Basic Care & Comfort 1

Question 1

Non- Pharmacological Efforts

What are the 6 main one’s that nurse do?

Answer 1

Non-Pharmacological means no medicine.

1. Distraction
2. Heat or cold therapy
3. Massage (never massage over bony provinces or legs)
4. Prayer
5. Music
6. Positioning

Question 2

Which Non- Pharmacological method works best in children?

Which method works best in teens?
Which method works best in adults?

Answer 2

• children is distraction
• Teens is coping statements such as I can do this and the pain is not so bad.
• The method that works best in the Adults is whatever they want

Question 3

Nutrition

Answer 3

Proteins= 4 calories per gram
Carbohydrates= 4 calories per gram
Fats= 9 cal per gram

Question 4

Hydration- To know hydration you have to be able to properly assess __________.

Answer 4

Dehydration

Question 5

What are the signs of dehydration?

1. )
2. )
3. )
4. )

Cardiac problems due to ____ which leads to _____ ____ pulses
Systolic blood pressure will _____
_______ hypotension
______ tachycardia

Explain- blood pressure ___ the heart rate goes ____ but the pulse will be very _____#

Answer 5

Dry mucous membranes
Poor skin turgor
Thirsty
Low urine output

Cardiac problems due to vasoconstriction which leads to weak thready pulse
Systolic blood pressure will drop
Orthostatic hypotension
Sinus tachycardia

Explain- blood pressure drops the heart rate goes up but the pulse will be very weak

Question 6

In dehydration urine levels may drop below ____ml hour

Answer 6

In dehydration urine levels may drop below 30ml hour

Question 7

Labs to watch in dehydration
USG: normal _____ to ___ increases
Urine color: dark _____ color

BUN/ creatine ratio: Normal ratio is ___to_____ Ratios greater than __blood is not getting to the kidneys so it is either ___ or ___

Answer 7

Labs to watch:
USG: normal 1.003 to 1.030 increases
Urine color: dark yellow color
BUN/ creatine ratio: Normal ratio is 10:1 to 15:1.

Ratios greater than 20:1 blood is not getting to the kidneys so it is either Dehydration or CHF

Question 8

What are the 4 common cause of dehydration?

Answer 8

Diarrhea
Nausea and; vomiting
UTI
fever

Question 9

Medicine that causes dehydration

Answer 9

Diuretics

Because they Increased the urine output and help your body get rid of water

Question 10

ReMar’s Tip: Oral hydration can be just as effective as IV hydration if started earlyenough. 
NCLEX TIPS: 
1.   
2.   
3.

Answer 10

1. If the patient is vomiting it is OK to still proceed with clear liquids or oral hydration because they tend to be digested better start with
2. Start with Very small amounts of fluids . With about 5ml a sip no more
3. If oral hydration is not tolerated then a NG tube not a IV.because we want to use the least invasive method first

Question 11

Bladder and ; Bowel Elimination
Urine

How much a day?
Odor?
Specific gravity
pH

Answer 11

Urine

How much a day? 1,000-2,000 ml per day
Odor? Ammonia is normal , if you smell musty think liver disease,

if it smells sweet think diabetes
Specific gravity :1.016-1.022
pH :4.6-8.0

Question 12

Why are UTI more common in women than men?

Answer 12

Because uretha in a woman is much shorter than a man!

In woman it about 1.5 -2.5 inches
In males it’s about 6-8 inches

Question 13

Alteration in normal urine pattern matching

1. Anuria =
2. Glycosuria =
3. Hematuria=
4. Pyuria =
5. Enuresis =

Answer 13

1. Anuria = no kidney function
2. Glycosuria =glucose in the urine
3. Hematuria=blood in the urine
4. Pyuria =Pus in urine
5. Enuresis =involuntary urination at night

Question 14

NEED TO KNOW NCLEX SKILL: Collection of 24 hour urine

1. )
2. )
3. )
4. )

Answer 14

1. Start with an Empty Bladder Ask patient to void then throw away.
2. All urine must be kept in One Container or 1jug or one drainage bag if they have a Foley catheter.
3. If one urine sample missed then _ they must start the whole process over again
4. Keep urine on ice to help bacteria from Fermenting

Question 15

Bowel

HANDLING NORMAL STOOL precautions?

Answer 15

Universal or Standard precautions

Question 16

How Often They Go (BM)

infant: ___ to ____times/day
Children & adults :go ___-__ times/day
Elderly : are prone to ___ , they to go every __ days

Answer 16

infant: 3 to 6 times/day
Children & adults :go 1-2 times/day
Elderly : are prone to constipation , they to go every three days

Question 17

Listen for bowel sounds in all four quadrants for __________ ____________

You are counting your bow sounds when you’re looking for ______

Less than ___Bowel sounds within ___ minutes may indicate your pt is ______

More than ____ bowel sounds within ____ minutes may indicate your patient has some problems with _______

Answer 17

5 minutes

You are counting your bow sounds when you’re looking for constipation

Less than 5 Bowel sounds within five minutes may indicate your pt is constipation

More than 30 bowel sounds within five minutes may indicate your patient has some problems with diarrhea

Question 18

When doing any enemas or digital removal of impaction watch out for:

Answer 18

Vagus nerve stimulation

The Vagus nerve has the ability to drop the heart rate

Question 19

Bowel Tests to know

1.Guaiac Test -looks for ___ that cannot be seen in the stool
2.Culture and Sensitivity-done on ___ ____ and; ____!
The culture is looking at which ______ are growing in the stool! The sensitivity part looks it would ____ are going to treat them the best

Answer 19

1.Guaiac Test -looks for blood that cannot be seen in the stool
2.Culture and Sensitivity-done on stool, urine and; blood!
The culture is looking at which Microorganisms are growing in the stool! The sensitivity part looks it would anabiotic’s are going to treat them the best