D439: FOUNDATIONS
1. SBAR Format: -model for effective communication identifying Situation, Back-
ground, Assessment, and Recommendation
2. Dosage Calculation (ml, tbsp->ml):
3. How do you use crutches?: -weight is on both hands
support weight at the hand grips, with elbow flexed at 30 degrees, position crutches
on the unaffected side when sitting or raising from the chair
-How to use crutches: Do Not Adjust Crutch Settings After Fitting (Should be 3 Finger
Widths Between Axilla and Top of Crutch) Support Body Weight on Hand Grips (Not
Axilla), With Elbows Flexed at 30 Degrees
4. Wound Care:
5. Blister Treatment: Blisters are stage 2 pressure ulcers
Nurse Actions:
What to watch for:
6. Braden Scale:: A tool for predicting pressure ulcer risk
-measures pressure ulcers
7. Heparin: Anticoagulant- prevents blood clotting
Antidote:
Route: sub q in the abdomen next to the umbilicus
-do NOT aspirate the site and don't massage the injection site to prevent hematoma
8. Oxygen Parameters: 90% or above is normal
<90%= increase the oxygen to 3L /min
9. Pt loses or decreased level of consciousness. What do you do next?: -as-
1/6
, sess their respirations (Airway, breathing, circulation)
10. Pt is unconscious what position should they be in when giving oral care?:
11. Emancipated Minor Criteria with HIPPA lAWS: No consent, no information
-legally adults
12. Restraints: -written consent is needed coming from relatives/significant others
-secure consent for each episode of application of restraints
-PRN (as needed) order is UNNACCEPTABLE
-to physically restrict voluntary movement or use chemicals to revise/restrict resident
behavior
-the first thing to check after applying restraints is capillary refill
13. UAP (unlicensed assistive personnel) teaching:: -when applying hand sani-
tizer it has to be applied IN BETWEEN fingers as well, so if you see the UAP apply
2/6
1. SBAR Format: -model for effective communication identifying Situation, Back-
ground, Assessment, and Recommendation
2. Dosage Calculation (ml, tbsp->ml):
3. How do you use crutches?: -weight is on both hands
support weight at the hand grips, with elbow flexed at 30 degrees, position crutches
on the unaffected side when sitting or raising from the chair
-How to use crutches: Do Not Adjust Crutch Settings After Fitting (Should be 3 Finger
Widths Between Axilla and Top of Crutch) Support Body Weight on Hand Grips (Not
Axilla), With Elbows Flexed at 30 Degrees
4. Wound Care:
5. Blister Treatment: Blisters are stage 2 pressure ulcers
Nurse Actions:
What to watch for:
6. Braden Scale:: A tool for predicting pressure ulcer risk
-measures pressure ulcers
7. Heparin: Anticoagulant- prevents blood clotting
Antidote:
Route: sub q in the abdomen next to the umbilicus
-do NOT aspirate the site and don't massage the injection site to prevent hematoma
8. Oxygen Parameters: 90% or above is normal
<90%= increase the oxygen to 3L /min
9. Pt loses or decreased level of consciousness. What do you do next?: -as-
1/6
, sess their respirations (Airway, breathing, circulation)
10. Pt is unconscious what position should they be in when giving oral care?:
11. Emancipated Minor Criteria with HIPPA lAWS: No consent, no information
-legally adults
12. Restraints: -written consent is needed coming from relatives/significant others
-secure consent for each episode of application of restraints
-PRN (as needed) order is UNNACCEPTABLE
-to physically restrict voluntary movement or use chemicals to revise/restrict resident
behavior
-the first thing to check after applying restraints is capillary refill
13. UAP (unlicensed assistive personnel) teaching:: -when applying hand sani-
tizer it has to be applied IN BETWEEN fingers as well, so if you see the UAP apply
2/6
