Critical items! Flashcards

1
Q

Handwashing

A
  • Apply soap to hands and wrists enough to produce soapy lather
  • Entire process should take 20 seconds
  • Turn off faucet with new clean dry paper towel.
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2
Q

Checking Radial Pulse

A
  • Explain
  • 2-3 fingers on radial artery
  • No thumb
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3
Q

Respirations

A

-Observe rise and fall of chest for one minute

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4
Q

Blood pressure

A
  • Explain procedure
  • Wrap cuff around arm, position 1-2 inches above elbow
  • Center arrow of cuff over brachial artery
  • Place stethoscope diaphragm over artery site
  • Pump
  • Release slowly and gradually
  • IF BEAT IS HEARD RELEASE PRESSURE, WAIT 30 SECONDS AND RESTART being careful to pump 20 mmHg higher.
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5
Q

Undressing client with limited use of limbs

A

Begin undressing with strongest side first
Begin dressing with affected side first
(Pullover)-place persons hands in sleeves starting with weak side

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6
Q

Making unoccupied bed

A

Don’t shake linens at any time

Assure there are no wrinkles

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7
Q

Making Occupied bed

A
  • Raise side rails or have two care givers present
  • Don’t shake linens at any time
  • Provide for privacy with top sheet or bath blanket and position the person on his or her side facing away from you toward raised side rail or second caregiver.
  • Raise side rail, go to other side of bed and lower side rail (Or trade places with other caregiver).
  • Remove privacy cover without exposing the person.
  • Raise side raid
  • Assure there are no wrinkles
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8
Q

Anti-embolic Stocking

A

Expose only the leg used for placement of the stocking

Ensure stockings are smooth and wrinkle free

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9
Q

Assisting client with eating

A
  • Before delivery, check tray with dietary card to make sure meal is correct.
  • Observe person for signs of choking:
    - Stop offering food or drink
    - Ask if they are OK
    - Encourage hard coughing
    - Offer sips of fluid when airway is clear
    - Report choking to the nurse
  • Record percentage of food and drink consumed
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10
Q

Proper Body Mechanics

A

Demonstrate proper body alignment including
-Wide base of support
-Back straight
Bend from hips and knees
Carry item close to body
Move feet and turn the whole body (No twisting)

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11
Q

Cleaning dentures

A

Decon hands and put on gloves
With dentures in hand, brush all surfaces until clean
Rinse under cool water
Remove gloves and decon hands

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12
Q

Peri-Care

A

-Raise side rails or have two care givers for safety
-Decon hands and put on gloves
-Drape the person so as to provide privacy, only expose what is needed
-Separate labia with thumb and forefiner, with soaped washcloth was down one side front to back changing to clean area of cloth with each stroke.
-Turn person on side facing away
-Clean rectal area front to back rotating to clean portion of rag each time
-remove gloves and decon hands
Replace linens and remove drape while maintaining privacy

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13
Q

Backrub

A
  • Raise side rails or have two caregivers for safety

- Expose back and buttocks keeping the rest of the body covered

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14
Q

Side-lying position

A
  • Raise side rails or have two caregivers present for safety
  • Adjust lower shoulder to prevent direct body pressure upon it
  • Flex upper leg and place in front of lower leg on pillow to prevent contact with lower leg. Support leg level from hip to foot.
  • Support upper arm with pillow, in front of body
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15
Q

Range of Motion exercises

A
  • Place person in supine position in middle of bed
  • Assure person is in the middle f the bed to provide for their safety
  • Move each joint slowly supporting part being execised. NEVER go beyond person’s joint resistance.
  • Cover person to maintain their privacy throughout procedure exposing only the area being worked on
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16
Q

Ambulation using transfer belt

A
  • Assure person is wearing non slip footwear and appropriate clothing
  • With person seated, apply gait belt snuggly around person’s waist
  • Using good body mechanics gasp gait belt with both hands, equal distance apart, assist person to stand.
  • Position self slightly behind and to the person’s side holding belt at the side and back.
17
Q

Assisting person with an affected side into wheelchair

A
  • Assure person is wearing non slip footwear and appropriate clothing
  • With person seated apply gait belt snuggly around the person’s waist.
  • Position wheelchair parallel or slightly angled, to the bed on person’s strongest side.
  • Lock the wheelchair brakes
  • Using good body mechanics, grasp the ai belt with both hands, equal distance apart and assist person to stand.
18
Q

Indwelling catheter female

A
  • Raise side rails or have second person present for safety
  • Decon hands and put on gloves
  • Drape person for privacy, uncover just enough to provide care.
  • Separate labia with thumb and forefinger, with moist soaped washcloth, gently wash down one side of labia from front to back rotating to clean portion of cloth with each pass.
  • Anchor labia between two fingers and wash from meatus down catheter tubing 4 inches with clean part of washcloth. Rinse with clear water in same manner as washed.
  • while maintaining privacy, turn person onto her side facing away.
  • clean rectal area from front to back rotating to clean portion of cloth with each stroke.
  • Remove gloves and Decon hands
  • Replace linens and remove drape while maintaining privacy.
19
Q

Giving bath

A
  • **Sequence of washing not important so long as eyes are claned first and perineum is cleaned last.
  • **During teting you will be expected to deliver partial bath including washing face, ears, neck, chest, arm, hand, axilla area
  • Raise side rails or have two caregivers present for safety
  • Remove top sheet from under the bath blanket without uncovering person
  • Wash the eyes (no soap) from nose toward ears using different area of cloth with each stroke.
  • Cover chest and abdomen with bath blanket and remove towel from chest without exposing person.
  • Raise the side rail or trade places
  • If gloves used remove and decon hands
  • Replace linen and remove drape while maintaining privacy.
20
Q

Commode Assistance

A
  • Assure person is wearing non slip footwear and appropriate clothing
  • With person seated apply giat belt snuggly around persons waist.
  • Using good body mechanics, grasp gait belt with both hands, equal distance apart and assist person to stand
  • Place call light within reach - Ask person to call when ready or assistance desired
  • Decon hands and put on gloves
  • Provide peri care.
  • Make sure person is safe then remove gloves and decon hands
  • Decon hands and put on gloves.
  • remove gloves and decon hands.
21
Q

Brushing hair

A

KWIIPE & PELLWD

22
Q

Charting

A
  • Black or Blue ink only
  • Mark vital signs in appropriate space
  • If required mark intake and output in % and cc or mL
  • Initial, sign bottom with full first, last, title (NA) and date
23
Q

KWIIPE

A
Knock on door
Wash hands
Introduce self
Identify patient
Provide for privacy
Explain procedure
24
Q

PELLWD

A
Place call light within reach of patient
Ensure patient is comfortable
Lower side rails (As per care plan)
Lower bed to lowest level
Wash hands
Document procudere