CH 33: Infection control

imflammatory reactions include---,source of pathogen growth=reservoir, what is portal of entry , host and infectious
agent, the best way to block the chain is by---, unused items in one client’s room, should not be used for another one,
esp paying attention to those respite cares who are temporary relief a regular caregivers,
Asepsis if free form pathogens but not sterile, hand washing is medical asepsis, surgical is covered with sterile gloves,

CH 37: Client Safety

Lock beds, wheelchairs, stretches before moving and after nursing care has been offered, Ethic is also a factor as well,

CH 46: Mobility and Immobility

Assessment for assisting mobility: eye: skin, ask: BM, listen (if client is seeking attention every 5 mins, try to find out
what is bordering her, even a social worker can be involved, they are suppose to be more open and understanding,
Empathy),

Immobility can affect systems:1 metabolic, I/O, 2. Resp-pneumonia, secretion, 3 cardio-DVT, oedema, 4 musculoskeletal-
atrophy, 5 urinary-UTI, 2000-2500 mls/day, 6 integumentart-pressure, 7phychosocial
BW: best before breakfast everyday or at least the same time, set the scale to 0 first,bariatric client p1222,

Pillow use for sim’s and side lying, perineal care catheterization, draw sheet’s position and usage, slider sheets
usage(easier than draw because it has handles, 2 nd choice will be a mechanical lift, transfer towards the strong side of
the body if hemiplegia,

Mechanical lift guidelines:

1. Used for clients who cannot safely or effectively wight bear, mentally or physically
2. machinery that manually lifts a client out of bed or chair via sling and transfers them to another place
3. slings come in many different types and sizes and should be fitted for the client and situation
4. mechanical lifts are never operated alone, must be 2 nurses present to ensure client safety
5. follow institutional guidelines with operating instructions
6. do not operate a lift that you are not familiar with, get help

To consider before transfer: 1 leg/trunk strength and stability 2 balance 3 co-operation 4 ability to follow instruction

Fowler’s position good for SOB, breathing difficult usually advised to even lean forward, assess for mobility
include:assess trunk and leg strength, balance and ability to follow commands and cooperate

# tib/fib has to use a cast, and young enough, a pair of crutches will improve mobility, crutch then unaffected leg when
decending

ROM: extension-increase angle ./. body parts, Abduction-limb away from bod, plantar flexion-foot in a downward
direction, circum direction-ball and socket jts can perform, opposition-only by the thumb

Paraplegia’s client ability, pressure ulcer’s 3 stages and risk factors and plans, it is important to protect bony
prominences from lying in bed and also under a brace, 1 st sign, red or white skin,

CH 38: Hygiene

Denture care include morning and Hs care, can be removed and reinserted by care provider of client

CH 31: Vital Signs

Temp: most and least accurate place, medication can raise or lower the body temp, tremors of muscles can generate
heat but to a violent contraction will be call convulsion, radiation of heat is possible, how about pain,

Rest: normal rate of an adult, eupnea, quiet and effortless, regular with chest rising and falling equally, if neck muscles
are involved then---, breathing rapidly, tachypnea, sleep apnea(stop breathing for 10-30 sec. during sleep because of
blockage, eg obesity) is a transient condition that needs to be monitored,

BP: normal ranges for all ages, diastolic sound, systolic and auscultatory gap,hypostatic hypotension affected by drug,,
long time ummobilization eg post op

Pulse

Oxygen saturation: normal 95-100%

CH 45: Bowel Elimination

The importance of balanced diet and fluid, constipation can be resolved, if not, review the diary and acute care by prune
juice, laxative, suppository, enema, if not resolved , impaction may cause death, ducolax supp is an enteral (GI) cathartic
which is also a laxatives but has a stronger effect,

Colostomy bag should be changed if it is 1/3 or ½ full any time.

Colostomy: transverse(loop), sigmoid colostomy,(end colostomy, double barrel), ileostomy-ileoanal reservoir, 3 kinds
p1153, continent ilostomy and kock

CH 44: Urinary Elimination

Urinary stoma;ileal loop, permant via transient, transureteroureterostomy-one outlet, double ureterostomy- 2 outlets,
continent urinary diversion(back flow may damage kidneys,

UTI: may have dysuria, incontinence and even confusion in the elderly,
Intake include liquid at room temp and IV fluids urine irrigations intakes, nasal gastric tube intake, output include
urine(urinary drainage bag), diarrhea, vomitus, emesis, from E/G tube’s drainage bag,

Urine collection: random, mid-stream and sterile, 24 hours, catheter port is for? Urinary drainage bag, should be
emptied at least q8h, when is ¾ full, before irrigation, before collecting 24 hours urine for test, clamp the bag before
taking sterile urine sample, may be washed with soap, rinsed with vinegar, stored in a towel.

Stress incontinence; what is it and how can it be corrected.

CH 43: Nutrition

Repair and build tissue:--- high fibre is not advised for post colostomy clients for the first week and also who has
diverticular disease: bowel stimulation or obstruction,

Dysphasia- puree diet, high Fowler’s with all meals, not in a rush, allow time to swallow and don’t lie down after meals
for at least 30 mins, because aspiration will be high esp with vomitus or regurgitation, clear fluid include: juice, plain
tea, clear soup, popsicle, not able to eat or drink for over 24 hours, it is a challenge for older adults for dehydration,

Balance diet good for normal persons, esp type 1 diabetics, skin should be well protected, esp foot and toes, congestive
heart failure usually has restricted water intake as cardiac output is not expected to be normal, or water will be collected
in the lower limbs, causing oedema of legs,
CH 34: Medical Administration

6 rights, name of the med, dosage, timing, route, and for how long to make a complete order,

Parenteral is a way other than through GI tract, eye drops are consider sterile solution, muscous membrane is consider
as a percutaneous way,

Orthostatic hypotension can be caused by antihypertensive(for hypertension) drugs or immobilization, a pair of ted
stocking may help, as stroke is a common complication, prognosis is long and difficult,

Antibiotics should be taking the full course and with food or milk, report if any abn findings esp, rash (allergy) GI upset or
bleeding,

Acute care usually offered in a hospital setting in a short time until diagnosed, treated or treatment has started and
expected to cont at home, visited by community nurse,

CH 16: Documentation and Reporting

Chart what you have done only, incident report is for what has happened accidentally and the aim is to improve the
quality by adjusting or making changes. Not documented, not done.