kaplan

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Preoperative exercises

teach exercises preoperatively
coughing, deep breathing, incentive spirometer, leg exercises, turning

Deep breathing

lay down in a comfortable position. Keep chest still and move abdomen, breath in thru nose and out thru mouth thru pursed lips

Coughing exercises

Teach the exercises preoperatively
semi- fowlers , make a splint- placing a pillow or blanket on incision, breath in thru nose and out thru mouth a couple of times and the last one, hold for 3 seconds then cough a couple of times

Incentive spirometer

semi- fowlers , breath in with mouth piece hold breath for 3 seconds keeping ball up and exhale normally

Leg exercises

semi fowler's, straighten knee raise leg and extend lower leg

Turning

every 2 hours,

Ethics

Rules and or standards that tell a professional how to act
Ethical standards are confidentiality, advocacy, research, promotion of public health
Helps settle conflicts by doing what's in the best interest of the pt

Pulse oximetry

Estimates degree of oxygen saturation in arterial blood Determines how well lungs delivers oxygen to blood
Used on a finger so nail polish or fake nail should be removed
Should be greater than 95
Nursing diagnosis- ineffective tissue perfusion, ineffective airway clearance, activity intolerance

Clear liquid diet

Gelatin, popsicle, tea, ginger ale, bouillon, fruit juice with pulp, milk
No solid , only liquid at room or body temp
Used with laxatives, empty GI, pt with GI distress - such as vomiting or diarrhea , and a surgical pt
Nursing diagnosis- fatigue, anxiety, imbalance fluid volume, imbalanced nutrition

Elastic stockings

Used to decrease risk of thrombus formation by putting external pressure and helping with venous return
Apply in the morning
Recognize potential thrombus such as unilateral swelling, tenderness, pain on dorsiflexion of foot , redness, warm
Nursing diagnosis- excess fluid volume, ineffective peripheral tissue perfusion, risk for impaired skin integrity, risk for injury

Making an occupied bed

Wash hands raise bed to working height
Place pt away from nurse with side rail on that side raised then pt rolls toward
Make sure linen don't touch clothes
Nursing diagnosis- risk of impaired skin integrity, activity intolerance, impaired physical mobility, impaired bed mobility, impaired transfer ability

Ambulation

Assess activity tolerance of pt walking should be done in steps first sit on side of bed, stand by bed and then walk progressively
They should be in a clutter free area and pt should wear nonslip slippers
If the pt should get dizzy during the walk at anytime they should be taken to bed, a chair, or lowered to the ground
Reduces conjunctures, improves circulation, promotes elimination, helps breathing

Ambulation

Types of walking
Gait belt
Walker
Crutches
cane

Nursing diagnosis

It should have a related to and AEB as evidence by
Is focused on what will happen to pt based on medical diagnoses
First statement is problem statement, second statement is etiological cause related to
Third statement is signs and symptoms

Nasogastric tube insertion

Tube into the stomach , measure from tip of nose to ear then to bottom of xiphoid process
Put in for feeding, medication, lavage, remove stomach
Ph should be 4 or less
If pt experience breathing problems the tube can be in lungs

Pressure ulcer

Localized dead tissue that happens over bony points; look for non-blaching skin
Do not massage
Risk factors- immobility, shear, friction and moisture
stage1- intact skin that's warm, pain or itching
Stage 2- partial thickness- superficial but loss epidermis and dermis
Stage 3- full thickness- deep crater
Stage 4- full thickness- damage to muscle and bone

Pressure ulcer Treatment

Stage1- frequent turning, positioning to relief pressure
Stage 2- maintenance of moist healing
Stage 3- debridement
Stage 4- skin grafts

Urinalysis

Examination of urine, normal values pH 4.6-8.0, pale yellow to amber, clear, specific gravity 1.010-1.030, no glucose, no keatones protein - 0-8
Collect specimen in catheter- clamp below port prior
Assess - color, smell, clarity, presence of sediments

Types of urinalysis

Random- pour at least 120ml , either pt on bed rest or ambulatory
Timed, clean- catch or midstream- routine analysis (not sterile)
24 hour sample- started early in the morning, empty bladder first start with the next void 200-300ml
Indwelling- clamp below port

Good Samaritan law

Says that in an emergency situation a professional is able to provide care as long that it is within their scope and if damage was done that was not intentional they hold no liability
Not obligated to assist but ethical responsibility is there
In an emergency you would help someone in need first

Enema

Cleansing colon and rectum, oil, water, or soap sud
Pt should lie on left side, hold no more than 18 inches above rectum insert no more than 4 inches tell pt how long to hold solution,
add solution then release clamp after solution progresses then re clamp

Priorities

Attend most important needs, situations that if left untreated will cause harm, using Maslow's hierarchy
Physiologic needs -oxygen, water, food, temperature, elimination, sexuality
Safety and security
Love and belonging -nurse relationship, and family and friends
Self- esteem- values and beliefs
Self actualization- strengths

Body mechanics

Wide base of support, bend at knees, use legs, hold close to body and face direction of moving
Teach pt proper ways to lift and body mechanics
Uses alignment, posture and balance

Low fat diet

Reduce calories due to fat, and reduce cholesterol
Food include- fruits, veggies, cereals, lean meat,
conditions used- atherosclerrosis, coronary heart disease, obesity, and cystic fibrosis

Lumbar puncture

Insertion of needle in spine between L3 to L5, to relieve pressure, give medication, take specimen,
Used to test for bacteria and blood
Lateral recumbent Fetal position
Post procedure- neurological assessment every 15 to 30 mins , position flat for 4 to 12 hours and drink 3000 ml of fluids

Changing dressings

Promotes healing of a wound by cleaning it out and keeping moist, and helps prevent infection
Things that will be needed- Sterile field, doctor's orders
Observe- color, smell, amount and type of discharge; watch for infection by seeing swelling, pain, heat , redness and odor
Clean from the wound out

Changing dressings

Nursing diagnosis- risk of infection, anxiety, body image, pain, no knowledge, skin integrity,

Informed consent

Pt agreement to a procedure, giving an explanation, benefits, risks and an alternative
Nurses job that the pt signed the consent and it was done voluntarily also that it is put in the chart
It may be implied or verbal or written
Whole procedure should be explained to pt by physician performing procedure
In an emergency situation where pt is unable to give consent physician is allowed to give treatment in best interest of pt

Urinary incontinence

Involuntary loss of urine, not normal part of aging
Promote pt to take 8 to 10 oz of fluid daily
Treatment- behavioral, pharmacological, surgical, other

Hair care

Grooming pt to their preference , promotes self esteem, and cleanliness
Cutting hair requires a consent
Assess hair for infestations, infections, lesions and such

Fecal impaction

Hard fecal matter stuck inside
Can have no bowel movement and diarrhea
Distended abdomen and cramping
Risks- immobility, malnutrition, dehydration , meds, confusion,
Removal- enemas, manual removing with digits and laxatives

Documentation

Written or typed legal record of all the things that was pertain to pt, progress notes, treatment and things of that nature
Should be timed, dated, accurate, signed, legible,
Should be written using professional words
When writing what pt is saying it should be written in a proper way, not exactly the words that they use

Blood pressure cuff

Most false high readings are due to cuff being to small
Proper size of cuff makes sure that reading is accurate
Don't deflate cuff to slowly not less than 2mm per heartbeat, of have cuff on to loose
Falsely elevated pressure means that cuff is to tight, and falsely high means that cuff is too loose

Transfer technique

Always let pt know what you will be doing before
If pt has weak side transfer them to stronger side
Encourage pt to help as much as possible
Use leg muscles instead of back muscles

Pulse sites

indicate circulation of blood thru the body
Radial is on thumb side, femoral is next to groin, carotid is in indent in neck, pedal is on top of foot,
Post tibial on inner side of ankle, popliteal- behind knee, temporal both sides of head
Apical - left on 5th intercostal space midclavicular

Toileting/ bedpan

Used for elimination for someone that is stuck in bed, for immobility or such (bedridden)
Pt elevated 30 to 45 degrees and raise the head of bed
Center the curved smooth edge under pt butt Upper end of pan is under buttocks near sacrum and lower extends under upper thighs
Always observe contents before disposal such as color, smell, amount, consistency

Stool specimen

Test used to check for blood, pathogens, parasites, fat, ect.
Need to collect walnut sized piece put into a clean container with a steal top and transported in bag
stool must not have urine, water, or toilet tissue
If it is checking occult blood samples should be taken from two different portions (sides)

Incentive spirometer

Used to maximize lung expansion
Breath in and exhale normally put mouth piece, inhale slowly and deeply hold breath for 3 seconds keeping ball elevated
Let pt take a few normal breaths before doing it again
Cough after procedure to remove secretions

Range of motion ROM

Passive and active exercises using the joints
Helps to reduce conjunctures, maintains joint mobility, improves and maintains muscle strength prevents atrophy
Repeat exercises at least 3 times
incorporate during daily exercises such as bathing

Low residue diet

Low fiber and cellulose diet that helps calm the stomach, used for lower gi surgery for diverticulitis, crohn's disease and ulcerative colitis.
Prohibited- whole wheat, corn, raw fruits, and vegetables and seeds, gas forming foods
Sample- roast lamb, buttered rice, white proceed foods

Confidentiality

Clients right to privacy, not allowed to share clients information with anyone else
Don't talk about pt in public area, leave computer on so that access to files and ect..
Pt needs to tells you who they allow their info to be shared with other wise pt info may only be given for diagnosis and treatment

Patient outcomes

Expected Condition of client after an intervention is done, problems, needs and goals are achieved in a specific time frame
Another name for interventions or goals, should be able to be measured by time, how much, how long and how far
SMART - specific, measurable, attainable, realistic and timely

Wound healing/ diet

Diet for wound healing, high in fat, protein, and carbs vitamins A,C,E and minerals, zinc and iron
Promotes wound healing, prevents infection,
Adjust meals and environment so to help pt with healing process

hemoptysis

Coughing up blood from lungs or bronchial tubes
Related disorders- lung cancer, pulmonary edema, tuberculosis, pneumonia, bronchitis
Look at sputum, symptoms, and find out where blood is coming form, such as mouth, or GI

Enteral tube feeding

Liquid food to the stomach for pt who cant or wont eat
Elevate head of bed at least 30 degrees, always check placement before giving food after feeding flush tubing, if continuous feeding flush every 4 hours , after feeding leave pt in semi-fowlers for 30 mins

Hypoxia

Not enough oxygen in the cells , restlessness, dizziness, confusion, fatigue, tachycardia, hypernea
Pt may use many pillows to lay down with
Check ABG's arterial blood gas- to check oxygen use in the body and oximeter to check oxygen in blood

Contact lenses

Transparent discs that lay flat on cornea to help correct vision
Need to be removed and clean to minimize infection and injury to the eye
Handling storing and cleansing are very important to keep safe
Always to contacts off unconscious patients

Apical pulse

Most strongly felt impulse, point of maximum impulse known as PMI
5th intercostal space at midclavicular
Deficit of pulse is difference between apical and radial pulse ; if deficit appears pulse radial pulse will be slower
Used to check rate and rhythm when periphal pulses not present

Insert Foley catheter

Place female in dorsal recumbent position or in sim's position
Sterile procedure
Always provide privacy

Impaired skin integrity

Can come from wound, trauma or surgery, pressure ulcer, immobility
Infection, bleeding and further breakdown may occur
Prevention is priority
Inspect for infection- by elevated temp, a lot of drainage, redness, swelling, pain and type of wound

Bone marrow biopsy

Checking number, size and shape of RBC,WBC, and platelet
Obtained from iliac crest (hip) and sternum, local anesthetic used

Maslow's hierarchy of needs

Physiologic- oxygen, food, sexuality, temp, elimination, physical activity and rest
Safety and security
Love and belonging- make a good relationship, friends and family
Self- esteem- goals, values and beliefs
Self actualization- focus on strenths

Hand washing

Wash in contact of fluids
Wash hands when you remove gloves
Wash hands before and after patient
Friction cause that bacteria to separate , and warm water
Remove jewelry, non- antimicrobial soap is acceptable in some forms

Setting goals

What we want to pt to be able to do in a specific amount of time
Short term- a few hours to a few days, long term- a few weeks to a few months
Should be smart
Reflective of the nursing diagnosis
Pateint, family and friends should be as involved as possible
Make sure that the outcomes are what we wanted to happen for the goal to be met
Handouts and informational items can help achieve goal

Airborne precautions

Used when pathogens can be transmitted thru the air
Pt should be in a private room that has a negative pressure with 6 to 12 air changes per hour, keep door closed
Put mask on pt that is being transported
Diseases include- varicella, tuberculosis, measles
Infectious agent cycle- infectious agent, reservoir, portal of exit, means of transmission, portal of entry, susceptible host

Suctioning

Sterile technique, raise head of bead to semi-fowlers, hyperoxygenate, lubricate with with sterile saline, insert with no suction, when removing twirl and add suction
Should be done for 10 to 15 secs
Trachea and nose is sterile, mouth is non sterile
Done when pt is having trouble clearing secretions, making gurgling sounds

Intake and output

Measure the fluids that are taken and what is given from body
Intake includes all liquids from mouth, feeding tubes, iv fluids and blood
Output includes urine, diarrhea, vomit, gastric suctioning and drainage
Record amount in milliliters
Anything fluid at room temp is a liquid
2500mls over 3 days

Magnetic resonance imaging

Diagnostic radiography
Nurse explains procedure, Takes off jewelry, and metal objects ask if patient has pacemaker, and clips and assess for claustrophobia
Helps to see anything that is not right in the body; people check to see abnormalities in body

Foot care

Prevents infection, and trauma
Pt with peripheral vascular disease we want to make sure sensation and circulation is adequate, want them to go to podiatrist to take care of feet
Cut nails straight across to prevent ingrown nail
Pts with diabetes should be in caution since they may lose sensation

Total parenteral nutrition

Hen pt unable to ingest nutrition orally they are given it in a central catheter
Hypertonic solution with high glucose and protein
Provides pt with needed nutrients and helps gain or keep weight and much more
Pts who may use- GI needs to be bypassed, on NPO,

Paracentesis

Removal of fluid from abdomen
2 to 3 L may be released
Check color, amount, characteristics, and VS after procedure
Before procedure check VS, weight, measure abdomen, and informed consent

Bronchoscopy

Tissue biopsy of trachea to remove foreign objects, to much secretions, find tumors.. Ect
Inserted thru nose or mouth
Nurse responsibility- explain procedure, maintain NPO for 6 to 12 hours,
After procedure- remain NPO, lay or sit on side and observe for respiratory problems

Thoracentesis

Takes out fluid of air from pleural space, get specimen, put medication or get biopsy
Pre procedure- explain, take vital signs, local anesthetic, informed consent
Sitting, over bed table, lying on side
After procedure,-listen to lungs, VS, check site
Helps pt breath more easily
1000ml removed, syringe or catheter with suction

Aseptic technique

Prevent the spread of infection
Medical asepsis- clean technique, makes sure that microorganisms are limited, and avoid spreading
Surgical technique- sterile technique try to eliminate microorganisms, cant touch any non sterile
When hands not visibly soiled may use alcohol based cleaner

Elevated body temperature

Oral temp above 101.0 and rectal of 100.4
Nursing actions- provide warm when chill, provide cool air when warm, provide fluids, decrease oxygen demand, administer antipyretic (reduce fever)
May indicate infection, or tissue damage

Postural drainage

Patient put in some positions to help move secretions from lungs
Can be coughed out or suctioned
Accompanied by percussion and vibration
Drink plenty of fluids
Perform two to four times a day 20to 30 minutes

Oral care

Maintaining cleanliness of oral cavity, brushing, flossing, mouth wash, cleaning dentures and taking care of lips
Prevents infection
Encourage pt to do what they are able to do

Epilepsy

Recurrent of seizures, due to brain or CNS irritation
Different types of seizures
Nurses responsibility- document type and characteristics of seizure, o2 and suctioning at bed side, position pt on back with head to the side or pt on side to prevent aspiration, medication

Wound irrigation

Used to clean out a wound by putting a warm solution in to drain out wound
After removing old bandage, make sterile field and fill syringe to irrigate wound
Continue til solution runs clear or prescribed about is done
Irrigate away from wound

Hazards of immobility

Pressure ulcers, hypercalcemia, negative nitrogen, cardiac, hypotension, stasis of respiratory secretions, depression, boredom
Nursing considerations- turning coughing deep breathing, skin care, high protein diet, ROM

Heat/ cold therapy

Apply heat or cold to the body to heal
Heat- vasodilation, metabolism, increase capillary permeability, 20 to 30 mins, doctors order
Cold- vasoconstriction, decreases metabolism, local anesthetic effect, 20 mins

Wet to dry dressing

Helps remove dead tissue from wound so do not moisten if stuck. Applied wet then dries in place
Replace by wetting gauze with prescribed medication and apply dry to top of that
Give pain medication before dressing change, wait for it to take effect

Positioning

Are certain ways we put the pt so that we can help them do certain things such as bathing, breathing, and certain procedures
This help to keep away from injuries and helps reduce pressure ulcers
Pt should be turn toward the nurse
Common positions- supine, dorsal recumbent, prone, side lying, Sims, and head elevated

Femoral angiogram

Helps check if pt has a vascular disease, or an obstruction
Dye is injected into the pts arteries and x rays are taken,
Ask pt if they have any allergies and watch for symptoms such as tachycardia, sweating, dyspnea, numbness, vomiting ect

Presbycusis

Age related hearing loss caused by changes that happen in the inner ear over time, unable to hear high pitched sounds
Nursing- should talk in front of client, try writing so that client can read, speak in good ear slowly and clearly, keep room well lit.
Sings and symptoms- tinnitus (ringing in ear), inability to hear in group settings, speech deteration

Therapeutic communication

Listening and understanding clients message, about things such as feelings and being able to accept it
Identify problems, goals and objectives
Silence, clarification and reflecting
Develops trust and opens communication

Communication

Pre interaction- review pt info, history and ect..
Orientation- talk to pt find out how pt verbalizes, give attention, be caring
Working-set goals, encourage pt, pt gives info and is updated about condition
Termination- discharge planning,
Avoid false assurance, touch is powerful

Feeding a client

Have pt be involved, position properly and provide hygiene and toileting as necessary, document intake and output
Use assistive devices that would fit in pt need to help pt participate in feeding for self esteem
Provide mouth care before and after meals
Injured or depressed pt may be anorexic

Fowlers position

Elevate head of bead for breathing and lung expansion, recovery, eating, communication
Low fowlers- 15-30
Semi- fowlers- 30-45
High fowlers- 60-90

Isometric exercises

Contraction and relaxation without moving joint
Such as pushing against a wall
Static exercise without shortening muscle

Electrocardiogram EKG,ECG

Graphic record of the heart and how it is working, so that they can detect any abnormalities
P wave- arterial activity
Pr- intervals of av node
Qrs- ventricular activity
T wave- repolarization
Leads are put on the body and lubricant used to enhance electrical current
No smoking or drinking caffine 24 hours, lie still during procedure

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