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When assisting a patient to stand and ambulate what are some important factors to consider?
1. make sure the client is wearing nonskid footwear.
2. Make sure the bed is in a low position.
3. Make sure the client is wearing a gait belt.
4. Brace your feet and knees against the patients feet and knees, paying attention to any known weakness.
5. Instruct patient to place arms around you between shoulders and waist. Ask the patient to stand as you move to an upright position.
6. Once up, place both hands on the gait belt and stand on the weaker side.
When teaching a person with a surgical incision in the abdominal area deep breathing technique what equipment should you include in your teaching?
A folded blanket or pillow to use for splinting the incision site.
What positions are best for deep breathing?
Fowler (80-90 degrees) or semi-Fowler's (30-45 degrees) position.
What are the 4 steps in deep (diaphragmatic) breathing?
1. Place hands on lower rib cage with tips of third fingers touching at midline.
2. Slowly take deep breath through the nose. The chest should expand as diaphragm moves down.
3. Hold breath for 2 to 5 seconds.
4. Slowly and completely exhale the breath through her mouth.
When teaching a patient to cough in conjunction with diaphragmatic breathing what are the 2 instructions?
1. complete 2 or 3 cycles of deep breathing.
2. On next breath have the patient lean forward and cough rapidly through open mouth using muscles of abdomen, thighs and buttocks. Cough several times on one breath being sure to splint with pillow if patient has abdominal incision. p 956 vol 2
When applying compression stockings what are some things to take into consideration?
The size of the patients legs, the condition of the client's skin for cleanliness, lesions, or circulatory changes and presence of edema, have the client's legs been elevated for at least 15 minutes. p 950 vol 2
What are steps to use when applying a sequential compression device?
1. Determine if elastic stockings to be used.
2. Place the regulation pump in a location that will ensure patient safety.
3. Place patient in supine position.
4. When using thigh high compression sleeves or thigh-high pneumatic air stockings, measure the thigh.
5. Place lower extremity on the open sleeve ensuring that the knee opening is at the level of the joint.
Leave one to two fingers distance between the sleeve and the extremity.
6. Set the regulating pump to the prescribed pressure
7. Instruct patient to call for assistance in disconnecting tubing from the sleeve. p 962 vol 2
What are the 8 steps to perform in incentive spirometry?
1. Breath out normally
2. Place mouthpiece in mouth and create a seal.
3. Breath in slowly and as deeply as possible through the mouthpiece monitoring depth of inspiration by viewing the gage. (establish goals to monitor progress)
4. Hold breath as long as possible (at least a slow 3 count)
5. Remove mouthpiece and exhale.
6. Rest for a few seconds
7. Repeat process 10x every hour while awake, if possible.
8. Cough after each set of 10 to clear lungs supporting with pillow if necessary. p 977 vol 1
After initial placement of an NG tube is confirmed, what are some ways to reconfirm?
Aspirate stomach and measure pH and ask the patient to speak.
How do you determine the length of tube to use for nasogastric insertion?
Measure from tip of nose to earlobe and from earlobe to xiphoid process. For a NE tube add 8-10 cm. p 561 vol. 2
When do you flush an NG tube?
Flush with 30mL water before and after feedings or every 4 hours for continuous feedings. p 567 vol 2
How often do you check residual volumes for a continuous NG tube feeding?
At least once per shift. If residual is 10% greater than the formula flow rate for one hour then hold the feeding for one hour and recheck.
What are the 6 steps to remove an NG tube?
1. Verify order for removal
2. Assist patient to high-Fowlers (80-90 degrees)
3. Clear tube secretions by injecting 190 mL of air through main lumen.
4. Ask patient to hold breath and gently but quickly remove tube.
5. Discard equipment
6. Provide or assist with nose or mouth care. p 573 vol 2
What are some things to keep in mind when assisting a patient with eating?
If the client is visually impaired identify locations based on a clock face.
Assist patient with preparing food if necessary.
If patient is in bed put the bed up to the highest tolerable position and adjust overbed table. p 585 vol 2
What are some things to keep in mind when doing a complete feeding?
Sit down and do not rush.
Make eye contact.
Provide adequate time to chew and swallow.
Ask the patient what food they would like.
Serve one food at a time in small amounts.
Serve finger foods.
Cue older adults with words and gestures.
Have casual conversation. p 585 vol 2
What are some guidelines for measuring intake?
Premeasure fluids before consumed if possible.
Record ice chips as half their volume.
Fluid intake includes: liquid in prepared meals, soups, anything that melts at room temp, liquid medications, fluids used to take pills and capsules, IV fluids, enteral and parenteral nutrition fluids, Instillation into GI Tract, Bladder irrigation. p 937 vol 2
What are some things to keep in mind when measuring output?
Note type and route.
Note unusual losses like saturated dressings, rapid breathing patterns or excessive perspiration.
Use a calibrated container and observe at eye level. Teach patient to keep toilet paper out of urine for accurate measurement.
Empty wound drains and other devices and weigh dressings if necessary. p 937 vol 2
When giving oxygen through a nasal cannula what are the 3 steps to perform?
1. Attach tubing to humidifier or adapter.
2. Place prongs in patients nares curved downward and place tubing around each ear.
3. Use slide adjustment device to tighten cannula in place under patients ears and pad tubing around ears if necessary.
p 849 vol 2
When giving oxygen through a simple mask what 2 steps apply?
1. Place mask on patients face from bridge of nose to under the chin.
2. Secure elastic band around patients head p 849 vol 2
What are the 3 basic steps when applying most forms of oxygen?
1. Attach flow meter to the wall oxygen source (the green meter on the wall)
2. Assemble oxygen equipment.
3. attach the humidifier to the flow meter, if you are not using a humidifier then attach the adapter to the flow meter. p848 vol 2
What is the procedure for measuring urine from an indwelling catheter?
1. While wearing gloves place the drainage spout and direct the flow of urine into the measuring device. Avoid touching the spout
2. Unclamp the spout and direct flow of urine to measuring device keeping spout away from sides of container.
3. Reclamp spout when bag is empty.
4. Wipe drainage spout with alcohol pad and replace spout into slot on collection bag.
5. Measure output at the end of each shift.
6. Discard urine
7. remove gloves and wash hands. p 605 vol 2
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