NR-226 Fundamentals – Patient Care

NR226 Final Exam Review

Kayexalate

used to remove potassium rapidly

Hypertonic enema (fleet phosphate)

draws water into colon

Enema precautions

lower enema bag if patient complains of cramping, decreases rate

NG tube considerations

x-ray and pH to check placement, check tube feeding residual

Nutrition screening: DETERMINE

Disease, Eating poorly, Tooth loss, Economic hardship, Reduced social contact, Medications,

Involuntary weight loss/gain, Need assistance in self care, Elderly

Clear liquid diet

Any liquid you can see through

Full liquid diet

all liquids, pudding, custard

mechanical soft

foods pureed to have smoother consistency than regular foods

Enteral nutrition

tube feeding formulas

Parenteral nutrition

TPN's- amino acids, vitamins, lipids, electrolytes

7 rights of medication (PMARTDR)

right patient, medication, amount, route, time, documentation, reason

Oral route

sublingual, buccal

Parenteral

IM, IV, subcutaneous, intradermal, epidural, intraosseous

Intramuscular injection

90 degree angle, 2ml in deltoid (acromion process), 3 ml in ventral gluteal, 3 ml in vastus

lateralis

z-track technique

displace top layer of skin from muscle to inject IM

Subcutaneous injection

45-90 degrees, abdomen, thigh (quad), lower back, triceps

Intradermal injection

15 degrees, allergy test, ppd test

Intravenous injection

large amount of fluid in short period of time

SOLER

sit facing patient, open position, lean toward patient, eye contact, relax

non verbal therapeutic communication

listening, silence, touch

verbal therapeutic communication

closed/open ended questions, restating, paraphrasing, clarifying, focusing