When verifying tube placement for enteral feedings, Aspirate 20-30 mL of gastrointestinal secretions.
Auscultate the epigastrium while injecting 5-20 mL of air produces a bubbling sound in the epigastrium and the upper left quadrant.
Intermittent feedings 300-500 mL several times a day administered for 30min.
Continuous feedings administered over 24 hours.
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.
When washing hands, apply 2-4 mL of liquid soap.
Wash hands for a minimum of 15 seconds.
When donning gloves, put glove on the dominant hand first.
Adult has 32 teeth.
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.
Homan's sign is pain felt when foot is flexed = venous thrombosis (blood clots)
Use the flat-disk side to transmit high-pitched breath sounds when auscultating chest.
Use a systematic zigzag procedure.
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.
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.
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.
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.