NURSING 150/150 AFinal Review.

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1. Surgical Aseptic- sterile is not the same as disinfectant • Sterile gloves- touch the inside of first gloves, not below waist line, can’t cross hand, can’t reach over. • Catheter- (Foley,... Straight) o Straight Catheter- temporary/in-n-out o Prostate • Wound- pressure ulcer (stages 2,3,4) o Stage 1 Pressure ulcer- Non-blanching. o Stage 4- Gently pack it with moist gauze and cover with dry dressing. (wet-to-dry) 2. Vital signs- • Pulse- 60-100, check for Rhythm, Volume, Rate o Radial Pulse- 2 fingers, Don’t push too hard. o PVD- thready pulse • B/P- 120/80, o PreHTN, HTN o Manual vs. Machine- Manual is better • Respiration- 12-20; older- 15-20 o Asymmetrical lung expansion- Call MD- Atelectasis or PNA. o IS- Incentive Spirometer, inhale (slow deep breaths) • Temperature- 96.8-99.5; Heat stroke has no sweat. • Pain- Subjective (whatever the pt. say) or it can be Objective as well. o When pt is in pain, increases all V/S. o Pain scale- o Abdominal Pain- do not palpate! Must Auscultate! • O2 Sat- 95-100% • Lung Sounds- o Asthma- wheezes o PNA-rales, rhonchi, crackles 3. When pt is Falling- don’t stop ........................................................................... [Show More]

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