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When verifying tube placement for enteral feedings, Aspirate 20-30 mL of gastrointestinal secretions.
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Auscultate the epigastrium while injecting 5-20 mL of air produces a bubbling sound in the epigastrium and the upper left quadrant.
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Intermittent feedings 300-500 mL several times a day administered for 30min.
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Continuous feedings administered over 24 hours.
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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.
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When washing hands, apply 2-4 mL of liquid soap.
Wash hands for a minimum of 15 seconds.
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When donning gloves, put glove on the dominant hand first.
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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.
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Homan's sign is pain felt when foot is flexed = venous thrombosis (blood clots)
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Use the flat-disk side to transmit high-pitched breath sounds when auscultating chest.
Use a systematic zigzag procedure.
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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.
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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.
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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.
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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.
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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
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Tub or shower temperature = 110 to 115
Enema temperature = 105
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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.
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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.
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Normal Vitals:
- Pulse: 60-100
- Respirations: 12-20
- BP: 100-140 over 65/95
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