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21 Cards in this Set
- Front
- Back
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What should you do for privacy before assessment?
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Pull curtain
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What should you ask pt before beginning assessment?
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Does pt need to pee?
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What do you tell pt before positioning him/her in bed?
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I'm going to lay you flat in bed. Can you flex your knees?
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What is the only exception for not putting pt flat in bed?
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Pt is on O2 or has respiratory problems.
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What position should you place O2 pts?
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Low fowlers
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What should you do BEFORE placing pt in low fowlers?
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Invoke CDM and tell CE you don't want to comromise pt's respiratory function, so you will leave pt in low fowlers.
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What should you ask pt after positioning flat in bed?
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Is pt having pain, and where?
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What can you do if pt is extremely fearful of touch around incision site?
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Remind pt of importance of assessment to check if tender or rigid, but don't push it! You may invoke CDM and explain why.
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BEFORE beginning assessment at all, what should you check on?
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Has pt had pain med, or do I need to give it?
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When looking at abdomen, what are you looking for?
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Distention, contour, size, note incision, dressings, JP or other drains, colostomy/ostomy appliance, g-tube, etc.
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What should you chart on?
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SACSACS
Size, appearance, color, shape, and condition of skin |
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Before auscultating or palpating, what should you do?
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Put on gloves if at risk of contact with body fluids.
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When listening to abdomen, where do you listen?
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Listen in all 4 quadrants with navel as intersecting point.
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Sounds are hypoactive if ___, Active/Normal if ___, and hyperactive if ___.
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1-5/min., 6-30/min., >30/min.
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How long should you listen to each quadrant for?
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1 minute
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How deep should you palpate abdomen?
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LIGHTLY 2-3cm in all 4 quadrants.
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What if pt c/o pain?
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Then invoke CDM and omit that region.
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What should you tell pt BEFORE palpating?
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Now I'm going to touch your stomach. Let me know if it feels tender when I touch.
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What should you measure at the end of assessment?
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Girth, but only if assigned.
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Where will you measure girth?
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Across the navel.
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What type of pts should you be careful with when measuring girth?
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Abdominal surgery pts, and pts with liver problems or ascites. Compare with baseline, and report to nurse STAT if sudden change.
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