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264 Cards in this Set

  • Front
  • Back
Movement of limbs away from the midline of the body.
Abduction
Movement of limbs toward the midline of the body.
Adduction
The process of gathering data about the client's healh status to identify the concerns and needs that can be treated or managed by nursing care.
Assessment
Movement of a joint in a circle.
Circumduction
A condition cuased when a blood clot (thrombosis) develops in the lumen of a deep vein, such as the tibial or popliteal.
Deep Vein Thrombosis (DVT)
Assigning responsibility for certain tasks to other people, thereby allowing the nurse to concentrate on aspects of care that require the skill of a registered nurse.
Delegation
Movement of the ankle away from the midline of the body.
Eversion
Movement from a flexed position; to increase angle at the joint.
Extension
To bend at a joint; to decrease angle of the joint.
Flexion
State of hypovolemia (low blood volume), or dehydration, in either the extracellular fluid (intravascular or interstitial) compartment or the intracellular fluid compartment.
Fluid Volume Deficit
State of hypervolemia (high blood volume) in the vascular compartment, the presence of edema in the interstitial compartment, or excess fluid in the intracellular spaces
Fluid Volume Excess
Bad, offensive breath
Halitosis
Movement of a joint beyond a straight position; further extension
Hyperextension
Inability to control urination or defecation
Incontinence
Is the action phase of the nursing process which the nurse provides services to reach the client goals; any treatment the nurse performs to enhance client outcomes.
Intervention
Movement of the ankle towards the midline of the body.
Inversion
Involving the nervous system (brain, spinal cord, cranial nerves, peripheral nerves.)
Neurological
Involving both the nervous and vasulcar system
Neurovascular
Blood pressure variation in which blood pressure drops by 20 mm Hg or more with postition changes; low blood pressure caused by the failure of compensatory mechanisms to regulate pressure as the client moves from a lying to a sitting or standing position.
Orthostatic Hypotension
Rhyhmic smooth-muscle contractions of the intestianl wall that propel the intestinal contents froward toward the anus.
Peristalsis
A profession rsponsible for the management of the movement system; focuses on clien's impairments, functional limitations, and disabilities.
Physical Therapy PT
Movement of the palm of the hand downward.
Pronation
Movement of a joint around an axis.
Rotation
Exerting a soothing or tranquilizing effect.
Sedation
Foul crusts or accumulations on the teeth, gums, or lips.
Sordes
Movement of the palm of the hand upward.
Supination
An individual, not licensed as a health care provider such as patient care techs or nuse aides.
Unlicensed assistive personnel (UAP)
Steps Before Nursing Procedures
1. Gather equipemnt
2. Confirm physician's order
*3. WASH HANDS- Wear app. PPE as indicated CDC
*4. Confirm client's identity. Introduce yourself. Check client's armband.
5. Explain procedure to client.
6. Secure work area. Clear all obstructions.
7. Protect client's privacy: close door, drape client, pull curtain as needed.
Prior to Nursing procedure why is it to perfom:
Step 1: Gather equipment?
Equipemnt should be ready before beginning procedure in order to save time.
Prior to Nursing procedure why is it to perfom:
Step 2: Confirm physician's order, if applicable.
When a Nursing procedure is part of medical therapy, a physician's order must be confirmed.
Prior to Nursing procedure why is it to perfom:
Step 3- Wash hands. Wear appropriate personal protective equipment (PPE) as indicated by teh Centers for Disease Control and Prevention (CDC).
Prevents spread of microorganisms from the client to the healthcare worker. PPE should be used whenever the healthcare worker faces a risk for exposure to any body fluid.
Prior to Nursing procedure why is it to perfom:
Step 4- Confirm client's identitiy. Introduce yourself. Check client's armband.
Enusres proper identification of client.
Prior to Nursing procedure why is it to perfom:
Step 5-Explain procedure to client.
Reduces anxiety and gains client's cooperation. Clients have the right to be infromed of all procedures.
Prior to Nursing procedure why is it to perfom:
Step 6- Secure work area. Clear all obstructions.
Provides a safe environment for performing procedure.
Prior to Nursing procedure why is it to perfom:
Step 7-Protect client's privacy: close door, drape client, pull curtain as needed.
Prevents exposing private body parts. Protects client's right to privacy.
What are the Steps After Nursing Procedures are complete?
1. Make client comfortable.
2. Dispose of equipment.
3. Wash Hands.
4. Document Care
5. Report any abnormal data to the appropriate personnel.
In Step 1 AFTER procedure:
What measures should be taken to ensure clients is comfortable and ensures clients safety.?
1. Straighten bed linens.
2. Adjust pillow.
3. Assit to comfortable position.
4. Assist to comfortable pos.
5. *Lower bed.
6. *Raise side rails.
7. Position call light within reach.
8. Position personal items within reach.
In Step 2 AFTER procedure: Why must you dispose of equipment?
Prevents cross contamination within client's environment.
In Step 3 AFTER procedure: Why must you wash your hands?
Prevents spread of microorganisms.
In Step 4 AFTER procedure:
What data must be entered in client's record?
Document care (if applicable)
1. Time of procedure.
2. Indication for procedure.
3. What was done.
4. How it was done.
5. Supplies used.
6. Pertinenet assessment and observations.
7. Client's tolerance and response to procedure.
8. Client's tolerance and response to procedure.
In Step 5 AFTER procedure:
Why must you report any abnormal data to the appropriate personnel.
Any abnormal finding must have a corresponding nursing action.
What is the first line of defense to prevent spread of infection between clients and between teh nurse and the client. It is a very simple skill but is is one of the most imporant and most over looked skills that the health care provider must perform.
HANDWASHING
This is required before and after each client contact and as needed to prevent transmission of microorganisms.
HANDWASHING
The number one cause of nosocomial infection (health casre facility acquired) is lack of proper?
HANDWASHING
What equipment is needed for the HANDWASHING skill?
1. Liquid soap in a dispenser
2. Sink with running water.
3. Disposable paper towels.
4. Cleansing sponge with a cuticle stick if needed.
Why is liquid soap used as opposed to bar soap.
Bar soap can transfer microorganisms onto the hands.
What is the running water used for in HANDWASHING?
Used to flush the microorganisms off the hands.
Why are disposable towels used instead fo the re-use cloth towels?
Re-use cloth towels spread microorganisms.
Why can a CUTICLE STICK be used during HANDWASHING skill?
To assit in cleaning under the finger nails.
If using a paper towel dispenser that requires manual advancing for HANDWASHING skill, what do you do?
Advance sufficient amoutn of paper approximately 4 to 6 inches.
Why is advancing 4 to 6 inches on a manual paper towel dispenser during the HANDWASHING skill required?
To provide hands a barrier to advance enough paper to completely dry hands to prevent recontamination of hands. Do not allow paper towl to touch sink or conter. These are considered dirty.
During HANDWASHING skill what temperature is the water, and why?
Warm and flowing. Hot water de;etes protective oils of the skin that leads to chafing; cold water can irritate to the skin.
Can the water during HANDWASHING skill be splashing, and why?
No, The sink and surrounding area are considered dirty areas. Anything that is touched with splashed water is considered dirty.
In step 5 of HANDWASHING skill what do you do with your hands, what level are they kept at, and what do you avoid.
Wet the hand and lower arms under running water while holding the hands lower than elbows. AVOID touching sink.
Why do you hold hands lower than elbows, and avoid touching the sink during HANDWASHING skill?
Allows microorganisms to run off the fingers. The sink is considered a dirty area.
How much liquid soap doyou apply to hands during HANDWASHING skill? How long do you rub all surfaces of hands?
You need a sufficeint amount of liquid soap to create a LATHER, for rubbing all surfaces at least 20-30 sec.
Why must you have enough soap, and rub for HANDWASHING skill?
Enough soap is needed to remove contaminants and the thorough rubbing employs the use of friction to remove micoorganisms.
Special attention should be paid to whcih areas of concentrated microorganisms during HANDWASHING SKILL?
1. Cuticle stick can be used to clean under the finger nails.
2. If cuticle stick not available use other fingernails of oppostie hand to clean under all finger nails.
3. Remove rings prior to hand washing.
4. Must wash thoroughly between fingers and creases of the skin.
How do you rinse your hands in the HANDWASHING skill, and why?
Allowing water to run off the finger tips. Allows the microorganisms to flow from the arms, down hands, off the fingertips, into the dirty sink.
How must you use the paper towels to dry hands in the HANDWASHING skill?
Pat dry starting at the fingertips moving up the hand towards elbow.
Why must you pat dry the skin instead of rubbing?
Patting prevents the movement of any remaining microorganisms. Vigorous rubbing chaffs the skin and will remove protective oils.
How do you turn of the water in the HANDWASHING skill?
By using a paper towel: DO NOT TURN OFF WITH BARE HANDS. Acts as a barrier to prevent clean hands from coming into contact with contaminated faucet.
True or False?
Alcohol based hand rubs may be used in certain facilities to complete hand hygiene between clients if hands are not visibly soiled.
True. The Center of Disease Control (CDC) states that htis hand hygiene technique can be utilized safely and prevents the transmission of microorganisms.
What was developed by the Centers for Disease and Prevention (CDC) to provide widest possible protection against transmission of infection?
Standard Precautions
PPE
How do CDC officials recommend healthcare workers to handle all blood and body fluids?
As if they contain infectious agaents, regardless of client's diagnossis.
What is an important component of medcical asepsis in the use of PPE as a barrier to reduce the transmission of organisms from the client to the healthcare worker?
HANDWASHING
When sould PPE be worn? Can PPE ever be used instead of HANDWASHING?
Whenever the healt care worker faces a risk for exposure to infectious substances. never be used instead of hand washing.
What does Standard Precautions apply to? What is the standard precaustions designed to do?
Blood, all body fluids, secretions and excretions, whether or not they contain visible blood, nonintact skin and mucous membranes. Reduces risk of transmission of recognized and unrecognized sources of infection.
Can PPE be a delegated procedure?
Aspects of the client's care may be delegated to unlicensed assistive personnel (UAP) who have proper training in the use of personal protective equipment.
What equipment is needed for the PPE skill?
Disposable gloves, gown, mask or face shield, goggles.
How do you put on your PPE gown? What are the steps and cautions when putting on PPE gown?
By picking up at the collar and letting it unfold w/o touching the floor, putting arms in sleeves one at a time, pulling up over the shoulders and tying the neck. Make sure gown wraps around body completely and bring waist ties from the front to back and tie.
Why is a PPE gown used? Why must you make sure it wraps compeletly around you?
Prevents transmission of organisms from nurse to client or from client to nurse. Ensures that all the clothing is covered by the gown, preventing accidental contamination.
After putting on PPE gown what is the next step?
Put on gloves. Hold first glove at wrist edge and put fingers into opening s and then repeating for second. Interlace fingers if needed to adjust fit of gloves.
What is the third step after applying PPE GOWN, and Gloves?
Put on mask 1ST postioning mask over nose and 2nd mouth.
Why are PPE masks worn?
Worn when ther is chance of contact with respiratory droplet secrections. Masks prevent microorganisms from splashing into the eyes or mucous membranes.
How do you hold PPE Mask when applying to face?
By its top and pinch metal strip over the bridge of nose for a snug fit. Eliminates air form entering around mask rather than through mask.
When usign a PPE Mask with stings that tie, what are steps to securing?
Pull upper strings over the ears and tie at the upper backof head. Tie two lower ties around back of neck so the bottom of the mask fits snugly under the chin. If the elestic is used instead of ties, follow the same positioning.
What is the 4th item put on after PPE gown is secured?
Goggles or face shield AFTER MASK IS IN PLACE.
Where are soiled items placed?
Biohazard bag. Labeling bags with biohazard alert symbol tells everyone that the contents are potentially infectious.
How do you remove your PPE?
Before leaving room, Untie gown at the waist. Allowed bc any surface under waist is considered contaminated, so strings at waist should be removed before ungloving. Remove gloves by grasping the outside of the cuff of one glove and pull the glove inside out over your hand. Hold the removed glove in other hand. Slip one ungloved finger under the cuff of the rmaining glove and pulldown and off so that the glove turns inside out. Discard BOTH gloves together. Remove gown. UNTIE NECK and let fall from shoulders. Slide hands through sleeves and remove them w/o touching outside of gown. Hold gown at inside shulder seams away from body, alling it to turn inside out . Fold contaminated side of gown inside. Discard in app. receptacle. Remove goggles 1st mask 2nd by untying strings and W/O touching outer suface of mask. UNTIE bottoms trings of mask 1st and top 2nd and lift off face. HOLD ONLY BY STRINGS and discard in app. receptacle. WASH HANDS!
According to CDC, ___,___, ___ have never been transmitted from a housekeeping surface but prompt removal and surface disinfection of an area contaminated by blood or body fluids is a fundamental aseptic practice and a OSHA REQUIREMENT.
Hepatitis B virus, Hepatitis C, and Human Immunodeficiency viruses.
Can CLEANING A BLOOD SPILL be delegated?
This procedure CAN be delegated to unlicensed assistive personnel with propr training.
FOR SMALL SPILLS what equipment is needed?
Disposable gloves (latex or rubber)
FOR LARGE SPILLS what is the quipement needed?
1.Double disposable gloves
2. Protective eyewear
3. Face mask
4. Disposable gown
What are the SPILL cleaning materials?
1. Disposable absorbent material sucha s paper towels
2. Red medical waste or biohazard bag.
3. Appropriate disinfectant
(10% bleach solution is recommended-1:10 parts bleach to water)
4. Forceps or other mechnancial means for picking up sharp objects.
OR
Commercially prepared spill kit which contains needed equipemnt.
____ and ___ are readily inactivated witha variety of germicides.
HBV and HIV
_____ _______ solutions are inexpensive broadspectrum germicidal solutions.
Sodium hypochlorite
Solutions of 1:___ to 1:__ are effectived deping ont he amount of organic material ( blood, mucus, and urine) but ______ is the moste widely used and recommended.
1:10 to 1:100 are effective.
1:10 is the most widely used and recommended.
What is usually in the commercially prepared spill kit?
Powder to solidify spill, scoop to pick it up, PPE and other materials needed for disinfection.
Why must you assess extent of blood and body fluid contamination when CLEANING A BLOOD SPILL?
Strategies for decontamination will differ based on teh setting and the volume of spill.
Control access to the area by______ when CLEANING A BLOOD SPILL, and why.
Blocking off the area of spill from others utnil clean up and disinfection is complete. Prevents tracking of blood or ther infected materials to other areas.
After containing the spill by using paper towels or other absorbent material you would remove any ______?
Visbile organic material with absorbant material.
What would you use to remove any broken glass or other sharp objects from area while performing CLEANING A BLOOD SPILL?
Forceps, tongs, plastic scoop or other mechanical means. It prevents injury from contaminated glass or needles.
Where do you place sharp object when CLEANING A BLOOD SPILL?
In a SHARPS container or other container and place the container in the biohazard bag. Prevents possibility that sharp objects will tear red biohazard bag.
Gently pour bleach or other EPA recommended disinfectant solution onto all contaminated areas how? Makes sure to use ___ bleach soulution or commercially prepared solution.
Pouring from outside toward inside prevents production of contaminated aerosols. Use FRESH bleach solution.
Leave bleach solution in contact with contaminated surfaces for how long and why?
At least a minute, perferably more. This allows enough time for the germicidal solution to inactive the germs.
Why would you wipe affected area with a new paper towel after bleach solution has been placed for at least a minutie during a BLOOD SPILL.
Provides final disinfection. Disinfection with bleach solution will be more effective when organic material has already been removed.
Why would you dry area with new paper towels in BLOOD SPILL?
Contaminated material will be fully removed.
Where would you place all contaminated material from CLEANING A BLOOD SPILL?
Biohazard bag. Follows protocol for hadling medical waste.
Removal of PPE for small spills?
Remove gloves and places in biohazard bag.
Removal of PPE for Larger spills?
1. Remove gown
2. REmove outer pair of disposable gloves
3. Remove face mask & protective eyewear.
4. Remove inner pair of gloves.
Why would you remove Outer gloves then mask and eyewear with INNER GLOVES.
This provents the introduction of blood or other potentially infectious material to the mucous membranes of the face via contaminated glove. Must remove outer gloves first.
When all PPE, spill control equipment and other contaminated items arein the _____ bag, ___ bag securely, )___ of according to policy.
Biohazard bag, seal bag, and dispose according to policy. This assures that medical waste is contained and disposed of properly.

WASH HANDS!
A change in _____ ______ can be a sign that there is an infection or an inflammatory process occurring in the body.
Body temperature
What affects body temperature?
Medications, and conditions. The nurse must be aware of the client's status in order to take the appropriate interventions.
Can ASSESSING A TEMPERATURE be an independent or dependent action?
It can be both.
Can ASSESSING A TEMPERATURE be delegated to unlicensed assistive personnel with proper training.
Yes; however, nurse retains the responsiblility for knowing the client's temps and taking the app. nursing interventions based on that knowledge.
What equipment is required for ASSESSING TEMPERATURE?
1. Thermometer (oral, rectal, tympanic)
2. Water soluable lubricating jelly if rectal
3. Thermometer probe covers
4. Unsterile gloves.
When choosing the the method of taking a temperature it should be?
The route chosen should be the safest and most convenient for the client.
Oral Temperatures for a Newborn?
N/A
Oral Temp. for Infant upt to 1 yr?
99.4
Oral Temp. for Toddler 1-3 yr?
99.0-99.7
Oral Temp. for 3-12 yr?
98.6
Oral Temp. for 12-18 yrs?
97.8 - 98.6
Oral Temp. for adult?
98.6 +/- 1
Oral Temp. for older adult?
97.6 +/- 1
When using a GLASS thermometer, what is the first step?
1. Inspect the thermometer for defects and wipe thermometer with alcohol swab OR place disposable probe cover.
Each glass thermometer will be used for only ONE client.
Shake the GLASS THERMOMETER with a flicking of the wrist motion unitil it reads _____ degrees.
Less than 96 degrees
How do you read a GLASS THERMOMETER?
It must held so that the numbers are read LEFT to RIGHT. It is slightly rotated in the hand until the column of mercary can be read.
Why are GLASS THERMOMETERS unsafe?
They have mercury in them . If broken the mercury requires special clean up/ removal procedures. NEVER USE with a very young client OR one that is combative and could bite the thermometer.
Place the GLASS THERMOMETER under the client's _____ for how long, and where?
Is placed in the sublingual pocket because of the rich supply of blood vessels found there. 2-4 minutes in place ensures more relaible results.
How long do you wait before measuring an ORAL TEMP. if client has smoked or ingested hot or cold liquids or food?
20 to 30 min. = false oral temp. readings
When you remove the probe cover to the GLASS THERMOMETER it should?
Be removed so that the contaminated area is covered and discard. It should peel back on itself and cover the area that came into contact with body secretions.
How do you prepare and ELECTRONIC thermometer?
Turn on the macing by removing the probe. Check to ensure for oral, rectal or tympanic route is selected. These thermometers can be programmed to take temp. using any of the routes.
Does an ELECTRONIC thermometer have a probe cover on it?
Yes, they are muli-client use of equipment. Probe covers must be used to prevent cross contamination.
Whend do you remove the ELECTRONIC thermometer?
You observe for the signal that the temp. has been taken. Some have an auditory signal, some have visual, and some have both.
When taking a TYMPANIC Temperature how do you pull the auricle on a CHILD?
Down and back
When taking a TYMPANIC Temp. how do you pull the auricle on an ADULT?
UP AND BACK
How do you position the tip of the probe when taking a TYMPANIC Temp?
Aimed at the nose. It must be directed toward the tympanic membrane or an errior in directions will result in incorrect readings.
How long does TYMPANIC maching to be complete?
Its and auditory signal and it will sound when complete. Usually takes 2 to 3 minutes.
Axillary Temps. are generally ___ degree below oral readings.
Generally 1 degree BELOW oral readings.
Where do you place the thermometer when taking an AXILLARY TEMP?
In the center of the client's axilla. For accurate readings, it must be placed in an area with the most surface content.
Where are the arms when taking an AXILLARY TEMP?
The arm with the thermometer must be placed across the chest.
How long do you wait for readings of the AXILLARY TEMP?
For 8-10 min; however not if it is electronic. Must remain in contact with surface area.
RECTAL TEMPS. are generally ___ degree ____ than oral.
Rectal temperatures are generally higher than oral.
There are some conditions in which a rectal temp. is contraindicated, suca as ____ or ___ or ____, due to possibility of rectal trauma.
Sucha as rectal or perineal surgery, or injury.
What position do you place the client if taking a RECTAL TEMP, and why?
Left Sims (side-lying) position and drape for privacy. The left Sims pos. provides for easy access to the client's anus. Draping the client is a matter of respect for the dignity of the client and minimizes the client's discomfort during the procedure.
Do you were gloves whie taking a RECTAL TEMP?
Yes, taking a rectal temp, has a greater risk of exposure to body secretions.
What do you apply to a RECTAL TEMP THERMOMETER?
Probe, and water soluble lubricating jelly with unsteril gloves. This will assist with insertion of the probe and minimizes trauma to the rectum. Also, PPE acts as a barrier between clients.
Home many inches or cm do you insert the RECTAL TEMP into the anus?
1.5 inches or 3-3.5 cm. Allows the probe to come into contact with the rectal mucosa. The probe should be angled toward the client's umbilicus.
How long do you hold the RECTAL thermometer in place for?
2-4 minutes are required for an accurate reading with a glass thermometer. The signal for an electric therm. HOLD THE PROBE IN PLACE ENTIRE TIME.
What reflects cardiovascular functioning and can be an indicator of pathologic processes occurring in the body.
PULSE
When taking a RADIAL PULSE, client must be in a ____ position and why.
Comfortable. If not relaxed then a false elevation in findings may occur.
How long may be necessary to wait before taking the PULSE on someone who is NOT relaxed.
10-15 min.
Normal PULSE per min:

Newborn?
100-180
Normal PULSE per min:

Infant to age 1
100-160
Normal PULSE per min:

Age 1-3
80-120
Normal PULSE per min:

Age 3-6
70-110
Normal PULSE per min:

Age 6-12
65-100
Normal PULSE per min:

Age 12-18
60-90
Normal PULSE per min:

Adult
60-100
Normal PULSE per min:

Older Adult
60-100
What is the position of the arm when ASSESSING RADIAL PULSE?
Place the client's arm across the client's own abdomen or in any relaxed position. The client should be comfortable and the wrist should be in a flat position to avoid a FALSE WEAK pulse resulting from gravity.
Why do you use your middle fingers when assessing the radial pulse and not the thumb and first finger?
These fingers have pulses of their own in them, and should not be used.
Why do you compress the radial artery, which occludes the pulse? Then gently relasing pressure until the pulse is felt?
By compressing the artery betweent eh fingers and underlying radius the blood can be felt "pulsating.' Occuding and rstorign the pulse verifies its presence.
What are you ASSESSING when taking a RADIAL PULSE?
The quality and rhnythm of the pulse as you count.
If the PULE is Irregular, thready, or weak, you will need to take what?
An apical pulse.
If the RADIAL PULSE is REGULAR, count the rate for ___ or _____ seconds and multiply by ___ or ____ to get the rate per min.
Count for 15 to 30 sec.
If 15 sec X 4= rate per min
If 30 sec X 2= rate per min
Never count RADIAL PULSE for less than ____ seconds because why?
Never less than 15 sec, as accuracy is lost and irregular beats may be missed.
How long is the MOST ACCURATE count for RADIAL PULSE?
1 MIN.
Can ASSESSING RADIAL PULSE be a delegated procedure to an unlicensed assistive personnel with proper training?
Yes, the nurse retains the responsibility for knowing the client's pulse and thaking appropriate nursing interventions based on that knowlege.
THERE MAY BE SOME TIMES WHEN IT IS INAPPROPRIATE TO DELEGATE PROCEDURE.
_____ is the act of breathing, is primarily involuntary but many factors affect the rate.
Respiration
What factors can affect the COUNTING RESPIRATIONS?
Awareness, Pain, excercise, fear, anxiety, or temperature.
When counting RESPIRATIONS, what is the nurse ASSESSING?
Rate, rhythm, depth, and effort.
Can assessing RESPIRATIONS be a procedure you can delegate to an unlicensed assistive personnel?
Yes, with proper training. The nurse retains the responsibility for knowing the client's respirations and taking appro. nursing interventions based on that knowlege. THERE MAY BE SOME TIMES WHEN IT IS INAPPR. TO DELEGATE.
What equip. is needed for ASSESSING RESPIRATIONS?
Watch with a second hand or digital watch.
When do you ASSESS the client's RESPIRATIONS?
When client is relaxed, quiet, and does not realize that the nurse is taking the respiratory rate. Wait at least 15 min. before counting respiratory rate if client is NOT relaxed.
After client's chest wall is visible and that nothing is hindering the client's respiratory movement. Observations of the abdomen may also be used to count respirations.
How long do you wait to ASSESS client's RESPIRATIONS if the client is NOT relaxed?
15 min.
Continue holding client's hand after counting the radial pulse and observe the client's ___ and ___ of the chest.
Rise and Fall
Each cycle of _____ and _____ is counted as ___ breath.
Inhalation, and exhalation is counted as 1 breath.
If having difficulty in ASSESSING RESPIRATIONS, what cant he nurse do?
By placing hand on the chest and counting. This is to FEEL the rise and fall of the chest.
What is RATE of RESPIRATION?
1 full Inhalation
1 full Exhalation
What is RHYTHM of RESPIRATION?
REGULAR
IRREGULAR
What is DEPTH of RESPIRATION?
DEEP, NORMAL, OR SHALLOW?
What is EFFORT of RESPIRATION?
Labored
Unlabored
How long do you ASSESS FOR RESPIRATIONS?
30 sec and multiply by 2 for an adult with NORMAL RHYTHM.
With INFANTS and CHILDREN or adults with an IRREGULAR RESPIRATORY rate, the nurse must count for how long?
Count for 1 full min.
What is definition of NORMAL RESPIRATION?
Regular rhythm, moderate depth, and no respiratory difficulty.
What are the normal RESPIRATIONS FOR :

Newborn
35-40 breaths/min.
What are the normal RESPIRATIONS FOR :

Infant to up to 1 yr
30-60 breaths/min.
What are the normal RESPIRATIONS FOR :

Age 1-3
25-40 breaths/min.
What are the normal RESPIRATIONS FOR :

Age 3-6
22-35 breaths/min.
What are the normal RESPIRATIONS FOR :

Age 6-12
20-30 breaths/min.
What are the normal RESPIRATIONS FOR :

Age 12-18
12-20 breaths/min.
What are the normal RESPIRATIONS FOR :

Adult
12-20 breaths/min.
What are the normal RESPIRATIONS FOR :

Older Adult
12-20 breaths/min.
Any abnormalities in respirations indicate what problems?
Oxygenation, which must be addressed immediately. Any abnormal finding must have corresponding nursing action.
The BLOOD PRESSURE provides _____ numbers. The first number is _______, and the second number is ____.
2 numbers provided.
Systolic
Diastolic
What is systolic pressure?
The amount of pressure the heart must exert to pump blood into the periphery.
1st number in BLOOD PRESSURE.
What is diastolic pressure?
Amount of pressure the heart is exerting during rest.
On BLOOD PRESSURE, the nurse reports ____/____.
Systolic/diastolic (120/80)
Can ASSESSING BLOOD PRESSURE be delegated to unlicensed ssistive personnel with proper training?
Yes, nurse retains responsibility for knowing the client's blood pressure and takin the approp. nursing interventions based on that knowledge. THERE MAY BE TIME TIMES WHEN IT IS INAPPROP. TO DELEGATE.
What equip. is needed when ASSESSING BLOOD PRESSURE?
Sphygmomanometer with cuff of CORRECT size
Stethoscope
What do you check to assure you have the proper size blood pressure cuff?
The cuff fits completely around the arm is about two-thirds the length of the client's UPPER arm.
What should the client avoid 30 min prior to assessing blood pressure?
Excercise, smoking, and ingestion of caffeine.
Can cause FALSE elevations of blood pressure.
If a BLOOD PRESSURE cuff is too WIDE, it may cause a FALSE _____ reading.
LOW
If a BLOOD PRESSURE cuff is too NARROW, it may cause a FALSE _____ reading.
HIGH
What is the proper placement of the arm when ASSESSING BLOOD PRESSURE?
Client's arm shold be level with the heart, palm up, and in a relaxed, comfortable position.
How long must a client relax atleast _____ min. prior to measurment?
5 min.
A FALSE ____reading will result if the arm is BELOW the heart level during blood pressure assessment.
HIGH
A FALSE _____ reading will result if the arm is ____ the heart level during assessment of blood pressure?
LOW
ABOVE
BLOOD PRESSURE should not be taken in arms with ____, ____, _____, or ____ ____. If blood pressure needed you access it in the ___ by using the ____ artery.
Not taken in HEMODIALYSIS, Intravenous lines, BREAST SURGERY, or traumatic injury.
Taken in the LEG, POPLITEAL ARTERY.
Where is the placement of the BLOOD PRESSURE CUFF?
1 in. above the client's ANTECUBITAL area directly over the BRACHIAL ARTERY.
A mercury gauge should be placed at ____ level and the needle of an ______ guage should be at zero.
Mercury gauges should be at EYE LEVEL.
The needle of the ANEROID guage should be at 0.
With a mercury manometer for blood pressure, eye level ABOVE mercury results in a FALSE _____ reading.
HIGH
With a mercury manometer for blood pressure, eye level BELOW mercury results in a FALSE _____ reading.
LOW
If the needle of an ANEROID manometer is not at zero the blood pressure reading will be?
INACCURATE
What must you do to the brachial artery before inflating the cuff?
Palpate
When locating the palpable pulse you inflate until?
Nurse can no longer feel the pulse.
What is palpable pulse?
When you inflate the cuff until the nurse can no longer fell the pulse. Release the cuff and observe the reading when the nurse can feel the pulse again. THIS IS CALLED PALPABLE PULSE.
Wait ___ to ____ seconds to obtain the client's blood pressure after taking the palpable pulse.
30 to 60 sec.
Why should you remember the palpable number?
When taking the blood pressure the nurse should inflate the cuff to just above this number (30 mm Hg) when obtaining the systolic pressure. It ensures that the cuff will be inflated sufficiently to obtain an accurate systolic reading.
Where do you place the bell of the stethoscope when take the blood pressure?
Lightly ove rthe brachial artery
Inflating the blood pressure cuff _____ will ensure accurate reading.
QUICKLY
Inflating the blood pressure slowly will result in an _____ reading.
INACCURATE
The ausculated reading should be slightly ____ than the paplable pulse reading.
SLIGHTLY HIGHER
You should deflate the BLOOD PRESSURE cuff _____ and _____.
Slow and steadily
When deflating the BLOOD PRESSURE cuff, listen for soft ______ sound. This is the client's _____ blood pressure.
Tapping sound, this is the client's SYSTOLIC blood pressure.
After systolic blood pressure is found continue deflating blood pressure SLOWLY. The nurse may hear ______, a _____ sound, a clear _____ or a ______ sound but the nurse must wait to heart the LAST soudn when determining the ______ blood pressure reading.
The nurse may hear a MURMUR, SWISHING SOUND, A CLEAR TAPPING, OR MUFFLED SOUND. Last soudn = diastolic blood pressure
Murmurs in blood pressure = ____ Korotkoff
Korotkoff II
Tapping in BLOOD PRESSURE = Korotkoff ____
Korotkoff III
Muffled in BLOOD PRESSURE = Korotkoff ____
Korotkoff IV
End of diastole in BLOOD PRESSURE = Korotkoff ___
Korotkoff V
End of diastole sound correlates with the beginning and end of diastole.
_____ sounds is best indicator of diastole in children.
Muffling = Korotkoff IV
Korotkoff ____ sounds may continue all the way to zero in children and athletes.
Korotkoff V= end of diastole


End of diastole sound correlates with the beginning and end of diastole.
After quickly deflating blood pressure cuff, wait ___ to ___ minutes if the nurse must recheck the blood pressure.
1 to 2 min before rechecking blood pressure
What is the Normal BLOOD PRESSURE:

Newborn:
S: 60-90 D: 20-60
What is the Normal BLOOD PRESSURE:

Infant to 1 yr
S: 85-105 D: 50-65
What is the Normal BLOOD PRESSURE:

Age 1-3 yr
S: 95-105 D: 50-65
What is the Normal BLOOD PRESSURE:

Age 3-6 yr
S: 95-100 D:55-60
What is the Normal BLOOD PRESSURE:

Age 3-6 yr
S: 95-100 D: 55-60
What is the Normal BLOOD PRESSURE:

Age 6-12 yr
S: 100-110 D: 60-70
What is the Normal BLOOD PRESSURE:

Age 12-18 yr
S: 110-130 D: 60-80
What is the Normal BLOOD PRESSURE:

Adult
S: 110-140 D: 60-90
What is the Normal BLOOD PRESSURE:

Older Adult
S: 120-140 D 70-90
Any abnormalities in blood pressure readings may indicate _______ problems.
Cardiac
If the client is going from a lying to a sitting position, wait at least ___ min. before taking the blood pressure?
2 min. Waiting will allow the body's compensatory mechansims to stabilize the blood pressure.
Changing the client's position in the bed helps maintain maximal function of the ___, ____ _____, ____ ___ ____, and prevents ___ _____.
Maintain maximal function of the joints, stimulates circulation, maximizes respiratory function, and prevents skin breakdown.
Can POSITIONING be delegated to unlicensed assistive personnel with proper training?
Yes, assesment of the client's ability to move by a nurse should be completed prior to delegation.
What is the equipment needed for POSITIONING skill?
Pillows
Turning or draw sheet
How do you turn a client in beed with minimal assistance?
A. Lock bed's wheels
B. Assess client's conditionl
C. Lower head of bed. RAise bed to comfortable working height.
D. Move client to one side of bed by sliding arms under client's shoulders and back, moving client's body to one side of bed.
E. Slide your arms under client's hips an dpull hips to side of bed. Then move client's feet and legs to side of bed.
F. Arms should be crossed on the chest and the legs at the ankles
G. Roll client TOWARDS you by placing one hand on clien'ts shoulder and the other on hips.
h. Turn client forward so that you can release one hand and position a pillow behind the client's back as needed.
i. A turning or draw sheet may be used if positioning requires add. personnel.
How far does a turning or draw sheet extend?
A turning or draw sheet extends from the client's shoulders to below the hips.
Assists in pulling the client's hips and shoulders in the direction of the turn.
How do you move the client UP in bed with MINIMAL assistance?
a. Have client bend knees and place feet flat on the bed.
b. Place one hand under client's BACK and one hand under the THIGHS
c. Ask client to push with LEGS on a count of three
d. Slide client toward the head of bed
e. A trapeze bar attached over the bed, can be used if client has good upper body strength and client can lift body with minimal assistance
F. a turning or draw sheet may be used if additional personnel is needed.
How do you place client in LATERAL/SIDE-LYING position?
The client is placed on the side wher ethe trunk is at a rgith angle to the bed. One or more legs are bent, and both arms extended in front of the body.
How do you place the client in SEMIPRONE/SIMS?
The trunk is rotated 15-30 degress forward from the lateral position. The superior arma nd leg supported in front of the body. Pillow under hed, between arms at head, under upper thigh, and pillow from knee to foot that is at right angle. If tall pillow between foot and bed.
How do you put the client in SUPINE?
The body is in a horizontal position with the client on their back. Pillow under head head, Trochanter rolls, pillow under ankle , if tall between foot and bed. If hand is flat on bed pillow from elbow to hand, with hand rolls.
How do you put the client in High-Fowlers?
The body is in a sitting psoition with the head of the bed elevated to 45 degrees. Pillows behind head, under elbows to hand and with hand rolls, pillow under knees, and heel protectors. If tall paitient, pillow at the end of bed between feet and bed frame.
How do you place client in Semi-Fowlers?
The body is in a sitting position with the head of the bed eleveated to 45 degrees.
Pillows behind head, under elbows to hand and with hand rolls, pillow under knees, and heel protectors. If tall paitient, pillow at the end of bed between feet and bed frame.
How do you place client in LOW-FOWLERS?
The body is in a sitting position with the head of the bed elevated to about 30 degrees. Clients knees are usually SLIGHTLY BENT.
Pillows behind head, under elbows to hand and with hand rolls, pillow under knees, and heel protectors. If tall paitient, pillow at the end of bed between feet and bed frame.
How do you place the client in PRONE?
The client is on abdomen with face turned to the side and one or both arms turned up. This position is seldom used due to possible complications (back). Pillows are under head, across chest from mid upper arm to mid upper arm, abdomen (where dip in back is), above knee, and from knee to toes, if tall between foot and bed. Hands have hand rolls.
How often to you change clients position?
Every 2 hours if client is not able to do so for themselves. Prevents skin breakdown, stimulates circulation, and promotes comfort.
What do you document in POSITIONING?
Client's tolerance of procedure. All data must be entered in client's record. Helps maintain continuity of care.
This skill increases mobility status, prevents complications of immobility, increases independence, and pormotes self-esteem?
Transferring a client from a bed to a wheelchair
How do you position wheelchair whent TRANSFERRING CLIENT FROM BED TO CHAIR?
Wheelchair or chair on client's STRONGEST side at 45 degree angle or PARALLEL to bed.
What do you do to the WHEELCHAIR when correctly positioned to bed in TRANSFERRING BED TO CHAIR?
Adjoust footrest and lock breakes. Adjusting foot brakes helps prevent tripping. Locking brakes prevents loss of balance.
Why should you put the wheelchair on the client's strongest side at a 45 degree angle or parallel to bed?
Facilitates a smooth, safe transfer. Have a client get out of bed on their strongeset side to help prevent loss of balance.
In TRANSFER FROM BED TO CHAIR, what do you do to the client?
Assist client to side-lying position. Lower side rail and stand near client's hips with foot near head of bed in front of and apart from other foot. This places nurse's center of gravity near client's greater weight.
What are the bed steps when TRANSFERRING FROM BED TO CHAIR.
Lock bed brakes, lower bed to lowest position, and raise the head of bed as far as client can tolerate. Decreases the amount of energy needed to move to a sitting position. Locking bed brakes prevents movement of bed.
After head of bed is raised and clientis in side lying position and side rail is lowered what do you then?
Swing client's legs over bed. At the same time, pivot your back le to lift client's trunk and shoulders. Keep back straight and avoid twisting. Support client's upper back as they come to sitting position. Moving their legs reduces friction from the sheets. Supporting thier upper body prevents client from falling backwards and transfers weight in the direction of motion and protects back from injury.
After client's feet are already swung over bed and client was raised in a sitting position, what do you do then?
Stand in front of client and assess for balance. Support in sitting position on the side of bed. Have client slide buttocks to edge of bed until feet touch floor. MAKE SURE CLIENT HAS NON-SKID SOLES ON SHOES OR SOCKS. Moving from a lying to sitting position can cause orthostatic hypotension. Dizziness and falling can occur. Assess patient.
When TRANSPORT FROM BED TO CHAIR is about to occur, where do you and the patient place arms during lift?
Client places hands on your shoulders or on the mattress on either side of the body. Assists client in using their leg muscles to stand. You place your hands under client's arms. Brace YOUR KNEES against client's KNEES as client stands. Prevents knees from buckling.
How do you move your feet when you TRANSFER FROM BED TO CHAIR?
Pivot on back foot until client feels wheelchair or chair against back of legs. Keep your KNEE against client's knees. MOVE SLOWLY. Pivoting prevents back injury. Moving slowly prevents dizziness.
Once client has felt the back of the wheelchair on their legs when TRANSFER FROM BED TO CHAIR skill is being performed what do you do?
Ask client to to grasp the armrests. This provides support. Flex your knees and hips while assisting client into wheelchair or chair. Prevents back injury by supporting weight with large muscles. Adjust footrests and leg supports if using a wheelcahir. rovides comfort and prevents leg and foot injuries. Assess cient's alignment and make client comfortable, provides comfort.
What are the steps in using a gait belt?
Place transfer belt around client's waist when client is in a sitting position on the side of bed. Assists in guiding client and offers support during transfer. Ensures client's safety. Stand in front of client and grasp the belt on both sides towards client's BACK. Roll your body and arms upward, pulling the client with the belt. Favor client's weaker side to help prevent falling. Document care and mobility status.