FINAL Flashcards
(54 cards)
Alternative interventions to attempt before using restraints
Distractions, frequent observation, diversion activities, sitting closer to nurses station, bed alarm, sitter, family, treatment change, environmental change, grip socks
Appropriate abbreviations to use for documenting vital signs
BP - blood pressure
RR - Respirations
HR - Heart rate
Temp - Temperature
Appropriate care of feet for diabetic patients
Put lotion on feet except for in-between the toes
Examine daily
File nails instead of cutting them
Slowly increase amount of time you wear new shoes
Avoid going barefoot
Appropriate infection control measure for a patient with TB
Airborne
M95 Mask
Gown
Gloves
Appropriate interventions for diagnosis of early osteoporosis
Weight bearing exercises,
Vitamin D + Calcium
Proper diet
Appropriate interventions to prevent back injuries in nurses
Bend at knees Keep back straight No more than 35 pounds per nurse wide base pivot keep what you're lifting close to your body
Appropriate methods for completing safe patient transfers
Gait belt
Use of equipment (hoyer, sit to stand, slideboard)
Bed patient is in is slightly higher than bed/stretcher they are going too
Neck stabilization if needed
Appropriate nursing diagnoses for patient prone to falling
Risk for injury
Risk for falls
Appropriate interventions for enema administration
Patient laying on left lateral side with right knee flexed
Insert 3-4 inches for adult
Insert 2-3 inches for child
Raise the bag 12-18 inches (30-45 cm)
If patient feels cramping in abdomen, lower the container to reduce pressure of flow
Have client retain fluid for prescribed amt or as long as possible
Luke warm temperature
Appropriate use of the logrolling method for position change
Spinal/back injury
Changing bed sheets
Assessment and terms used for vital signs
Respiration Rate Heart Rate Temperature Blood Pressure Oxygen Saturation Assess pain
Differentiate assessment findings for localized and systemic infections
Localized – heat, excoriation, erythema (redness)
Systemic – Fever, tachycardia, tachypnea, restlessness, low BP, flaring nostrils, malaise, fatiguied
Assessment of the urinary system
Color Clarity Amount Odor skin assessment (watch for erythema- redness)
Interventions for preventing UTI
Wipe front to back Empty bladder completely Fluids Decrease amount of sugar intake Urinate after sexual intercourse Wear cotton panties Wash with mild soap and water
Method for cleaning hearing aids
NO ALCOHOL
Clean with soapy water if ear mold is detachable
If not clean with damp cloth
Blow out excess moisture and use pipe cleaner or toothpick
Factors affecting/ causing alterations in vital sign
Age Exercise Hormones Stress Environment Medications Obesity Smoking Food intake Fever cause heart rate to go up
Interventions for a patient with contractures
Ambulation
ROM
devicesuyt
Interventions for preventing UTI
Wipe front to back Empty bladder completely Fluids Decrease amount of sugar intake Urinate after sexual intercourse Wear cotton panties Wash with mild soap and water
Interventions to reduce risk of infection
hand hygiene
disinfecting
proper ppe
Methods for promoting healthy and normal elimination patterns
*pooper scoop* position output offer fluids privacy exercise report results size consistency accult blood odor perastslasis
Normal and abnormal assessment findings for urinary and fecal elimination
clear yellow, within pH of 4.5-8,no blood , 1200-1500ml per day
brown, log shaped, formed soft
abnormal- black tarry, blood, offensive odor, cloudy, hard dry, pungent odor
Normal assessment of hair
evenly distributed
clean
no parasites or signs of infection
Nursing assessment to determine risk for injury
Level of conciousness
strength/ ROM
Activity tollerance
Nursing care for a urinary diversion
make sure stoma is clean, pink, moist, go from stoma out when cleaning
