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19 Cards in this Set
- Front
- Back
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How do you begin the assessment? 4 steps. |
1. State name and role 2. Confirm patient identity by asking and checking the bracelet 3. Describe nursing interventions, provide the right to refuse, and then ask for consent 4. Continue with nursing interventions |
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What are three things you should keep in mind at all times? |
• Bed height • Side rails • Moving person safely principles |
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How do you don PPE? 6 steps |
1. Check type of isolation and prepare corresponding protective equipment 2. Hand hygiene 3. Don a clean gown a. Unfold and put on the gown b. Fasten ties at the neck c. Overlap gown at the back and fasten ties 4. Don a face mask a. Lower edge under the chin b. Adjust the metal strip over the bridge of the nose 5. Don a face shield 6. Don clean disposable gloves a. Use gloves to cover the cuffs of the gown |
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How do you doff PPE? 8 steps |
1. Untie waist of gown if tied in the front 2. Remove gloves and perform hand hygiene 3. Remove face shield and perform hand hygiene 4. Untie neck of gown 5. Untie waist of gown if tied in the back 6. Remove gown by grabbing the inside 7. Wrap gown and dispose properly, and perform and hygiene 8. Remove the face mask and perform hand hygiene |
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What are three principles of moving persons safely? |
• Bed raised/lowered to proper height at the waist • Front-to-back weight transfer motion while facing the patient • Always have palms facing down and elbows close to the body |
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What are the six patient bed positions? Describe them. |
• Fowler’s (low, semi, high) o Bed is angled at the middle at the person’s hip • Orthopneic o Sitting position in which the individual leans slightly forward being supported by a table or their arms • Prone o Lying horizontally on the torse, with face facing one way • Supine/dorsal o Lying horizontally on the back, with face and torso facing up • Sim’s o Lying on lateral side, with pillows supporting arm and leg on top • Trendelenburg o Supine position with bed angled having head lower and feet higher |
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What are the ten rights of medication? |
1. Right patient 2. Right time 3. Right medication 4. Right dose 5. Right route 6. Right assessment 7. Right patient education 8. Right to refuse 9. Right documentation 10. Right evaluation |
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How do you administer inhaled medication? |
Note: Bronchodilator before corticosteroids 1. Shake inhaler for 2-5 seconds 2. Connect inhaler to chamber or directly to patient’s lips 3. Patient administers puffer and inhales for 3-5 seconds at the same time o With a chamber, patient can take 2-3 breaths 4. Patient holds their breath for 10 seconds, or as long as they can 5. Ask patient to exhale slowly through pursed lips 6. Wait 30 seconds before using again/60 seconds before using another medication 7. Ask patient to rinse mouth with water 8. Rinse and clean chamber with mild soap and water after each use. 9. Let chamber air dry before next use. 10. Document in MAR |
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How do you administer topical medication? |
1. Hand hygiene and don gloves 2. Remove old patch and fold in half, discard 3. Assess for skin reactions from old patch 4. Clean area with water and then dry 5. Remove hair with scissors, NEVER shave 6. Remove half of protective film on the patch, touching the non-medicated part 7. Apply the exposed half of the patch 8. Remove the other half of the protective film 9. Press the patch onto the skin for 10 seconds, making sure it adheres 10. Document in MAR |
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How do you administer ophthalmic medication? |
1. Hand hygiene and don gloves 2. Wet a 2x2 with NS solution 3. Clean each eye from inner to outer canthus 4. Ask patient to look up 5. Stabilize the head and pull down the lower eyelid with the non-dominant and anchor the dominant hand on the forehead to drop the medication 6. Instill the drops in the outer third of the lower conjunctival sac 7. Ask patient to close their eyes 8. Press on the nasolacrimal duct for 30 seconds 9. Document in MAR |
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How do you administer otic medication? |
1. Hand hygiene and don gloves 2. Assist the patient into a side lying position 3. Wet a 2x2 with NS solution 4. Clean the pinna and canal of the ear 5. Straighten ear canal by pulling pinna upwards and backward 6. Instill the drop along the side of the ear canal 7. Gently press on the tragus a few times 8. Ask patient to remain in side lying position for about 5 minutes 9. Insert a small cotton fluff at the outer ear canal for 15-20 minutes 10. Document in MAR |
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How do you change an incontinence brief? |
1. Perform hand hygiene and don gloves 2. Assist patient into side lying position 3. Carefully remove and then roll up old incontinence brief 4. Dispose of the old incontinence brief 5. Remove gloves, perform hand hygiene, don new gloves 6. Prepare new incontinence brief and lay it on the bed o Sticky pads should be on the upper side near the back 7. Roll patient back into supine position onto the brief 8. Position incontinence brief onto patient and attach sticky pads 9. Remove gloves and perform hand hygiene |
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How do you perform a bed bath - face? |
1. NEVER use soap on the face 2. Wet both face cloths with warm water (one for washing, other for rinsing) 3. Start with eyes going from inner to outer canthus 4. Switch to a new part of the cloth for each stroke 5. Proceed with remainder of the face and ears going from top to bottom motion 6. Rinse off wash cloth in basin |
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How do you perform a bed bath - arms? |
1. Only uncover area needing to be cleaned 2. Place a dry towel under the arm 3. Rub soap onto wash cloth 4. Supporting the arm, clean from the hand going up to the shoulder 5. Rinse the soap off with the rinse cloth 6. Pat dry with the towel 7. Rinse off wash cloth in basin |
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How do you perform a bed bath - chest? |
1. Only uncover area needing to be cleaned 2. Rub soap onto wash cloth 3. Wash the chest, displacing the breasts to clean under them 4. Rinse the soap off with the rinse cloth 5. Pat dry with the towel 6. Rinse off wash cloth in basin |
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How do you perform a bed bath - legs? |
1. Only uncover area needing to be cleaned 2. Rub soap onto wash cloth 3. Clean leg from top of the legs moving downwards toward the feet 4. Rinse the soap off with the rinse cloth 5. Pat dry with the towel 6. Rinse off wash cloth in basin |
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How do you perform a bed bath - peritoneal? |
1. Only uncover area needing to be cleaned 2. Rub soap onto wash cloth 3. Clean peritoneal area from front to back 4. Clean anal area last 5. Rinse the soap off with the rinse cloth 6. Pat dry with the towel 7. Place all linens in linen disposal |
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How do you perform a urinary sample via urinary catheter? |
1. Perform and hygiene and don gloves 2. Clamp urinary catheter below the port using gauze as a barrier 3. Wait 15-20 minutes before collecting sample 4. Clean Luer lock connecter for 15-30 seconds and let dry completely 5. Open and attach syringe to catheter without touching the tip 6. Draw required amount urine (usually about 3 mL) 7. Transfer urine sample to container without contaminating and not over the bed 8. Close container and label container 9. Unclamp urinary catheter 10. Remove gloves and perform hand hygiene |
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How do you perform ostomy care? |
1. Perform and hygiene and don gloves 2. Check for leakage around stoma 3. Empty stoma bag 4. Remove skin barrier from top to bottom, holding the skin 5. Clean surrounding skin with wet cloth, then dry 6. Nursing Assessment o Stoma colour, size, shape, bleeding, surrounding skin 7. Remove gloves, perform hand hygiene, don new gloves 8. Use stencil to measure stoma 9. Use scissors to cut skin barrier to proper size 10. Skin prep the area surrounding the stoma 11. Place stoma bag from bottom to top 12. Seal stoma bag with clamp 13. Remove gloves and perform hand hygiene |
