N126 Lab Flashcards
Catheterization
gather supplies before you begin - catheterization kit: catheter, lube, sterile gloves, bottom drape, fenestrated drape, 2 pieces of 2” tape
knock, gel hands, intro, explanation - put this catheter in your bladder and it’s going to drain your urine
2 forms of ID - name, birthday/medical ID #, allergies
close curtains - privacy
take out catheterization kit from plastic bag, make trash bag with plastic bag
get 2 pieces of 2” tape, tape on table
positioning patient
raise bed up, head down
bend knees, legs open
open up catheterization kit, put close to patient
put bottom drape under patient
put fenestrated drape on top
setup equipment
put on sterile gloves
lube catheter tube tip, connect syringe to catheter port, pretend iodine on cotton balls
cleaning and insertion
hold labia/penis open, keep hand there
clean labia - one side, other side, middle, with all cotton balls
clean penis - circles on tip from center out with all cotton balls
(go around sterile field, stay within 1” of borders, keep field clean)
“this should be uncomfortable but not painful, take a deep breath in”
put catheter into urethra (once urine in tube go 2” more)
inflate balloon, gently tug
secure and clean up
clean up kit
gel, change gloves
hang catheter on bottom hook
apply 2” tape, 1 piece on leg, catheter, 2nd piece on top, fitted
check to see that there’s no loops / kinks
trash fenestrated and bottom drapes
fix patient’s gown, cover
lower bed down, head up, bag doesn’t touch the floor
throw away gloves, gel
“anything else I can do for you before I leave”
side rails up, call light
Head to Toe Assessment
no percussing on the front, not listening trachea, not checking carotid brutis, not checking JVD
gather supplies before you begin - stethoscope, penlight
knock, gel hands
intro
name & birthday / medical record number, allergies
LOC - A&O x4 person, place, time, event
Neural exam -
questions - headaches, seizures, tremors, loss of vision, hearing, taste, smell, or touch
PERRLA - pupils equal round reactive to light accommodation
squeeze crossed fingers - equally strong, close eyes, wiggle fingers, what finger am I touching 2x
radial pulses - equal bilaterally, good rate, rhythm, quality
skin - warm, dry, good color, good cap refill, no edema or swelling, normal turgor - forearms, no bruises, lesions, or rashes
Heart and lungs in the front
questions - do you have any history of heart or lung problems
Heart - 4 spots, aortic - 2nd intercostal space R of sternum, pulmonic - 2nd intercostal space L of sternum, tricuspid - 4th or 5th intercostal space L of sternum, mitral - 5th intercostal space L of midclavicular line, use bell in reverse
Lungs - front, 10 spots, deep breath in and out
Abdominal - lay bed flat, questions, look, listen, feel
questions - when was last bowel movement, consistency - hard, firm, color, nausea, vomiting, diarrhea, constipation
shape - flat, look for pulsation, umbilicus midline and inverted
auscultate - 4 sides, hypoactive, normal, or hyperactive bowel sounds
palpate - 4 quadrants
skin - warm, dry, good color, not distended, no masses or pulsations, soft, no bruises, lesions, or rashes
Feet - pressing soles of feet - push against hands, pressing top of feet - push up
close eyes, wiggle toes, touch toes 2x
pedal pulses - equal bilaterally, good rate, rhythm, quality
skin - warm, dry, good color, good cap refill, no edema or swelling, no bruises, lesions, or rashes
Lungs in back - sit up, fold arms, head down
Lungs - back, 10 spots, deep breath in and out
excursion - deep breath with thumbs- chest wall expansion symmetrical
99 - fremitus, feel 3x
percussion on back
are you feeling any dizziness? walk to a place and back to bed, good posture, gait, well groomed
GCS 15 , appropriate responses, cooperative, speech was clear, able to express thoughts clearly, reality based
“anything else I can do for you before I leave”
side rails up, call light
gel hands
Incentive Spirometer
gather supplies before you begin - incentive spirometer
knock, gel hands, intro, explanation - “are you ready to learn about the incentive spirometer?”
2 forms of ID - name, birthday/medical ID #, allergies
close curtains - privacy
assess current knowledge
“tell me what you know about the incentive spirometer”
provide accurate info
explanation - “important to take deep breaths to keep your lungs nice and clear”
10x / hr or 10x / 2 hrs
suck air in through this
nice slow deep breaths, let it go down on its own, side scale lets you know good, better, best, not too fast - hyperventilate
mark it, reach that mark
if incisions hurt, hug a pillow while doing it
evaluate learning
have patient demonstrate
mark it
demonstrate again
“do you have any questions for me and is there anything else I can do for you before I leave”
side rails up, call light
gel hands
NG Tube
Polly Molly Dolly rode a trolly
Before getting meds -5 rights, why
Patient
Meds - look up meds - side effects, drug interactions, nursing considerations - head up 30 min, allergies
Dose - safe
Route - is route safe
Time - time to take meds vs. current time, last time taken, how often each day
Reason - why
At med cart -5 rights, why
for each drug - write out drug name and amount
Patient
Meds - name of drug, expiration, allergies
Dose - safe, measure out
Route - is route safe, NG tube
Time - time to take meds vs. current time, last time taken, how often each day
Reason - why
At patient bedside - 5 rights, why, doc
gather supplies before you begin - meds, emesis basin, pH paper, syringe, 4 cups, towel
knock, gel hands, intro, explanation - here to give you meds through your NG tube
2 forms of ID - name, birthday/medical ID #, allergies
check sheet with wristband
close curtains - privacy
nursing considerations - head up 30 min
bed up, put on towel, pH paper ready
for each drug
Meds - name of drug, “normally take these drugs at home”
Dose - safe “normally take this amount”
Route - is route safe, NG tube
Time - time to take meds vs. current time, last time taken, how often each day
Reason - why, “why are you taking this med”
check placement - clamping throughout gloves on pull up aspirate with syringe check pH - color, low number in stomach put back aspirate if big enough amount
give meds - clamping throughout pull out plunger from syringe attach syringe to NG tube water 25 mL med 1 med 2 water 25 mL
head up 30 min
secure NG tube to gown
document
“is there anything else I can do for you before I leave”
gloves off, gel hands
bed down, side rails up, call light
Oral Medication
Polly Molly Dolly rode a trolly
Before getting meds -5 rights, why
Patient
Meds - look up meds - side effects, drug interactions, nursing considerations - BP, allergies
Dose - safe
Route - is route safe
Time - time to take meds vs. current time, last time taken, how often each day
Reason - why
At med cart -5 rights, why for each drug Patient Meds - name of drug, expiration, allergies Dose - safe Route - is route safe, PO Time - time to take meds vs. current time, last time taken, how often each day Reason - why
At patient bedside - 5 rights, why, doc
gather supplies before you begin - meds
knock, gel hands, intro, explanation - here to give you meds
2 forms of ID - name, birthday/medical ID #, allergies
check sheet with wristband
close curtains - privacy
nursing considerations - check BP, document BP
for each drug
Meds - name of drug, “normally take these drugs at home”
Dose - safe “normally take this amount”
Route - is route safe, PO
Time - time to take meds vs. current time, last time taken, how often each day
Reason - why, “why are you taking this med”
after each drug checked put wrapped into cup
when all drugs checked, pop into cup
see patient take meds
document
“is there anything else I can do for you before I leave”
bed down, side rails up, call light
gel hands
Sub Q Injection
Polly Molly Dolly rode a trolly
Before getting meds -5 rights, why
check blood sugar, match with insulin
breakfast tray here and ready to be eaten or already eaten
Patient
Meds - look up meds - side effects, drug interactions, nursing considerations - blood sugar levels, breakfast ready, allergies
Dose - safe, based on blood sugar
Route - is route safe, sub Q
Time - time to take meds vs. current time, last time taken, how often each day
Reason - why
At med cart -5 rights, why
Patient
Meds - name of drug, expiration, allergies
Dose - safe, based on blood sugar
Route - is route safe, sub Q
Time - time to take meds vs. current time, last time taken, how often each day
Reason - why
get med - pull up to units desired, inject into bottle, withdraw that much, get rid of bubbles, cap
At patient bedside - 5 rights, why, doc
gather supplies before you begin - sub Q needle
knock, gel hands, intro, explanation - here to give you meds
2 forms of ID - name, birthday/medical ID #, allergies
check sheet with wristband
close curtains - privacy
nursing considerations - blood sugar, breakfast ready
bed up
Meds - name of drug, “normally take these drugs at home”
Dose - safe, based on blood sugar
Route - is route safe, sub Q, last spot
Time - time to take meds vs. current time, last time taken, how often each day
Reason - why, “why are you taking this med”
pick different spot than last time “do you have any questions before I give your insulin” inject 90 degrees dispose of needle document
“do you know what it feels like when your blood sugar is low, if your blood sugar gets low - cold, shaky, call me, is there anything else I can do for you before I leave”
bed down, side rails up, call light
gel hands
