Final Review Flashcards
1
Q
What are the initial manifestations of low oxygen?
A
- tachypnea
- tachycardia
- restlessness from panicking
- pale skin, mucous membrane
- elevated BP
2
Q
What are the last manifestations of low oxygen?
A
- stupor
- cyanosis
- bradypnea
- bradycardia
- hypotension
- cardiac dysrhythmias
3
Q
What are some factors that affect urinary elimination?
A
- age
- stress
- meds
4, preggerz - diet
- mobility
- pain
- psychosocial factors
4
Q
What is the most common cause of UTIs?
A
E. coli
5
Q
What are the types of incontinence? Which is the most common?
A
- stress- most common
- urge
- overflow
- reflex
- functional
- total
6
Q
Describe crackles or rales
A
fine to coarse bubbly sounds as air passes through fluid or re-expands collapsed small airways
7
Q
Describe wheezes
A
high-pitched whistling, musical sounds as air passes through narrowed or obstructed airways
8
Q
Describe rhonci
A
coarse, loud-low-pitched rumbling sounds
9
Q
What is a pneumothorax?
A
air in the thoracic cavity
10
Q
What is atelectasis?
A
collapsed alveoli
11
Q
What are Si/Sx of atelectasis?
A
uneven chest and diminished lung sounds
12
Q
What items are included in PPE?
A
gown, masks, gloves
13
Q
What are the 3 most common reactions to latex products?
A
- irritant contact dermatitis
- latex allergy
- allergic contact dermatitis
14
Q
What is the average time to wash your hands?
A
15-30 sec.
15
Q
When you should you wash your hands with soap and water vs. just geling?
A
Always wash your hands after coming in contact with a C. dif patient or if your hands are visibly soiled otherwise it is okay to gel.
16
Q
When should you perform hand hygiene?
A
- before and after caring for a patient
- touching blood, bodily fluids, secretions, excretions, and contaminated items
- between tasks and procedures
17
Q
List the transmission-based precautions
A
- contact
- droplet
- airborne
18
Q
Describe contact precautions
A
requires gloves and gown. Pt is in a private room to prevent cross-contamination.
19
Q
Example of contact precautions
A
VRE, MRSA, C. dif, wound infxns, and herpes simplex
20
Q
Describe droplet precautions
A
used when a disease is transmitted by large droplets.
requires a surgical mask within 3 ft of the pt, gown and gloves
21
Q
Examples of droplet precautions
A
influenza, pneumonia
22
Q
Describe airborne precautions
A
used with pts who have diseases that are transmitted by smaller droplets. isolation requires negative airflow.
N95 respirator, gown and gloves
23
Q
Examples of airborne precautions
A
TB, MMR
24
Q
What is the primary method to reduce infection?
A
handwashing
25
Normal Blood pressure
120/80
26
What is the approx. value for low BP
90/60
27
What is the approx. value for high BP
175/90
28
Normal heart rate (adult)
60-100 bpm
29
Tachycardia
>100 bpm
30
Bradycardia
<60 bpm
31
Normal respiratory rate
12-20 breaths/min
32
Tachypnea
>20 breaths/min
33
Bradypnea
<12 breaths/min
34
Normal Temp
98.7 F
35
If a UAP reports an unusual VS do we take their word for it? If no, then what?
No, I assess the patient myself. If VS are same, then assess the patient by asking how they are feeling and about recent activities
36
When I am taking HR what am I also assessing?
strength, rhythm, abnormalities
37
If HR should abnormality on the radial pulse, what is the next step?
Check the apical pulse for full 60 s
38
How should you assess pain?
by using the pain scale (0-10) and PQRST
39
What is PQRST?
```
Precipitating factors
Quality
Region
Severity
Timing
```
40
According to PQRST, what kind of questions would you ask to assess S?
Severity. What is your pain level on a scale of 0-10? Does it interfere w/ activities? Does it force you to sit dow, lie down?
41
According to PQRST, what kind of questions would you ask to assess R?
Region. Where does it hurt? Does it radiate?
42
According to PQRST, what kind of questions would you ask to assess Q?
Quality. What does it feel like? Stabbing? Dull? Sharp?
43
According to PQRST, what kind of questions would you ask to assess T?
Timing. When does it start? How long does it last? Frequency?
44
According to PQRST, what kind of questions would you ask to assess P?
What brings about the pain? What are you doing when the pain starts? What makes it better?
45
What are the 4 physiologic responses to pain?
transduction, perception, transmission, and modulation
46
What is the difference between pain threshold and pain tolerance?
threshold is when one begins to feel pain while tolerance is how much pain one can endure or accept
47
Acute pain
temporary, typically less than 6 mos, limited tissue damage with an identifiable cause
48
Chronic pain
long-lasting, longer than 6 mos, leads to great personal suffering
49
What are some factors that affect pain?
age, genetics, religion or spirituality, coping style, culture, and previous experience
50
What is the common effective method for pain?
analgesics
51
If an analgesic is given PO how long does it take to be effective?
30-45 mins
52
If an analgesic is given IV how long does it take to be effective?
3-5 mins
53
What are 2 types of analgesics?
NSAIDS & opioids/narcotics
54
What are some examples of NSAIDS?
motrin, aspirin, naproxen (aleve)
55
What are the common side effect of NSAIDS?
GI bleeding, heartburn, nausea, and upset stomach
56
What is the trade name for acetaminophen?
tylenol
57
What are some examples of narcotics?
Diladud, vicodin, oxycontin, norco, tramadol
58
What are some common effects on narcotics?
dry mouth, constipation, and drowsiness
59
What is an effective communication style from nurse to physician?
SBAR
60
What does SBAR stand for?
Situation, Background, Assessment and Recommendation
61
If you tell the physician that the patient is diabetic and admitted to the hospital for dehydration 2 days ago at 0700, what part of SBAR is this?
Background
62
If you tell the physician that he should come see the patient in 2 hours after pain meds were administered to speak with the patient and you recommend they move to telemetry, what part of SBAR is this?
Recommendation
63
If you tell the physician, hi my name is Nurse Nelson, and I am calling about David Cartell in Rm 214, what part of SBAR is this?
Introduction
64
If you tell the physician, that David Cartell just had a glucose check and it was 232 mg/dL before meals, and needs an insulin prescription STAT, what part of SBAR is this?
Situation
65
If you tell the physician that the pt's VS, pain level, and HR, what part of SBAR is this?
Assessment
66
Wha should you do before calling a physician?
1. Assess the patient
2. Review the chart
3. Know admitting Dx
4. Keep info concise
67
What is the nursing process?
ADPIE
68
What does ADPIE stand for?
```
Assess
Dx
Planning
Implementation
Evaluation
```
69
If I identify the patient's problem, what part of the process am I doing?
Dx
70
If I perform nursing actions, delegate tasks, supervise other health care staff, and document, what part of the process am I doing?
Implementation
71
If I ask myself if the pt meet the planned outcomes, were interventions effective and appropriate, and modification is needed, what part of the process am I doing?
Evaluate
72
If I set priorities, determine pt goals with the pt, and select nursing interventions, what part of the process am i doing?
Planning
73
If I am gathering information on the pt such VS, lab values, medical history and validating, interpreting and clustering data, what part of the process am I doing?
Assessment
74
Say your ABCs
```
Airway
Breathing
Circulation
Disability- LOC
Exposure
```
75
What are some factors that affects wound healing?
age
loss of skin turgor
slower tissue regeneration
decrease in collagen
76
Serous drainage
portion of serum is watery and clear
77
Sanguineous drainage
contains RBCs and thick
78
Serosanguineous drainage
contains both serum and blood
79
Purulent drainage
pus (WBCs) with foul smell, result of infection
80
Purosanguineous drainage
pus and blood (newly infected wound)
81
What is the difference between evisceration and dehiscence?
An dehiscence partial or total rupture of a sutured wound usually with separation of underlying skin layers and evisceration involves protrusion of visceral organs through a wound opening
82
What are risk factors for pressure ulcer development?
shearing, friction, altered LOC, impaired sensory perception, friction and moisture, neglect, nutrition
83
Describe a Stage I pressure ulcer
skin is not broken, nonblanchable redness, may feel warm or cool to toucj, tissue is swollen and congested, possible discomfort
84
Describe a Stage II pressure ulcer
skin is broken, down to epidermis to dermis, reddish-pinkish bed without slough or bruising, superficial and can appear an abrasion, blister or shallow crater, scant drainage, edema persists
85
Describe a Stage III pressure ulcer
skin is broken- down to SQ fat, damage or necrosis can extend down to but not through underlying fascia, deep crater w/o exposed muscle or bone. Drainage and infection are common
86
Describe a Stage IV pressure ulcer
skin is broken- down to bone or muscle. sinus tracts, deep pockets of infxn, tunneling or undermining eschar (black) or slough (tan, yellow or green) not painful anymore
87
Describe an unstageable pressure ulcer
actual depth is unknown w/ no determination of stage bc eschar or slough obscures the wound
88
If evisceration occurs what should you do?
cover area with sterile towels and call physician immediately
89
What is the depth measurement for mild edema (1+)?
2mm
90
What is the depth measurement for moderate edema (2+)?
4mm
91
What is the depth measurement for moderate-severe edema (3+)?
6mm
92
What is the depth measurement for severe edema (4+)?
8mm
93
What is the Braden Scale?
Measurement tool for pressure ulcer risk
94
What are some nursing interventions for preventing pressure ulcers?
1. Rotating a pt q2h
2. Keep skin clean, dry, and intact
3. Ambulate patients
4. Use pressure supportive devices
5. Inspect skin frequentlt
6. Clean the skin with a mild cleansing agent and pat it dry immediately following urine and stool incontinence
7. Bathe with tepid water and avoid scrubbing
8. Do not massage bony prominences
9. Provide adequate hydration
95
When changing a dressing how we do we assess the wound?
TACO
96
What does TACO stand for?
Texture- thick, watery
Amount- scant, copious
Color- purulent, serous, etc.
Odor- foul
97
How should you go about a physical assessment?
assess the body by systemd
98
When observing the eyes what are we looking for?
PERRLA: Pupil, Equal, Round, Reactive and Accommodation
99
Which CN are we observing during eye examination?
CN II & III
100
How should you assess LOC?
ask if they know where they are, why they are there, who is the president, and their name
101
Which 3 step method should you use during assessment?
inspect, palpate, and auscultate
102
What is the purpose of an assessment?
baseline data and plan of care
103
When assessing the lungs, how many sounds should I listen to anterior? Posterior?
Anterior: 6
Posterior: 8
104
What are the auscultatory sites for the heart in order?
Aortic, Pulmonic, Erb's Point, Tricuspid, and Mitral/ Apical
105
What are the 2 sounds expected when listening to the heart?
lub (S1 sound)-dub (S2 sound)
106
What is happening during lub? dub?
lub- ventricular systole (contraction) and dub- ventricular diastole (relaxation)
107
What is an S3 sound?
Ventricular gallop
108
What is an S4 sound?
atrial contraction
109
Which groups of people experience S3 sounds?
pregnant women and CHF
110
What does a ventricular gallop sound like? When does it occur?
Ken-tuck-y and occurs after S2
111
What does an atrial gallop sound like? When does it occur?
Ten-es-see and occurs before S1
112
What are audible when blood volume in the heart increases or its flow is impeded or altered?
Murmurs
113
What is the difference between infiltration and phlebitis?
infiltration- cold in temp, edema, and blanching
| phlebitis- red in color and hot in temp
114
Who is most at risk for falling?
1. elderly
2. those w/
- decreased visual acuity
- generalized weakness
- urinary frequency
- gait and balance problems
- cognitive dysfunction
115
What are some ways to prevent falls?
1. Make sure the call light is within reach
2. Place bed alarms
3. Keep table or nightstand within reach
4. Bed is in its lowest position
5. Fall Risk alerts
6. Place those confused and fall risk closer to the nurse's station
116
For an adult on restraints when should they be given a break?
q2h
117
When can seclusions and restraints be used?
1. with physician's order
2. the pt at harm to themselves or others
3. signed within 24 hours
118
When should a restraint prescription renewed?
q24h
119
What are a nurse's responsibilities for a pt on restraints?
1. assess skin integrity q2h
2. Monitor VS
3. Explain the need for the restraints
4. Ask client for consent
5. Use a quick-release knot
6. 2 finger fit
7. Never leave the client alone w/o restraints
8. Remove to ensure good circulation
9. Tie restraints to the bed frame where they will not tighten when bed lower or heightens
10. Evaluate regularly to determine if restraints are needed.
120
What is the most common sleep disorder?
insomnia
121
What is the inability to get an adequate amount of sleep and to feel rested?
insomnia
122
Sleep apnea
more than 5 breathing cessations lasting longer than 10 s/ hr during sleep
123
Narcolepsy
sudden attacks of sleep or excessive sleepiness during waking hours
124
Nocturnal enuresis
bed-wetting
125
What does the sleep cycle consist of?
4 stages of NREM and a period of REM
126
Describe Stage 1 NREM
1. very light sleep
2. only lasts a few mins
3. VS and metabolism beginning to decrease
4. awakens easily
5. feels relaxed and drowsy
127
Describe Stage 2 NREM
1. deeper sleep
2. 10-20 mins long
3. VS and metabolism continuing to slow
4. requires slightly more stimulation to awaken
5. increased relaxation
128
Describe Stage 3 NREM
1. Initial stages of deep sleep
2. 15-30 mins long
3. VS continue to decrease but remains regular
4. difficult to awaken
5. relaxation with little movement
129
Describe Stage 4 NREM
1. delta sleep
2. deepest sleep
3. 15-30min long
4. VS low
5. Very difficult to wake up
6. physiologic rest and restoration
7. enuresis, sleepwalking, sleeptalking
8. repair and renewal of tissue
130
Describe REM sleep
1. vivid dreaming
2. about 90 mins after falling asleep
3. longer with each sleep cycle
4. varying VS
5. very difficult to awaken
6. cognitive restoration
7. avg length 20 min
131
What are some factors that can affect sleep?
1. illness
2. current life events
3. emotional stress or mental illness
4. exercise
5. fatigue
6. sleep environment
7, medication
132
Exercise promotes sleep is at least how many hrs. before bedtime?
2 hrs
133
What are the 3 parts to a NANDA nursing diagnosis?
Diagnostic label, related to and as evidenced by
134
What are some influential factors that affect bowel elimination?
1. stress
2. diet/nutrition
3. exercise/ activity
4. age
5. hydration/fluid
6. pain
135
Define incontinence
inability to control defecation, often caused by diarrhea
136
Define diarrhea
loose or watery stool
137
Define constipation
difficult or infrequent evacuation of hard, dry feces
138
What are some interventions for constipation?
increase liquid intake, ambulation or activity, and increase fiber
139
What is the normal range of diet one should consumer per day?
25-30 g/ day
140
If a patient exhibits red stool, what is your thoughts? Do you presume it is blood?
No, I do not immediately think it is blood, but ask about the patient's diet. Specifically ask if they have been consuming any beets, which may cause stool to be red. Also it can be the result of hemorrhoids
141
If a patient exhibits black tarry stool, what are your thoughts?
Assess the patient and ask if the patient is taking any iron supplements
142
When is okay to say one has a diarrhea or constipation?
3x/day or 3x/week
143
Straining while defecation is an indication of what?
diarrhea
144
If a patient isn'g getting enough fiber, what is a fiber supplement?
metamucil
145
Sierra a patient is experiencing severe diarrhea, what medication helps?
lomotil
146
If you tell the physician about lab and diagnostics, what part of SBAR is this?
Recommendation
147
If a patient has pneumonia what are some nursing interventions?
twisting, deep breathing and coughing
148
If a patient is having diarrhea and has infection or bacteria in stool, can you still give lomotil?
no because you want them to get rid of the infxn or bacteria
149
Supine
laying on back "spine"
150
Prone
laying on stomach
151
Semi- Fowler's
45 degrees sitting up
152
Full-Fowlers
90 degrees sitting up
153
Sim's
on the side with one leg bent
154
What is an example of a stool softner?
colace
155
Define impaction
stool hardening and will not pass
156
What can impaction lead to?
obstruction
157
What are the 4 types of enemas?
1. cleansing
2. return-flow
3, medicated
4. oil-retention
158
Na
136-145
159
Ca
8.6-10
160
Cl
99-109
161
K
3.5-5.5
162
Mg
1.5-2.5
163
PaCo2
35-45
164
PaO2
80-100
165
HCO3
22-28
166
Actual act of having a bowel movement
defecation
167
What are the 7 rights of medication?
Right:
1. patient
2. medication
3. dosage
4. time
5. time
6. refusal
7. documentation
168
How do you know you have the right patient?
2 patient identifers: name, medical record number and date of birth. never the patients room number
169
When do you do your 3 medication checks?
1. when you get the order
2. when you prepare the medication at the pixis
3. patient's bedside
170
What are the 11 routes for medications
1. PO
2. IV
3. IM
4. IVPB
5. Buccal
6. SQ/SC
7. PR
8. IVP
9. SL
10. MDI
11. ID
171
What are the routes for enteral medications?
1. PO
2. SL
3. PR
172
What are the routes for parenteral meds?
1. SC/SQ
2. IV
3. IM
173
What meds are given SQ?
1. anticoagulants
| 2. insulin
174
What degrees should you give SQ/SC?
30-45
175
What are the sites to give SQ injection?
1. abdomen
2. back of the arm
3. back of the thigh
4. buttocks
176
what angle should you give an IM injection?
90
177
If you aspirate an IM injection and get blood with a narcotic what do you do? regular meds?
you discard the med with another nurse witnessing you in both scenarios
178
What are some sites for IM injection?
1. deltoid
2. vastus lateralis
3. ventrogluteak
179
What is the important about MDI?
Make sure the lips are sealed
180
What is important aspect of a spacer?
spacer allows more of the medication to enter into the lungs
181
If Jane has a patch, what is important teaching information?
alt. sites and can never wear more than one patch at a time
182
What med is given ID?
TPPD
183
What is stat?
within 15 mins
184
What is now?
within 90 minutes
185
At what degree do you give ID? How should needle be placed?
10-15 degrees and the bevel of the needle should be up
186
BID
Twice per day
187
TID
three times per day
188
QID
four times per day
189
QD
every day
190
PRN
as needed
191
NPO
nothing by mouth
192
What is the onset time for SQ and IM?
3-20 mins
193
If a patient refuses to take their meds, what do you do?
1. Assess and ask why don't you want to the medication.
| 2. then document the patient refused and gave you the medication and time
194
If Sue is getting meds at 0800, what time range do you have to give her meds?
0730-0830. You have an half hour window before and after
195
If a patient is vomiting and has PO med due, what do you do?
call the doctor to see if you can get another order, if another med can be given IV or another route
196
What are high alert medications?
1. heparin
2. insulin
3. K+
197
What do you do before you administer high alert medications?
you have another nurse check it for you independently
198
Black-box warning
what the FDA puts out about med that can be potential harmful (ex. Ritalin )
199
Complementary alt. therapy
eastern meds.
200
Types of complementary therapies
1. accupuncture
2. oils
3. herbs
4. chakras
5. reflexology
6. visualization
7. distraction
8. reflection
201
What is the difference between Eastern and Western meds?
Eastern do not use meds they use herbs and more of a holistic method
202
Holistic
body, mind and spirit
203
AC
Before meals
204
HS
at bed time
205
BC
after meals
206
When should do accu-chek?
ac and hs
207
hyponatremia
low NA level <136. causes cells to swell
208
Hypernatremia
high Na level >145 causes swell to shrink
209
Respiratory acidosis
lungs are unable to excrete CO2
210
Respiratory alkalosis
lungs are excreting too much CO2
211
What is the result of respiratory alkalosis?
hyperventilating
212
What is the result of respiratory acidosis?
hypoventilating
213
Metabolic acidosis
increase acid
214
Metabolic alkalosis
increase bicarbonate
215
How do you assess Acid Base with lab values?
1. look at pH
2. look at CO2 and HCO3- values
3. Use Rome
216
What does ROME stand for?
Respiratory Opposite Metabolic Equal
217
So how do determine if alkalosis and acidosis for respiratory?
If pH value and PCO2 values are opposite: if pH is up and CO2 is down= alkalosis if pH is down and CO2 is up= acidosis
218
So how do you determine if alkalosis and acidosis for metabolic?
If pH value and HCO3 values are the same: if pH is down and HCO3- is down= acidosis and if pH is up and HCO3- is up= acidosis
219
Common Si/Sx of respiratory acidosis
oversedation, cardiac arrest and CHF
220
Common Si/Sx of respiratory alkalosis
hyperventilation and pulmonary embolus
221
Common Si/Sx of Metabolic acidosis
renal failure, poisonings, and diarrhea
222
Common Si/Sx of metabolic alkalosis
excessive antacids, NG suctioning and vomiting
223
Hypovolemia
low volume of blood, H2O
224
What kind of patient is hypovolemic?
dehydrated, burns
225
Common Si/Sx of hypovolemia
1. tenting or poor skin turgor, dry mouth
2. increase thirst
3. fatigue
4. decreased urine output
5. flat veins
6. high HR (tachycardia)
7. low BP
8. headache
9. dizziness
226
Common Si/Sx of hypervolemia
1. edema
2. distended neck veins
3. high BP
4. low HR (Bradycardia)
5. SOB
6. strong pulse (bounding)
7. crackles in the lungs
8. increased urine output
9. weight gain
227
What is the best indicator of hypervolemia? How do you assess?
the best indicator is weight gain and you assess by weighing the patient t daily
228
Interventions for hypervolemia
1. low Na+ diet
2. decrease H20 intake
3. check input and output
4. check VS
5. check lab values
6. elevate HOB
7. elevate extremities or reposition
8. check weight
229
What is the normal intake of fluids/day?
2500-3000
230
How do we get nutrition?
1. diet
| 2. IV
231
What is considered intake?
anything you take PO, IV and TPN
232
What is considered output?
anything this is coming out your body: vomiting, suctioning, drain, diarrhea
233
What is the difference between PPN and TPN?
TPN goes directly to the heart
234
What direction does the fluid move in a hypertonic solution? hypotonic solution?
hypertonic into the cell and hypotonic out of the cell
235
What type of solution is a lactated ringer?
isotonic solution
236
What do you typically use to check a patient's nutritional status?
BMI (Body mass index)- height (m2) and weight (kg)
237
BMI OF 25-30 is considered what?
overweight
238
What is the BMI for an obese patient?
more than 30 kg/m2
239
What are you at risk for if you are obese?
at risk for diabetes, CAD, hypertension
240
dysphagia
difficulty swallowing
241
If a person has dysphagia or aspiration precaution what type of liquids would you give them?
thick liquids
242
If a person is malnourished what do you observe?
```
dehydration
lab values- low albumin (plasma protein)
dry skin or puzzling
brittle hair and nails
decayed teeth
lips cracked or die
```
243
Clear liquid diet
```
things you can see through:
water
cranberry juice
chicken broth
jello
apple juice
```
244
high fiber diet
whole grains, raw and dried fruit
245
mechanical soft diet
clear and full liquids plus diced or ground foods
246
full liquid
clear liquids plus diary products all juice, pureed vegetables
247
NG
1. Assess the nares- inflammation
back of throat- ensure they have a gag reflex and no obstruction
2. measure tip of the nose to the ear to the xiphoid process
3. lubricate the tip
4. start insertion while drinking water and chin to chest
248
What verifies an NG tube placement?
X-ray
249
What is the actual act of peeing called?
micturition
250
dysuria
difficulty peeing
251
nocturia
peeing at night (children, preggerz, diuretics)
252
oliguria
diminished output
253
hematuria
blood in the urine
254
polyuria
excessive urination
255
What kind of patients have difficulty urinating?
patients with UTIs
256
Si/Sx of UTI
1. burning
2. color (dark)
3. excessive urinating but its scanty
4. urgency to pee
5. hematuria
6. foul smelling
257
What can make urine foul smelling?
1. bacteria
2. asparagus
3. blueberries
4. B12
5. beets
6. medications
258
pyridium
make urine turn orange (ozo has pyridium in it )
259
Si/Sx of UTIs mimic what kind of diseases?
STIs
260
What kind of test do you order to check for WBCs in urine?
culture and sensitivity urine test
261
What are some preventions for UTIs?
1. cranberry juice
2. wipe front to back
3. no tight jeans
4. no bubble baths
5. increase H2O (>3000 ml)
262
What are the 2 types of urinary diversions?
1. continent urinary reservoir- ureters imbedded in the reservoir
2. orthotopic neobladder- ileal pouch replaces the bladder
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Cystectomy
removal of the bladder
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What are the types of urinary specimens?
1. dipstick- change colors determining on the color
2. urinalysis
3. C&S- looking for infection
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Once the urine leaves the body is it considered sterile?
no
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When you want to get a C&S how do you get sterile urine?
midstream or clean-catch
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What are the 2 types of catheters?
1. indwelling/ folley- held by a 10 ml water balloon
| 2. in and out
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How do you know if a catheter is in the bladder?
urine will come out, if not drops come out immediately, massage or push on the bladder
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How many ml can the bladder hold?
600-1000 ml
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How do you remove a folley?
take a 10 ml syringe and aspirate on the port of the balloon so the balloon will just fall out
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What are you look at when you are assessing the urine?
1. color- anything dark is abnormal
2. smell
3. amount
4. transparency/ clarity
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How many ml/hr should we be voiding?
30ml/hour
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What happens if your patient is urinating less than 30ml/hour?
inform the physician after assessing the patient
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What are some nursing dx for urinary elimination?
1. urinary continence
2. risk for infection
3. altered urine function
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During a head-to- toe when do we assess urinary elimination?
1. assess the bladder for distention
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alveoli
gas exchange
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ventilation
processing of moving gases in and out (inhalation and exhalation)
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Hemaothorax
blood in the thoracic cavity
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Anpea
absence of breathing
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Hypoxia
no oxygen in the lungs
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What factors can influence oxygenation?
1. positioning
2. obstruction
3. asthma
4. exercise
5. smoking
6. Medication
7. stress
8. allergies- pollen, abstesis
9. environmental
10. age
11. substance abuse
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How do we know the difference between respiratory distress and choking?
if choking they cannot talk, respiratory distress they can talk
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Assessing chest
1. ensure chest symmetrical
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Trache suctioning
suction on the way up or your way out
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What are the 3 types of chest physiotherapy? Who can do this?
1. postural drainage
2. percussion
3. vibration
Nurse or RT can do this
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What is the purpose of chest physiotherapy?
loosening up chest secretions
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What is our main concern after surgery regarding respiratory system?
pneumonia
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What are some interventions for post-op patients regarding respiratory?
ambulation and lung exercises
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What are lung exercises for post op patients?
deep breathing and coughing using incentive spirometer
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How do you use an incentive spirometer?
5-10 breaths/hour
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How do we prevent pneumonia for post op patients who are bed-ridden?
TCDP- turn cough and deep breath and repositioning them to prevent pneumonia
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Factors that influence bowel elimination
1. stress
2. age
3. exercise
4. hydration/fluids
5. diet- high fiber diet
6. pain
7. activity/inactivity
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How many g of fiber do you need daily?
25-30 g
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What is an example of a stimulant?
ducolax and caffeine
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What are basic interventions to promote bowel elimination?
1. ambulation,
2. increase liquid intake
3. increase fiber
4. increase activity
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What are the interventions after basic ones for bowel eliminiation?
1. stimulant
2. stool softner
3. Digital disimpaction
4. enema
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A what height should you hang a soapsuds bag?
12-18 in above the anus
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What position is the patient in for enemas?
left side sim's
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How far you going to into the anus for an enema? adult?
3-4 in
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What are hemorrhoid?
enlarged blood vessels that can be itchy and uncomfortable
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What kind of patient has diarrhea?
C. diff
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When can you get hemorrhoids?
straining with constipation
| women with multiple pregnancies
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What are the 2 types of hemorrhoids?
1. internal
| 2. external
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What kind of baths do patients with hemorrhoids or vaginal labor get?
Sitz bath
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Fecal Occult Blood Test or Guaiac
determines if there is hidden blood in a stool specimen
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How do you collect a stool softner?
by using a hat
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What is O&P test for stool?
ova and parasite
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What is an ostomy?
surgical incision in small intestines outside the body. Patient move their bowels into the bag. Also relieves gas, so bag will become full of air
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Nursing Dx for bowel elimination
1. constipation
2. diarrhea
3. altered body image
4. knowledge deficit
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When do we use NG Intubation?
1. GI bleed
| 2. nutritional reasons
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If you test the pH of gastric secretions, what pH do you expect?
3-4
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What position do you put a patient in to place a bed pan?
Fowler's
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How often do we need to reposition a patient?
q2h
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What are the interventions for Stage I pressure ulcer?
repositioning, pillows, and heel protectors
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What are the interventions for Stage II pressure ulcer?
Transparent dressings
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What are the interventions for Stage III pressure ulcer?
Specific dressings prescribd by doctor
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How do we measure a pressure ulcer?
width, length, and depth
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What type of aphasia is the inability to name common objects or express simple ideas in words or writing?
expressive aphasia
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What type of aphasia is the inability to understand written or spoken language?
receptive aphasia
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How do you care for a patient with aphasia?
greet and call them by name
speak clearly and slowly using short sentences
Do not shout
ask simple questions
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What cranial nerves are involved with PERRLA?
3, 4,6
