Term
| Standard/completion protocol definition |
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Definition
| The complete Standard Protocol includes the essential steps that must be done consistently with each patient contact to deliver responsible and safe nursing care. |
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Term
| standard protocols BEFORE the skill |
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Definition
1 Verify health care provider's orders if the skill is a dependent or collaborative nursing intervention.
2 Gather equipment/supplies and complete necessary charges according to agency policy
3 Perform hand hygiene for at least 15 seconds following the Hand Hygiene guidelines
4 Introduce yourself to patient (and family),
5 Explain the procedure and describe what the patient can expect in simple terms.
6 Adjust the bed to appropriate height and lower side rail on the side nearest you
7 Provide adequate lighting for procedure.
8 Provide privacy for patient. Position and drape patient as needed. |
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Term
| standard protocols DURING the skill |
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Definition
Promote patient independence, decision making, and involvement if possible
Assess patient tolerance, being alert for signs of discomfort and fatigue. |
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Term
| standard protocols AFTER the skill |
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Definition
1 Assist patient to a position of comfort, and organize needed toiletry or personal items within reach.
2 Be certain patient has a way to call for help with call-light or alarm in easy reach, and be sure patient knows how to use it
3 Raise the appropriate number of side rails and lower the bed to the lowest position. Side rails are considered a restraint and cannot be used to prevent a patient from getting into and out of bed
4 Dispose of used supplies and equipment.
5 Remove and dispose of gloves, if used. Perform hand hygiene for at least 15 seconds.
6 Document and report patient's response and expected or unexpected outcomes. |
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Term
| Nurses are legally and ethically obligated to keep information about patients ______ |
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Definition
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Term
| what information about a patient's status can you share with other patients or family members? |
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Definition
NONE
unless given permission by the patient. |
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Term
| can you disclose patient information to medical staff not involved in the patient's care? |
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Definition
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Term
| the 1996 legislation to protect patient privacy for health information |
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Definition
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Term
| Even though nursing care may have been excellent, in a court of law “care not ______is care not _____.” |
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Definition
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Term
| Health care–associated infections (HAIs), formerly called _______ are those that result from delivery of health services in a health care setting and were not present on admission |
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Definition
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Term
| Hand hygiene is a general term that applies to ___, ___, ____, or ____ (4 things) |
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Definition
| handwashing, antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis. |
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Term
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Definition
| refers to washing hands thoroughly with plain soap and water. |
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Term
| An antiseptic handwash is defined as |
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Definition
| washing hands with water and soap containing an antiseptic agent. |
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Term
| An antiseptic hand rub is |
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Definition
| an alcohol-based waterless product that, when applied to all surfaces of the hands, reduces the number of microorganisms on the hands. |
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Term
| Surgical hand antisepsis is |
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Definition
| an antiseptic handwash or antiseptic hand rub that surgical personnel use before performing a surgical procedure |
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Term
| The decision to perform hand hygiene depends on four factors: ( |
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Definition
| (1) the intensity or degree of contact with patients or contaminated objects, (2) the amount of contamination that may occur with the contact, (3) the patient's or health care worker's susceptibility to infection, and (4) the procedure or activity to be performed |
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Term
true/false
large refillable containers of lotion are allowed to be used in medical settings |
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Definition
FALSE
Large, refillable containers of lotion have been associated with HAIs and should not be used. |
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Term
| critical thinking defined |
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Definition
"the process of purposeful, self-regulatory judgment, which uses reasoned consideration to evidence, context, conceptualizations, methods, and criteria..
or..
thinking about your thinking while your thinking :) |
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Term
| he move from a supine to a vertical position redistributes about 500 mL of blood; immobile patients may have decreased ability for autonomic nervous system to equalize blood supply, resulting in ______ _____. |
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Definition
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Term
| TYPES of transfer techniques: |
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Definition
1) assisting patient to standing
2) assisting patient from bed to chair
3) lateral transfer from bed to stretcher using slide board
4)use of hydraulic lifts to transfer patient |
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Term
| assisted falling technique steps |
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Definition
| A, Stand with feet apart to provide broad base of support. B, Extend one leg and let patient slide against it to the floor. C, Bend knees to lower body as patient slides to floor. |
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Term
| Range of Motion definition |
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Definition
| range of motion refers to the distance and direction a joint can move between the flexed position and the extended position |
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Term
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Definition
| logrolling is turning a patient as a single unit while maintaining straight body alignment at all times. The procedure is used for patients with suspected or confirmed injuries or surgeries to the spine who must avoid twisting. |
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Term
| what is considered the "5th vital sign" |
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Definition
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Term
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Definition
| temperature, pulse, respirations, and blood pressure |
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Term
| demonstrate assessing apical pulse |
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Definition
Assist patient to supine or sitting position
Locate anatomical landmarks ( angle of louis) to place stethoscope at apex of heart at 5th ICS |
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Term
| demonstrate radial pulse assessment |
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Definition
| Place tips of first two or middle three fingers of your hand over groove along radial or thumb side of patient's inner wrist |
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Term
| demonstrate assessing blood pressure |
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Definition
1) have patient rest for 5 mins prior
2)select correct cuff size
3)patient should be sitting with arm supported at heart level
4)inflate cuff
5)deflate cuff slowly listening for kortcoff sounds and using accurate pulse time/measurements |
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Term
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Definition
(1) Weigh the patient before breakfast, at the same time each day.
(2) Use the same scale each time.
(3) Ensure that the scale is properly balanced.
(4) Weigh the patient in the same amount of clothing each day (i.e., hospital gown or pajamas).
(5) Have the patient void before weighing.
(6) Avoid weighing any equipment attached to the patient such as drainage bags or telemetry units. Hold the equipment while actually weighing the patient. |
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Term
| Personal hygiene-Oral care of unconscious pt |
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Definition
| Oral hygiene may be required as often as every 1 to 2 hours. For unconscious patients, first assess the patient's gag reflex and determine the type of suction apparatus needed to prevent aspiration. Unconscious patients are at risk for oral infections because of the absence of saliva movement and production, which leads to large numbers of gram-negative bacteria in the oral cavity. |
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Term
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Definition
| Dependent patients with beards or mustaches need assistance keeping the facial hair clean, especially after eating. Shaving facial hair is a task most men prefer to do for themselves daily. Because some religions and cultures forbid cutting or shaving any body hair, be sure to obtain consent from these patients. |
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Term
| good blood pressure ranges |
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Definition
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Term
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Definition
| A restraint-free environment is the first goal of care for all patients. Patients who need temporary restraints include those at risk for falls and confused or combative patients at risk for self-injury or violence to self or others. Physical or chemical restraints should be the last resort and used only when all other reasonable alternatives fail. |
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Term
| Measuring Intake and Output |
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Definition
| measures intake (liquids taken orally, by enteral feeding, and parenterally) and all output (urine, diarrhea, vomitus, gastric suction, and drainage from surgical tubes). You total and evaluate I&O at the end of each shift or at specified times, such as every 24 hours. |
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Term
| Infection control-how to prevent spread of infection |
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Definition
| HAND HYGIENE, barrier techniques (e.g., use of gloves and gown), and routine environmental cleaning, medical asepsis techniques and surgical asepsis techniques. |
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Term
| What is a nosocomial/healthcare acquired infection? |
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Definition
| Health care–associated infections (HAIs), formerly called nosocomial infections, are those that result from delivery of health services in a health care setting and were not present on admission. |
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Term
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Definition
| Personl Protective Equipment. Barriers such as gloves, masks or respirators, eyewear, and gowns to protect health care providers from exposure to blood and body fluids. Should be properly disposed of BEFORE leaving pt room! |
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Term
| Types of nosocomial infections |
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Definition
HOSPITAL–ACQUIRED : a result of the health care system
EXPOSURE to infectious agent while in health care facility even if not apparent at the time
IATROGENIC INFECTION- related to a client’s treatment or diagnostic procedure; eg through an IV line or after respiratory suctioning
EXOGENOUS- as a results of the facility or personnel; eg. A URI from contact with a caregiver who has a URI
ENDOGENOUS- from clients themselves –or- reactivation of a previous dormant organism such as tuberculosis; eg vaginal yeast in woman receiving antibiotic |
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Term
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Definition
| droplet < 5 µm. Diseases such as tuberculosis, measles, chickenpox (varicella). use respiratory protective equipment (mask) during care. |
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Term
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Definition
| droplets > 5 µm. Include diseases such as rubella, mumps, diphtheria, strep, pneumonia, scarlet fever, and pertussis. spread (by cough, sneeze, spit, talk) if host and source are within 3 feet. use respiratory protective equipment (mask) within 3 feet. |
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Term
True/false
sub lingual temperature readings are generally a degree higher than body cavity temperature readings |
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Definition
False
vaginal/rectal/temporal readings are generally a degree higher than oral readings. |
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Term
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Definition
Direct - client or environment contact (wound infections, Resp Syncytial Virus, multi-drug resistant organism… MRSA, C-Diff, VRE, etc).
Indirect contact: tissues, surgical dressings, water, food.
Use PPE (gown, gloves, mask) when contact with body secretions. |
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Term
| normal respiration rate for adults |
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Definition
| 12–20 breaths per minute. |
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Term
| Medical Asepsis Principles |
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Definition
• Use hand hygiene with an appropriate alcohol-based instant hand antiseptic or soap and water as an essential part of patient care and infection prevention.
• Always know a patient's susceptibility to infection. Age, nutritional status, stress, disease processes, and forms of medical therapy place patients at risk.
• Recognize the elements of the chain of infection and initiate measures to prevent the onset and spread of infection.
• Consistently incorporate the basic principles of asepsis into patient care.
• Protect fellow health care workers from exposure to infectious agents through proper use and disposal of equipment.
• Be aware of body sites where nosocomial infections are most likely to develop (e.g., urinary or respiratory tract). This enables you to direct preventive measures. |
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Term
| normal respiratory rate for children 3-6 years |
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Definition
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Term
| Surgical Asepsis Principles |
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Definition
All items used within a sterile field must be sterile.
• A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated.
• Once a sterile package is opened, a 2.5 cm (1 inch) border around the edges is considered unsterile.
• Tables draped as part of a sterile field are considered sterile only at table level.
• If there is any question or doubt about the sterility of an item, the item is considered unsterile.
• Sterile persons or items contact only sterile items; unsterile persons or items contact only unsterile items.
• Movement around and in the sterile field must not compromise or contaminate the sterile field.
• A sterile object or field out of the range of vision or an object held below a person's waist is contaminated.
• A sterile object or field becomes contaminated by prolonged exposure to air; stay organized and complete any procedure as soon as possible. |
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Term
| average adult heart rate: |
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Definition
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Term
| measurements of the pain scale |
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Definition
0-10
0 being no pain, 10 being the worst thing ever. |
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Term
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Definition
nasal cannula 1-6 L/ min; 24-45%
oxymizer 1-15 L/min; 24-100%
venturi mask 4-12 L/min; 60-80%
partial rebreather 8-12 L/min; 40-70%
non-rebreather 10-15 L/min; 60-80% |
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Term
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Definition
| 90% or higher; if less apply oxygen and call MD. |
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Term
| How do you calculate BMI? |
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Definition
weight in LBS / height in inches
or
weight in KG/ height in meters |
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Term
| It is legally advisable to administer only the______ that you prepare. |
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Definition
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Term
| Five common types of medication orders: |
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Definition
Standing order
PRN (as needed) order
Single (one-time) order
Stat order
Now order. |
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Term
| Six ”RIGHTS” of Med Administration |
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Definition
1. Right Drug
2. Right Dose
3. Right Client
4. Right Route
5. Right Time
6. Right Documentation |
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Term
| 3 effects to monitor during drug administration |
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Definition
Therapeutic effects.
Side effects.
Adverse reactions. |
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Term
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Definition
Oral = into the mouth
Topical = on top of the skin
Sublingual= mucous membrane
Inhalation = into the lungs
Rectal = into the rectum
Vaginal = into the vagina |
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Term
| describe the technique for liquid medications through a feeding tube |
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Definition
Elevate head of bed 45 degrees;
Verify tube placement;
Aspirate for residual;
Flush tube w/15-30 ml water;
clamp tube keeping syringe attached; administer medication
allow flow by gravity;
flush w/ 30-60 ml water if only one dose;
use 15 ml flush between multiple doses and follow last med w/ 30-60 ml |
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Term
| 3 types of needles that we have dealt with, and how they are measured |
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Definition
3 ml ….marked in tenths;
1 ml Tuberculin… marked in tenths;
Insulin…marked in Units, usually 100 Units |
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Term
SubQ shot sites are based on speed of medicine delivery. organize the 4 main sites from fastest to slowest
(the 4 sites = butt, abdomen,thighs,arms) |
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Definition
| Absorption speed is based on site: #1-abdomen; #2-arms; #3 thighs; #4-buttocks |
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Term
| Normal Blood Glucose measurement range |
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Definition
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Term
| the Deltoid IM injection site can only be given up to how much medication at a time? |
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Definition
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Term
| Intradermal injection MAX dosage? |
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Definition
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Term
| TB syringe needle length and gauge ranges |
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Definition
length 3/8 - 5/8
gauge 25-27 |
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Term
| how do you calculate IV flow rate in GTTS/MIN?? |
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Definition
Volume
-------- X (drop factor) = Rate
Time |
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Term
FLUID INTAKE
what fluids are measured? |
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Definition
Oral liquids,
Enteral tube feedings,
Parental feedings
IV fluids |
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Term
FLUID OUTPUT
What fluids are measured? |
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Definition
Urine
Diarrhea
vomitus,
NG drainage
wound drainage
chest tube drainage |
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Term
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Definition
0.9% normal saline (NS)
has the same osmolality as blood plasma
increases intravascular fluid volume without causing fluid to move to other compartments |
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Term
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Definition
0.45% saline
Lesser concentration of solutes than plasma
Moves water into the cells |
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Term
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Definition
3% saline
greater concentration of solutes than plasma
Move water out of the cells and into the blood vessels |
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Term
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Definition
Cleansing – promote complete evacuation
Medicated – contain pharmacological agents
Carminative (Harris or return-flow) – relieves accumulated flatus |
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Term
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Definition
gastronomy tube
Percutaneous Gastrostomy Tube (PEG):
Percutaneous or Jejunostomy Tube (PEJ or J –Tube |
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Term
| Describe Nasogastric Tube (NG/NI) Insertion |
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Definition
Flexible tube passed
through nares, nasopharynx
High Fowlers; Breathe & relax; Occlude one nares, then other, to select one with greater air flow
2. Measure distance to insert tube:
Obtain distance from tip of nose to earlobe to xiphoid process. Marker or tape site.
3. Curve tube end; lubricate; extend neck back
4. Insert tube along floor of nasal passage aiming down toward ear. Do not force past resistance.
5. Stop just above oropharynx and explain next step requires swallowing
Flex head forward and swallow small sips. Advance 1-inches w/each sip
7. STOP if cough, gag, choke. Withdraw and let pt. rest.
8. If not, continue- watch for coiling in back of throat
9. Advance until tape mark is reached. Anchor to cheek with tape until placement is checked
and esophagus into
stomach. |
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Term
| how do you verify NG tube placement? (different ways) |
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Definition
Ask client to speak
Inspect posterior pharynx for coiled tube
Flush 30 cc air then aspirate to obtain gastric contents
Measure pH with color-coded pH paper [Gastric ph: 4 or less; Intestinal: >4 ]
Measure amount of exposed tubing for future reference
X-ray …indisputable placement verifier |
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Term
| how much contents need to be in the stomach for you to hold an NG tube feeding? |
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Definition
| Aspirate contents; * if >100 ml, hold feedings (or per agency policy) |
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Term
| describe venipuncture procedures ( administering a venous IV) |
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Definition
Apply tourniquet
Locate sites: inner arm & dorsal surface of hand
Palpate vein for resistance
Cleanse site chosen for insertion
Stabilize vein below insertion site with skin taut
Puncture skin with catheter at 10-30 o angle
As catheter enters skin, look for blood return in flashback chamber
Then lower catheter flush with skin
Advance catheter into vein….
Apply pressure above insertion site with index finger/dominant hand
Release tourniquet
Retract stylet by pushing safety tab
Flush injection cap slowly
Connect IV tubing to catheter tubing; Secure connector
Place tape under catheter hub
Criss-cross ends of tape (chevron over) hub
Apply transparent dressing
Place tape over transparent dressing
Fold 2x2 gauze in half, under catheter hub
Apply 2x2 gauze over site…and Label dressing ! |
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