cheat sheet

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cheat sheet
2010-05-17 18:42:48

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  1. When verifying tube placement for enteral feedings, Aspirate 20-30 mL of gastrointestinal secretions.
  2. Auscultate the epigastrium while injecting 5-20 mL of air produces a bubbling sound in the epigastrium and the upper left quadrant.
  3. Intermittent feedings 300-500 mL several times a day administered for 30min.
  4. Continuous feedings administered over 24 hours.
  5. By end of third trimester, fetus is approximately 20 inches and 7.0 to 7.5 pounds. Weight gain is 5-7 ounces per week for 6 months.
  6. When washing hands, apply 2-4 mL of liquid soap.
    Wash hands for a minimum of 15 seconds.
  7. When donning gloves, put glove on the dominant hand first.
  8. Adult has 32 teeth.
  9. Heart sounds: Auscultate the heart in all four anatomic sites, aortic, pulmonic, tricuspid, apical.
    keep the client in supine position with head elevated 30-45 degrees.
  10. Homan's sign is pain felt when foot is flexed = venous thrombosis (blood clots)
  11. Use the flat-disk side to transmit high-pitched breath sounds when auscultating chest.
    Use a systematic zigzag procedure.
  12. The nurse usually examines the posterior chest first, then the anterior chest.
    • Anterior: Start above the clavicle starting on the clients right side. Move to left, then down and right.
    • Posterior: Start at apices.
  13. 4-7 hours after a meal, bowel sounds in the RLQ may be heard continuously over the ileocecal valve.
    Listen to irregular gurgling noises occurring about every 5-20 seconds.
  14. Bowel sounds 4-32 per minute.
    • If bowel sounds are absent, listen for 3-5 minutes before concluding that they are absent.
    • When palpating abdomen, depressed lightly 1 cm or to the depth of the subcutaneous tissue with the pads of your fingers.
  15. Orally: allow 15-30min elapse between client's intake or smoking and the measurement. Leave in for 2minutes.
    • Rectal: assume a lateral position. Apply lubricant to the thermometer. Insert .5 to 1.5 inches. 3minutes adults, 5minutes neonates.
    • Axillary: Make sure pit is dry. 9minutes adults. 5 minutes children.
    • Tympanic: Select ear opposite the side client may have been lying. Use right hand to measure right ear, left to left = proper angle. Gently pull the pinna upward and back. Straight back for children under 3.
  16. F = 1.8xC + 32
    • 2 step blood pressure: 1. Palpation (of brachial or radial) 2. Auscultation (to brachial)
    • Wait 1-2 minutes before moving on to 2nd step
    • Release valve to drop 2-3mm Hg per second
  17. Tub or shower temperature = 110 to 115
    Enema temperature = 105
  18. Woundcare: Clip hair about 2 inches around wound
    • Catheters:
    • Sterile technique
    • Clean catch method needs 30-60mL.
    • Inspect the penis 30minutes after applying condom catheter.
    • Female urethra: 1.5 inches. Male: 8 inches.
    • Lubricate the insertion tip 2-6 inches for males.
    • Patient is in supine position with legs flexed.
    • Hold 2 inches away from tip for females. 3-4 for males. 1 for baby or small boy.
    • Lift the penis to a position perpendicular to the body.
    • Balloon catheter is 5 or 30ml inflated. Insert catheter an addition 1-2 inches beyond point of urine flow.
    • Complete void before timed specimen starts.
  19. Client in left side recumbent position or sims.
    • Enema: Lubricate 2 inches
    • Run solution through tubing to let air escape.
    • Insert tube 3-4 inches in an adult.
    • Low enema = 12 inches. High enema = 18 inches.
    • Clamp to stop flow for 30 seconds if needed, then restart slowly.
    • Instruct patient to hold 5-10min for cleansing enema. 30 for retention.
  20. Normal Vitals:
    • Pulse: 60-100
    • Respirations: 12-20
    • BP: 100-140 over 65/95