NURS 2001 Lab Guides 1-7

• allow providers to follow client’s care from one facility to another

• enhance communication b/t providers

• improve patient care and provide for better health outcomes overall

What are some advantages of EHRs?

subjective, objective, assessment, and plan charting

What does SOAP documentation stand for?

type of documentation that omits the plan of care and utilizes flow sheets

What are PIE models used for?

the acronym is used to help nurses with proper documentation practices, it stands for factual, accurate, complete, and timely

What does the FACT acronym stand for and how do nurses use it?

can be punished by termination from the health care facility, fines, or imprisonement

What consequences can occur if a nurse violates HIPAA?

complete baths, partial bed baths, therapeutic bath, shower, and tub bath

What are the different types of patient baths?

a shower chair

What important equipment is needed with a shower?

• Soak the client’s hands and feet in a basin of water for a short period of time

• then wash the hands and feet w/ soap and water

• when drying hands and feet, be sure to dry b/t each finger and each toe

• if trimming the client’s fingernails or toenails, cut them straight across to prevent injury or trauma to surrounding tissue

• clean under nails using an orangewood stick or the end of a plastic applicator stick to remove debris that can harbor micro-organisms

• shape the nails and smooth rough edges using s nail file

• apply lotion or moisturizer to the client’s hands and feet

How should standard nail care/trimming be performed?

there’s more chance of infection and skin irritation/breakdown

Foot and nail care differs for those with diabetes mellitus, peripheral neuropathy and peripheral vascular disease how?

• Circumcised

  • Wash the patient’s upper thighs and inguinal area

  • clean the tip of the penis at the urethral meatus in a circular motion from the center outward

  • wash the shaft of the penis from the tip to the base in a downward motion

  • wash the scrotom including the underlying skin folds

  • wash the outer buttoscks

  • wash the inner buttocks

• Uncircumcised

  • retract the foreskin and clean the tip of the peins at the urethral meatus in a circular motion from the center outward

  • return the foreskin to its original position. 

How does perineal cleaning differ b/t a client with a circumcised versus uncircumcised penis?

• clean the perineal area from front to back to prevent contamination from the rectal area to the urethra

• use a separate area of the washcloth for each area or a new washhcloth if the one you are using becomes soiled

• after washing and rinsing thoroughly, pat them dry to prevent skin irritation and breakdown

what are the steps of perineal care for the client with a vagina?

• you provide perineal care frequently to help prevent skin breakdown and infection

• the procedure is the same as for routine perineal care w/ one difference

  • after you have washed, rinsed, and dried the perineal area, apply a cream or ointment on the perineum and surrounding skin as prescribed to protect the client’s skin

How do you care for an incontinent client’s perineum?

• they should be in the fowlers position

  • position w/ head of the bed raised b/t 45 degrees and 60 degrees

• can also sit on the edge of the bed or stand at the sink

Clients who are independent with oral care should be positioned in which bed position?

• dont assume their capabilities, assess their level of dependence and invite them to participate in any way they can

• hygiene is important for clients who are receiving oxygen therapy, have a nasogastric tube in place, or are NPO (receiving nothing by mouth)

What are the key points of oral care for the dependent client?

• When cleaning dentures in sink, place a towel or a washcloth in the bottom of the sink to avoid breakage if you drop them.

How can you help prevent dentures from breaking when the nurse is caring for them?

use cool or tepid water; if dentures have metal, avoid soaking them overnight b/c this can cause corrosion

What temperature is used for cleaning and replacing dentures? What if the dentures contain metal?

• use electric razor for:

  • clients taking anticoagulants or high doses of aspirin or for those who have low platelet counts or bleeding disorders

• use disposable razor:

  • when the client’s skin is soft before beginning to shave it

Explain when you would use a disposable razor versus an electric razor

• pull the skin taut and use long, firm strokes to shave the larger areas of the face and short downward strokes to shave around the chin and lips. also shave in direction the hair grows.

• shave close to skin for clients w/ curled or kinky hair

what is the direction and technique of facial shaving a client?

• occupied

  • change the bottom, sheet, top sheet, and the pillowcase. leave the same mattress pad, blanket, and bedspread in place if they are not wet or soiled

• unoccupied

  • dont tuck in or miter the corners. instead fold them to the bottom 3rd of the bed to make transferring the client from the stretcher to the bed easier

  • for open bed, fold back the top covers so that it is easy for the client to get back into bed

Explain the differences b/t making an occupied and unoccupied bed

• Lower the bed to its original position and make sure the wheels are locked to keep the client from falling

• place call light, bed controls, client-controlled analgesia button, and any other devices the client needs w/ in client’s reach

How do you ensure safety after making a client bed?

• assess the client’s overall health status and afocused assessment following

  • check skin integrity and bony prominences in area where the restraint will be

  • assess color, temp, capillary refill, distal pulse, and range of motion of extremity that wil be restrained

  • using appropriate pain scale for client, evaluate the client’s pain level

  • obtain a set of vital signs and oxygen saturation immediately prior to application of restraints

    • check IV site or any other device that will be affected by the restraint

What are the assessments required prior to restraint application?

for 15 mins every 2 hours or per facility policy

How often should restraints be removed?

immediately

When would you notify the provider of a unexpected event with restraints?

turning from side to side w/ the belt restraint remaining snug around the clients waist indicates a proper fit

How can the nurse ensure the restraint fits snugly but not too tight?

• Height Standing

  • client is positioned against the wall w/ a tape measure. they must stand erect w/ feet together and w/ out shoes. heels, butt, shoulders, and head should be touching wall. 

  • place ruler across top of client’s head and against the wall w/ tape measure

  • record height in cm or ft and in.

• Height Lying

  • client is supine w/ body fully extended

  • on sheet, mark top of client’s head and heels

  • extend mark to side of bed

  • measure distance b/t marks w/ a tape measure

  • record height in cm or ft and in.

• Weight Standing

  • for balance beam → balance scale by sliding weights to 0 position and adjusting movable knob on back of scale. Electronic scales automatically calibrate and balance before each use

  • weigh client at same time each day and w/ same clothing and no shoes. be sure client has pooped prior to weighing

  • assist client to stand on scale

  • slide weight down until indicator balances on the beam-balance scale or read the digital read-out on electronic scale

  • record weight to nearest 0.5 # or 0.2 kg.

• Weight Lying

  • balance bed scale as above

  • slide client in supine position onto platform

  • remove all linens and clothing except for gown

  • measure and record weight as above

How are patient’s measured for weight and height?

• rapid weight gain → retaining fluid

• rapid weight loss → losing body fluid

What does rapid patient weight gain or rapid patient weight loss mean?

• the use of medicine cups, graduated cups, containers, and urine collection devices

How do you convert milliliters to ounces?

• oral fluids (water, milk, juice, soft drinks, etc.)

• ice chips

• foods that become liquid at room temp

• tube feedings

• parenteral fluids (IV’s piggtybacks, and blood transfusions)

• GU irrigant

What fluids are counted toward fluid intake?

• Urinary Output

• Vomit and liquid feces

• Diaphoresis

• Tube drainage

• Wound drainage

What patient fluids are considered output?

they are at risk for fluid volume deficit

patients whose output exceeds intake are at risk for what?

fluid volume excess

patients whose input exceeds output are at risk for what?

the transient discomfort or physical stress signaling actual or potential tissue damage and characterized by an identifiable cause, a short duration, and resolution with healing

What is acute pain?

• it increases heart and respiratory rates and blood pressure, along with diaphoresis, pallor, dry mouth, restlessness, nausea, and anxiety.

• examples of physiological processes affected are reduced gastric secretion and motility, increased blood sugar, decreased urine output, and bronchiolar dilation

What happens to the sympathetic nervous system during an acute pain episode? What physiological processes are occurring as well?

longer than 3 months

How long does chronic pain generally persist for?

• manifestations of chronic pain are more likely to be behavioral rather than physiological. Many people become discouraged, depressed, and withdrawn

are there any physiological changes w/ chronic pain?

a pain scale

what does documentation of pain management require?

• requires that the client rate their pain on a scale from 0 to 1, w/ 0 meaning no pain and 10 reflecting worst pain.

what is the numeric rating scale (NRS)? How do you interpret the pain scores?

• the visual analog scale rate pain in intensity from no pain to worst possible pain w/ out numbers

How does numeric rating scale differ from visual analog scale?

a non-verbal or non English speaking client

Who would you use the Wong-baker FACES pain rating scale for?

• Infants/ young children → cry

How do those in different developmental stages respond to pain?

• activity level, appearance, vital signs

What are some objective behaviors that may indicate pain?

family, friends, or SO

Who would you ask for subjective second party data from in regards to patient pain?

• infants and neonates

• Crying, Increase in O2, Increase in vital signs, Expression on face, Sleeping

What does CRIIES stand for and who is it used for?

• in infants and children 2 months to 7 yrs old

• Facial expression, Leg movement, Activity, Crying, Consolibility

What does FLACC stand for and who is it used for?

temperature, pulse, respiration, and blood pressure

What are the 4 vital sings most often assessed?

they may also be measured depending on the reason a client needs health care

where do pain and oxygen saturation fit in obtaining vital signs?

sitting or reclining position with the head of bed elevated 45 to 60 degrees

How do you position a client when obtaining respiratory rate?

30 seconds

How many seconds do you count respirations for?

one minute

How long would you count reparations for it the rhythm was abnormal?

b/t 12 to 20 breaths per min

the expected respiratory range for a healthy adult client is what?

breaths per min or rr

how do you label respirations during documentation?

a supine or sitting position

How do you position a client when obtaining a radial and an apical pulse?

• For apical pulse: placing the bell or diaphragm of stethoscope at the side 

• For radial pulse: place pads of fingers in the groove along the radial or thumb side of the patients inner wrist

What is the landmark for the point of maximal impulse?

30 seconds and multiply that number by 2

What is the length of tome you would typically count pulses for?

if its abnormal

When would you count radial/apical pulse for 1 minute?

• measure rate, rhythm, and evaluate quality or strength (is it normal, weak or thready, full or bounding, absent), 

What 3 components do you assess when obtaining the pulse?

•  the systolic and diastolic pressures

What does BP measure?

• normal BP for a healthy adult is from 90 to 119 mm Hg systolic and 60 to 79 mm Hg diastolic

• an infants BP is much lower

What is the expected range for a healthy adult and what differs between the BPs of an infant versus an adult?

• the width of the cuff should be 40% of the circumference of the midpoint of the limb on which you position the cuff, and the length of the bladder should be twice the width the bladder should encircle at least 80% of the arm

 How do you ensure the blood pressure cuff is the appropriate-size?

• Systole is the contraction phase of the cardiac cycle. during this phase blood is driven into the aorta and pulmonary arteries; Diastole is the relaxation phase of the cardiac cycle where the heart muscle is relaxed and the chambers of the heart fill with blood

What is the difference between systole and diastole?

• the Korotkoff sounds help you determine the clients systolic and diastolic pressures

What is the purpose of the Korotkoff sounds during a manual blood pressure reading?

•  the manometer needle drops at a rate of 2 to 3 mm Hg per second

When the bulb valve is released, what is the rate the manometer needle should drop?

• supine position as well as in the standing positon

What are the patient positions you assist the patient to when obtaining an orthostatic blood pressure?

• most common types of thermometers are electronic, tympanic, and temporal thermometers

Wet are the routs of obtaining a patient temp?

• oral body temp of 36 C to 38 C or 96.8 F to 100.4 F is normal

What is an acceptable oral body temperature range?

• rectal temp = 0.5 C (0.9 F) higher than an oral temp; axillary temp = 0.5 C (0.9 F) ower than an oral temp. expected reference range is 37.1 to 38.1 C (98.7 to 100.5 F)

How do the values of a rectal, oral and axillary temperature differ?

• eating, drinking, smoking or exercising can alter oral temp; not suitable for those with mouth sores or facial injuries or cannot keep mouth closed around the thermometer probe

What are contraindications to taking an oral temperature?

• the probe tip is placed in the sublingual pocket of mouth

here is the probe tip placed in the mouth for oral readings? 

• it measures the hemoglobin molecules that are saturated with oxygen

what does oxygen saturation measure?

10 ti 30 seconds

What is the length of time you should wait before recording an oxygen saturation?

• making a general overall indicatiors of health

• the patients name, if the patients skin is wet or dry, temperature and texture of skin, can the patient move extremities, physical appearance, body structure, mobility behavior, 

What is a general survey and what are you assessing?

• in the absence of visible soiling of hands and when contamination from spore-forming organisms is unlikely use sanitiizer

When would you use hand soap versus alcohol-based hand rub/hand sanitizer?

• before caring for a client and after contact w/ anything in the room

when do you perform hand hygiene when caring for a client?

they harbor micro organisms

Why should health care providers avoid having artificial nails?

20 seconds

What is the minimum amount of times a nurse should wash their hands with soap and water?

• Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another client

When should gloves be donned?

to provide barriers to infectious materials

what is the purpose of wearing masks?

• ex is a N95 respirator and it is used for case-specific procedure where particulates and secretions create a high risk of infection for the health care worker

  • n95 → used for protection against solids

what is a respirator and when is it used?

goggles, shields, safety glasses, and even full-face respirators

Which devices can be used for face and eye protection?

• rritant contact dermatitis

• allergic contact dermatitis (delayed hypersensitivity)

• latex allergy

what are 3 most common reactions to latex products?

• the disposing of needles, syringes, and scalpels in a puncture-resistant container

what are sharps containers used for?

specimens that are potentially infectious

what would a nurse place in a biohazard bag?

• hold soiled linens away from the body to prevent contamination of clothes. Avoid shaing or tossing linens. to prevent transmitting infection, do not place soiled linens on the floor 

How do you care for soiled linens?

clean, dry, flat work surface

What type of surface should a sterile field be prepared on?

• the inner surface of the sterile drape or kit, except for the 1 inch border around the edges is the sterile field to which you may add additional sterile items

When opening a sterile drape, what is the significance of the 1-inch border?

• no avoid crossing over the sterile field with the container or the nonsterile hand

Is it acceptable to cross over a sterile field?

• the closed-gloving technique is preferred method and is used by surgical staff when applying gloves at the beginning of a procedure.

• the open-gloving technique is used when changing a glove during a procedure or when performing a procedure that requires only the use of sterile gloves

When would a nurse use the open-gloving technique as opposed to the closed-gloving technique?

• specific procedure performed, time the procedure was done, client’s response to care, if the client has a latex sensitivity or allergy, any specimens or cultures obtained and sent to the lab, or condition of the site (size, color, drainage, etc.)

• no because it is expected that all employees follow those standard guidelines

When documenting a procedure that was performed in a sterile manner, what should the nurse include? Is it necessary to document the procedure was performed with aseptic technique

lower lobes of lungs

Which lung lobes can be assessed posteriorly?

• stethoscope

• the sequence in the shape of a ladder. you can start right to left or left to right

What tools are used to auscultate the lungs? What is the sequence?

• position the client sitting or lying on their back

• client who have respiratory disease will sit in a position that is comfortable for them to breathe (ex. tripod)

How do you position the patient when performing a lung assessment?

• heard to the right and left of the trachea and larynx. Bronchial breath sounds are ausculated over the anterior chest only

  • have a loud intensity and high pitch. clients inspiration is a shorter duration than the expiration

Describe bronchial breath sounds?

• heard over the right and left major bronchi. 

  • especially on right, have a moderate intensity and pitch

  • bronchovesicular inspiration and expiration duration are equal

describe bronchovesicular breath sounds?

•  ausculated over the anterior and posterior chest wall. Vesicular breath sounds are heard over a large percentage of the bilateral lung fields from the clavicle to the lower rib cage

  • have a more intense and loud airflow in the  upper anterior lobes but have a softer intensity with a low pitch throughout the other lobes. these breaths are soft-sounding like wind blowing through trees. Vesicular inspiratory sounds last longer than expiratory sounds

describe vesicular breath sounds?

• heard over the trachea of the anterior neck area

  • have a loud intensity and high pitch. both inspiration and expiration duration of sounds are equal

describe tracheal breath sounds

• various lung conditions that cause fluid, inflammation, or consolidations can take up the space around not fully inflated alveoli

What do crackles in the lungs signify?

• whistling, high-pitched musical sounds made when air flows through narrowed airway passages

• client may have inspiratory wheezes, expiratory wheezes, or both.

• can be caused by asthma or bronchitis b/c of edema in the bronchioles, airway swelling

What are wheezes and what does it mean?

count the length of each respiratory cycle

When counting the respiratory rate of a patient with Cheyne-stokes respirations, biot respirations and agonal respirations, you also count the length of what?

• a simple face mask is a low-flow oxygen-deivery device that fits loosely over the nose and mouth, used for short term oxygen therapy.

• nasal cannula → common oxygen-delivery device consisting of a length of tubing w/ two small prongs that are inserted into the nares

what is the difference b/t a nasal cannula and a simple face mask?

used to deliver high flow rates and high concentrations of oxygen

what is a nonrebreather used for?