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What should a patient do before having their blood pressure taken?
Avoid caffeine/smoking, rest 5 minutes before taking BP
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
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.
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
Indirect contact transmission
Involves transfer of an infectious agent through a contaminated intermediate object
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
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
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
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
When are syringes larger than 5 mL used?
Administer IV meds, add meds to IV solutions, irrigate wounds
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
Cannot be delegated; have patient sip water; can go into lungs; clients w; impaired LOC are at risk for aspiration
Cultural/spiritual nursing process
You must know yourself/your values before you can help the patient. Always.
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
Protect, aid in homeostasis, promotes healing, supports, promotes thermal insulation, protects client from seeing it; provides moist environment
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