NSS II Flashcards
Temperature’s normal range?
36.0 - 37.5^C
Pulse’s normal range?
60-100 beats per min
Respiration’s normal range?
12-20 breaths per min
Blood Pressure’s normal range?
Systolic = 125-110mmHg
Dystolic = 60-80mmHg
What are 2 arteries used to measure blood pressure?
Brachial artery
Popliteal artery
3 Characteristics of pulse?
Rate
Rhythm
Volume
3 Characteristics of respiration?
Rate
Rhythm
Depth
5 health education for patients with hypothermia?
-Wear extra layers of clothes/ provide more blankets
-Encourage mobilization
-Eat warm food that is high in carbohydrates & drink warm fluids
-Check temperature frequently
-Relief discomfort
List all the protective devices
Limbs
Vests
Belts
Mittens
The purpose of putting on restrains
Restrain movement of one or more extremities
Restrain the patient’s use of fingers
Restain body movements
Health education, when the patient is on, restrains
-Check circulation of restained area
-Educate & explain to the patient the use of restraints
-Ensure self-care needs are met for the patient
-Ensure restraints are only used to protect against self-harm & remove them when safe
-Ensure restrainers are used for safety reasons and not for punishments
Potential complications when the patient is on restrains
Strangulation
Dehydration
Fecal impaction
Infection Pneumonia
Bruising
Pressure ulcers
Depression
Nursing considerations when collecting sputum for a patient who can expectorate
-Sit the patient up and offer mouth care/ rinse mouth with water
-Ask the patient to start deep breathing & coughing to help facilitate sputum expectoration
-Instruct patient to cough & expectorate 15-30 ml of sputum into a sterile specimen container
-Ensure the container is clearly labeled
-Offer oral hygiene to patients after the procedure to reduce halitosis
Purpose of collecting stool specimens?
Monitor the effectiveness of treatment
To screen for colon cancer
Detect any parasites
Purpose of obtaining a swab specimen?
Identify the presence of pathogens
MRSA( Methicillin- Resistant Staphylococcus Aureus)
Determine the sensitivity of bacterial calls to antibiotics
Monitor treatment of an infection
3 common sites for the collection of swabs
Nasal Cavity
Axellia
Groin
Factors of pain?
Age
Gender
Culture
Emotional
Previous experience of pain
Environment
Types of patients that require gastric specimen collection
Patient with a history of gastric ulcers
A patient suspected of gastric infections
Patients who consume non-corrosive substances
3 purposes of collecting blood specimens for culture & sensitivity
To determine a fungal infection
To determine the type of antibiotics to kill the bacteria/fungi
To assess organ function
Nursing considerations for an enrolled nurse role for drug admission
Check expiration date
Ensure 5 Rights
Observe side effects
Calculate the correct amount of drug to administer
Educate patient & family about specific medications
Identify potentially hazardous areas within the workplace environment
Toilet
Common areas (corridors/lifts/stairs)
Patient’s room/ward/cubical
Waste disposal room
