Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Postural drainage 

-Uses gravity to facilitate removal of bronchial secretions

-Client placed in variety of positions to facilitate drainage into larger airways (lungs and bronchi into trachea)

-Secretions may be removed by coughing and suctioning 

-Prevents complications of stasis of respiratory secretions 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Nasogastric Tube Insertion 

-Tube from nose into stomach inserted to instill medication, food, or fluids, to remove stomach contents, to obtain specimen for lab analysis

-To measure properly measure distance from tip of nose to earlobe plus the distance from earlobe to bottom of xiphoid process

-Verify placement by evaluating gastric aspirate; aspirate should have pH of 4 or less 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Cardiac: Pulses 

-Measurement of the # of times the heart beats per minute 

-Types: temporal, carotid, apical point of maximal impulse, radial, ulnar, brachial, femoral, popliteal, dorsalis pedis, posterior tibialis 

-Use the pads of the first 2 or 3 fingers to palpate 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Positioning

-Proper positioning can help maintain proper body alignment, prevent injuries, optimize ROM and comfort, facilitate breathing, eliminate secretions, promote cardiovascular function, encourages normal ADLs, prevention of pressure, friction and skin shear 

-Turn the patient towards the nurse 

-Frequently used positions: dorsal recumbent, prone, supine, side lying, Fowler's, Sims 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Angiogram

-Dye injected into the arteries and X-rays taken of the vascular system 

-When the dye is injected the client will feel warmth 

-Check for history of allergies, symptoms of allergic reaction include dyspnea, nausea and vomiting, sweating tachycardia, numbness of extremities 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Pressure Ulcer 

-A localized area of necrotic tissue that develops when soft tissue is compressed over a bony prominence 

-Risk factors include: impaired sensory perception, impaired mobility, altered level of consciousness, shear, friction and moisture 

-How to prevent: frequent assessment, reactive hyperemia, keeping client's skin dry, reposition client using a draw-sheet, implement a turning schedule, provide adequate nutrition and fluids 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Ambulation

-Assess activity tolerance of client, strength, mobility status, mental status, degree of personnel and equipment 

-Determine rest points in advance

-Ambulate in progressive stages

-Inform client of rationale and specific goals for walking 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Hearing impairment 

-Hearing loss can be conductive, sensorineural, and mixed 

-Conductive loss are caused by interruption of sound passing through the external auditory canal and middle ear 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Hemoptysis 

-Expectoration or coughing up blood from respiratory tract, including larynx, trachea, bronchi, lungs 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Bed-Making

-Beds need to be kept clean, dry, and comfortable 

-Perform asepsis when changing bed linen by keeping soiled linens away from uniform and not putting any linen on floor (directly into dirty linen basket)

-Use proper body mechanics, ensure privacy and safety of client 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Nursing process

-A problem-solving, systematic approach used by nurses to meet and treat client's responses to actual and potential healthcare needs and problems 

-Assessment, nursing diagnosis, client goals, client outcomes, implementation, evaluation 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Nasogastric Tube Insertion 

-Tube from nose into stomach inserted to instill medication, food, or fluids, to remove stomach contents, to obtain specimen for lab analysis

-To measure properly measure distance from tip of nose to earlobe plus the distance from earlobe to bottom of xiphoid process

-Verify placement by evaluating gastric aspirate; aspirate should have pH of 4 or less 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Dressing Change

-Must determine the type of dressing, presence of drains, frequency of dressing change, solutions or ointments used 

-Assess the skin that is under the tape, perform thorough handwashing before and after change 

-Do not touch fresh or open wound w/o wearing sterile gloves 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Legal Terms 

-Advance directives: written statement by a competent person that specifies decisions for an individual's treatment in the event of serious illness or injury 

-Confidentiality: code of ethics safeguards client's right to privacy; client has right of records; information about the client can be used only for purposes of diagnosis and treatment 

-Informed consent: the client's agreement to have a procedure performed after an explanation of risks, benefits, expectations, and alternatives to the procedure 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Intake and Output

-Measuring client's 24-hour intake and output evaluates client's fluid status

-Intake includes all liquids taken by mouth, through nasogastric of jejunostomy feeding tubes, IV fluids, and blood and its components 

-Output includes urine, diarrhea, vomitus, gastric suction, and drainage from post-surgical wounds and other tubes 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Parenteral Nutrition (PN)

-Intensive nutritional support, an excess of 2,500 kcal/day; usually given when client is unable to ingest, digest, or absorb the nutrients in oral foods 

-Centrally administered through catheter (Hickman or Broviac, or triple lumen) into subclavian or internal jugular vein 

-If given too rapidly, client experiences glucose overload and excessive diuresis with the excretion of glucose 

-Client may develop dehydration and shock, headache, nausea, postural hypotension, seizures 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Exercise: Isometric

-Performed by client

-Alternate contraction and relaxation without moving joint

-Maintains strength when joint immobilized, as in a cast 

-Resistive isometric exercise is done when client pushes or pulls against manual or mechanical resistance, contracting muscles and increasing their strength, such as pushing against a wall or pressing hands together 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Thoracentesis

-Allows aspiration of fluid or air from pleural space, obtain specimen for analysis, relieve lung compression, obtain lung tissue for biopsy, instill medications into pleural space 

-pre-procedure preparation includes explain procedure, take vital signs, position client sitting with arms on pillow or overbed table or lying on side in bed

-Teach client to expect stinging sensation with injection of local anesthetic and feeling of pressure when needle is inserted 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Maslow's Hierarchy of Needs 

-Maslow identifies five levels of needs

-Physiological needs, safety or security needs, love and belonging needs, esteem and self-actualization 

-Client progresses up the hierarchy when attempting to satisfy needs 

-Low-level needs must be met first 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Body Mechanics

-Principles of good body mechanics include a wide base of support, low center of gravity, alignment of line of gravity with its base of support, bending at the knees, using the stronger muscle group (legs), holding the lifted object close to the body, facing the direction of movement rather than twisting, avoiding lifting when possible, pushing rather than pulling, alternating periods of rest and activity 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Incontinence 

-Involuntary loss of urine, enough to cause social or hygienic problems

-Not a normal part of the aging process, but occurs frequently in older adults

-Multiple structural and functional causes and 5 basic types 

-5 basic types: urge, stress, overflow, functional, and mixed 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Antiembolism (Elastic) Stockings

-Elastic stockings are used to decrease risk of thrombus formation by exerting external pressure on lower extremity muscles and superficial leg veins, prevents stasis and promotes venous return in the lower extremities by maintaining external pressure

-Do not apply if skin lesions, gangrene are present 

-Must be properly sized 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Enema

-Introduction of a solution into the rectum and sigmoid colon for cleansing or therapeutic purposes 

-Includes oil retention, soapsuds, and tap water 

-Position patient on left side 

-Do not administer in presence of abdominal pain, nausea, vomiting, or suspected appendicitis 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Assisting Client with Meals

-Help a client at meal times with preparing to eat or to eat a meal 

-Prepare by opening containers, cutting food into bite-sized pieces and buttering bread 

-Maximize independence and involvement of client 

-Support dignity 

-Encourage social aspects 

-Offer toileting before beginning 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Nursing process

-A problem-solving, systematic approach used by nurses to meet and treat client's responses to actual and potential healthcare needs and problems 

-Assessment, nursing diagnosis, client goals, client outcomes, implementation, evaluation 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Catheter: Urinary

-Indwelling: urinary catheter that remains in place by means of an inflated balloon 

      -Closed drainage system used to prevent contamination

-External: condom catheter, noninvasive urinary collection device (may be applied to prevent skin irritation from urinary incontinence)

-Suprapubic: Insertion of a catheter into abdominal opening into the bladder 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Respiratory: Respirations 

-Respiratory rate: to obtain, perform hand hygiene, and provide privacy; place client in a comfortable position with client's chest visible; place client's arm across abdomen and place nurse's hand on client's upper abdomen;after observing a complete respiratory cycle, begin to count for a full minute 

-Hypoxia: insufficient cellular tissue oxygenation; indications include apprehension, restlessness, dizziness, confusion, fatigue, tachycardia, hyperpnea, dyspnea 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Contact lenses

-Oval thin transparent discs that fit directly over cornea to correct vision 

-Hard and soft types

-Need periodic removal and cleaning to prevent infection and corneal injury (abrasions or ulcers)

-Careful handling, cleansing, and storage are essential to maintaining lens integrity and safety 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Wound Healing

-Primary intention: skin edges well approximated or closed, heals quickly with minimal chance of infection and scarring 

-Second intention: left open to close filling in from bottom up with scar tissue, severe scarring, longer time frame to heal 

-Tertiary: left open for several days before closure and being allowed to close by primary intention 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Diet: Clear Liquid

-Maintains fluid balance

-For surgical clients and clients experiencing acute vomiting or diarrhea 

-Sample menu items are gelatin, ice pops, tea with lemon, ginger ale, bouillon, fruit juice without pulp

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Wound Care

-Post-op wound care includes: assessing surgical site, assessing drainage, noting type of sutures, if edges of wound are well approximated, anticipate infection 3-5 days post-op (if problems occur)

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Preoperative Care

-Pre-op checklist includes ensuring that informed consent is signed and attached to client record before any medications are given and that all lab tests, chest x-ray, EKG have been completed

-NPO, administer pre-operative medications, remove dentures, jewelry and nail polish 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Legal Terms 

-Advance directives: written statement by a competent person that specifies decisions for an individual's treatment in the event of serious illness or injury 

-Confidentiality: code of ethics safeguards client's right to privacy; client has right of records; information about the client can be used only for purposes of diagnosis and treatment 

-Informed consent: the client's agreement to have a procedure performed after an explanation of risks, benefits, expectations, and alternatives to the procedure 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Heat/Cold Therapy

-Therapeutic application of heat or cold to the body to cause local or systemic reactions

-Precautions required if impairment of circulation, skin and tissue integrity, neurosensory status, or mental status

-Both heat and cold decrease muscle tension

-Heat promotes vasodilation, decreases blood viscosity, increases metabolism of tissues, increases capillary permeability 

-Cold promotes vasoconstriction, increases blood viscosity, decreases metabolism of tissues, has local anesthetic effect 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Tube Feeding: Enteral

-Enteral tube feeding is delivery of liquid food to the stomach, distal duodenum, or proximal jejunum by way of a tube

-Can be continuous or intermittent 

-Ensure that feeding is at room temperature, elevate head of bed at least 30 degrees, verify tube placement, check for gastric residual, return residual to stomach unless greater than 100mL, flush tubing with 30 mL of water, initiate feeding, flush tubing with 30 mL water 

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Dressing Change

-To change a dressing, it is important to determine type of dressing, presence of drains, frequency of dressing change, solutions or ointments used 

-Assess skin beneath tape, thorough handwashing before and after dressing change 

-Do not touch fresh or open would without wearing sterile gloves 

-Change dressings when they become wet

Stephanie O'Brien

H#00198407

Kaplan Fundamentals A 

Catheter: Urinary

-Indwelling: urinary catheter that remains in place by means of an inflated balloon 

      -Closed drainage system used to prevent contamination

-External: condom catheter, noninvasive urinary collection device (may be applied to prevent skin irritation from urinary incontinence)

-Suprapubic: Insertion of a catheter into abdominal opening into the bladder