RN, LPN, CNA

18.3557-662

Nursing

Careers

Spend more time with pt that any other member of healthcare team

AM & PM Care Oral hygiene Offer bedpan/urinal Monitor elimination Assist with

dressing/undressing Bathe pt Skin care Follow pt care plan Perform ROM

Provide body alignment/positioning

Care for hair and nailsShave ptApply hot coldMake bedAmbulateFeed ptRecord I &O

Nursing Responsibilities

AM & PM Care

Read 18-11 & 18-12

Skin Management

Skin is first line of defense Observe/Assess for

Appearance Pale, flushed, bruising, open areas, rashes cyanotic,

jaundice, diaphoresis Skin turgor – good, tented

Temperature Dry, hot, warm, cold

Pain- if yes rate on scale

Pressure Sores, Bed Sores, Decubiti

Areas sensitive (as risk) Shoulders, elbows, hips, sacrum, Heels, Ankles, Ears,

ToesHow to prevent

Change position at least every 2 hours Keep skin clean Massage reddened areas to increase circulation Keep linen free of wrinkles Specialized beds

Documenting Pressure Sores

Stage of breakdownSize of breakdown in centimetersSteps taken to care for breakdown

Oral care

Reduces odorHelps prevent tooth decayIs refreshingRelieves dry lips18.14-18.19

Offering a Bedpan/Urinal

Urinary check offSolid waste- bowel movement, feces, stoolLiquid waste- urinating, voidingLiquid bowel movement – diarrheaImpaction- if solid waste is not eliminated

(N,V) Laxative- a medicine for relieving constipation Suppository- a solid medical substance that melts

upon insertion into the rectum

Ambulation- Walking

Maintains staminaIncreases joint mobilityImproves muscle toneHelps prevent lung congestionImproves circulationHelps prevent blood clotsHelps maintain independenceProvides sense of accomplishment

Bathing a Pt – 18.43-18.53

Removes perspiration and dirtRemoves odorIncreases circulationAllows for exerciseGives opportunity to observe skinProvides relaxationBed bath, partial/completeTub, shower, whirlpool

Hair and Nail Care

Keep hair cleanKeep nails trimmed and clean

Do not cut nails of a diabetic ptShave your male pt dailyDressing/undressing

Dress weak or most involved side first Undress weak or most involved side last

Terminal/Postmortem Care

Prosthetic Devices

DenturesGlassesHearing Aids Artificial limbsArtificial eyesArtificial breastPlace these items in a safe place so they are

not lost

Bed making

18.55-18.58Making a closed bedMaking an occupied bedMaking an opened bed

Preparing the Pt for a meal

Assist pt to wash handsRemove unpleasant

itemsOffer opportunity to use

restroomRaise HOB / position in

chair/transport to dining area

Check to be certain right tray for that patient and correct diet

Place food within reach

Check the tray to make sure everything is there

Prepare any item pt cannot manage- open containers Butter bread, cut meat,

open milk, season foodTell pt where each

item is using face of clock if pt is blind

Fluid Imbalance –dehydration vs edema

Dehydration is caused by Diarrhea Vomitting Bleeding Excessive perspiration

(diaphoresis) Poor fluid intake

Symptoms of dehydration Fever Decreased urine Urine is concentrated Wt loss Membranes are dry Tongue is coated and

thick Skin hard and cracks

Edema

Edema is caused by: High salt intake Infections Injuries or burns Certain kidney

diseases Certain heart diseases

or heart inefficiencies Sitting too long in one

position Infiltration of IV fluid

Symptoms of Edema: Decrease in urine

output Gain in weight Puffiness/Swelling Sometimes shortness

of breath

Measuring I & O

Intake All liquid taken by

mouth Any food item that turns

to liquid at room temp All IV intake All tube feeding

1cc = 1ml 30 cc = 1 oz 30 x (number of ounces) =

cc 30 x 8 = 240cc

Output Urine Liquid stool Emesis (vomit) Suctioned secretion Drainage Excessive perspiration

Enemas

Urinary Output

Incontinent Pt