Nursing Tips
Restraints: When to Remove
Restraints should be removed immediately once a patient is no longer a risk to themselves or others.
Restraints: When to Remove
Restraints should be removed immediately once a patient is no longer a risk to themselves or others.
Restraints
Restraints should be applied to a portion of the bed frame which moves up and down with the bed, but cannot move on its own (i.e., not the side rail).
Restraints
Restraints should be applied to a portion of the bed frame which moves up and down with the bed, but cannot move on its own (i.e., not the side rail).
General Anesthesia: Nursing Care
After general anesthesia, keep a patient NPO until their gag reflex/swallowing ability returns.
General Anesthesia: Nursing Care
After general anesthesia, keep a patient NPO until their gag reflex/swallowing ability returns.
Cutaneous Pain
Cutaneous pain involves the skin (e.g., a paper cut) while somatic pain involves deeper tissues such as bones and joints.
Cutaneous Pain
Cutaneous pain involves the skin (e.g., a paper cut) while somatic pain involves deeper tissues such as bones and joints.
Caring for a restrained patient
When caring for a restrained patient, a new order is required every 24 hours.
Caring for a restrained patient
When caring for a restrained patient, a new order is required every 24 hours.
Seizure Precautions
If a patient is on seizure precautions, pad the bed side rails, and ensure oxygen, suction, and vital signs equipment is in the patient's room.
Seizure Precautions
If a patient is on seizure precautions, pad the bed side rails, and ensure oxygen, suction, and vital signs equipment is in the patient's room.
Sterile Field Preparation
During sterile field preparation, open the top flap away from your body first. Then open the flap on the right side using the right hand, and the left side using...
Sterile Field Preparation
During sterile field preparation, open the top flap away from your body first. Then open the flap on the right side using the right hand, and the left side using...
Closed Drain: Nursing Care
After emptying a closed drain (e.g., Jackson-Pratt, Hemovac), fully compress the canister and replace cap in order to ensure negative pressure is applied to the area.
Closed Drain: Nursing Care
After emptying a closed drain (e.g., Jackson-Pratt, Hemovac), fully compress the canister and replace cap in order to ensure negative pressure is applied to the area.
Unstageable Pressure Wound
A pressure wound base which is covered in slough or eschar is considered to be unstageable.
Unstageable Pressure Wound
A pressure wound base which is covered in slough or eschar is considered to be unstageable.
Enemas: Nursing Care
Patients receiving enemas may report cramping. Lower the solution container if cramping is reported.
Enemas: Nursing Care
Patients receiving enemas may report cramping. Lower the solution container if cramping is reported.
Crutches: Patient Teaching
A patient using crutches should be taught to ascend stairs leading with the strong leg and descend by leading with the weaker leg.
Crutches: Patient Teaching
A patient using crutches should be taught to ascend stairs leading with the strong leg and descend by leading with the weaker leg.
Patient Controlled Analgesia (PCA) Pumps
Patient Controlled Analgesia (PCA) pumps should only be used by the patient. Educate families/visitors not to press the button for the patient!
Patient Controlled Analgesia (PCA) Pumps
Patient Controlled Analgesia (PCA) pumps should only be used by the patient. Educate families/visitors not to press the button for the patient!
Protective/Reverse Isolation
A patient on protective/reverse isolation should be provided a private room with positive-pressure airflow. Do not allow flowers or live plants into the room, and screen all visitors for illness.
Protective/Reverse Isolation
A patient on protective/reverse isolation should be provided a private room with positive-pressure airflow. Do not allow flowers or live plants into the room, and screen all visitors for illness.
24-Hour Urine Collection
A patient asked to do a 24-hour urine collection should be taught to discard the first void and then collect all urine voided over the following 24 hours.
24-Hour Urine Collection
A patient asked to do a 24-hour urine collection should be taught to discard the first void and then collect all urine voided over the following 24 hours.
Clear Liquid Diets
A patient on a clear liquid diet may have items that are transparent and liquid at room temperature (e.g., water, clear sodas, pulp-free juices, popsicles, jello, black coffee, clear broth).
Clear Liquid Diets
A patient on a clear liquid diet may have items that are transparent and liquid at room temperature (e.g., water, clear sodas, pulp-free juices, popsicles, jello, black coffee, clear broth).
When to Perform a Medication Reconciliation
A medication reconciliation should be done during admission, upon transfer to another floor/unit/facility, and at discharge.
When to Perform a Medication Reconciliation
A medication reconciliation should be done during admission, upon transfer to another floor/unit/facility, and at discharge.
Braden Scale: Pressure Injuries
A Braden scale score ≤ 18 indicates a patient is at risk for pressure injuries. In this case, take measures to prevent injuries of this type.
Braden Scale: Pressure Injuries
A Braden scale score ≤ 18 indicates a patient is at risk for pressure injuries. In this case, take measures to prevent injuries of this type.
Suctioning
When performing suctioning, apply suction intermittently while withdrawing the catheter and rotating it for 10-15 seconds.
Suctioning
When performing suctioning, apply suction intermittently while withdrawing the catheter and rotating it for 10-15 seconds.
Blood Glucose Key Points
Key points when taking a patient's blood glucose: Place hand in dependent position; Pierce outer; Wipe away first drop of blood; Hold test trip NEXT to the blood drop
Blood Glucose Key Points
Key points when taking a patient's blood glucose: Place hand in dependent position; Pierce outer; Wipe away first drop of blood; Hold test trip NEXT to the blood drop
Abdominal Wound Dehiscence
For abdominal wound dehiscence with evisceration: Place saline-soaked gauze over wound; Don't try to reinsert organs!; Prepare patient for possible surgery.
Abdominal Wound Dehiscence
For abdominal wound dehiscence with evisceration: Place saline-soaked gauze over wound; Don't try to reinsert organs!; Prepare patient for possible surgery.
Applying Restraints
When applying restraints, make sure 2 fingers can fit between restraint and patient, se a quick release knot, and don't place restraints on side rail.
Applying Restraints
When applying restraints, make sure 2 fingers can fit between restraint and patient, se a quick release knot, and don't place restraints on side rail.
Reporting Urine Output
REPORT urine output that is less than 30ml/hr! Decreased urine output can be indicative of shock, sepsis, and kidney failure.
Reporting Urine Output
REPORT urine output that is less than 30ml/hr! Decreased urine output can be indicative of shock, sepsis, and kidney failure.
Enteral Feeding
Enteral feeding: Confirm placement with x-ray; Measure gastric contents; Hold feeding if residual exceeds ~500ml; Flush feeding tubes.
Enteral Feeding
Enteral feeding: Confirm placement with x-ray; Measure gastric contents; Hold feeding if residual exceeds ~500ml; Flush feeding tubes.
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