Review for module 3b
- 1. Review for Module 3(part 2) Quiz ADLs: shaving, bathing, dressing, hair care, mouthcare, perineal care Vital signs: normal ranges, guidelines for measuring Pressure ulcers: stages, causes, prevention Nutrition: essential nutrients, sources of, types of diets, feeding guidelines Hydration: measuring Intake and Output, amount of fluid needed, dehydration/edema- causes and prevention, treatment Feeding tubes, types of and guidelines for use Range of motion exercises: terms and guidelines for Hot and cold applications: types and guidelines Special care: pulse ox, oxygen therapy, ace wraps, nonsterile wound care shaving: to use a disposable razor shave in direction hair grows, hold skin taut, apply pressure to any nicks in skin and report to nurse, place used razor in sharps container; if man is on anticoagulant or is a diabetic, shave with electric razor perineal care: front to back for female; for male in circular manner from meatus (opening) to scrotum, retract foreskin if uncircumcised routine mouthcare: fowler's position (must be able to expectorate), done after breakfast and HS; mouthcare on NPO, comatose, dying, or confused person done Q2h with swabs in lateral position haircare: if tangled, begin combing in sections from ends of hair towards scalp, pin up, braid if long, style age appropriate and in way resident likes; never cut hair dressing: offer choices, undress unaffected arm/leg first; when dressing, dress affected arm/leg first baths: no soap on face, eyes cleaned inner to outer canthus; rinse all soap and pat dry; bathe from cleanest to dirties area; only expose are being washed; allow resident to participate; partial bath includes eyes, face, hands, axillae, perineal area, back; temp of bath water 105-115 (110 perfect) vital signs: see chart pressure ulcers: stage one- discoloration, stage two- blister, stage three-open sore, stage four bone, fat and muscle visible; causes: immobility, friction, shearing, urinary incontinence, poor nutrition and hydration; turn every 2 hours, use powder, drawsheet, pillows to relieve friction, leave in low fowler's to prevent shearing, assist with meals and fluid, keep skin clean and dry; lotion to all bony prominences nutriton: fats for storing vitamins energy; protein for healing and growing, carbs for energy; water soluble vitamins (all B complex and C) must be replaced daily, lost through sweat, urine, BM; fat soluble vitamins (A,D, E and K) stored in body fat. See food guide pyramid.
- 2. Feeding: sit, resident's hands cleaned, mouthcare ac, offer choices, alternate food with liquid, fill spoon 1/3 full, monitor for pocketing, coughing, eating really slow; leave up for minimum of 30 minutes pc hydration: need 2000-2500cc to have optimum health; less than 1500cc can lead to dehydration; If on I&O, total at end of shift, 1 ounce=300cc/mls; intake includes all fluids resident drinks and foods such as jello, ice cream, yogurt and some soups, output is urine, diarrhea, emesis and wound drainage dehydration: dry skin, dry gums and tongue, oliguria (less than 500cc/24 hrs), sunken spaces around eyes; treated with encourage or force fluids order- give small amount of a variety of fluids Q2h while awake fluid retention: evidenced by wt gain, edema, SOB, ascites (fluid in stomach); treated with fluid restriction- remove water cup/pitcher, post sign, only allowed a set amount of fluid/day given to resident by staff (usually 1500cc); will need mouthcare Q2h feeding tubes: NGT (down nose into stomach), fed in fowler's and leave up after feeding stop, NPO, clean around tube, replace tape as needed, GT directly into stomach, Mouthcare Q2h Range of motion: to prevent atrophy and contractures, must be ordered; exercise to point of resistance, never force, stop of pain and report, support above and below joint flexion- bending extension-straightening rotation- moving around abduction- moving away adduction-moving toward plantar flexion- foot pushed down dorsal flexion- foot pushed up Hot/cold applications: see chart Pulse oximeter: measure amount of oxygen in the blood; normally 95-100%, remove nail polish, place over warm finger or earlobe O2: remove flammables, small electrical appliances and wool items, place no smoking sign on door; never adjust flowrate, but monitor for water level in humidifier bottle, bubbling, rate, cleanliness of mask or nasal cannula, adjust straps, never turn off unless RN instructs ace wraps: placed on a figure 8 manner, check after 30 minutes to make sure color and temp are good nonsterile dressing change: gloves to remove dressing, wash hands, gloves to replace dressing (if cleaning wound, use 3 pairs of gloves
- 3. Route time to measure range notes axillary 7 to 11 minutes 96.6-98.6 least accurate oral 3 to 5 minutes 97.6-99.6 wait 15 minutes if hot/cold liquid take exercise or cigarette; don't take on mouthbreather, dying, weak, comatose, confused , oral problems rectal 1 to 3 minutes 98.6-100.6 most accurate; lubricate, hold in place ½ inch Pulse 60-100, using radial artery tachycardia >100 bradycardia <60 don't use your thumb to measure Respirations 12-20 one breath in + one breath out= 1 respiration dont tell person you are measuring, pretend to still be taking pulse Blood pressure S<140 or D<90 use correct size cuff over brachial artery Hot moist- warm compress, warm soak in tub, sitz bath Hot dry- heating pad, aquathermia pad Cold moist- sponge bath, cool compress Cold dry- cooling pad, ice pack Never place directly on skin, leave on no more than 20 minutes, check every 5 minutes