Question

Discuss steps in  

1.) abdominal assessment

2.) administering an enema

3.) inserting an indwelling catheter

4.) donning and removing PPE

5.) providing post mortem care

6.) taking the apical pulse

7.) obtaining wound drainage and urine specimen for culture and sensitivity test

8.) providing bed bath

9.) providing oral care to an unconscious patient

10.) providing hygiene to immobilized client

11.) administering enteral feeding

12.) taking a tympanic temperature

13.) transferring client from bed to a wheelchair

14.) teaching a client how to use a cane

Interventions

Discuss the nursing interventions for the following

1. Collecting date from a newly admitted client

2. Preventing insomnia

3. Promoting skin integrity

4. Administering cold application

5. Discharge teaching

6. Unexpected death

7. Client with diarrhea

8. Non-pharmacological interventions for pain management

• Guided imagery

• Biofeedback

• Meditation

• Music therapy

9. documenting an incident report

10. Receiving telephone prescription  

11. Securing consent form

Answer 1

1) Abdominal assessment :-

#. Order of Assessment of the abdomen :-

Inspection, Auscultation, Percussion and Palpation

step 1

Look for visible pulsations, skin color, contour, lesions, rashes, scars, distension

step 2

notice color, location, umbilicus

step 3

note symmatry and color/contour of abdomen/ no aortic pulsations or persitaltlic waves visible

step 4

auscultate abdomen in all 4 quadrents while at the same time checking for bowel sounds (clicks and gurgles)

step 5

auscultate the abdomen for vascular sounds- includes the aorta, renal arteries, iliac arteries, femoral arteries. You shouldnt hear anything no swishing

step 6

purcuss for abdomen tones over all 4 quadrants

step 7

palpate the abdomen in all 4 quadrants and then palpate using deep palpation technique if patient complains of pain in a particular area palpate that area last. We are looking for enlarged organs, masses or tenderness

step 8

palpate for kidneys on each side of the abdomen

step 9

palpate liver at right costal boarder

step 10

assess for rebound tenderness last if patient reports pain by pressing deeply and gently into abdomen and withdrawing hand rapidly

step 11

palpate for skin temperature, texture, presence of masses

step 12

palpate then auscultate the femoral pulses in the groin

2) Administering an enema :-

1. prepare as ordered and prime tube to get air out.

2. encourage patient to empty bladder

3. place bedpan or commode nearby for the patient to use

4. put on clean gloves and PPE

5. position the patient in left sims

6. place fluid impermeable pad under patient

7. remove cap from enema and lubricate distal tip

8. gently inset the lubed tip into the rectum 2 to 3 inches with tip pointing toward the umbilicus

instruct the patient to bear down to help relax the muscles around the alimentary canal

9. unclamp the enema and allow the solution to flow into the rectum slowly

10. slowly withdraw the tip of the enema prevents reflex emptying of the bowel

11. instruct the patient to retain the enema as prescribed have them hold as long as they can ~15 minutes

tell them not to flush toilet

3) Inserting an indwelling catheter :-

Inform patient of the procedure you will be performing.

Get supplies and place patient in correct position

Drape patient with the sterile square and/or fenestrated drapes

Prepare sterile field with supplies

Don sterile gloves.

Clean urethral meatus with antiseptic swabs, one for each area

Attach syringe with 10mL of fluid to tubing and lubricate catheter

Insert and advance catheter

When urine appears in tubing, advance the catheter another 1-2 inches

Inflate catheter balloon

Gently pull catheter until resistance is felt

Secure catheter tubing to patient's leg and attach the bag to bed below the level of the bladder.

4) Donning and removing PPE :-

The order of donning PPE :-

Wash hands for 15 seconds, gown, mask, eye covers, hair net, shoe covers, gloves, and than wash hands.

#. The order the removing PPE :-

Gloves, gown, eye covers, mask, hair net, shoe covers, and than wash hands.