Priority Nursing Actions Allen's Test
Priority Nursing Actions Allen's Test
Priority Nursing Actions Allen's Test
Allens Test
Explain procedure to client
Apply pressure over ulna and radial arteries
Ask client to open and close hand repeatedly
Release pressure from ulna
Assess extremity color distal to pressure point
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Blood Sample
Check HCP order
Identify food, medication, and other factors affecting procedure
Identify client
Explain procedure
Draw blood
Apply pressure to puncture site
Send blood to lab
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Infection Suspected and Central Venous Catheter Site
Notify HCP
Remove catheter, prepare for possible restore in different location
Remove catheter tip and sent it to the lab
Obtain a blood culture from the client
Prepare for antibiotic administration
Document what happened, the action taken, and the clients response
Inserting IV line
Check HCP order, get correct materials
Select site/ palpate the vein for resilience
Clean skin with alcohol swab in circular motion
Stabilize vein below insertion site and puncture skin, observe for blood in flashback
chamber (in no blood is observed, try again but make sure to use a new kit)
Apply pressure above insertion w/ nondoment hand, retract catheter tubing, secure IV,
begin flow
Tape and secure IV, label (date/time)
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Removing IV line
Check HCP order
Turn off IV, remove dressing while stabilizing the catheter
Apply pressure with gauze and remove slowly
Apply pressure for 2-3 minutes
Inspect IV site
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Transfusion Reaction
Stop transfusion
KVO w/ Normal saline
Notify HCP
Stay w/ client and monitor vitals every 5 minutes
Administer emergency medications
Obtain urine specimen
Return tubing to blood bank
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Adult CPR (CAB= Compressions, airway, breathing)
Determine unconsciousness
Check pulse at carotid artery
Perform chest compressions
Open airway, using the head tilt- chin lift
Check breathing and deliver breaths
Administering Medication via a Nasogastric Tube
Check order
Pre medication (make sure it can be crushed or if capsule, it can be opened)
Dissolved medication in 15-30 mL of water
Verify client and explain procedure
Check tube placement, check residual content and bowel sounds
Draw medication into a catheter- tip syringe, clear excess air from syringe, insert
medication into tube
Flush tube with 30-15 Ml of water or N.S.
Clamp tube for 30-60 minutes
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Eclampsia
Remain w/ client, call for help
Ensure open airway, turn client on side, give oxygen by mask at 8-10 L/min
Monitor fetal heart patterns
Administer medications as prescribed to control seizures
After seizure has ended, insert oral airway and suction as needed
Prepare for delivery
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Prolapse Cord
Apply finger pressure w/ gloved hand
Put client in trendelenburgs or modified sims or knee- chest position
Give oxygen at 8-10 L/min by face mask
Monitor FHR and assess the fetus for hypoxia
Prepare IV fluids or increase rate of existing solution
Prepare for immediate birth
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Drawing up Insulin
Wash hands
Gently rotate NPH insulin bottle
Wipe off tops of insulin vials w/ alcohol sponge
Draw back amount of air into syringe that equals total dose
Inject air equal to NPH vial
Inject air equal to regular insulin dose into regular insulin vial
Draw up regular insulin
Draw up NPH insulin
Paracentesis
Obtain consent
Obtain vitals, including weight
Have client void
Position client upright
Apply dressing to site
Monitor vitals, weigh client, client should be on bed rest
Measure amount of fluid
Label and send fluid to lab for analysis
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Respiratory Suctioning
Explain procedure to client
Assist client to upright position
Perform hand hygiene and don protective garb
Prepare/ turn on suctioning equipment
Hyperoxygenate client
Insert catheter WITHOUT suction applied
Apply suctioning intermittently while ROTATING and WITHDRAWING the catheter
Hyperoxygenate client
Listen to breath sounds
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If Pulmonary Embolism if Suspected
Notify Rapid Response Team
Reassess the client and elevate HOB
Administer oxygen
Obtain vitals and check lung sounds
Prepare to obtain an ABG
Prepare to administer heparin therapy or other therapies
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