final exam Flashcards
safety precautions
- lock wheels of the wheelchair to prevent it from moving on the client when sitting down
- call bell should be within reach @ all times, teach client to use call bell
- keep clients bed in low position
- put fall risk id on clients wrist
dirty linen
- all linen that touches floor should get put in linen bag
location of pt
pt at risk for fall should be near the nursing station
history of falls precuations for showers
put a bath seat in it
gait belt
helps support the client while walking. gait belt keeps the client center of gravity stable and helps prevents falls
precautions
- 95 mask is required for airbone precautions
- gloves are required when coming in contact with bodily fluids
- hand hygiene should be preformed in between every glove use
hippa
- when complying with hippa remember that documentation provides info to facilitate communication amoung members of the health care team and plan appropriate therapies when evaulating progress
insurance
- health care facilites hvae insurance that covers all employees
- recommended that nurses obtain their own professional liability insurance
violations of hippa
- sharing a computer password with coworkers would violate hippa
- sharing lab findings with a client family would be a violation of hippa unless the family is considered an authorized person
documentation provides
info to facilitate communication among all members of the healthcare team
interprofessional team
- an occupational therapist can assist with clients who have physical challenges with adaptive devices to help with self care activities
applying critical thinking skills
helps pt focus on their values and beliefs within their mangement of care
what does a nurse consider whom is critically thinking
immediate action with a pt condition worsens
a nurse who improves plan of care….
while thinking back on interventions and their effectiveness is critically thinking
what does concept map promote
clinical decisions and critical thinking -
nursing process and exploring other option for pt care
promote critical thinking
cane
- instruct client to move a cane an advance their weak leg forward to the cane followed by the advancing strong leg past the cane
- provides clients body weight to be distributed between the cane and the stronger leg
where should height of the cane be
equal distance between the floor and the hip
which side should the cane be on
strong side of pt. body
how should the elbows be when holding cane
keep their elbow slightly flexed when they use their cane
walker
client should lift the walker in advance it and then set it down
- nurse should walk slightly behind client who is using a walker in case they need assistance
how should the client move feet with walker?
the client should move one foot up to the walker and move the walker first
where should the walker land on a person body
below the level of the clients waste
nursing process first step
assessment
includes:
- organizing clients data
- nurse should assess the client’s date first and then analyze the data to determine what is a priority
steps of nursing process
assessment analysis planning implementation evaluation
nursing plan of care
comes after implementation of care
- plan following by evaluation to determine the effectiveness of the interventions that the nurse has done
sterile field
- open package over a sterile package over the middle of sterile field
- pull flaps of the package away from body, grasping it from side to side to avoid reaching over the sterile field and contaminating
- label into palm of hand so that the solution doe snot drip down the label in ruin it
restraints
- use a quick release tie fro easy removal in emergency
- two fingers should fit under restraint
- padding should be applied against bony promises with restraints to prevent friction and potential skin breakdown
how often should restraints be removed
remove every two hours according to facilities policy
- assess skin and whether or not the restraint is too tight
where should restraints be secured to
an area of the bed frame that moves with the client when repositioning
- not to the siderail
- head of bed is okay
how often does provider renew prescription for restraints
every four hours
what should a nurse do before restraints
consider alternative methods versus restraints
- restraints will physically help a client for moving freely however, they are a last resort
being in bed immobile increases
breakdown of bone tissue
- results in high calcium
complications of immobility
- contractures of the extremities
- extra fluid in lungs
- pressure ulcers
- constipation
- not able to cough affectively
- low oxygen levels
- feet cant flex
foot board
feet not flex helpful to prevent foot drip in bed
proving hygiene
- make sure personal items are used when changing linens
- do not make the bath water too hot
- move with direction of growth when shaving to prevent burns
oral care
- head should be turned so pt does not aspirate
- turning pt head to side during mouth care is better than putting the nurses thumb or fingers into the mouth
activities of daily living (ADLs)
- performing oral hygiene, bathing oneself and getting dressed
- occupational therapist assist the most with activities of daily living
urine specimen collection
female:
- client should clean area of the perineum from front to back to avoid bacteria entering specimen
- client should begin a stream of urine and then pass the container intoto the urine stream when obtaining the sample
- wash off bacteria at the distal urethra that may contaminate sample
what contributes to constipation
- excessive laxatuve use
- ignoring the need to use bathroom
- inadequate fluid
what results in hardening of stool
reducing fluid flows the passage of food through the intestine
what promotes bowl emptying
- increase fiber in diet
- increasing activity
what prevents constipation
increasing vegetables
urinary incontience
- assit client every 2 hours creates regular pattern of toleting to prevent incontience
- protect pt. skin
discontinuing catheter
pt should be laying down in a supine position
when incontienence is suspected what should u do
bladder scan
pressure ulcers
reposition client every 2 hours especially when sore is at stage 3
- transparent dressing is first choice for stage 1 ulcer
- stage 3 pressure ulcer has necrotic sub c tissue
when assessing a pt. fluid status the nurse should reveiw
- health history
- lab data
- clinical assessment
adult water ratio
50-60% of total body weight
infants water ratio
75-80% of total body weight
2/3 of body fluid is
intracellular
1/3 of body fluid is
extracellular
factors to fluid volume deficit
- excess gi loss
- diaphoresis
- fever
- hemmorrhage
- insufficient intake
- burns
- diuretic therapy
- aging: older adults have less body water and decreased thirst
fluid volume deficit clinical manifestations
- weight loss
- dry mucus membranes
- increased heart rate and respirations
- thready pulse
- capillary refill less than 3 sec
- weakness, fatigue
- orthostatic hypotension
- poor skin turgor
late symtoms of fluid deficit
- oliguria
- decreased cvp
- flattened neck veins
diagnostic procedures
- serum electrolytes
- bun/creatinine
- hct
- urine specific gravity and osmolarity
fluid volume deficit nursing interventions
- monitor vital signs
- monitor skin turgor
- maintain strict i&o
- weight pt. daily
- monitor lab are ordered
fluid replacement as ordered
- increase oral fluid intake
- initiate oral rehydration solution
- anticipate giving iv fluids for severe dehydration/maintain as ordered
- initiate fall precautions
medications for fluid volume deficit
- electrolyte replacement
- intravenous fluids
fluid volumem excess
fluid intake or retention is greater than the body needs
volume excess contributing factors
- kidney failure
- heart failure
- cirrhosis
- interstitial to plasma fluid shifts: burns, hypertonic fluids
- excessive water intake
fluid volume excess clinical manifestations
- cough, dyspnea, crackles
- increased blood pressure
- tachypnea and tachycardia
- bounding pulse
- weight gain (1L= 1kg)
- increased urine output
- increased central venous pressure
- edema
fluid volume excess diagnostic procedures
- serium: electrolyte, bun, creatinine, hct
- urine: specifc gravity and osmolality
chest x-ray if respiratory complications are present:
- increased work of breathing
- tachypnea
- low o2 saturation
nursing interventions volume excess
monitor respiratory rate, symmetry and effort
- monitor heart sounds
monitor for edema:
- measure on scale
- 1+ (minimal) to 4+ (severe)
- monitor dependent edema by measuring circumference of extremities
fluid volume excess nursing interventions
- monitor for ascites
- measure abdominal girth
- weight pt. daily
- maintain strict i&o
- monitor vital signs
- administer diuretics
- limit fluid intake
- provide frequent skin care
- semi fowlers position: reposition pt. minimum of evert 2 hours
- restrict sodium intake
hypovolemia
occurs when there is a decrease in blood volume within the bidy due to loss of body fluids or blood
- excessive sweating, large burns, diuretics, inadequate fluid intake, and increased urination can lead to hypovolemia
- causes nose, mouth, other mucous membranes to dry out, the skin to lose elastivity, and urine output to decrease
- body then tries to compensate for volume loss by increasing the heart rate and strength and contractions
hypovolemia untreated
- blue discoloration of lips and nails beds
- change in alertness or level of consciousness
- chest pain, tightness, or pressure
- palpitations
- no urine production
- tachycardia- increased heart rate
- tachypnea- rapid breathing
- decreased bp
- weak pulse
hypovolemic shock
which is when the body has lost 20 % or 1/5 of its blood or fluid supply
- treatment is aimed at controlling fluid or blood loss, replacing those components and restoring overall circulation
Hypervolemia
- fluid overload, is a condition where the body has too much water.
- caused by: problems with the kidneys as they are responsible for balancing the salt and fluid in the body.
- The goal of treatment is to rid the body of excess fluid.
