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fundamentals
Standard Precautions
Hand Hygiene
Wash In / Wash Out
Alcohol-Based Hand Rub
Hand Washing
Personal Protective Equipment (PPE)
Gown
Face Mask
Goggles/Face Shield
Gloves
Donning and Removing PPE
Discard Sharps in Puncture-Resistant Container
Cough Etiquette
2 mins
Contact Precautions
Private Room
Wash In / Wash Out
Personal Protective Equipment (PPE)
Gloves
Gown
Limit Time Patient Leaves Room
Leave Equipment In Room
Special Linen Handling
Same Pathogen, Same Room
History of Contact Isolation
Preventative Education
2 mins
Droplet-Airborne Precautions
Private Room
Droplet
Droplets Larger than 5 Microns
Being Within 3 Feet of Patient
Surgical Mask with Face Shield
Type of Infection or Condition
Airborne
Airborne Infection Isolation Room (AIIR)
Droplets Smaller than 5 Microns
N95 Respirator
Type of Infection or Condition
2 mins
Aseptic Technique
Invasive Procedures
Skin Integrity Broken
Sterility
Hands Up for Scrubbing
Keep Objects in View
Only Sterile Objects in Field
Only Sterile Touches Sterile
Contamination
Edges of Sterile Field
If Sterility Questioned
If Wet or Prolonged Exposure to Air
Considerations
Never Leave Sterile Area
PPE Order
2 mins
Level of Consciousness: Descriptive guide for Glasgow Coma Scale
Conscious
Confused
Delirious
Somnolent
Obtunded
Stuporous
Comatose
3 mins
Use of Restraints
Use Guidelines
During Emergency
Protecting From Harm
For Limited Time
Considerations
Last Resort
May Further Agitation
Frequent Observation
Obtain Order Within 1 Hour
Quick-Release Tie
2 mins
Prevention of Falls
Risk Factors
Physical Aging
Polypharmacy
Environmental
Hospital / Facility Prevention
Call Light within Reach
Assistive Devices Available
Bed Alarms
Home Prevention
Improve Lighting
Remove Home Hazards
Priority Nursing Interventions
Promote Exercise
Fall Risk Assessment
2 mins
Seizure Precautions
Reduce Environmental Stimuli
Identify Triggers
Aura
Pad Side Rails
Bed Lowest Position
Oxygen and Suction Available
Consideration
Monitor Therapeutic Drug Levels
2 mins
The Nursing Process
ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
2 mins
Lung Sounds - Wheezes
Location
Throughout Lung
Description
High Pitched
Sounds Like
Musical
Cause
Air Moving through Narrowed Airways
38 secs
Lung Sounds - Crackles
Location
Lower Lobes
Description
Fine/Coarse
Sounds Like
Fine: Twisting Hair through Fingers
Coarse: Velcro
Cause
Collapsed Small Airways and Alveoli "Popping Open"
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