Teaching for a Patient who takes eliquis
bleeding precautions
fall precautions (risk of bleeding, bruising)
will bruise easier
use soft toothbrush, an electric razor
avoid use of NSAIDS careful use of aspirin
5 Steps of Nursing Process
Assessment Diagnosis Planning Implementation Evaluation
Order of Doffing PPE
gloves, gown, face mask. goggles, mask
A patient has Influenza. What precautions will you place them in and what equipment does it require
Droplet- private room or client with same infection
mask, Goggles, Gloves, Gown
Assessment you can see, feel, smell or hear
Objective
10 Rights of Medication (list at LEAST 5)
Patient, med, dose, route, time, documentation, to refuse, response, education, reason,
Types of Nursing Diagnosis
Actual, Risk for, Health Promotion
Indications for Foley catheter insertion
critically ill, retention, wounds, perioperative, prolonged immobiliation, hospice
What does SBAR stand for
Situation, Background, assessment, reccomendation
The nurse checks for this by gently pressing on the patient's skin over the shins or ankles, looking for pitting that indicates fluid retention.
Edema
Assessment monitoring required for administering Lasix
electrolytes (hypokalemia), intake and output, weight, blood pressure.
Guidelines for Nursing Process GOALS
SMART
specific, measurable, attainable, realistic, timely
List areas you can give a subQ injection
what angle do you give the injection at
abdomen, back of arms, thigh
45- 90
PH 7.23, Co2 65, HCo3 35
What does this ABG show?
Respiratory acidosis
Lung sounds most likely to be heard in a patient with COPD
Wheezes
List 2 adverse effects of psychiatric medications
Tardive Dyskenisia, weight gain, constipation, dry mouth, urinary retention, ED.
At what stage do you determine if the patient has achieved the expected outcomes
Evaluation
Methods of checking NG tube placement
X-ray. Other methods include checking gastric pH (usually < 4) or hearing a "whoosh" of air.
postioning of a patient with a PEG tube. why?
30-45 degrees. Risk of aspiration
Heart sound at the right second intercostal space at the right sternal border near the sternum
Aortic
What should you assess for before giving hydrocodone- acetaminphen. name 2 side effects. Name the antidote.
respiratory rate, LOC, blood pressure, heart rate, level of pain.
constipation, drowsiness, dizziness, nausea, respiratory depression.
Narcan!
Name a nursing diagnosis for this patient
asthma exacerbation, lung sounds wheezing, dry cough, shortness of breath, spo2 91% on 3 L of oxygen, states "I just wish I could clear my lungs out and breathe easier". appears figety, anxious. states she cannot wait to leave and vape and see her cats
ineffective airway clearance
ineffective breathing pattern
impaired gas exchange
anxiety R/T
knowledge defecit
Position for giving an enema
left lateral SIMS. (laying on left side with right knee flexed)
List 4 safety methods for high fall risk patient
Hourly Rounding (4 P's) bed low, call light within reach, belongings within reach, wheels locked, bed alarm, non slip foot wear, clear pathway of clutter, move closer to nurses station, patient safety sitter.
Normal Sodium level
Normal potassium level
135-145
3.5-5.0