100% Verified
Absent Bowel Sounds - ✔✔Auscultate 5 mins per quadrant (Silence means NOTHING) (20
minute total) assess for an obstruction and notify MD
Normal IM injection reaction - ✔✔Burning at site, itching at site, bruising
Abnormal IM injection Reaction - ✔✔vomiting, constipation, dry mouth, rash (systemic)
TB testing - ✔✔1. Must be read 48-72 hrs (assessed)
Document date, time of injection and reading, as well as result
Mild swelling is normal
TB result-negative - ✔✔10mm- healthcare workers are a strict 10
TB result-positive - ✔✔red, raised (induration)
Positive TB result - ✔✔This means that the person has been exposed to TB
At risk for TB - ✔✔nursing homes, jails, homeless, certain meds, some other countries,
healthcare workers
Hyperglycemia - ✔✔hot and dry-sugar high
,Hypoglycemia - ✔✔cold and clammy-needs some candy
Symptoms of Hyperglycemia - ✔✔extreme thirst, frequent urination, dry skin, hunger, blurred
vision, drowsiness, nausea
Symptoms of Hypoglycemia - ✔✔shaking, tachycardia, sweating, anxious, dizzy, hunger,
impaired vision, weakness, fatigue, headaches, irritable
insulin - ✔✔NPH-longer lasting (cloudy)
Regular- faster acting (clear)
Order of Insulin Draw - ✔✔cloudy(air), clear(air),clear(insulin), cloudy(insulin)
70-110 - ✔✔Normal BS
Vision Intervention - ✔✔Annual Eye Exam
Vision Assessment - ✔✔PERRLA, peripheral testing, snellen chart, Hx (changes in vision?, dark
spots?, flashes?, issues in certain lighting?)
Vision pt education - ✔✔Certain drops can burn eyes, burning is better than being blind
(miotics)
, Hearing interventions - ✔✔1. Face to face
Speak clearly, slowly and directly
Eliminate background noise
Hearing Treatment - ✔✔audiology
Cataract Assessment - ✔✔1. dimness
misty vision
blurriness (milky haze)
Glaucoma - ✔✔High IOP
Timolol - ✔✔Glaucoma Tx
ARMD risks - ✔✔1. depression
ignoring Sx
injuries, falls, accidents, mobility
ARMD sight - ✔✔Loss of central vision- can see on side(may place things to one side or other)
Glaucoma Sight - ✔✔Loss of peripheral vision-side vision