Fundementals Flashcards
post tonsillectomy interventions
1.discourage coughing/clearing throat as it can lead to bleeding 2.ice collar for pain 3.analgesics 4.avoid milk products (pudding) b/c they coat the mouth and promote clearing of the throat
interventions for fall risk
1.room close to nursies station 2.clutter free and good lighting at night 3.call light near reach 4.bed in lowest position
restraints interventions
1.notify the provider immediately 2.assess every 2 hours 3.always tie to bed frame 4.max 24 hours
what are the different classes of fire
Class A: paper, wood, cloth, or trash Class B: flammable gas or liquid Class C: electric fire
transfering from bed to chair to vice versa
position client so that client is moving toward the strong side
moving clients in bed
ask them to raise their head and cross their arms across their chest
semi fowlers
30 degrees 1.feeding 2.head injury/surgery 3.increased ICP
fowlers
45-60 1.post abdominal surgery
high fowlers
90 degrees 1.dyspnea 2.NG tube insertion
supine
lying on back with a small pillow 1.spinal cord injury (no pillow though)
prone
lying on abdomen with head to side 1.post lumbar puncture 6-12 hours 2.post myelogram 12-24 hours (oil based dye) 3.post tonsillectomy and adenoidectomy 4.immobilized or unconscious
side lying
most body weight on lateral aspect of lower ilium 1.post abdominal surgery 2.post tonsillectomy and adenoidectomy 3.post liver biopsy (right side) 4.unconscious
Sims
lying on left side with most weight on anterior aspect of ilium, humerus and clavicle 1.enema administration
lithotomy
1.perineal, rectal, vaginal procedures
trendelenburg
head and body lowered while feet are elevated
1.during labor if umbilical cord pressure is trying to be relieved
modified trendelenburg
supine with legs elevated
1.shock
reverse trendelenburg
head elevated while feet are lowered
- cervical traction
- feeding clients restricted to supine position such as post cardiac cath
dorsal recumbent
- urinary catheterization (females)
- abdominal assessment
- wound evisceration
crutches
- correct fit (3 finger widths between axilla and top of the crutch
- elbows flexed
- do not bear weight on axilla
- 6-10 inches
non weight bearing crutches
means that you have one leg that can not bear any weight
- advance both crutches and the affected extremity while balancing on the good leg
- move good leg forward beyond crutches
- move both crutches then the affected extremity
4 point gait
used when you have partial weight bearing on both legs
- move right crutch forward (6-10 inches)
- move the left leg to even it with the left crutch
- move left crutch foward
- move right foot forward to even with right crutch
3 point gait
used for people that have one leg that can not bear weight
- move both crutches forward with weight on unaffected leg
- shift weight to crutches and move unaffected leg forward
2 point gait
opposites move at the same time
1.right foot and left crutch forward
walking up and down stairs with crutches
good foot heaven bad foot hell
- when going up unaffected leg goes up first and the crutches move with the affected leg
- affected leg goes down first and crutches still move with the affected leg
canes
- size is measured from greater trochanter to floor
- goes with unaffected side
- moves forward 6-10 inches
- move cane forward first while bearing weight on good leg. move the bad leg forward shift weight to cane then move good leg forward past the cane.
walkers
for sizing the clients wrists should be even with the hand grips on the walker while the arms are dangling downward
- advance walker 12 inches
- move the affected lower limb then the good one
- do not use a rolling walker if support is needed due to weakness or for parkinsons
sterile field
the 1 inch border is nonsterile.
all objects stay above waist and within vision
airborne diseases
measles, varicella, TB
- Negative pressure room with HEPA filter
- must wear FIT tested N95
- apply a small particulate mask to client if they wanna leave the room for a medical reason only
droplet precautions
- for droplets larger then 5 mcg
- can put with another person with same organism
- keep door closed
- mask is required when personnel is within 3 ft of client
protective isolation
clients who have bad immune systems
- no fresh flowers, fruits or veggies
- for max protection positive pressure room
putting on and taking off PPE
- when putting it on goes up the body then hands
- removal is alphabetical (gloves, goggles(face shield), gown, mask)
how long is hepatitis A contagious for
the first 7 days after the onset of jaundice
how often should you get a routine physical
females every year starting at 20
males every 3-5 years starting at 20 then anually at 40
how often should you get dental assessments
every 6 months
how often do you check BP
after age 20 every 2 years unless its higher then 120/80 then its every year
how often do you check blood cholesterol
every 5 years if no risk factors begining at 20
how often do you monitor Blood glucose
every 3 years starting at age 45
Colorectal screenings
- fecal occult blood anually starting at 50
- flexible sigmoidoscopy every 5 years or colonoscopy every 10 years OR double contrast barium enema every 5 years or CT colonography every 5 years
how often should you do a PAP smear
every 3 years starting at 21
how often mammogram
yearly after age 40
how often prostate exam
annual digital rectal exam (DRE) and prostate specific antigen (PSA)
morse fall scale
what is benzoin
its a cream that you put which helps protects the skin and also helps tape stick better.
different types of blood
- whole blood-has all components of blood therefore must be used within 24 hours of collection b/c it clots up easily
- Packed RBCs contain only HgB
- fresh frozen plasma is taken from whole blood and contains plasma + clotting factors + blood proteins
blood transfusion rates to know
first 15 mins do 2ml/hr
never exceed 5ml/min (300mL/hr)
normal urine pH
4.6-8.0
how often should regular IV tubing be replaced
96 hours or 4 days
what should you do if you left a catheter in for to long and the tip broke off
apply a tourniquet high on the extremity and notify the provider
classic early sign of infiltration. What about nerve damage
coolness also swelling, tenderness, pallor. For nerve damage the classic sign is tingling
how would you treat phlebitis
- discontinue
- elevate
- warm compress
gait assessment
ask patient to demonstrate four different gaits
- normal gait
- heel to toe (tandem walking)
- tip toe (foot str and coordination)
- walk on heels (coordination)
Weber test
place tuning fork on top of head or midforehead. With conductive hearing loss the patient hears the sound better in the bad ear. With sensorineural loss the patient hears the sound better in the good ear.
Abdominal assessments…
what is Borborygmi
what is Mcburneys point
where are abdominal sounds the loudest
how many bowel sounds are normal
- hyperactive bowel sounds
- rebound tenderness in the right lower quadrant
- right lower quadrant (the ileocecal valve)
- 5 to 30 per min is considered normal.
what is a continuous sensation of vibration documented as
a thrill (indicates stenosis)
The stetoscope. 1.Diaphragm vs bell
2.how do you wear it
the diaphragm is better for low pitched sounds. angle the earpieces toward your nose
glassgow coma scale
- Eye opening (4)
- Verbal response (5)
- Motor response (6)
testing CN 5
ask patient to bite down and feel the temporal muscle and masseter muscle contract. Also check the sensory branch by asking patient to close eyes and see if they can feel like touch of forehead, cheeks, chin
CN 11
Accessory
Ask patient to move head to each side while you uprovide resistance. Ask to shrug shoulders while you provide resistance
what does a hearing aid that whistles indicate
improper size or to much ear wax
effects of magnesium and calcium on GI system
Mag-diarrhea and cramping
Calcium - constipation (decreases peristalsis)
how to avoid nausea of chemotherapy
- avoid highly seasoned food
- dont eat 2 hours before chemo
which nutrient promotes the absorption of PO iron
vitamin C
according to my pyramid how many cups of veggies should you eat per day
2.5
symptom of chlamydia reinfection
mucopurulent cervicitis - yellow vaginal discharge
easily induced vaginal bleeding
urinary frequency and abdominal pain
may also be asymptomatic
if a client scheduled for surgery suddendly reports that they have a latex allergy what should the nurse do
move the surgery up to the first surgery of the day. The latex dust from the previous day would have already settled.
