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27 Cards in this Set
- Front
- Back
A G.I Study with risk for constepation |
X-ray exam- Gastrointestinal series Barium Swallow can contribute to constipation |
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Medications for Diarrhea |
Lomotil Imodium Motofen Paregoric Opium Tincture |
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Hourly Urine Output |
There should be at least an hourly urin output of 30ml Average urine output daily is 1000-1500mL |
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Explain Kegel (pelvic exercises) |
Performing regular kegel exercises may greatly reduce or stop incontinence for some patients. Concentrate on stopping the flow of urine when voiding by tightening the pelvic muscles. Squeeze pelvic muscle and hold for 10 seconds. Relax and for 10 seconds. Do the exercise 3 times per day. |
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Study which indicates Urinary Tract Infection. |
Midstream (Clean catch) Urine Specimen: |
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Best way to monitor a pulse oximeter? |
Used for patient thought to be at risk for hypoxia. The normal Sp02 is greater than 90% Functions best without nail polish on patient finger No nail polish, artificial nail Fingertip most common place to check 02 saturation. |
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Nursing Responsibiltites for Diet Tray |
Check the diet sheet Clear table place diet tray on it Position patient in high fowler's position Position the table with food tray in front of patient Protect patients bed, clothing, ect.. Open containers of food, utensils, condiments Remove tray, offer hand hygiene and oral care. |
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Best way to place food on plate for a patient who is Blind |
Orientatne patient to food on tray Describe what foods are on the table Describe the plate as if it is a clock face with particular foods positioned |
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Normal Glucose |
70-120 |
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Prep patient for MRI |
Any medal device on or inside the patient, prostethics. Possible sedate patient if too anxious Remove any transdermal patches. |
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Inspection on a physical exam? |
-Visual exam to detect any abnormal signs or qualities. -Used to observe, -General apperance -Skin tone, color, and temp -Rashes, scars, lesions -Respirations -Characteristics of movement |
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Useing a Stethoscope |
-Auscultation is the process of listening to the sound produced in the body with the aid of a stethoscope. Heart sounds Lung sounds Bowel sounds Blood pressure |
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Diaphragm of Stethoscope |
Used to detect high pitched sounds. breath sounds bowel sounds normal heart sounds The "Diaphragm" (large, flat) is held firmly against the skin and may leave a ring on the skin when lifted. |
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Bell piece of the Stethoscope |
"Smaller" (Cupped side) Used to detect low pitched sounds such as abnormal heart sounds made by the valves, held lightly against the skin. Pressing harder obliterates the low-pitched sounds. |
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Respiratory Problems and Nursing interventions |
Tracheostomy COPD Sinus Disorder Retractions Chocking **Nursing Intervention-Turn, cough, and deep breath every patient every 2 hours with respiratory problems |
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Capillary Refill |
Check capillary refill time by observing the color of the nail bed and then compressinf the nail bed with the thumbnail or the distal end of a capped pen *Release pressure and note how quickly the color returns to the nail bed. ** (Normal refill time is less than 3 seconds). |
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Assessing Bowel Sounds(Best Position) |
*Best position to assess bowel sounds is the supine position Assess bowel sounds upon admission and once per shift Normal(Active) 5-30mins Hyperactive-Very frequent Hypoactive- long periods of silence Absent- no sounds |
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Intervention for patient wanting to leave against medical advice. (AMA) |
-The patient has the right to leave -Listen to the patient Answer questions -offer to ask the doctor or nurse supervisor to speak with the patient. -Notify doctor asap if patient wants to leave after intervetions. ** The patient is asked to sign a form an AMA Document if patient refuses to sign AMA |
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Bradycardia |
Normal pulse 60-100bpm -Bradycardia- less than 60bpm -the average adult pulse rate is 72bpm |
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Saftey Measures for transferring to bed |
Check to ensure that the wheels are locked on the wheel chair -have the patient grasp both arms of the chair and push up and out of the chair to a standing position *Assist patient by placing one arm under the axilla and the other arm under the elbow |
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Transfering patient continues |
Have patient place hands on bed and lower to sit on bed Remove slippers from patients feet, swing patient's feet into bed Cover patient, raise side rail, place call bell within reach. |
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Fall prevention interventions |
Three most common factors that predispose a person to falls are -1, impaired physical mobility -2, altered mental status -3, sensory or motor deficits |
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Injury Prevention Interventions |
Most common injuries amongst patients are -Falls -Burns -Cuts -Bruises -Fights with others -loss of personal possessions -choking -Electrical Shock |
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Stage 3 Pressure Ulcers |
Stage 3 is full thickness skin loss that looks like a deep crater and may extend to the fascia. *Subcutaneous tissue is damaged or necrotic *May be damage to surrounding tissue |
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Positioning a spinal cord injury |
Suspine Position, patient resting on their back. Recommended after spinal surgery *Logrolling must be done when positioning the pt. or changing linen *Maintain straight body alignment |
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Preventing the spread of infection |
-Infection prevention and control rely on medical and surgical asespsis. *Follow standard precautions and transmission-based precautions to prevent or control the spread of microorganisms *Hand Hygiene |
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