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REMAR V2- #5 (Basic Care & Comfort)
When bathing a client always start with: Face, then upper body to lower body Elderly care: The skin Prone to tears Drier skin Always assess the skin of elderly clients Diabetic Skin Care Wash and dry feet daily Do not soak Do not cut toe nails Do not use lotion between the toes Check for skin break downs Who should be delegated to give the client a bath? UAP How many hours of sleep for clients 0-1 years? 14 – 20 hours of sleep Place infant on back to reduce SIDS (Sudden Infant Death Syndrome) How many hours of sleep for clients 2 – 8 years? 10 – 14 hours of sleep
How many hours of sleep for adults? 7 – 9 hours of sleep Recommended not to exercise before bed How many hours of sleep for clients 65+? 7 – 9 hours of sleep There is a decline in deep sleep patterns Insomnia Routine sleep patterns are established What are signs of dehydration? Oliguria (little urine output) Cool skin Poor skin turgor Dry mucous membranes Skin tenting, weight loss, sunken eyes, hypotension, tachycardia, lethargy, and headache When dehydrated urine levels may drop below the normal? 30 mL/h Indications of:
- UTI
- Diarrhea
- Vomiting
- Diabetes Rehydration Treatment Start with oral hydration at 5 mL Do not force oral fluids If oral fluids are not tolerated, the next step is NG Tube not IV fluids
Pyuria Pus in the urine Enuresis Involuntary discharge of urine Collection of a 24-hour urine specimen Start with an empty bladder Ask patient to void then throw it away All urine must be kept in 1 container If one urine sample is missed you have to start all over again Keep the urine on ice If the client is on their period during a 24-hour urine collection you should: Notify the provider and let them make the call What is the correct order for the RN to perform an abdominal assessment? I.A.P.P. – Inspect, Auscultation, Percussion, Palpate When handling stool what precautions do you use? Universal or Standard Precautions What are the factors that affect bowel patterns? Privacy Age Pregnancy Hydration Diet
Definition of constipation Fewer than three bowel movements per week Definition of diarrhea 3 or MORE liquid stools in a 24 hr period When you are doing an enema watch out for: Vagus nerve stimulation Stool Guaiac Test Screens for fecal occult (hidden blood) For a positive diagnosis of colon cancer screening there has to be 3 positive Guaiac tests Culture and Sensitivity Used to determine the best treatment for bacteria in the stool The nurse administering an enema to a client knows that the tip of the tubing should be inserted into the rectum while the client is in a sitting position, as on the toilet. False – The patient should be in the lateral SIMS position if receiving an enema
