Basic Care & Comfort 1 Flashcards
Non- Pharmacological Efforts
What are the 6 main one’s that nurse do?
Non-Pharmacological means no medicine.
- Distraction
- Heat or cold therapy
- Massage (never massage over bony provinces or legs)
- Prayer
- Music
- Positioning
Which Non- Pharmacological method works best in children?
Which method works best in teens?
Which method works best in adults?
- children is distraction
- Teens is coping statements such as I can do this and the pain is not so bad.
- The method that works best in the Adults is whatever they want
Nutrition
Proteins= 4 calories per gram Carbohydrates= 4 calories per gram Fats= 9 cal per gram
Hydration- To know hydration you have to be able to properly assess __________.
Dehydration
What are the signs of dehydration?
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- )
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Cardiac problems due to ____ which leads to _____ ____ pulses
Systolic blood pressure will _____
_______ hypotension
______ tachycardia
Explain- blood pressure ___ the heart rate goes ____ but the pulse will be very _____#
Dry mucous membranes
Poor skin turgor
Thirsty
Low urine output
Cardiac problems due to vasoconstriction which leads to weak thready pulse
Systolic blood pressure will drop
Orthostatic hypotension
Sinus tachycardia
Explain- blood pressure drops the heart rate goes up but the pulse will be very weak
In dehydration urine levels may drop below ____ml hour
In dehydration urine levels may drop below 30ml hour
Labs to watch in dehydration
USG: normal _____ to ___ increases
Urine color: dark _____ color
BUN/ creatine ratio: Normal ratio is ___to_____ Ratios greater than __blood is not getting to the kidneys so it is either ___ or ___
Labs to watch:
USG: normal 1.003 to 1.030 increases
Urine color: dark yellow color
BUN/ creatine ratio: Normal ratio is 10:1 to 15:1.
Ratios greater than 20:1 blood is not getting to the kidneys so it is either Dehydration or CHF
What are the 4 common cause of dehydration?
Diarrhea
Nausea and; vomiting
UTI
fever
Medicine that causes dehydration
Diuretics
Because they Increased the urine output and help your body get rid of water
ReMar’s Tip: Oral hydration can be just as effective as IV hydration if started earlyenough. NCLEX TIPS: 1. 2. 3.
- If the patient is vomiting it is OK to still proceed with clear liquids or oral hydration because they tend to be digested better start with
- Start with Very small amounts of fluids . With about 5ml a sip no more
- If oral hydration is not tolerated then a NG tube not a IV.because we want to use the least invasive method first
Bladder and ; Bowel Elimination
Urine
How much a day?
Odor?
Specific gravity
pH
Urine
How much a day? 1,000-2,000 ml per day
Odor? Ammonia is normal , if you smell musty think liver disease,
if it smells sweet think diabetes
Specific gravity :1.016-1.022
pH :4.6-8.0
Why are UTI more common in women than men?
Because uretha in a woman is much shorter than a man!
In woman it about 1.5 -2.5 inches
In males it’s about 6-8 inches
Alteration in normal urine pattern matching
- Anuria =
- Glycosuria =
- Hematuria=
- Pyuria =
- Enuresis =
- Anuria = no kidney function
- Glycosuria =glucose in the urine
- Hematuria=blood in the urine
- Pyuria =Pus in urine
- Enuresis =involuntary urination at night
NEED TO KNOW NCLEX SKILL: Collection of 24 hour urine
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- Start with an Empty Bladder Ask patient to void then throw away.
- All urine must be kept in One Container or 1jug or one drainage bag if they have a Foley catheter.
- If one urine sample missed then _ they must start the whole process over again
- Keep urine on ice to help bacteria from Fermenting
Bowel
HANDLING NORMAL STOOL precautions?
Universal or Standard precautions
How Often They Go (BM)
infant: ___ to ____times/day
Children & adults :go ___-__ times/day
Elderly : are prone to ___ , they to go every __ days
infant: 3 to 6 times/day
Children & adults :go 1-2 times/day
Elderly : are prone to constipation , they to go every three days
Listen for bowel sounds in all four quadrants for __________ ____________
You are counting your bow sounds when you’re looking for ______
Less than ___Bowel sounds within ___ minutes may indicate your pt is ______
More than ____ bowel sounds within ____ minutes may indicate your patient has some problems with _______
5 minutes
You are counting your bow sounds when you’re looking for constipation
Less than 5 Bowel sounds within five minutes may indicate your pt is constipation
More than 30 bowel sounds within five minutes may indicate your patient has some problems with diarrhea
When doing any enemas or digital removal of impaction watch out for:
Vagus nerve stimulation
The Vagus nerve has the ability to drop the heart rate
Bowel Tests to know
1.Guaiac Test -looks for ___ that cannot be seen in the stool
2.Culture and Sensitivity-done on ___ ____ and; ____!
The culture is looking at which ______ are growing in the stool! The sensitivity part looks it would ____ are going to treat them the best
1.Guaiac Test -looks for blood that cannot be seen in the stool
2.Culture and Sensitivity-done on stool, urine and; blood!
The culture is looking at which Microorganisms are growing in the stool! The sensitivity part looks it would anabiotic’s are going to treat them the best
