning
Nutrient to promote wound healing
What is protein?
Risk factors for dehydration
Elderly
Confused
NPO
Causes of Respiratory alkalosis
Hyperventilation (anxiety, fear) Mechanical ventilation, overactive thyroid
Steps to insert nasogastric tube
Measure, insert, ask patient to swallow as it is being inserted, insert to measured area, obtain X-ray for placement
Clinical Manifestations of anaphylaxis
Stridor, wheezing, dyspnea, hypotension, tachycardia, Erythema, laryngeal edema
Steps to perform oral hygiene
Q2H if NPO or unconscious
High-Fowler's for conscious, Sims if unconscious
Assess mucous membranes
Assessments done on Braden Scale
Nutrition, moisture, mobility, ambulation, friction, sensory
Nursing interventions for urolithiasis
Assess pain, monitor I & O, strain urine for stones, encourage fluid intake.
Monitor for complications - cystitis
Steps to ambulate with walker
Move weak leg with walker then unaffected leg forward
Levels of pain severity scale
What is:
1-3 - Mild
4-6 - Moderate
7-10 - Severe
Administer bronchodilator
Educate about triggers
Peak flow meter daily
Interdisciplinary team member to manage/monitor nutritional status
What is a dietitian?
Levels of hypertension, urgency & emergency
Normal - Less than 120
Elevated - 120-129
Hypertension: Stage 1 - 130-139
Stage 2 - Over 140
Hypertensive urgency - emergency but no target organ damage
Hypertensive emergency - over 180 - organ damage
Risk factors for fluid volume overload
Heart failure, kidney failure, increased fluid intake, IV fluid
Causes of Metabolic Alkalosis
Overuse of antacids, vomiting, gastric suctioning
Steps to administer enema
Review type and pt history, place in left sims, insert towards umbilicus, instil medication, monitor for vagal response.
Nursing interventions for anaphylaxis
Stop the trigger, oxygen, antihistamine, protect airway, corticosteroids, education the client, medical alert
Factors that influence personal hygiene practices
What is timing, culture, socioeconomic class, developmental levels, assistance needed, ability, personal preferences?
Nursing interventions for Herpes zoster
Place in isolation, monitor & reduce pain, prevent scratching
Complications of benign prostatic hyperplasia
What is urinary tract infection, urinary retention, hydronephrosis?
Nursing interventions for gout
Monitor pain level, encourage fluid intake, no alcohol, limit foods high in purine.
When to reassess pain interventions?
What is 30 mins - 1 hour after administration of pain meds.
Nursing care for patients on oxygen
The interdisciplinary team member that manages swallowing ability?
What is speech therapist?
Nursing interventions for peripheral arterial disease
No compression on lower legs, do not elevate, allow for legs to dangle, encourage patient to change positions often.
Nursing interventions for fluid imbalances
Fluid overload: monitor I & O, monitor VS, monitor electrolytes, monitor respiratory status. Restrict fluid
Fluid deficiency: monitor I & O, VS, electrolytes, encourage fluid, monitor for fluid overload
pH 7.22
HCO3 12
CO2 36
Metabolic Acidosis
Complications of Irritable bowel disease
What are electrolyte imbalances; dehydration, malnutrition, anemia?
Nursing interventions for patients with systemic lupus erthyematosus
Monitor urine output, periods of rest, monitor urine output, avoid sick people & crowds, monitor pain, avoid sun, avoid stress
Steps to administer oral medications
Verify order with MAR, Verify medication with MAR, Prepare medication, hand hygiene, provide privacy, Verify patient, educate, assess, verify medication with MAR & patient, administer meds, evaluate patient
Characteristics of skin cancer
What is:
Asymmetry
Border
Color
Diameter
Evolving
Nursing care for clients with indwelling catheters
Assessment of neurovascular
What is:
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
Poikilothermia
Nursing interventions for pain
Assess pain with PQRST
Mild pain - nonpharmacologic interventions
Moderate pain - analgesics
Severe pain - opioid analgesics
Types/purposes of oxygen delivery devices
Nasal Cannula - 1-6L/min
Simple face mask - 5-10L/min
Nonrebreathing mask - 6-15 L/min - provides 100% oxgen - should not be given to COPD
Venturi mask - 24-80% FiO2 - Exact control of oxygen, good for COPD patients
Steps to administer tube feeding
Continous - administered with a pump. Check residuals Q4H, administer water flushes. Formula is good for 24 hrs, administer at room temp
Bolus/Intermittent - Given by gravity at intervals throughout day, check residuals before administration, flush with water before and after.
Both - Sit up at 30 degrees
Nursing interventions for peripheral venous insufficiency
Compression stockings, monitor for wounds/wound care, elevate legs, avoid any restrictive clothing around waist
Clinical manifestations for fluid volume deficit & fluid volume overload
Fluid volume overload - BP elevated, Jugular vein distention, respiratory distress, edema
PH 7.29
CO2 59
HCO3 25
Respiratory Acidosis
Nursing interventions for diarrhea
NPO then BRAT diet, encourage fluid intake, monitor I & O, monitor electrolytes
Nursing interventions for contact dermatitis
Types of isolation & what they are for
Standard - hand hygiene & gloves - everyone
Contact - hand hygiene, gloves & gown - MRSA, C.Diff
Droplet - Hand hygiene, gloves, gown & mask - flu
Airborne - Hand hygiene, gloves, gown & N95 mask & place in negative pressure room - TB, chickenpox
Nursing interventions for skin breakdown
What is:
Linens free of wrinkles
Turn Q2H
Adequate nutrition/hydration
Keep clean and dry
Minimize pressure to sites
Nursing care for urinary tract infections/cystitis
monitor I & O, education, encourage fluids, take antibiotics, apply heat, teach prevention of infections
Steps to walk with cane
Cane on unaffected side; move affected leg & cane together then unaffected side.
Nonpharmacologic interventions for pain
What is:
Guided imagery, heat/cold packs, quiet/dark environment, massage
Nursing interventions for COPD
Encourage cough & deep breath
Position in high-Fowler's
O2 sat between 88 - 91%
Stop smoking
pH - 7.50
CO2 - 41
HCO3 - 32
Metabolic Alkalosis
Nursing interventions for GERD
Avoid trigger foods, no smoking or alcohol, avoid laying down after eating, raise HOB 4-6 inches, medications as prescribed, monitor for complications - respiratory/aspriation
Clinical Manifestations and Nursing interventions for urinary retention
Assess bladder, I & Os, bladder scan, straight catheterization or foley catheter
Nursing interventions to care for fractures
Keep cast dry, monitor for numbness, color, pulselessness, temperature paralysis, monitor skin integrity, teach patient about cast care