Fundamentals - Random things from CPL lectures, Exam 1

glucose more than 200

indicates hyperglycemia

glucose less than 70

indicates hypoglycemia

When taking someones blood glucose, you need to wipe away

the first drop of blood

airborne precaution requirements

Private room

N95

Negative pressure airflow

Clients wear surgical mask when outside of the room

droplet precaution requirements

private room; mask must be worn for anyone entering room; standard precaution when handling contaminated resp secretions, PPE removal upon exit

contact precaution requirements

- Private room or room with clients with the same infection

- Gloves & Gown at entry of room•

- Dedicated equipment in room (stethoscope, etc.)•

- Clean & disinfect reusable equipment (vital sign cart) before using onother clients

- PPE removed at point of exit

Protective precaution requirements

- Private room

- Positive airflow

- HEPA filtration for incoming air

- Masks for the client when out of room

medical asepsis does _______ require things to be sterile

NOT

SBP over 140

OR

DBP over 90

hypertension

SBP less than 90

hypotension

Axillary temp

+1

tympanic temp

-1

rectal

-1

major six rights of med admin

patient, dose, medication, time, route and documentation

other rights of med admin

to refuse, assessment, evaluation, education

uncontrolled prescription meds

monitored by a provider, do not pose risk of addiction

controlled prescription meds

potential for abuse and addiction, have a "scheduled" classification, dependence risk decreases the higher the classification

pregnancy risk

- FDA assigns Pregnancy Risk Categories (A, B, C, D, & X)according to potential harm during pregnancy

- Category A is least potential harm while Category X is most potential harm

why is intake and output important?

- assesses for dehydration

- assesses for retention

- assesses for electrolyte imbalance

how long do you measure intake and output for?

over 24 hours

what is intake?

anything that is liquid at room temperature

what is output?

anything excreted from the body

each kg of weight gained/lost overnight is equal to

1L of fluid retained or lost

high fowlers

60-90 degrees

semi fowlers

30-45 degrees

fowlers

45-60 degrees

prone

lying face down

sims

lateral with one knee and thigh up

lithotomy

stirrups

Trendelenburg

position on back feet elevated higher than head

Reverse Tredelenburg Position

The head of the bed is raised and the foot of the bed is lowered

orthopneic position

sitting up and leaning over a table to breathe (COPD)

sling transfer

a patient transfer from a bed, wheelchair, toilet, or shower using a liftmachine and flat piece of material placed under the patient

sliding board transfer

a piece of equipment that is flat and rigid, used for patients who cannot complete a transfer between two surfaces or if a standing transfer is not safe

gait belt

can also be used as a device to assist an unsteady patient with ambulation.T he nurse holds the gait belt to steady themselves and the patient as they move around together.

rotate patient every ____ hours to prevent skin breakdown

2

diabetic clients DO NOT

soak hands or feet

types of report

incident report, change-of-shift report, transfer report, telephone/verbal orders, telephone report