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Hesi study guide Most important to implement when donning sterile gloves? Keep gloved hands above the elbow. Center of gravity for older adults is upper torso but for adults is hips. An important diet modification to lower cholesterol is lowering your intake of beef (saturated fat) to less than 4 ounces a week. Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action. When transferring elderly with left-sided weakness, Move the chair parallel to the right side of the bed, and stand the client on the right foot. uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices. After completing an assessment then determine the etiology of the problem. Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body. Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished. The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium. The client should be positioned in a semi-sitting (Fowler's) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. When performing passive ROM exercises to shoulder hold arm above and below the elbow. Open Resources for Nursing (Open RN) In addition to using standard precautions and transmission-based precautions, (also called medical asepsis) is the purposeful reduction of pathogens to prevent the transfer of microorganisms from one person or object to another during a medical procedure. For example, a nurse administering parenteral medication or performing urinary catheterization uses aseptic technique. When performed properly, aseptic technique prevents contamination and transfer of pathogens to the patient from caregiver hands, surfaces, and equipment during routine care or procedures. The word “aseptic” literally means an absence of disease-causing microbes and pathogens. In the clinical setting, aseptic technique refers to the purposeful prevention of microbe contamination from one person or object to another. These potentially infectious, microscopic organisms can be present in the environment, on an instrument, in liquids, on skin surfaces, or within a wound. There is often misunderstanding between the terms aseptic technique and sterile technique in the health care setting. Both and sterility are closely related, and the shared concept between the two terms is removal of harmful microorganisms that can cause infection. In the most simplistic terms, asepsis is creating a protective barrier from pathogens, whereas is a purposeful attack on microorganisms. Sterile technique (also called surgical asepsis) seeks to eliminate every potential microorganism in and around a sterile field while also maintaining objects as free from microorganisms as possible. It is the standard of care for surgical procedures, invasive wound management, and central line care. Sterile technique requires a combination of meticulous hand washing, creation of a sterile field, using long-lasting antimicrobial cleansing agents such as betadine, donning sterile gloves, and using sterile devices and instruments. Principles of Aseptic Non-Touch Technique(ANTT) is the most commonly used aseptic technique framework in the health care setting and is considered a global standard. There are two types of ANTT: surgical-ANTT (sterile technique) and standard-ANTT. Aseptic non-touch technique starts with a few concepts that must be understood before it can be applied. For all invasive procedures, the “ANTT-approach” identifies key parts and key sites throughout the preparation and implementation of the procedure. A is any sterile part of equipment used during an aseptic procedure, such as needle hubs, syringe tips, needles, and dressings. A is any nonintact skin, potential insertion site, or access site used for medical devices connected to the patients. Examples of key sites include open wounds and insertion sites for intravenous (IV) devices and urinary catheters. ANTT includes four underlying principles to keep in mind while performing invasive procedures:
Preparing and Preventing Infections Using Aseptic TechniqueWhen planning for any procedure, careful thought and preparation of many infection control factors must be considered beforehand. While keeping standard precautions in mind, identify anticipated key sites and key parts to the procedure. Consider the degree to which the environment must be managed to reduce the risk of infection, including the expected degree of contamination and hazardous exposure to the clinician. Finally, review the expected equipment needed to perform the procedure and the level of key part or key site handling. See Table 4.3 for an outline of infection control measures when performing a procedure. Table 4.3 Infection Control Measures When Performing Procedures
Use of Gloves and Sterile GlovesThere are two different levels of medical-grade gloves available to health care providers: clean (exam) gloves and sterile (surgical) gloves. Generally speaking, clean gloves are used whenever there is a risk of contact with body fluids or contaminated surfaces or objects. Examples include starting an intravenous access device or emptying a urinary catheter collection bag. Alternatively, sterile gloves meet FDA requirements for sterilization and are used for invasive procedures or when contact with a sterile site, tissue, or body cavity is anticipated. Sterile gloves are used in these instances to prevent transient flora and reduce resident flora contamination during a procedure, thus preventing the introduction of pathogens. For example, sterile gloves are required when performing central line dressing changes, insertion of urinary catheters, and during invasive surgical procedures. See Figure 4.15[1] for images of a nurse opening and removing sterile gloves from packaging. See the “Checklist for Applying and Removing Sterile Gloves” for details on how to apply sterile gloves. Video Review of Applying Sterile Gloves[2]Which action should the nurse implement first?Assessment is the first step of the nursing process and takes priority over all other steps.
What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV medications quizlet?What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV medications? Insert a Huber-point needle into the port.
What is the most important reason for starting intravenous infusion in the upper extremities rather than the lower extremities of adults?The superficial veins of the upper extremities are preferred to those of the lower extremities for peripheral venous access because cannulation of upper-extremity veins interferes less with patient mobility and poses a lower risk for phlebitis.
Which finding should the nurse identify as a client risk factor for pressure ulcers?Which finding should the nurse identify as a client risk factor for pressure ulcers? Rashes in the axillary, groin, and skin fold regions. During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer.
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Which action is most important for the nurse to implement when donning sterile gloves?
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