1101 Kaplan Fundamentals Nursing

prevent contractures, relieve pressure, promote circ., pulmonary func./drainage

minimize hip flexion

Sims (side w/ knee bent
drain oral secretions. good for enema, perineal care.

increase venous return, allow lung expansion. good for heart and lungs.

head and knees elevated
venous return, pressure off lumbar-sacral


promote extension of hip joint. allows mouth to drain. use for unconscious.

by patient. contract/relax muscle w/o moving joint. maintains muscle strength w/ immobilized joint.

active assisted
active resisted

transferring pt.
basics: move pt. toward stronger side, use large muscles, use drawsheet, have assistance

assist w. self care

geriatric consideration

prevent contracture
frequent position changes/ ROM exercises

prevent osteoporosis
weight bearing, diet

prevent constipation
ambulate, increase fluids, privacy, stool softeners

prevent urinary stasis
void normal, increase fluids, low calcium diet, watch I&O

prevent pressure ulcer
turn, clean, dry, ambulate, diet (protein, vitamin, carbs), air matress, moving bed, watch for low albumin

prevent thrombus
leg exercises, ambulate, turn, avoid gatching bed, use TED hose

prevent increase in cardiac workload
don’t hold breath, no Valsalva, rise slowly

prevent resp. stasis
turn, cough, deep breath, postural drainage, incentive spirometer

apical pulse
5th intercostal, midclavicular,INFANTS 100 (120-140) 180. Most accurate. Measure apical/radial if heart irregular — diff. is pulse deficit.

pt. outcomes
changes in pt. health you hope to acheive. goals are BROAD, outcomes are SPECIFIC/MEASURABLE–they come directly from nursing diagnosis

cough up blood

physio, safety, love, self-esteem, cognitive, aesthetic, self-actual, transcendance

visulaize lower airways. can larynx, trachea, bronchi, bronchioles. diagnose lung problems.

highest incidence for younger than 10, older than 65. falls is main concern.

measured each shift, 24 hrs., and hourly in ICU. output=urine, liquid stool, vomit, fluids from suction, drainage. input=oral, semisolid, ice, parenteral, enteral fedings, irrigations.

incentive spirometer
pts. with atelectasis, pnuemonia, had abdominal/chest/pelvic surgery, prolonged bedrest, hx of lungs probs.

airborne precs.
protective resp. device, private room, neg. pressure, door closed-pt. in. Varicella, Measles, Tb.

bone marrow biopsy
fever, yellow drainage=osteomyletis, watch bleeding/infection. no sports 48 hours. Ileac older than 2. 1 year old use tibia. no sternum or scapula.

clear liquid diet
for thirst/maintain fluids. Not for calories, GI stim., or nutrients.

SOAP=problem oriented. collaborative.

no smoking, caffeine, lay still. 40-60 mins., gets a baseline

asleep some, may be sleep deprived prior, flickering lights

enteral tube feeding
room temp food, elevate HOB, check residual, flush, feed, flush. diarrhea if food too cold, too much.

PAD-femoral angiogram
allergies to dye, written consent, NPO after midnight, watch catheter site, v/s, observe extremity for numbness, tingling, pain or loss of function, — pt will have to keep the leg straight for at least 6 hrs after the procedure to prevent bleeding from the femoral artery — ASSESSING FOR PERIPHERAL ARTERY DISEASE

PAD-foot care
warm water, dry, lotion, wear clean socks.

cool, brown skin. edema, decreased pulses. — BEDREST, ELEVATE LEGS, WARM/MOIST PACKS, ELASTIC HOSE (6-8 WEEKS), AMBULATE, ANTICOAGS.

heat/cold therapy
heat causes vasodilation when you want inflammation to begin healing. Cold causes vasoconstriction to limit bleeding. Use cold within first 48 hours. Must apply heat and cold every 20 minutes

Inability to control bladder and/or bowels.
urge-strong, sudden urge
overflow-constant dribbling
reflex-large amt. urine retained. CNS disease

insert Foley
sterile gloves
lube cath tip and place in sterile cath tray
wipe meatus from front to back w/ iodine
insert 2-3 ins. into urethra, additonal inch until urine flow
inflate balloon, apply traction to cath., tape to thigh

low fat diet
Diet for treatment of liver & gallbladder diseases. fruit/veg, cereal, lean meat

low residue diet
leaves minimal residue in intestinal tract. bland foods, pasta, tender meat, white bread, NO nuts, seeds, skin on fruit (high fiber), dairy, whole wheat, bran.

Good Samaritan law
This law deals with the rendering of first aid by health care professionals at the scene of an accident or sudden injury. It encourages health care professionals to provide medical care within the scope of their training without fear of being sued for negligence

lumbar puncture
into subarachnoid space to obtain specimen, relieve pressure, inject dye/meds. fetal position at edge of bed. neuro assess q15, flat for several hours, encourage PO fluid, watch drainage.

is a procedure for withdrawing fluid from the abdominal cavity. Generally done when fluids are crowding the lungs

A technique that uses magnetic fields and radio waves to produce computer-generated images of soft tissue. Screen for pacemaker, metal parts. Lie still ~hour.

preoperative exercises
they have to show they understand. Checklist: informed consent, labs, skin prep, bowel prep, IV, NPO, preop meds, remove personals, nutrition if needed

Age-related hearing loss.

stool specimen
fecal occult
for quantitative analysis
for C. diff, leak-proof container; swab; visible blood or mucous should be included because they contain microbes; contamination of normal flora may be excessive; refrigerated to inhibit normal flora growth

wear eyewear, hyperoxygenate, semi fowlers. do not apply suction in and intermittently out.

This is when a needle is inserted in the thoracic cavity (between ribs) into the pleural space to remove fluid or air. Sit upright, slightly forward during this procedure. Check for Crepitis (air under tissue) when assessing patient.

total parenteral nutrition
when enteral feeding is not possible. USE: large vessel, RAPID dilution, watch for infection, hyperglycemia and fluid overload.

verify tube placement w/ xray, use asceptic technique, infuse at constant rate — start at 50ml/hr to 100-125ml/hr
change tubing/filter q24
monitor weight, labs, I&O

peripheral=supplements oral, less than 2 weeks
central=into subclav vein, ~4 weeks, can be PICC, percutaneous, single or triple lumen.

save 1st AM specimen, clean meatus first, overnight spcimen more concentrated, midstream, normal is <100,000 colonies

wound healing diet
Protein, Vit C, B2

wound irrigation
flushing of an open wound using a medicated solution, water, sterile saline. they are ordered to clean the area of pathogens and other debris and to promote wound healing., Done just before applying new dressing, Best used when granulation tissue has formed, should be done gently to prevent disturbing healthy cells

Which is considered a normal physiologic change during pregnancy? a. ECG T-wave changes b. Increased cardiac output c. Increased bleeding time d. Decreased renal perfusion increased cardiac output Which of the following exercises should be taught to a pregnant woman …

“1. A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what “”type 2″” means in relation to diabetes. The nurse explains to the patient that type 2 diabetes differs from type 1 diabetes primarily in that with …

A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Ask the patient to lie down to complete a full physical assessment. b. Briefly …

Nurse Berlinda is assigned to a 41-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of: a. 45 units/L b. 100 units/L c. 300 …

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