Advanced Nursing Skills 1: Special Procedures Flashcards
What is the purpose of the physical assessment?
- To evaluate the client’s current physical condition
- To detect early signs of developing health problems
- To establish a baseline for future comparisons
- To evaluate the client’s responses to medical and nursing interventions
What should amenities should the physical assessment room have access to?
- Easy access to a restroom
- A door or curtain that ensure privacy
- Adequate warmth for client comfort
- A padded, adjustable table or bed
- Sufficient room for moving to either side of the client
- Adequate lighting
- Facilities for handwashing
- A clean counter for placing examination equipment
- A lined receptacle for soiled articles
Name situations when physical assessment is used.
- A comprehensive head-to-toe assessment is done on:
- Patient admission
- When it is determined to be necessary by the patient’s status.
- The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition.
- Any unusual findings should be followed up with a focused assessment specific to the affected body system.
Identify the supplies needed for each situation.
- For a basic physical assessment a nurse requires
- Gloves
- examination gown
- cloth or paper drapes
- scale
- stethoscope
- sphygmomanometer
- thermometer
- penlight or flashlight
- tongue blade
- assessment form
- a pen
What general data needs to be gather during a physical assessment?
- Physical appearance in relation to clothing and hygiene
- Level of consciousness
- Body size
- Posture
- Gait and coordinated movement
- Use of ambulatory aids
- Mood and emotional tone
What is a diagnostic examination?
- Procedure that involves physical inspection of body structures and evidence of their function.
- Facilitate by use of technical equipment and techniques such as:
- Upper & Lower GI series
- Gastroscopy
- Gallbladder series
- Proctology
- Radionuclide imaging
- Lumbar puncture
- Paracentesis & Thoracentesis
What are general nursing responsibilities?
- Preprocedural care
- Consent must contain three elements:
- capacity
- comprehension
- voluntariness
- Consent must contain three elements:
- Preparing clients
- Example NPO
- Obtaining equipment and supplies
- Arrange the examination room
- Position and drape the client
What is the importance of proper positioning of the client?
Patient positioning refers to the techniques nurses use with their patients to maintain a neutral body alignment.
Proper patient positions help to:
- Protect the patient from potential problems related to immobility and injuries
- Promote the overall health of the patient
- Keep the patient safe during procedures, such as in operating rooms or in recovery
As a nurse, you’ll need to take many details into account when choosing your patient’s position. For example, you should think about the position of any medical devices, such as catheters, or any risk factors of this particular patient, such as incision sites. Patient safety should be one of your top concerns.
What is post procedural care?
- Attend to the client’s comfort
- Assess vital signs and client stability
- Care for specimens
- Record and report data
- Intake & Output
What are pre-procedures for the upper and lower GI series?
- NPO
- stomach, small intestine & colon must be clear
- Informed consent
- Assess for allergies
- Client teaching
- MD may order enema to ensure colon is clear.
- Bowel preps:
- Go-lytely
- Magnesium citrate
- Fleet phoso soda
- Contraindicated in clients with abdominal pain, heart disorders, renal function, rectal/anal lesions, pregnant women.
What are post-procedures for the upper and lower GI series?
- Watch for signs of bowel obstruction
- Give laxatives or stool softeners as ordered
- Monitor for constipation
- Increase oral fluids
- Observe client’s stools
- Note if client passes barium
