Hesi Practice

However, there are additional guidelines in terms of assessing the patient for prolonged catheter use. There should be frequent assessment and evaluation of the patient’s need for continued use. It is important to note that in addition to determining the patient’s need for catheterization, prior to insertion the nurse should also complete the following:

Only when it is absolutely necessary should a catheter be inserted into a patient. Every patient is assessed for the need for a Foley catheter. If the Foley is inserted, assessments are also then done daily to see if the need is still valid. If the reason is not justifiable the catheter must be removed from the patient (Joint Commission releases new NPSG for CAUTI, 2011). Nurses must follow guidelines while inserting indwelling catheters as well. Aseptic technique is critical to maintain during this process. The use of sterile equipment and a sterile procedure helps to reduce the risk of CAUTI. If in any way the catheter becomes contaminated during the process of insertion, the nurse should discard of the entire catheter and start with a new, sterile kit. Proper hand hygiene is very important before and after contact with indwelling catheters to decrease risk of infection. Maintenance of a close drainage is system is also important that way bacteria are not able to get in and cause infection (Revello & Gallo, 2013). Decreasing the number of times Foleys are inserted and how long they stay in for can help reduce the risk of CAUTI since the longer a Foley stays in, the higher the risk of infection becomes. Nurses must keep the catheter line patent, with no kinks to allow urine to flow freely through into the collection bag. When a urine sample must be obtained it must be done in a sterile

The majority of nurses are still auscultating air insufflation over the abdomen to check the placement of nasogastric tubes, since it was the method that was taught for many years. It is an easy and less expensive way to check the placement, but research has shown that it is not reliable. Research showed that sounds can be transmitted to the epigastrium no matter where the nasogastric tube is placed. It does not matter if it is in the lungs, esophagus, or stomach, it can still be heard through the stethoscope (De Boer, J., Smit, B., Mainous, R., 2009).

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate?

X Safe and Effective Care Environment X Management of Care X Safety and Infection Control X Health Promotion and Maintenance X Psychosocial Integrity X Physiological Integrity X Basic Care and Comfort X Pharmacological and Parental Therapies X Reduction of Risk Potential X Physiological Adaptations

The nurse recognizes that what information in the client's history supports a diagnosis of gestational diabetes?

The only intervention identified within the scope of nursing practice is to use sterile technique. Central line insertion, intubation, and prescription are functions of the physician.

2. The nurse is doing preconception counseling with a 28-year old woman with no prior pregnancies. Which of the following statements made by the client indicates to

3) A nurse takes care of a patient with cardiac dysrhythmia. Which of the following laboratory values is a priority for the nurse to monitor?

The patient will require surgery to repair the hole in the intestines, and subsequently will have a drainage tube, NG tube, and feeding tube. All drains will need to monitored for placement/movement, and drainage. Input and output will be closely monitored and recorded. The patient will remain on NPO, or nothing by mouth, to rest the bowels along with frequent assessments to monitor for infection and bleeding. The nurse will need to monitor for bowel sounds, vital sign changes, temperature changes, pain, abdomen girth, and wound/incision inspections. The following labs will require monitoring: CBC, H&H, albumin, BUN & creatinine, glucose, and ABG’s and lactic acid if sepsis is suspected. Careful and frequent monitoring of labs will alert the nurse if the patient develops sepsis, or hypovolemia due to excessive bleeding (Belinhof, et al., 2012). In addition to vital signs and labs, the nurse will also include patient assessment into consideration before drawing conclusions by means of critical thinking. After the full assessment has been made, the nurse will report any findings to the health care provider that require further investigation or

Throughout the placement of a chest tube, the patient should be assessed for complications of chest tube drainage and for re-expansion of the lung. A nurse should assess the lungs and the thorax for tracheal deviation, nonsymmetrical movement of the chest, emphysema, changes in the pattern of breathing, adventitious lung sounds, and presence of a pneumothorax (tympany).

In this assignment we will discuss the holistic assessment process on admission to the clinical area and the duties that the nurse has throughout this process. We will also consider the medical conditions Mr C is presenting with and the appropriate care the nurse should provide relating to specific conditions. We will also discuss the pathophysiology of each of his conditions. Within the assignment we will discuss the post-operative care Mr C will be given by the nurse and the reasoning for this care. Including airway and breathing, circulation, pain management and psychological care. Whilst still in the clinical area we will explore the process of discharge planning and the role of the nurse throughout this process. Lastly we will

My first nursing intervention was to also get a certified translator. I did not however, have no nursing intervention for the N.G. tube because the diet for a bowel surgery changes to a different diet within 24-48 hours based assess of bowel movement and flatus. I also assess the bowel movement before pain instead because based on Maslow hierarchy the physiological needs to be assess before assessing the patient comfort level. I did check the values of fluids and feeding. You have great interventions. However, I have a different one and a different order.

Going forward we will keep our tape to secure our PEDS patients in our PEDS vent in the heart center. Remember if the baby is not born in our SCN it is now considered a pediatic patient. We can use the vent in the heart station to ventilate them. I have enclosed a picture and a link to demonstrate the correct way to tape an Peditric ET tube. Also see my self or John if you need a one on one.

The nurse would want to ensure adequate nutrition for the baby and preventing aspiration or infection