basic patient care Flashcards
what is basic patient care?
- making beds
- ADLs (bathing, eating , restroom, oral care)
- vital signs
- transferring patients
- assistive devices
- Report changes
goals of patient care
- promoting independence
- collaborate
- involve family
Before providing patient care…
introduce yourself
ID patient using 2 proper identifiers
hand hygiene
ensure patient is verbally understanding
while bathing patients you are…
observing skin breakdown or difficult ROM
bathing is…
essential to maintaining personal hygiene
bath water temp
37- 46 C (98.6-115 F)
routine bath temps should be…
40.5-43.3 C (105-110 F)
You are giving a patient a bath, you have gathered all your supplies and turned on the shower, before bathing the patient you should ask…
the patient to feel the water
ensure privacy by…
- closing door
- closing curtains
- keep body parts covered with bath blanket
when assisting with bathing, how can you ensure safety for your patient?
- check for wet floors
- assist patient in & out of shower/tub
- use nonskid mats/socks
- never leave patient alone
- call light is within reach
- protect IV/surgical sites form moisture (infection control)
to ensure safety during bed baths…
keep bed rails up on the opposite side you are working on
what technique do you use to wash a patient?
- wash from cleanest to dirtiest areas
- long, firm strokes
- rinse well
how do you dry a patient after bathing?
gently pat the patients skin to prevent skin breakdown/injury
partial bath includes…
face, neck, hands, back, armpits, buttock, perineal area
perineal care technique…
wash anterior to posterior (front to back)
If your patient has a catheter never…
- raise drainage bag higher than patient’s bladder (can cause infection)
when doing peri care with a catheter…
- ensure slack in tubing
- secure bag on side of bed (never bed rail)
- clean w/ soap & water at insertion site
catheter care should be done…
twice daily
after removing a patient’s dentures…
place in wash basin containing lukewarm water (hot water can damage them)
how do you remove upper denture?
break suction using thumb & forefinger
use gauze, gentle pressure, & tug downwards
how do you remove lower denture?
break suction by lifting it up & twisting sideways
what do you use to clean dentures?
denture cleaner (NOT tooth paste, can scratch them)
to make reinsertion of dentures easier, what do you do?
moisten dentures proir
when dentures are not being used…
place in a cup w/ lukewarm water or denture solution with patient’s name & room number
sitz baths are used for…
- childbirth
- vaginal/rectal surgery
- hemorrhoids
the nurse delegates you to giving a patient a sitz bath. how long does a patient sit in the bath for?
20-30 mins
what is a sitz bath?
appliance filled with warm water placed on the toilet to sooth perineal/rectal areas
when should oral care take place?
- when awaken
- after meals
- prior to bedtime
what can cause your patient to need more frequent oral care?
- if they are NPO (nothing by mouth)
- medications (can make mouth dry)
How do you assist a patient with oral care…
- brush each tooth gently in a circular motion
- 45 degrees to the gum
- back to front of mouth
after oral care what is most important?
flossing
how should you position an unconscious patient during oral care?
on their side facing you
Where should you place a towel and emesis basin during oral care on an unconscious patient?
towel under head and emesis basin under chin
what do you NEVER do during oral care on an unconscious patient?
place you fingers in their mouth
throughout oral care…
explain the procedure (even to unconscious patient)
when providing oral care check for…
- red/irritated gums
- bleeding
-canker sores
-pus - infection
- foul smell or fruity breath
bed making aids with…
comfort, healing, & infection control
when is the best time to change the bedding?
when the patient is OOB (unoccupied)
- ambulation
- showing
- procedure
supplies for bed making…
fitted sheet, mattress pad, flat sheet, pillow case, draw sheet, absorbent pad, blankets, linen bags
when transporting clean linens…
hold away from your body (prevents pathogens on uniform from transferring to patient)
before changing linens…
check for patients personal belongs in the bed
if substances have leaked through the bed…
wipe mattress down, then place linens on the bed
turning, boosting, repositioning improperly can lead to….
excessive workload on your spine and injury to patient’s skin
before you change linens on an occupied bed…
complete any task that could soil the sheets (bathing or lab draw)
steps to making occupied bed
- ROLL patient to one side of bed
- TUCK sheets to be removed under patient
- REPLACE sheets on unoccupied side
- TUCK fresh sheets under the patient
- ROLL patient to fresh side
- REMOVE old linens
- COMPLETE the linen change
when making an occupied bed make sure…
- bed rails are up and locked when you roll the patient
- explain procedure throughout
- provide patient w/ reassurance
when do patients usually need assistance with dressing?
in morning, prior to bed, when clothes become soiled
when assisting with dressing watch for
- IV lines/drains/ tubes
- weakness that could make dressing difficult
allowing the patient to wear and choose their own clothes and dress themselves as much as the can, provides what?
a sense of independence/ control
you patient with a weak side needs assistance with dressing, how do you dress/undress them?
Dress them starting with the weak side, and undress them ending with the weak side
if a patient is connect to an IV line and needs assistance with taking off a gown…
take arm without the IV first, then gently remove gown over the IV site/tubing
How should you put a clean gown on a patient with a IV line
thread the IV bag through the sleeve, hang the bag on the IV pole, then assist putting the arm gently through the gown
if IV tubing is connected to an infusion pump…
ask RN to disconnect
before preforming grooming…
check with patient & nurse to see what is needed & level of assistance
hair washing can be done…
during shower/bath, at sink, in bed
water temp for hair washing….
40.5-43.3 C
prior to hair care…
comb hair to remove all tangles
to ensure patient comfort during grooming
use towels and pillow cases to make sure patient is dry and comfortable
when assisting with toileting…
be aware of any restrictions the patient may have
When the patient is in the restroom make sure…
call light is within reach
when assisting with toileting NEVER….
leave a confused/ unstable patient alone
what can you do to make a bed pan more comfortable for the patient?
run warm water over the pan & place baby powder on the rim
after the patient uses the restroom in the bedpan/urinal….
- measure intake/output
- empty pan/urinal, then clean
- clean & dry peri area
when assisting with toileting you are reporting what kind of finding to the nurse?
diarrhea, constipation, blood in stool/urine, mucous in stool, burning/pain during urination, frequent urination, incontinence
before assisting a patient with eating…
check with nurse about dietary restrictions/precautions
before assisting with eating…
assist with toileting
to avoid chocking while assisting with eating…
raise HOB or have patient sit up in chair
Where should sit when assisting with eating
across from patient
when assisting with eating you should…
monitor proper swallowing
what should you do if you are assisting a stroke patient with eating?
Direct food towards unaffected side of the mouth
what is the safest utensil to use when assisting with eating?
a spoon
before weighing your patient…
- zero the scale prior to use
- clear the area of tripping
types of scales
- mechanical
- chair scale
- bed & sling scales
chair scale
subtract the weight of the wheelchair
bed & sling scale
Subtract weight of bedding/equipment
active listening
mindfully hearing & attempting to comprehend the meaning of words
patients have the right…
to full disclosure about their care
smile, eye contact, erect posture, & giving the speaker attention, giving feedback by paraphrasing is examples of….
effective communication
verbal communication
sharing information between individuals using spoken words
nonverbal communication
behavior that complements, negates, or substitutes for spoken words
gestures, mannerism, facial expressions, body posture, eye contact, stance, and movements such as touch, personal space, & overall appearance is examples of…
nonverbal communication
an interaction between a health care professional & a patient that aims to enhance the patient comfort, safety, trust , health, & well being
therapeutic communication
therapeutic communication includes
strategies that convey understanding & respect, with the intention of encouraging patients to express their feeling and ideas
how can you help with pain when assisting a postoperative patient that has had abdominal surgery with turn, cough, and deep breathing?
hold a pillow to the incision site while coughing
how many second should you instruct your patient to hold their breath for when using a incentive spirometer?
3 seconds
normal BP for an adult?
120/80
what do you do if your patient gets a cut that is bleeding?
get a gauze & hold for 2 mins with pressure, then check
epistaxis
nose bleed
what do you do if your patient if your patient is having a seizure?
- clear the area to prevent patient injury
- stay with your patient
what do you do if your patient say they feel dizzy and they feel like they’re going to pass out?
place head between their knees
ABCs
- airway
- breathing
- circulation
1 oz. is equal to?
30mLs
signs of infection
- redness
- swelling
- fever
- warmth around wound
- foul odor or drainage
anything sterile is out of your scope of practice as a PCT. True or False?
true
a patient’s dressing is soaking through, loose, and nonadherent. what do you do?
notify the nurse
drains that exit surgical wounds help?….
drain the fluid that would otherwise pool around the inside of the wound
fluid & other material can leak around the wound
drainage
pool in the wound
exudate
What is purulent
Drainage that contains pus
- sign of infection
- white, yellow, green
5 rights of delegation
right
- task
- circumstance
- person
- direction
- supervision
what is most important about Maslow’s hierarchy of need?
physiologic
your patient is saying they are having trouble going to the restroom (pooping), what should you looking out for?
- no stool for 3 days or more
- stool that is hard & pebble like (sign of dehydration)
What is located in the inside of the upper arm?
Adult brachial pulse
the first drop of blood for a glucometer test is?
not accurate
plasma consist of?
- water
- nutrients
- proteins
when taking care of a patient with vision loss…
- explain everything that is taking place
- lead to desired locations
- avoid phrases like “sit over there”
what do you never want to do if your are taking care of a patient with hearing loss?
- DO NOT speak louder
- DO NOT speak while doing activities
what is your main goal?
to keep your patient safe
what is your priority when taking care of a patient with developmental delays?
meeting physiological needs
- be encouraging
ROM helps prevent what?
contractions and loss of muscle mass
how often should you turn an immobile patient?
every 2 hours
when it comes to taking care of a patient on oxygen, as a PCT you must….
- become familiar with equipment
- be able to report changes in oxygen status to RN
How should the non-rebreather mask expand and collapse?
should expand when patient exhales but should not totally collapse when inhaling
healthy oximetry rate
95% (anything less, notify RN)
capillary refile should return within
3 seconds
when suctioning, how long should you suction for?
no more than 15 seconds at a time
what do you do if your patient is experiencing SOB or dyspnea?
sit patient upright and notify RN immediately
dark stool indicates what?
GI bleed in upper track
red/blood in stool indicates what?
bleeding in the lower GI track
Pale/light stool indicates what?
A problem with liver
accumulation of body fluid in a body part, area, system (swelling)
edema
when is one of the only times you wouldn’t notify the RN that your patient has had no stool for more than 3 days?
unless they are NPO (nothing by mouth)
what is the normal color of urine?
pale straw color, yellow/amber
what can cause a shift in fluid in the body?
- kidney disease
- pulmonary edema
- heart failure
if your patient has urine with unexplained unusual color, odor, volume , concentrated/diluted, blood, or no urine/scant amounts you should?
notify RN immediately
report to RN immediately if you notice emesis with…
- blood
- coffee-ground material
- objects other than food
(leave for the RN to inspect)
normal glucose values for a female
40- 450
normal glucose values for a male
50 - 450
normal adult respiratory rate
12-20 BPM
the body’s natural defense for fighting micro-organisms and is a normal reaction to illness
fever
radial pulse
thumb side of wrist
carotid pulse
on neck below jaw bone
newborns respiratory rate
30-50/min
bradypnea
RR is less than 10/min
-adverse effects of medications
tachypnea
RR is greater than 20/min
- maybe sign of being anxious
when taking a patients BP, avoid performing on arms on the same side of…
- IV line
- injury
- burns
- mastectomy
signs of hypoxia
- anxiety
- lack of concentration
- fatigue
- hypertension
- cyanosis (turning blue)
- dyspnea (SOB)
- increase/decreased HR
canes
for patients who can bear weight but have a weakness on one side of the body
- handle should be at hip level
crutches
patients who cannot bear full weight on at least one leg
walkers
provide most stability for patients who can bear weight
- 4 legs & 2 or 4 wheels
- hand grips should be at hip level
room temp
22 C (72.6 F)
how should you document bodily fluids?
amount, color, & consistency
how should describe stool?
loose, semi-formed, soft, or hard
when should you activate emergency response
- no pulse
- no breathing
what are the situations of immediate notifications of the nurse
- cyanosis
- SOB
- difficulty breathing
- changes in loss of consciousness
- falls
- uncontrollable bleeding
- chocking
- sudden unbearable pain
patient is experiencing SOB/dyspnea
place patient in an upright position then, call the nurse immediately
indications dressing wound needs to be changed
- moisture or drainage soaking the dressing
- looseness of dressing
- nonadherence of the adhesive portion of the dressing/tape securing it
- REPORT THESE FINDINGS TO NURSE
wound drains
help prevent fluid & drainage from accumulating in the wound and delay healing
ostomy care consist of…
- emptying pouch, cleansing the ostomy & skin around it, and reapplying the appliance
colostomy
opens from large bowel & expels feces into ostomy appliance
- liquid to semi-liquid to solid stool
ileostomy
drains liquid stool from the distal part of the small bowel into ileostomy appliance
when should you empty ostomy pouches
when bag is half ful
where should you wipe for the ostomy care
wipe the lower 5.1 cm (2 in) of the pouch
where can hospice take place
- in patient’s home
- hospital
- long-term care facility
- designated hospice facility
for hospice care, your goal as a PCT is to…
be compassionate, respectful, & comforting for patients & family members, as well as supportive toward other members on care team
palliative care
patient unlikely to live longer than 6 months
before removing an IV infusion…
check with nurse if provider prescribe discontinuing
should you put gauze on the IV site as you are removing the catheter?
yes but DO NOT apply pressure when removing
how should you pull the transparent tape/dressing
towards the insertion site
how should the hub of the needle be
parallel to the skin
after removal of IV catheter
- inspect tip is still intact
- examine for infection
Maslow’s hierarchy of needs
- physiologic
- safety & security
- love and belonging
- self-esteem
- self-actualization`
if patient is bleeding
- apply pressure with gauze for several minutes
- DO NOT keep checking
- if still bleeding after several minutes call for help
what to do if your patient is experiencing epistaxis (nose bleed)
- have patient sit up and lean forward
- apply pressure to nostrils by pinching nose
- pressure for 10 to 15 mins
- if still bleeding, insert gauze, and notify nurse
s/s of shock
rapid pulse, increased shallow breathing, blank stare, cold, pale, clammy skin
what to do if patient is experiencing shock
- call for help
- ensure open airway
- if patient is lying down, position head below the body
- keep warm & safe until help arives
what to do if patient is experiencing shock
- call for help
- ensure open airway
- if patient is lying down, position head below the body
- keep warm & safe until help arrives
Expected output of urine in a 24 hour period
750 - 2,000 mLs
RACE
Rescue
Activate
Confine
Extinguish
HIPPA
Health insurance Portability and Accountability Act
what is HIPPA for
a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.
sanitization
reducing the number of microorganisms by removing debris with soap and water prior to disinfecting
sterilization
technique for destroying pathogens and their spores on inanimate objects, using heat, water, chemicals, or gases
disinfection
cleaning something (work area, equipment) using chemicals that kill pathogens but not their spores
OSHA
requires disposal of infectious & hazardous waste according to safety standards
- use of PPE
- Safety data sheets (SDSs)
where do you dispose non sharp hazardous waste
in biohazardous bags
what denture should go in first
top
if patient is unsteady, and you need to weight them on a scale without handles, what can you do to help keep them from losing their balance and falling?
place a walker
suctioning a tracheostomy
put the catheter through the tracheal canula until you feel resistance, the pull back 1 cm. Apply intermediate suction by placing your thumb over the suction control valve. while suctioning, rotate the catheter and do not suction longer than 10 seconds
how often should you round
every 1 hour
removing an IV catheter is…
not a sterile but a clean procedure
compressive devices (SCDs)
- device that promotes blood flow in the legs and feet, preventing blood clot formation
how many finger should fit beneath a compressive sleeve?
2 fingers
how often should you check a compressive device
every 8 hours
- inspect the skin
- check circulation of skin and below the skin
what can you do as a PCT with a sterile field
you can set one up but you cannot perform sterile procedure
OBRA
omnibus budget reconciliation act
- protect long term patients in facilities
what position should a postmortem patient be placed in
semi-fowler’s with pillow under head
how often should you empty a catheter drainage bag
every 8 hours
how deep should compression be during CPR
2 inches
what position should the patient be in when applying antiembolism stockings
supine
how many times should a patient repeat the use the spirometer
every 1 to 2 while awake
how do you make an open bed?
fan fold the blanket to the bottom of the bed
what is serous drainage
clear & thin, may be present in a healthy wound
what is serosanguineous drainage
containing blood, may also be present in healthy healing wound
what is sanguineous drainage
primarily blood
what is purulent drainage
thick, white, & pus-like
may be indicative of infection and should be cultured
occlusive dressing
air cannot come in contact with wound (solid film)
nonocclusive dressing
holes, & air can supply to it can come in contact with air
compression device
-check every 8 hours
- inspect skin & circulation of skin & below skin
what type of puncture is a glucometer (glucose test)? and what does it contain?
- dermal puncture
- contains capillary blood
what do you do after collecting capillary blood for a glucose test?
- give patient a gauze to go on the finger tip to stop the bleeding
- capillary punctures usually stop bleeding promptly & bandage is not needed
vital signs are a key indication of
homeostasis
older adults may have a slightly lower body temp.
true or false
true
radial pulse
thumb side of the wrist
- common for adults
brachial pulse
- inside upper arm
- common on children
carotid pulse
neck below the jawbone
- common for emergency response
the stronger the pulse the…
better the circulation
auscultation
measuring the heart with a stethoscope listen and count the apical pulse rate at the apex of the heart
where should the BP cuff be located
lower edge of the BP cuff should be 2.5 cm (1 inch) above the crease of the inner elbow
steps for manual BP
- find the radial pulse
- inflate cuff until you cannot hear a pulse
- then inflate the cuff additional 30mmHg
- place stethoscope on L brachial artery &slowly release
apical area
most reliable and accurate method to record and document the pulse rate of a patient with atrial fib.
palliative care
to relieve of distressing physiologic symptoms at the end of life, such as pain & difficulty breathing
hospice is for
patients who are unlikely to live longer then 6 months
where can hospice care take place
- in a patients home
- long-term care facility
- designated hospice facility
sings of adequate perfusion
warm skin, pink mucous membranes, strong peripheral pulses, capillary refill that is less than 2 secs
oral temp
36.5 to 37.5 C (97.6 to 99.6 F)
tympanic temp
37 C (97.6 F)
temporal temp
36.5 to 37.5 C (97.6 to 99.6 F)
normal BP
120/80
newborns average HR
120-160/min
average infant HR
80-140/min
toddlers average HR
80-130/min
Pre-k average HR
80-120/min
6 - 15 y/o average HR
70-100/min
newborns RR range
30-50/min
bradypnea
less than 10/min
tachypea
greater than 20/min
what is the expected range for a 2 y/o to adult fasting glucose level
70 to 110 mg/dL
adult fasting glucose expected range
74 to 106
60 to 90 y/o fasting glucose range
82 to 115
older tan 90 y/o fasting glucose range
75 to 121
random glucose expected range
less than 200 mg/dL
postprandial (2hrs after eating) glucose expected range for 0 to 50 y/o
less than 140 mg/dL
postprandial glucose range for 50 to 60 y/o
less than 150 mg/dL
postprandial glucose range for 60 and older
less than 160 mg/dL
females critical vales for blood glucose
less than 40 and greater than 450
males critical values for blood glucose
less than 50 and greater than 450
how should the nonbreathier mask expand and collapse
expand when patient exhales and not totally collapse when inhaling
if patient is receiving oxygen at a flow rate of greater than 4L/min or has symptoms of dry mouth. what do u do?
attach flow meter to a humidifier
what should you check for on the humidifier
- if it is bubbling
- if water level is not getting low
what can make the patient on oxygen more comfortable
- applying water - soluble lubricant to the nares
- provide oral care frequently
s/s of hypoxia
anxiety, lack of concentration/focus, fatigue, hypertension, cyanosis, dyspnea, increase/decrease in HR/RR
capnography
measures oxygen level in the blood
What degree should you raise the HOB for suctioning
45 degrees
When should you notify the nurse when you patient is on oxygen
- if oximetry is less than 90%
- if oxygen tank almost
- big difference between the prescribed oxygen flow rate & flow rate on flow meter
- any sudden changes in patient’s condition
Hand-splints help with
Proper positioning and alignment by keeping thumb slightly adducted in opposition
Patients that are at high risk falls
- older patients (elderly)
- certain medications
What should you clean a venipuncture site with, if the patient has a allergy to shellfish?
Chlorhexidine gluconate
Is hospice reimbursed by Medicare & Medicaid. True or false?
True
Continuous Pulse oximetry
Measures oxygen dioxide in exhaled air
Bariatric beds
Accommodate more weight and are wider than standards
Alternating pressure beds
Circulate air or water under patient, shifting pressure and reducing risk of developing pressure ulcers
Airflow beds
Containing small beads that in constant motion by circulating
- prevent pressure ulcers and keeps patients skin dry
Pulmonary therapy beds
Vibration and percussion to patient at risk for respiratory complications & also helps prevent ulcers
Where should apply restraints
On the wrist, under the patients clothing
When should the coding of the glucometer be checks
Every time it is used
