Critical items! Flashcards
Handwashing
- 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.
Checking Radial Pulse
- Explain
- 2-3 fingers on radial artery
- No thumb
Respirations
-Observe rise and fall of chest for one minute
Blood pressure
- 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.
Undressing client with limited use of limbs
Begin undressing with strongest side first
Begin dressing with affected side first
(Pullover)-place persons hands in sleeves starting with weak side
Making unoccupied bed
Don’t shake linens at any time
Assure there are no wrinkles
Making Occupied bed
- 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
Anti-embolic Stocking
Expose only the leg used for placement of the stocking
Ensure stockings are smooth and wrinkle free
Assisting client with eating
- 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
Proper Body Mechanics
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)
Cleaning dentures
Decon hands and put on gloves
With dentures in hand, brush all surfaces until clean
Rinse under cool water
Remove gloves and decon hands
Peri-Care
-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
Backrub
- Raise side rails or have two caregivers for safety
- Expose back and buttocks keeping the rest of the body covered
Side-lying position
- 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
Range of Motion exercises
- 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
Ambulation using transfer belt
- 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.
Assisting person with an affected side into wheelchair
- 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.
Indwelling catheter female
- 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.
Giving bath
- **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.
Commode Assistance
- 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.
Brushing hair
KWIIPE & PELLWD
Charting
- 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
KWIIPE
Knock on door Wash hands Introduce self Identify patient Provide for privacy Explain procedure
PELLWD
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
