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27 Cards in this Set

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A G.I Study with risk for constepation

X-ray exam- Gastrointestinal series


Barium Swallow can contribute to constipation

Medications for Diarrhea

Lomotil


Imodium


Motofen


Paregoric


Opium Tincture

Hourly Urine Output

There should be at least an hourly urin output of 30ml




Average urine output daily is 1000-1500mL

Explain Kegel (pelvic exercises)

Performing regular kegel exercises may greatly reduce or stop incontinence for some patients.




Concentrate on stopping the flow of urine when voiding by tightening the pelvic muscles.




Squeeze pelvic muscle and hold for 10 seconds. Relax and for 10 seconds. Do the exercise 3 times per day.

Study which indicates Urinary Tract Infection.

Midstream (Clean catch) Urine Specimen:





Best way to monitor a pulse oximeter?

Used for patient thought to be at risk for hypoxia.


The normal Sp02 is greater than 90%


Functions best without nail polish on patient finger


No nail polish, artificial nail


Fingertip most common place to check 02 saturation.



Nursing Responsibiltites for Diet Tray

Check the diet sheet


Clear table place diet tray on it


Position patient in high fowler's position


Position the table with food tray in front of patient


Protect patients bed, clothing, ect..


Open containers of food, utensils, condiments


Remove tray, offer hand hygiene and oral care.





Best way to place food on plate for a patient who is Blind

Orientatne patient to food on tray


Describe what foods are on the table


Describe the plate as if it is a clock face with particular foods positioned



Normal Glucose

70-120

Prep patient for MRI

Any medal device on or inside the patient, prostethics.


Possible sedate patient if too anxious


Remove any transdermal patches.

Inspection on a physical exam?

-Visual exam to detect any abnormal signs or qualities.


-Used to observe,


-General apperance


-Skin tone, color, and temp


-Rashes, scars, lesions


-Respirations


-Characteristics of movement



Useing a Stethoscope



-Auscultation is the process of listening to the sound produced in the body with the aid of a stethoscope.


Heart sounds


Lung sounds


Bowel sounds


Blood pressure

Diaphragm of Stethoscope

Used to detect high pitched sounds.


breath sounds


bowel sounds


normal heart sounds


The "Diaphragm" (large, flat) is held firmly against the skin and may leave a ring on the skin when lifted.

Bell piece of the Stethoscope

"Smaller" (Cupped side)


Used to detect low pitched sounds such as abnormal heart sounds made by the valves, held lightly against the skin. Pressing harder obliterates the low-pitched sounds.

Respiratory Problems and Nursing interventions

Tracheostomy


COPD


Sinus Disorder


Retractions


Chocking


**Nursing Intervention-Turn, cough, and deep breath every patient every 2 hours with respiratory problems



Capillary Refill

Check capillary refill time by observing the color of the nail bed and then compressinf the nail bed with the thumbnail or the distal end of a capped pen


*Release pressure and note how quickly the color returns to the nail bed.


** (Normal refill time is less than 3 seconds).

Assessing Bowel Sounds(Best Position)

*Best position to assess bowel sounds is the supine position


Assess bowel sounds upon admission and once per shift


Normal(Active) 5-30mins


Hyperactive-Very frequent


Hypoactive- long periods of silence


Absent- no sounds

Intervention for patient wanting to leave against medical advice. (AMA)

-The patient has the right to leave


-Listen to the patient


Answer questions


-offer to ask the doctor or nurse supervisor to speak with the patient.


-Notify doctor asap if patient wants to leave after intervetions.


** The patient is asked to sign a form an AMA


Document if patient refuses to sign AMA

Bradycardia

Normal pulse 60-100bpm


-Bradycardia- less than 60bpm


-the average adult pulse rate is 72bpm



Saftey Measures for transferring to bed

Check to ensure that the wheels are locked on the wheel chair


-have the patient grasp both arms of the chair and push up and out of the chair to a standing position


*Assist patient by placing one arm under the axilla and the other arm under the elbow

Transfering patient continues

Have patient place hands on bed and lower to sit on bed


Remove slippers from patients feet, swing patient's feet into bed


Cover patient, raise side rail, place call bell within reach.



Fall prevention interventions

Three most common factors that predispose a person to falls are


-1, impaired physical mobility


-2, altered mental status


-3, sensory or motor deficits

Injury Prevention Interventions

Most common injuries amongst patients are


-Falls


-Burns


-Cuts


-Bruises


-Fights with others


-loss of personal possessions


-choking


-Electrical Shock



Stage 3 Pressure Ulcers

Stage 3 is full thickness skin loss that looks like a deep crater and may extend to the fascia.


*Subcutaneous tissue is damaged or necrotic


*May be damage to surrounding tissue

Positioning a spinal cord injury

Suspine Position, patient resting on their back.


Recommended after spinal surgery


*Logrolling must be done when positioning the pt. or changing linen


*Maintain straight body alignment



Preventing the spread of infection

-Infection prevention and control rely on medical and surgical asespsis.


*Follow standard precautions and transmission-based precautions to prevent or control the spread of microorganisms


*Hand Hygiene