Fundamentals HESI

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Temperature range for adults

36-38 C (96.8-100.4 F)

Average oral temp

37 (98.6)

Average rectal temp

37.5 (99.5)

Average axillary temp

36.5 (97.7)

Pulse range

60-100 bpm

Respiration range

12-20 bpm

Prehypertension range

120-139/80-89

Stage 1 Hypertension

140-159/90-99

Stage 2 Hypertension

Over 160/ over 100

Where should a blood pressure cuff NOT be placed?

Not on site of IV, fistula, mastectomy

What should a patient do before having their blood pressure taken?

Avoid caffeine/smoking, rest 5 minutes before taking BP

What sounds represent blood pressure noises?

Korotkoff's sounds (1st-systolic, 4th-diastolic)

What is the most BP can vary between arms and still be considered normal?

10

Normal respirations in newborns

35-40

Normal respirations for infants

30-50

Normal respirations for toddlers

25-32

Normal respirations for children

20-30

Normal respirations for adolescents

16-20

Normal respirations for adults

12-20

Intervention for insomnia

Sleep and exercise; encourage client to begin walking routinely during the day, but not 2-3 hours before bedtime

Who can perform catheter insertions?

RNs. UAP can only position patient, report discomfort, report characterization of urine

How far should a catheter be inserted?

2-3 inches for female; 7-9 inches for male

Chain of infection

Infectious agent/pathogen --> reservoir/source for growth --> portal of exit from reservoir --> mode of transmission --> portal of entry to host --> susceptible host

Showering with an IV

Adjust IV flow rate to KVO and remove IV tubing from pump. Reset after shower is over.

Logrolling

Obtain assistance; place pillow between client's knees (prevents tension on the spinal column). Cross client's arms (prevents injury).

Measuring intake and output

I-O= Total; when you flush a GI tube, have an IV running, or wash the perineum, yo have subtract this from your output. Check I&O every 8 hours. Weight can tell if fluid retention

Two types of contact transmission

Direct and indirect

Direct contact transmission

Applied to care and handling of contaminated body fluids

Indirect contact transmission

Involves transfer of an infectious agent through a contaminated intermediate object

Droplet precautions

Used for diseases that are transmitted by large droplets that are expelled into the air 3-6 feet. Mask, hand hygiene, dedicated care equipment. Ex. influenza

Airborne precautions

Used for diseases that are transmitted by smaller droplets that remain in the hair for long periods of time. Requires negative air flow; air filtered through HEPA filter

Protective environment

Focuses on clients w/ transplants or gene therapy; positive airflow (>12 exchanges/hour).

Basic contact precautions for protective environments

Hand hygiene before and after entering room; dispose of contaminated supplies in a way that prevents the spread of germs; use protective barriers; protect all persons who might be exposed during transport

Heat application guidelines

Must have health care provider's orders

Do's for applying heat/cold therapy

Explain sensations to be felt; report changes immediately; provide timer and call light; look up safe temps

Don'ts for applying heat/cold therapy

Don't let client adjust temp; don't allow client to move application or place hands on wound; make sure client can move away from temp source; don't leave client who can't feel temp changes

How long can a restraint order be good for?

4 hours for adults, 2 hours for children (9-17) and 1 hour for under 9

IM site/ ventrogluteal

Deep site situated away from major nerves and blood vessels; less chance of contamination; easily ID by bony landmarks; total IM volume is 3mL

6 Rights of Medication Administration

Right dose, right time, right patient, right route, right documentation, right medication

Syringe sizes used for IM and subQ injections

1-3ml

When are syringes larger than 5 mL used?

Administer IV meds, add meds to IV solutions, irrigate wounds

Insulin syringes

.3-1 mL (calibrated in units). Most are 100 U

Tuberculin syringe

16ths of minim and 100ths of a mL. (capacity of 1mL). intradermal or subQ

Incident pain

Pain that is predictable and elicited by a specific behaviors such as physical therapy or wound dressing changes

End-of-dose failure pain

Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic

Spontaneous pain

Pain that is unpredictable and not associated with any activity or event

Pulse Ox site

Finger (remove nailpolish) or earlobe

Oxygen flow meter

Meter that controls the amount of oxygen when using a nasal cannula or mask

What level should O2 stats remain above?

90%

What is prune juice used for?

Bowel stimulation

Diarrhea nursing diagnosis

Diarrhea related to...

NG tubes

Cannot be delegated; have patient sip water; can go into lungs; clients w; impaired LOC are at risk for aspiration

Intermittent tube feedings

Done periodically

Bolus tube feeding

Large feeding done over 20-30 minutes

Continuous tube feeding

Done continuously

Elimination in bedside chair

Can be delegated; remind assistant to report any abnormal findings

C. diff

Can't use hand sanitizer; must wash with soap and water

SBAR

Situation, background, assessment, recommendation

Noctural emissions

Normal

Cultural/spiritual nursing process

You must know yourself/your values before you can help the patient. Always.

Penrose drain

Lies under dressing; pin placed in drain to prevent it from slipping into the wound

Skin break down

Related to shear, friction, altered LOC, impaired mobility/sensory perception and moisture; lead to ulcers

How should darker skinned individuals be assessed for skin breakdown?

Use natural/halogen light; will appear darker than surrounding tissue with purplish/bluish hue; have initial warmth with coolness as tissue devitalizes; may appear taut, shiny, scaly

Wound dressings

Protect, aid in homeostasis, promotes healing, supports, promotes thermal insulation, protects client from seeing it; provides moist environment

Hypokalemia

Low K; normally 3.6 to 5.2 mmol/L; lower than 2.5 mmol/L can be life-threateningin

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