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Quiz 1 (wk.1-2)
Infection, vital signs,NGT, elimination + catheter
| Question | Answer |
|---|---|
| types of hand hygiene | - alcohol-based (foams/gels) - handwashing |
| how long should you wash your hands for | 15-20 seconds (CDC) |
| when is it ok to use hand sanitizer rather than washing | when your hands are not visibly soiled and pt does not have C. diff |
| handwashing steps: | 1. remove any jewelry 2. wait for water to warm 3. wet hands thoroughly 4. wash with soap for 15-20s 5. rinse soap of thoroughly 6. dry hands completely |
| how should you turn off a non-pedal sink | discard the paper towel used to dry hands and use a new paper towel to turn off the faucet |
| 3 types of non-sterile gloves | -latex -nitrile -vinyl |
| sterile gloving steps | 1. select specific size 2. open paper package 3. open tabs at top and bottom. use the 2 center tabs to open 5. put glove on dominant hand by using the cuff 6. for the second hand slide 2 fingers under the cuffed edge and guide it on |
| what should you remember once the sterile gloves are on | do not touch anything with the gloves prior to the procedure. place your hands in front of you |
| ppe donning steps | 1. hand hygiene 2. gown 3. mask 4. eye protection 5. gloves |
| ppe doffing steps | 1. gloves 2. eye protection 3. gown 4. mask 5. hand hygiene |
| standard precautions | use w/ all pts. (when potential for contact w/ fluids) |
| contact precautions | use when pathogens can be transmitted by direct/indirect contact -MRSA, vancomycin-resistant enterococcus (VRE), diarrheal illness, RSV |
| droplet precautions | pathogens can be spread via droplets of mucus and airway secretions (talking, coughing, sneezing) - flu, pertussis, respiratory syncytial virus (RSV), bacterial meningitis |
| airborne precautions | infectious diseases spread via droplets in the air - TB, chickenpox, measles, |
| enhanced barrier precautions | used w/ high-contact nursing home residents with wounds and/or known novel or targeted multidrug-resistant organisms (MDRO) |
| standard precautions | -hand hygiene -gloves -possibly: gown, apron, mask, goggles, shoe covers |
| contact precautions | -hand hygiene -gloves -gown -possibly: goggles/apron |
| droplet precautions | -hand hygiene -basic mask -gloves -goggles/face shield -gown |
| airborne precautions | -hand hygiene -N95 -gloves -gown -goggles/face shield -used in hand with a (-) air pressure room and closed door |
| enhanced barrier precautions | -hand hygiene -gown -gloves |
| chain of infection | -infectious agent -reservoir -portal of exit -mode of transmission -portal of entry -susceptible host |
| what ? should you ask pts before temp check | if they have had anything to eat or drink, smoked, chewed gum or tobacco w/in the past 15-30 minutes |
| what do you need to do with your personal equipment (steth) before vitals | sanitize w/ alcohol |
| temp check steps (oral) | 1. hand hygiene & equipment 2. take probe out and apply cover 3. place probe into pts mouth (under the tongue on the posterior sublingual pocket) 4. have a pt place their mouth around the probe but not bite it 5. when the thermometer beeps remove it |
| radial pulse steps | 1. hand hygiene 2. locate radial site (peripheral artery) 3. assess rhythm and quality of pulse 4. count for a full minute (or 30s x 2) 5. document |
| respirations steps | 1. done w/o alerting patient of performing 2. after radial pulse pretend to keep checking it (move fingers away from radial site) 3. count rise and fall of chest for 1 min (or 30s x 2) 4. document |
| blood pressure steps | 1. choose correct bp cuff size 2. find baseline 3. find brachial pulse, and place index marker on it while placing cuff 4. pump up to baseline 5. when pulse is no longer heard, release at 2-4 mmHg per sec 6. systolic = 1st beat/diastolic = last beat |
| what size should a bp cuff be for a pt | 2/3 the size of their arm |
| where should a pts arm be positioned during bp | at heart level w/ palm up |
| how to find baseline bp | 1. find radial pulse 2. pump bp cuff until you can no longer feel the pulse 3. record the point where the pulse is no longer felt 4. add 30 to that # |
| Adult respiration range | 12-20 |
| Adult BP range | less than 120/ less than 80 |
| Adult BPM range | 60-100 |
| Adult temp range | 36C-38.5C/96.8F-101.3F |
| Adults Sp02 range | 85-100 % /50-140 BPM |
| apical pulse steps | 1. find the apical site ( left mid-clavicular, 5th intercostal space) 2. listen w/ stethoscope for 1 full minute |
| when should the apical pulse be used | when confirming cardiac or BP abnormalities |
| what should you do if you cannot see the rise and fall of the pts chest | place their hand on their chest and yours on top of their in order to feel the rise and fall. do this while still pretending to check their radial pulse |
| how do rectal and tympanic temps vary from oral | they are usually 0.5c or 1f higher than oral temps |
| how do axillary and temporal temps vary from oral | they are usually 0.5c or 1f lower than oral temps |
| what ages should oral temp be used | 4yrs + |
| what ages should tympanic temp be used | 3yrs + |
| how should you take the temp of an unconscious pt | rectal, tympanic, or scanner is preferred -NEVER take by mouth |
| how far should a rectal thermometer be inserted | -Newborn : 0.6-1.3cm (1/4-1/2in) -Child: 1.3-2.5cm (1/2-1in) -Adult : 3.8cm (1.5in) |
| - Tachypnea | quick,shallow |
| - Bradypnea | abnormally slow |
| - Apnea | cessation of breathing |
| Dyspnea | Difficult labored breathing during which the indv has a persistent, unsatisfied need for air and is distressed |
| Orthopnea | Ability to breath only in upright Sitting or standing positions |
| Hemoptysis | blood in sputum |
| Productive cough | Cough w/expectorated secretions |
| Nonproductive Cough : | Dry, harsh cough w/o secretions |
| bariatric blood pressure | bp measurement at the wrist has proven to be affective |
| Orthostatic blood pressure | measuring blood pressure changes when moving from lying or sitting to standing, specifically to diagnose orthostatic hypotension |
| Orthostatic blood pressure steps | 1. have pt lie down for 5 mins 2. measure bp and pulse 3. have pt sit up and dangle legs. repeat bp and pulse 4. have pt stand. repeat bp and pulse |
| Orthostatic blood pressure abnormalities | -drop in systolic bp greater or equal to 20 mmHg -drop in diastolic bp greater or equal to 20 mmHg -any lightheadedness or dizziness |
| what should you ask prior to NGT insertion | if the pt has denture or wears contacts |
| when prepping NGT what should you do with the packaging | keep the NGT in the packaging until you're ready to measure |
| how do you assess nasal patency | occlude one nostril and have the pt blow through the other. test for both and choose the one w/ better airflow. if patency is the same for both then choose the one closest to you |
| NGT equipment | -gloves -NGT -chuck -basin -tape -cup -entero syringe |
| how should you set up the tape for NGT insertion | place 1 piece on the edge of the table w/ 3 extras attached to it 1. initial placement 2. to secure initial placement (make w/ a fork cut) 3. attach tube to gown |
| what should a NPO pt do during NGT insertion | dry swallows to assist with insertion |
| NGT tube measurements | 1. tip of nose to earlobe 2. earlobe to xiphoid process |
| what should you do if there is resistance during insertion of NGT | -tube may need to be twisted a bit during insertion - if there is a lot of resistance or none at all then check the mouth with your pen light to ensure tube is not coiling in the mouth |
| methods for determining NGT tube placement | -chest x-ray (preferred) -CO2 detector: Any color change indicates placement In the respiratory tract. -Aspirate stomach contents: pH should be acidic (1-5) -aspirate air into the stomach and listen for "whoosh" |
| NGT tube insertion pt. 1 | 1. HIPIE 2. ensure pt is in sitting position (chuck on chest, basin in lap & remove pillow) 3. ask abt dentures, contacts, or adhesive allergies 4. check patency 5.measure tube & lube for insertion 6. have pt tilt head back & insert to 1st marking |
| NGT tube insertion pt. 2 | 7. have pt tuck their chin to their chest have them start to swallow 8. insert to second marking 9. secure the tube to the nose w/ tape 10. check for correct placement and attach to pt gown 11. document |
| if you aspirate gastric contents an NGT tube for placement. what should you do after | push gastric contents back into the tube |
| five safety considerations when assisting a patient with dysphagia to eat. | 1. Positioning: have pt @ 90 degree angle 2 . Minimize distractions 3. consistency: thickened liquids & pureed foods, no straws 4. technique: give small bites, have pt. to chew thoroughly 5. Monitoring & equipment: observe for signs of aspiration |
| providing feeding assistance | 1. HIPIE 2. check tray: pt name, diet type, and completeness 3. position yourself and pt (if permitted, pt in a chair) 4. ask pt in which order they'd like to eat and warn pt of food temp 5. allow time for chewing and swallowing before offering more |
| when should you provide fluids during feeding assistance | when requested by pt. if they are unable to request then offer every 3-4 mouthfuls (use a straw or special cup to avoid spills) |
| if a pt is unable to sit upright during eating how should you position them | laterally |
| what should you do if your pt is visually impaired during feeding assistance | ID food placement as you would describe time on a clock (ex. potatoes at 8 o'clock) |
| dietary intake %'s | refused (only a few bites or refusal)= 0% poor = 25% fair = 50% good = 75% all (all food eaten or minimal left) = 100% |
| breakfast %'s | toast/muffin = 10% milk = 10% cereal = 10% juice = 10% main place = 60% |
| lunch/dinner %'s | soup/salad = 10% milk/juice = 10% bread = 10% dessert = 10% main plate = 60% |
| open system tube feedings | -Requires manual handling of the feeding formula (Poured into bag/syringe) - More prone to contamination -tubing should be change Q24 hours to minimize risk |
| closed system tube feedings | -Utilizes pre-filled containers that connect directly to the feeding tube - less likely to become contaminated -can be used w/ a feeding pump to regulate the drip automatically - often preferred due to convenience safety |
| ADPIE | Assessment, Diagnosis, Planning, Implementation, Evaluation |
| Systolic vs Diastolic | Systolic = pressure during contraction Diastolic = pressure at rest |
| pulse sites | Radial (wrist), carotid (neck), apical (5th ICS midclavicular) |
| Clean vs Sterile Technique | Clean = routine care Sterile = invasive procedures or catheter insertion |
| HIPIE | -hand hygiene -introduce -provide privacy -ID patient -explain procedure |
| equipment needed for urine specimen collection | - specimen cup w/pt info - Leur-lock syringe or needleless syringe - Gloves, alcohol pads, biohazard bag (w/ pt. urine specimen requisition in it) |
| obtaining urine specimen pt. 1 | 1.HIPIE 2. clamp the catheter tubing 15-20 minutes prior 3. w/ gloves on take your alcohol swab & syringe clean the access port 4. Using the needleless syringe, attach it to the port & aspirate the urine ( @ least 2mL) |
| obtaining urine specimen pt. 2 | 5. transfer urine to cup & place in biohazard bag (w/ requisition slip inside) 6. remove gloves and unclamp tubing 7. hand hygiene |
| if a catheter does not have a needleless port how should the sample be gathered | you will use a syringe with a needle attached. the needle will be inserted into the port and urine will be aspirated in that manner |
| To open sterile package | -Open top flap of kit away from yourself -Open left-hand flap away - Open right-hand flap away - Open bottom flace towards you rotate the package so it's squared -Make sure the flap closest to you lines up w/the tables edge so it doesn't touch you |
| where is the catheter balloon attached on the tubing | the orange tip. make sure to not place it on the port |
| how should a female patient be cleaned for catheter insertion | - Spread & clean labia top to down (clean the furthest side 1st and the closest side to you second) - clean right down the middle also clean When sterile field is of importance use your non-dominant hand to spead and dominant to clean |
| when is betadine used to clean a patient vs a washcloth | betadine is used just prior to insertion of the catheter (when sterile field is in use) A washcloth is used when sterile field is not in play and the patients perianal area is being prepped (use a different part of the cloth or new swabs for each area) |
| steps for catheter insertion pt. 1 | 1. HIPIE, don gloves, and ask about allergies 2. assess bladder for tenderness 3. perform perianal care and ID the meatus 4. place pt in dorsal recumbent position 5. dof dirty gloves and re perform HH 6. confirm trash is near & prep sterile materials |
| steps for catheter insertion pt. 2 | 7. sterile drape will be first, place it under pt 8. dawn sterile gloves (be sure that sterile kit and sterile glove kit do not touch each other) 9. you are now sterile so only touch the sterile part of the kit |
| steps for catheter insertion pt. 3 | 10. if you prefer it, drape your triangled drape now (place on perineum) 11. open your betadine and attach the balloon 12. lube 2-3 inches of the catheter 13. transfer the sterile kit to the sterile drape on pt bed (in b/t legs) |
| steps for catheter insertion pt. 4 | 14. clean area w/ betadine, using a new swab for each section (use your non-dominant hand to spread and dominant to clean) 15. use your dominant (still sterile) hand to insert the tube. DO NOT touch the perineum w/ your non-dominant (non-sterile) hand |
| steps for catheter insertion pt. 5 | 16. insert until you see urine in your tubing, after that insert for 1-2 more inches 17. inflate the balloon and ensure it is secure by tugging 18. when done, secure the tube to the patients thigh and place the bag on the designated bed hook |
| steps for catheter insertion pt. 6 | 19. ensure patient is comfortable 20. clean up and perform hand hygiene 21. document insertion |
| how should a male patient be cleaned for catheter insertion | -hold penis firmly, upright (if needed pull back foreskin) -wipe from center of meatus in a circular motion around the glans to the base (repeat 3x using a new swab/cloth each time) -use dominant hand to clean and non-dominant to cleanse |
| applying condom catheter pt.1 | 1.HIPIE, don gloves, and ask about allergies 2. lower sheets and blanket, place bath sheet across pt chest and towel across lap 3. cleanse the area w/soap and water 4. apply like a normal condom (leave 1-2 in at the top) |
| applying condom catheter pt. 2 | 5. connect condom sheath to tubing 6. secure tubing to pt thigh w/ leg strap 7. hang bag on designated hook 8. clean up and remove gloves 9. ensure pt comfort and document |
| daily catheter care | 1. HIPIE and gloves 2. wash urinary meatus & proximal catheter area (soap & water or bathing wipes can be used). be careful not to pull on the catheter 3.dry gently 4. remove gloves and HH |
| 7 principles of Sterile field | 1 . Field above waist 2.Hands above waist 3. Open package away 4. Don't turn your back on the sterile field 5. Don't reach over the sterile field 6. Don't let the sterile field get wet 7. 1-inch border is contaminated |
| removal of indwelling catheter pt.1 | I . HIPIE 3 . Place pt. In supine position 4 Clean urinary meatus (soap & water) 5. Use syringe to deflate balloon 6. Once deflated, gently pull out the catheter Check that tip is intact, if broken report immediately as parts may be in the bladder |
| removal of indwelling catheter pt. 2 | 7. cleanse perianal area again 8. perform HH and ensure pt comfort 9. document |
| what does drinking water or dry swallows ensure during NGT insertion | that the airway is closed |
| when should you check for residual of an NGT pt | -per doctor or hospital orders -every feeding/flushing -movement of pt (departments) -pt in distress |
| when should you hold feeding for a NGT pt | if the residual is 100% of the feeding rate (ex. 30 mL/hr and residual is 30) re-check after 30 mins, if residual is 50% or less then you may resume |
| when is a g tube used over NGT | when the patient will have it placed more permanently |
| what should you check a g tube for | check the insertion site and inside of the drainage sponge for infection |
| what dressing is used for a g tube | a drainage sponge (fenestrated) - never use regular gauze |
| what should you do if a pt begins to aspirate during feeding | -stop feed -turn pt on their side and suction -administer O2 -alert physician |
| how long should a pt be kept in semi-fowlers position after eating | 30 mins - 1 hour |
| if you cannot set a flush on the kangaroo pump then what should you do | pause the feed and manually flush |
| what should you do if you meet resistance while flushing a NGT tube | if possibly kinked then follow the lines if clogged try: milking the tube or using certain enzymes to break down the clog (7-up or cranberry juice can be used in a pinch) |
| what should you do if a patient has no residuals but c/o abdominal pain or distention | alert the physician |
| when is suctioning a NGT used | for bowel rest and decompression |
| what should be documented during NGT insertion | measure markings, side of nose used, size of tube, time, placement confirmation, pt toleration, if any resistance was met, color of gastric contents |
| input | any full or clear liquids you consume (ice cream, tea, water, fluids, meds, jello, blood etc.) |
| output | stool. urine, vomit, wound drainage, dialysis output |
| 1 oz | 30 mL |
| 1 tablespoon` | 15 mL |
| 1 teaspoon | 5 mL |
| how would you calculate CBI output | document input w/ irrigation and w/o irrigation total= urine + irrigation to find urine only just sub the irrigation amount |
| 1 cup | 8 oz (240mL) |
| 1 pitcher | 25 oz (750mL) |
| if your pt leaves your care (ex. going to radiology) is it your responsibility to document fluid o's and i's they had while gone? | no, it is the responsibility of the other nurse or caretaker who is with them |
| how do you calculate output for peds | weight of diaper and # of occurences |
| how do you calculate output for older adults | # of diapers/pads |
| if pt is continent and not on strict I/O how would you document | # of times gone to the bathroom and time |
| how to document solid stool/ non-caught vomit | by size |
| how to measure wound drainage | if on gauze: size (sm,m,l) woundvac: you can get exact amt |
| ice chips amount for I | half the amount of the cup ex. pt had 240mL of ice chips --> counts as 120mL |
| reasons for NGT placement | -nutrition (pt w/ dysphagia or high aspiration risk) -med administration (can't swallow) -gastric compression -diagnostic (allows for gastric contents to be aspirated) |
| reasons for urinary catheter placement | -urinary retention or obstruction -surgery (pre/post-op) -chronic conditions (neurogenic bladder or spinal cord injury) -strict monitoring of urine output -hospice -sacral/perineal wounds |
| which anatomical site of the chest is the apical pulse located at | mitral |
| pulse site located below the inguinal ligament | femoral |
| pedal pulse is located: | top of the foot |
| enema positioning | pt on left side w/ top leg bent |
| alterations in bowel elimination | flatulence diarrhea constipation incontinence diverticulitis obstructions |
| types of bowel obstructions | mechanical: blocks in the intestinal lumen (scarring, hernias, tumors, volvulus) functional: inability of peristalsis |
| infection signs | fever swelling redness (rubor) drainage congestion bowel alterations malaise lymphadenopathy altered consciousness |
| infections dx test | CBC C&S CRP ESR Serologic test (spec. antibodies) Radiographic (ex. CXR for chest infection) |
Created by:
tabithaj23