Final Flashcards
(324 cards)
1
Q
Florence Nightingale (4)
A
- First nurse epidemiologist
- Sanitary/hygiene reform/concerned with the environment of the patient
- “Notes on Nursing: What It Is, and What It Is Not” published in 1859; established the first nursing philosophy based on health maintenance and restoration
- Nicknamed the “lady with the lamp” during the Crimean War
2
Q
What does ANA set and who does it protect?
A
Standards of nursing practice and protects nurses
3
Q
7 Roles of Nurses
A
Autonomy
Accountability
Caregiver
Advocate
Educator
Communicator
Manager
4
Q
Autonomy (of nurse)
A
you can do it!! An essential element of the professional identity of a nurse is that they are able to perform independent nursing interventions (things nurses do to help a patient) without a medical order.
5
Q
Accountability (2)
A
- responsible professionally and legally for the type and quality of nursing care provided.
- remain current and competent in nursing and scientific knowledge and technical skills.
6
Q
Caregiver
A
help patients and families maintain and regain health, manage diseases and symptoms, and attain max functioning and healing.
You help patients set realistic goals and meet them.
7
Q
Advocate
A
you protect your patient’s human and legal rights and provide assistance is asserting these rights. We are the voice of the patient many times when they can’t speak or don’t know what to ask.
8
Q
Educator
A
Nurses teach patients and families. We explain disease processes, teach about medications, skills, reinforce learning , evaluate their learning process. Some are formal and planned and some are informal and unplanned.
9
Q
Communicator
A
essential to the nurse-patient relationship (know patient’s personality) and your relationship with everyone else you will work with . You will communicate with other nurses, patients, families, and other healthcare professionals
10
Q
Manager
A
coordinates the activities of members of their group. As a nurse you will use appropriate leadership styles to talk to patients and other staff in order to coordinate safe, effective care for your patients.
11
Q
What differentiates APRN and RN? (2)
A
- APRN have higher clinical knowledge and skills
-APRN has 6-8 years of total education, can be masters or doctorly prepared.
12
Q
Medical assistant (schooling and role)
A
- 3-6 months of education in hospital, technical college or community college
- VS, bathe, change linens, serve meals, weigh patient, I and O, etc
13
Q
LPN/LVN (schooling, role, difference from RN)
A
- usually 12 months of education at a community college.
- Do treatments (lung care, feeding, oral meds), skills, direct patient care (e.g., observe and report clinical changes, perform wound care, and ADLs), teaching reinforcement
- No initial assessments during the day, no admit and discharge, no initial teaching; under RN
14
Q
Registered Nurse (schooling, role, difference in levels)
A
- Associate degree or Bachelors Degree,2-4 years of education.
- All Assessment, Admission and Discharge, IV, skills, Community Focus, Teaching;
- BSN has more health assessment skills, community focus, and leadership
15
Q
TNA
A
State board of nursing, Each state has a board of nursing, they are concerned for the public’s safety. They regulate nurse practice acts and licensing
16
Q
Nurse Practice Acts
A
Every state has one and it says what a nurse can and can’t do that is different from the accepted national standard of practice for a nurse.
17
Q
TNA vs ANA
A
TNA (aka “The State Board”) - concerned about public safety; reprimand you if you do wrong and can take your license
ANA- concerned about nurse safety and advocacy; set professional standards and practice
18
Q
NSNA
A
National Student Nurses Association
- interested in your rights as a student
19
Q
Autonomy in Ethics
A
- commitment to include patients in decisions about all aspects of their key. It is a key feature of patient-centered care
- freedom from external control, must respect patient independence
Ex. informed consent, patient education, patient advocacy, right to refuse medication
20
Q
Beneficence
A
Nurses practice in the best interest of helping others. The agreement to act with beneficence implies that the best interests of the patient remain more important than self interest.
-patient interest> self-interest
21
Q
Nonmaleficence
A
Maleficence means to harm or hurt, so nonmaleficence refers to the avoidance of harm or hurt. In nursing practice, we vow to do no harm to the patient.
-balance risks and benefits
22
Q
Justice
A
fairness in distribution of resources
23
Q
Fidelity
A
faithfulness, agreement to keep promises. Follow through on your promises and actions.
-loyalty
24
Q
ANA code of ethics describes (3)
A
- Nurse’s commitment to the patient
- set of guiding principles that all nurses must follow
- duties of nurse to profession and society
25
5 ANA code of ethics
- Advocacy
- Responsibility
- Accountability
- Confidentiality
- Social Networking
26
Advocacy
to support of a particular cause. Standing up for the health, safety and patient rights of others is an example.
27
Responsibility
the respect of one’s professional obligations and to follow through. Every agency that you we will go into in clinical has policies and procedures. Responsibility means that when you are in that agency you follow those policies and procedures. You agree to remain competent.
28
Confidentiality (2)
health care team's obligation to respect patient's privacy from outside sources
- HIPAA( Health Insurance Portablity and Accountability Act of 1996) mandates confidentiality and protections of patient’s personal health information
29
Purpose of Cultural Assessment (3)
helps nurses gain an understanding of the meaning of the illness to the patient, expectations the patient has regarding treatment and care, and the patient’s perception about the process.
30
The very first step in becoming culturally competent and providing culturally congruent care is ______.
cultural awareness and acknowledging your own biases
31
Blue phone in hospital means?
It is for medical interpreter
32
Social determinants of Health
SDOH are the conditions in which people are born, grow, live, work, and age. This includes conditions within a health care system.
33
Stereotyping
The process by which people acquire and recall information about others based on race, sex, religion, etc., leads to prejudice; what you say or think
34
Prejudice
Unjustified negative attitude based on a person’s group membership;
35
Discrimination
When a person acts on prejudice and denies another person one or more of their fundamental rights (food, sleep, healthcare, happiness)
36
5 steps to develop cultural competence
1) Cultural awareness
2) Cultural desire
3) Cultural encounters
4) Cultural knowledge
5) Cultural skills
37
Cultural awareness
An in-depth self-examination of one's own background, recognizing biases, prejudices, and assumptions about other people
38
Cultural Encounter
Cross-cultural interactions that provide opportunities to learn about other cultures and develop effective intercultural communication
39
Nurse's role in safe medication administration (6 parts)
- Follow 7 rights of drug administration
- Assess patient’s ability to self-administer medications
- Monitor side effects
- Do not delegate any part of the medication administration process to nursing assistive personnel (NAP)
- Educate patient and families about medications
- implement nursing process to integrate medication therapy into patient care
40
7 rights of medication administration
```
Right medication
Right dose
Right patient
Right route
Right time
Right documentation
Right indication/reason
```
41
6 patient rights
1. to be informed about their care
2. to make decisions about their care
3. to refuse care
4. to be listened to by their caregivers
5. to receive info in a way that meets their individual needs
6. to be informed of errors; transparency
42
When are side rails not a restraint? (3)
- when they ↑ patient mobility and stability when moving into or out of bed
- if patient can freely exit the bed and move in it
- to prevent sedated patient from falling out
43
Most common restraint
side rails
44
When is a medication order required?
for every medications that the nurse will administer to a patient
45
When to administer "on call" medication?
when the operating room staff members notify you that they are coming to get a patient for surgery.
46
When to administer STAT? now?
Administer STAT immendiately; now within 90 minutes
47
When to administer time critical medications?
within 30 minutes before or after the scheduled time
48
When to administer antibiotics? (time frame)
30 minutes before or after they are scheduled to maintain therapeutic blood levels.
49
When to administer routinely ordered non time-critical medications?
1 to 2 hours before or after the scheduled time or per agency policy.
50
5 things that should be on medication order
Drug name
Dose strength
Route
Frequency
If PRN—Indication for use
51
What counts as a restraint?
any chemical (drugs not to treat patient's condition), manual method, physical, mechanical device, or material or equipment that immobilizes or reduces the ability of a patient to move freely unless to prevent harm during activity
-THEY ARE TEMPORARY
52
How often to monitor patient in restraints?
Every 15 minutes for violent behavior and to tend to needs
Every 2 hours for nonviolent behavior to lossen or remove restraints
53
When can restraint be used? (4)
Reduce the risk of patient injury from falls
Prevent interruption of medical therapy such as traction, IV infusions, nasogastric (NG) tube feeding, or Foley catheterization
Prevent patients who are confused, disoriented, combative from removing life-support equipment
Reduce the risk of injury to others by the patient
54
What needs to happen for safe restraint use? (4)
- face-to-face physician order within 24 hrs (60 minutes if violent)
- use all alternatives before restraint ----NO PRN
- use least restrictive alternative
- select alternative based on patient situation
55
10 things to monitor while patient in restraints
- Vital signs
- Skin integrity
- Nutrition
- Hydration- offer water
- Extremity circulation (2 fingers)
- Range of motion (ensure call light placement in reach)
- Hygiene
- Elimination needs
- Cognitive functioning and Psychological status
- Need for restraint
56
8 Alternatives to restraints
- de-escalation
- trained sitter (companionship and supervision)
- Move patient closer to nurse’s station
- Distraction
- Frequent observations and attention to needs
- Bed alarms/chair alarms (no slip socks, low bed)
- Family involvement
- discontinue bothersome treatment ASAP
57
11 pieces for fall prevention
1. Fall risk assessment (conducting routinely per agency policy)/ Identify fall risks (Apply yellow color-coded wristbands to identify fall risks; Fall risk wheel on door)
2. Hourly/purposeful rounding
3. Adaptation of the environment (Remove excess furniture and equipment; Safety bars near toilets; adequate lighiting)
4. Reduce the number of psychoactive medications
5. Attention to postural hypotension
6. Established elimination/toileting schedules
7. Call lights and personal belongings within reach
8. Bed safety alarms or motion detectors
9. Use of assistive devices (walkers, canes, wheelchairs (brake locks), )
10. Management of foot problems and footwear (rubber-soled shoes or slippers)
11. Assign Physical therapy for balance, strength, gait
58
How to resolve ethical dilemmas? (3)
- know thyself
- To resolve ethical dilemmas, you must rely on facts instead of beliefs and values
- A strong emotional reaction hints at a belief vs a fact
59
When to ask about patient allergies?
Immediately ask about and document patient allergies from the moment you start care
60
Patient Care Hand-Off (2)
*A transfer and acceptance of patient care responsibility using effective communication.
*High-quality hand-off is complex and structured. (a Joint Commission Standard)
61
I in IPASStheBATON for Handoffs
Introduction (Introduce yourself and your role or job (include patient)); write name on whiteboard
62
P in IPASStheBATON
Patient (Name, identifiers, age, sex, location)
63
A(1st) in IPASStheBATON
Assessment (Present chief complaint, vital signs, symptoms, and diagnosis)-new nurse quickly assesses
64
S (1st) in IPASStheBATON
Situation (Current status or circumstances, including code status, level of (un)certainty, recent changes, and response to treatment)
65
S (2nd) in IPASStheBATON
SAFETY Concerns (Critical lab values or reports, SES factors, allergies, and alerts (falls, isolation))
66
What is SBAR? What does it improve? What does it stand for? (3)
* A common language and tool for communicating critical information to healthcare providers in a standardized, structured, and timely manner.
* Improves perception of communication and information about patients between health care professionals.
* Situation, Background, Assessment, and Recommendation
67
B in IPASStheBATON
Background ( Comorbidities, previous episodes, current medications, and family history)
68
A(2nd) in IPASStheBATON
Actions (What actions were taken or are required? Provide brief rationale)
69
T in IPASStheBATON
Timing (Level of urgency and explicit timing and prioritization of actions)
70
O in IPASStheBATON
Ownership (Who is responsible (person or team) including patient or family?)
71
N in IPASStheBATON
Next (What will happen next? Are there anticipated changes? What is the plan?
Are there contingency plans?)
72
What are 4 situations of Interprofessional Collaboration?
-Patient rounding
-Rapid Response Team
-SBAR
-Interprofessional education
73
S in ISBAR
Situation (concise statement of the problem)
74
B in ISBAR
Background
- Pertinent and brief information related to the situation.
- Diagnosis and co-morbidities
- Relevant background clinical information (i..e. medications, specialists, procedures)
75
A in ISBAR
Assessment
- Analysis and considerations of options
- What are your assessment findings?
- What do you think the problem is?
76
R in ISBAR
Recommendation
- Action requested/recommended
- What do you suggest needs to be done?
- What are you requesting?
- Is everyone clear about what needs to be done?
77
What is TeamSTEPPS in IPC? What are the 5 principles?
-evidence based team work (increases team awareness and communication; decreases barriers to patient safety)
-Principles: team structure, communication, leadership, situation monitoring, mutual support
78
CUS Tool in IPC
I am Concerned
I am Uncomfortable
This is a Safety Issue
79
HIPPA Privacy vs Security rule
Privacy rule: requires disclosures of PHI be limited to specific info required for particular purpose
Security rule: specifies administrative, physical/ and technical safeguards for 18 elements of PHI in electronic form
80
What did Florence Nightingale say about health informatics?
To Err Is Human: Building a Better Health System: appropriate technologies can help to reduce errors and ensure patient safety
81
11 legal Guidelines for Documentation
1. No retaliatory comments or opinions about HCP or patient
2. Correct all errors promptly
3. Record facts
4. Discuss communication you initiated for orders or clarification
5. Document only for yourself
6. Avoid generalized statements “status unchanged” or “tolerated well”
7. Begin with date and time, end with signature and credentials
8. Password protection
9. Do not leave blank spaces or lines
10. Do not erase or scratch out errors made while recording
11. Record all written entries legibly using black ink and not felt tip pen or erasible ink
82
4 Guidelines for Quality Documentation
- Only include facts
- Write in short sentences
- Use simple, short words
- Avoid the use of jargon or abbreviations
83
6 standards for Quality Documentation
-Factual (avoid opinions and vague terms; only subjective data should be from patient
-Accurate (avoid irrelevant details)
-Appropriate Usage of Abbreviations
-Current (document right after things occur)
-Organized
-Complete (appropriate and essential info)
84
5 Error-prone abbreviations
- U, u for unit
- QD or QOD for daily or every other day
- IU for international unit
- trailing and leading zeros
- MS , MSO4, MgSO4 for morphine sulfate and magnesium sulfate
85
SOAP
-Documentation Method to identify interprofessional problems
Subjective, Objective, Assessment, Plan
86
What is the Rationale and Correct Action for the following documentation Guideline:
Correct all errors promptly.
Rationale: Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide evidence.
Correct Action: Avoid rushing to complete documentation; be sure that information is correct
87
What is the Rationale and Correct Action for the following documentation Guideline:
Record all facts.
Rationale: Record must be accurate, factual, and objective.
Correct Action: Be certain that each entry is thorough. A person reading your documentation needs to be able to determine that a patient received adequate care.
88
What is the Rationale and Correct Action for the following documentation Guideline:
Document discussions with providers that you initiate to seek clarification regarding an order that is questioned.
Rationale: If you carry out an order that is written incorrectly, you are just as liable for prosecution as the health care provider.
Correct Action: Do not record “physician made error.” Instead document that “Dr. Smith was called to clarify order for analgesic.” Include the date and time of the phone call, with whom you spoke, and the outcome.
89
What is the Rationale and Correct Action for the following documentation Guideline:
Document only for yourself.
Rationale: You are accountable for information that you enter into a patient’s record.
Correct Action: Never enter documentation for someone else (exception: if professional has went home and forgot to document something)
90
What is the Rationale and Correct Action for the following documentation Guideline:
Avoid using generalized, empty phrases such as “status unchanged” or “had good day.”
Rationale: This type of documentation is subjective and does not reflect patient assessment.
Correct Action: Use complete, concise descriptions of assessments and care provided so that documentation is objective and factual.”
91
What is the Rationale and Correct Action for the following documentation Guideline:
Begin each entry with date and time and end with your signature and credentials.”
Rationale: Ensures that the correct sequence of events is recorded; signature documents who is accountable for care delivered.
Correct Action: Do not wait until the end of shift to record important changes that occurred several hours earlier; sign each entry according to agency policy (e.g., M. Marcus, RN).
92
What is the Rationale and Correct Action for the following documentation Guideline:
Do not erase or scratch out errors made while recording.
Rationale: Charting becomes illegible: it appears as if you were attempting to hide information or deface a written record.
Correct Action: Draw single line through error, write word “error” above it, and sign your name or initials and date it. Then record note correctly.
93
What is the Rationale and Correct Action for the following documentation Guideline:
Do not leave blank spaces or lines in a written nurse’s progress note.
Rationale: Allows another person to add incorrect information in open space.
Correct Action: Chart consecutively, line by line; if space is left, draw a line horizontally through it and place your signature and credentials at the end.
94
What is the Rationale and Correct Action for the following documentation Guideline:
Record all written entries legibly using black ink. Do not use pencils, felt-tip pens, or erasable ink.
Rationale: Illegible entries are easily misinterpreted, causing errors and lawsuits; ink from felt-tip pen can smudge or run when wet and may destroy documentation; erasures are not permitted in clinical documentation; black ink is more legible when records are photocopied or scanned.
Correct Action: Write clearly and include appropriate abbreviations using black ink
95
BUN and Creatinine normal range
BUN-6-24
Creatinine-0.6-1.2
96
When does BUN increase? What does it mean if BUN and creatinine are high?
BUN increases with dehydration and decreases with ECF excess. If BUN and Creatinine are high, there may be dehydration and kidney failure
97
Hematocrit and Hemoglobin normal range
Hematocrit (% of RBC in blood)-36-48
Hemoglobin (amount of protein in RBC)—12-16
98
Hematocrit to Hemoglobin ratios
Normal 3:1
Dehydration/Hypovolemia: >3:1
Fluid Overload: <3:1
99
Purpose and 2 examples of Isotonic fluids
-increase ECV but do not enter cells; given for dehydrated, hypotensive, or hypovolemic shock
- Normal Saline (0.9%)
- Lactated Ringers-includes Na+, K+, Ca2+, Cl−, and lactate, which liver metabolizes to HCO3−
100
10 Signs of Hypovolemia/dehydration
1. sudden weight loss (overnight)
2. decreased skin turgor (elasticity)/tenting
3. postural hypotension
4. no tears or sweat, dry mucus membranes
5. Tachycardia
6. Rapid Thready pulse (comes and goes; difficulty finding)
7. Flat neck veins
8. Restlessness/decreased LOC
9. Sunken eyes
10. Oliguria (less than 30 mL/hr)
101
9 signs of hypervolemia/ fluid overload
1. Sudden weight gain (overnight)
2. Confusion
3. Orthopnea (unable to breathe laying down)
4. Hypertension
5. Tachypnea (fast breathing)
6. Crackles/rales in lower bases of lungs
7. Bounding pulse (high heart rate)
8. Distended neck veins
9. Pulmonary edema
102
Purpose and 5 Examples of Hypertonic fluids
Used to draw water from cells.
* 3% or 5% NS
* D10W (becomes hypotonic in body)
* D5 ½ NS (becomes hypotonic after D5 absorbed)
* D5 NS (becomes isotonic after D5 absorbed)
* D5 LR (becomes isotonic after D5 absorbed)
103
Purpose and 2 Examples of Hypotonic fluids
§ Used to expand ECV and hydrate cells before surgery
§ 0.225% NS
§ 0.45% NS
104
Infiltration and Extravasation Assessment Findings (3)
- Skin around catheter site taut, blanched, cool to touch, pitting edema;
- may be painful as infiltration or extravasation increases
- infusion may slow or stop
105
Infiltration and Extravasation Nursing Intervention (5)
§ Stop infusion (discontinue if not vesicant; if vesicant disconnect and aspirate and give antidote) and call HCP
§ Remove the IV catheter
§ Prop the arm
§ Do not apply heat or cold unless ordered, (can react with substance and cause tissue necrosis)
§ Do not apply pressure (can cause more contact with skin)
106
Phlebitis (vein inflammation) Assessment Finding
hard, red, painful, hot lump where IV site is ; may or may not have red streak or palpable cord along vein
107
Phlebitis Nursing Interventions (5)
§ Take out IV and call doctor.
§ Elevate affected extremity
§ Do not apply heat or cold without order.
§ May need IV antibiotics.
§ Start new IV line proximal or in other extremity
108
Infection of IV site Assessment Finding
Redness, burning ,swelling, weeping or discharge; not hard
109
Infection of IV site Nursing Intervention (3)
§ Remove catheter and contact HCP
§ Need antibiotics to prevent sepsis
§ Clean skin with alcohol and culture drainage if ordered
110
Air embolism Nursing Interventions (3)
- Prevent further air from entering the system by clamping or covering the leak.
- Place patient on left side, preferably with head of bed raised, to trap air in the lower portion of the left ventricle.
- Call emergency support team and notify HCP
111
Listening (3)
* Planned and deliberate act in which the listener is present and fully engages the patient in a nonjudgmental and accepting manner.
* Interpret and understand what the patient is saying
* necessary for meaningful interactions with patient
112
Knowing the patient(3)
* Knowing means striving to understand an event as it has meaning in the life of the other
* helps to select the most appropriate and effective nursing therapies and interventions (nurse understands how illness, treatment, or rehabilitation affect the patient and family)
* Facilitated by continuity of care and clinical expertise
113
Causes, Description, and healing of Secondary intention wound
Causes: Stage 2 Pressure ulcers, burns, severe laceration, or surgical wounds that have tissue loss or contamination
Description: Wound edges not approximated
Implications: Wound heals by granulation tissue formation, wound contraction, and epithelization
114
Providing Presence (and 4 outcomes)
Person to person encounter conveying a closeness and sense of caring; involves being there and being with
Outcomes: relief of suffering, decrease anxiety, decrease in the sense of isolation and vulnerability, and personal growth
115
Causes, Description, and healing of primary intention wound
Causes: surgical incision (sutures, staples), hematoma (internal bleeding)
Description: Wound that is closed
Implications: Healing occurs by epithelization; heals quickly within minimal scar formation
116
Causes, Description, and healing of tertiary intention wound
Causes: Wounds that are contaminated and require observation for signs of inflammation
Description: Wound that is left open for several days
Implications: Closure of wound is delayed until risk of infection is resolved; more scaring
117
Gauze dressing
– most common, absorbent, wick away exudate and can use for packing
118
Difference between red, yellow, and black wounds
Red: healthy regeneration of tissue, granulation; goal is to keep moist
Yellow: Presence of purulent drainage and slough
Black: Presence of eschar that hinders healing; needs debridement
119
Self-adhesive, transparent film dressing
– traps moisture, allows viewing, adheres to undamaged skin, does not need secondary dressing
120
Hydrocolloid dressing (2)
adhesive, occlusive; useful to absorb exudate, maintain wound moisture, slowly liquify necrotic debris; impermeable to bacteria
-used as prevention in high friction area and on IVs
121
Hydrogel (2)
-- hydrates wounds, absorbs small amounts of exudate, debride by softening necrotic tissue; be wary of periwound maceration
—require secondary dressing
122
Calcium alginate (3)
– highly absorbent, no trauma when removed
– do not use on dry wounds
- require secondary dressing
123
Negative-pressure wound therapy (3)
§ suction promotes healing, reduces edema and contracture, collects exudate)—good if dehiscence occurs
§ Avoid when necrotic tissue with eschar present; fistulas, malignancy, evisceration or nerves exposes,
§ Express caution if high risk for hemorrhage, MRI, defibrillation
124
Nursing interventions to prevent pressure ulcers (5)
-turning every 2 hrs in bed
- turning every one hour in chair
-keeping patient dry with clean linen
-keep head at or below 30 degrees to prevent shear and friction
- cover moist areas with zinc oxide
125
Braden Scale Factors (3)
-RN completes daily
-six measures on sensory perception, moisture, activity, mobility, nutrition, friction and shear
-No risk 18-23; Mild risk: 15-18. Moderate risk: 13-14. High risk: 10-12. Severe risk: less than 9
126
Patient history factors in Venous Ulcer (5)
-chronic nonhealing ulcer (scaring may be present)
-no claudication (muscle pain when active) or rest pain (or neurologic deficit)
-moderate discomfort
-ankle or leg swelling and full veins
-pulse present
127
Cause of venous ulcer
Due to improper functioning of the valves in veins causing blood to pool in lower legs b-c can not return to heart
128
Interventions for Venous Stasis Ulcers (3)
-long term wound care (unna boot, damp-to-dry dressing)
-elevate extremity
-DO NOT encourage prolonged sitting or standing
129
Arterial Ulcer (description and appearance)
Full-thickness wound on lower leg feet, heels, or toes
“Punched out” appearance-smooth edges, smooth, shiny extremity
130
Patient history factors seen in arterial ulcer (6)
-pain while resting
-claudication after walking
-cold feet
-pallor with elevation
-skin or hair atrophy
-Gangrene or neurolgic deficits
131
Cause of arterial Ulcer
Refers to poor blood circulation to the lower leg and feet due to atherosclerosis leading to tissue ischemia
Not a pressure ulcer
132
Who are the interprofessional team members for skin integrity? (2)
- Physical therapy for moving patient
- Wound/ostomy care nurse for infected surgical site, venous stasis ulcer OR stage 3, 4, or suspected deep tissue pressure ulcer
133
Interventions for Arterial Ulcer (2)
-provide warmth for areas to promote vasodilation
-treat underlying cause (surgical, revasculation)
134
Acute/Transient pain (4)
-protective
-usually has identifiable cause and self limiting
-mild to severe (may have facial expressions, guarding, muscle tension
-hindered recovery if not adequately managed and may lead to chronic pain
135
What is the most reliable indicator of pain?
What the patient says (OLDCARTS and numeric scale) or their behaviors (if nonverbal), vital signs are not reliable
136
Chronic pain (4)
-prolonged; > 6 months
-does not always have identifiable cause (idiopathic
-may not have physiological response (mild warm skin, pupils normal or dilated)
-leads to great personal suffering and pain management must be individualized
137
Nociceptive vs neuropathic pain
- Nociceptive- normal pain transmission; aching
- Neuropathic- from pathology; burning, sharp shooting including sympathetically mediated, deafferentation (loss of afferent CNS input), neuralgia, central pain
138
Stage I pressure ulcer appearance, Dressing (3), and treatment (2)
Intact skin with localized area of nonblanchable redness (not purple or maroon)
* Dressing: none, transparent, hydrocolloid
* Treatment: turning, adequate hydration
139
Stage II pressure ulcer appearance, treatment (3), and dressing (3)
* Partial-thickness skin loss with exposed dermis; may be blister; no fat or deeper tissues visible
-no slough or eschar
* Treatment: turning, nutrition, manage incontinence
* Dressing: composite film, hydrocolloid or hydrogel (w. gauze or foam top)
140
Stage III Pressure ulcer appearance and dressing (5)
* Full-thickness skin loss with visible fat; no visible muscle, bone, or tendon
* slough, eschar, epibole, undermining, tunneling may occur (pain may not be felt)
* Dressing: hydrocolloid, hydrogel, calcium alginate, wet gauze, growth factors
141
Stage IV Pressure Ulcer appearance, treatment (1), and dressing (3)
* Full-thickness skin & tissue loss with exposed or palpable fascia, muscle, bone (not sanguineous drainage)
* Slough, eschar, tunneling, undermining, epibole may be present
* Treatment: perhaps surgical
* Dressing: hydrogel, calcium alginate, gauze
142
Unstageable/Unclassified pressure ulcer and Dressing (4)
Fully obscured thickness skin and tissue loss due to slough or eschar; stage III or IV if eschar removed (do not remove stable eschar on heal or ischemic limb)
Dressing: none (w/ dry eschar not being removed), adherent film, gauze (w/ solution), enzymes
143
Suspected Deep Tissue Injury
Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister
144
Difference b/w physical dependence, addiction, and tolerance
* Physical dependence: state of adaptation with a specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist ( physiological symptoms if withdrawn)
* Addiction: A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations (need medicine even when not in pain
* Drug tolerance: A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time (need bigger and bigger dose for an effect)
145
6 non-pharmacological pain relief interventions
* Relaxation
* Guided imagery
* Distraction
* Herbals
* Massage
* Cold and heat application
146
When to not use cold therapy? (2)
If patient is shivering or site already edematous
Do no use w/o physician order or directly on skin
147
When to not use hot therapy? (3)
If wound acute, locally inflamed, or actively bleeding
Do not use w/o physician order or directly on skin
148
6 safety measures for heat and cold applications
1. Do not use on sensitive skin
2. Encourage pt to report discomfort immediately
3. Check temp of application
4. Check patient and skin frequently every 20 minutes during therapy (observe for redness, pain, or tingling)
5. Do not allow patient to adjust temperature settings
6. Do not leave unattended a patient who is unable to sense temperature changes or move from the temperature source
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6 adverse effects of opioids
- Nausea and vomiting
- Respiratory depression
- Constipation
- Itching
- Urinary retention
- Altered mental status
150
When is pain assessed? And who can assess it?
At least once a shift
Before pain med administration
After pain med administration (1 hr after oral, 15-30 mins after IV)
RN, not UAP
151
Migraine w/o aura Headache (5)
* Chronic, episodic disorder where BVs in brain overreact to a triggering event, causing spasms in arteries at base of brain, cerebral arteries dilate
* Long duration: 4-72 hours
* Familial, women > men
* Intense, throbbing unilateral pain
* Worsens with movement, photophobia or phonophobia, Nausea & vomiting
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First/prodromal phase of migraine (4)
* Aura may last several minutes to 1 hr
* Well-defined focal neurologic dysfunction
* Pain usually preceded by visual disturbances
* Neurologic changes: numbness, acute confusion, aphasia, vertigo (spinning environment), unilateral weakness, drowsiness
153
Headache phase of migraine (2)
* Headache with N/V
* Unilateral, frontotemporal, throbbing pain in head which is worse behind one eye or ear
154
Termination phase of migraine (2)
* Pain changes to dull
* Headache with N/V lasts 4-72 hrs (elders may have aura w/o pain (visual migraine))
155
Triggers of Migraine (6)
-menstruation
-food (caffeine, red wine, MSG)
- high intensity light
-stress
-weather changes
-sleep pattern changes
156
Complementary and Alternative therapies for Migraines (6)
- Yoga, meditation, massage
- Exercise
- Biofeedback
- Vitamin B12
- Acupuncture and acupressure
- Darken room, lie down, cool cloth on head
157
Pharmacology for managing migraines (2 for mild, 5 for severe)
* Mild migraines: Acetaminophen, NSAIDs
* Severe migraines: (use sparingly to avoid rebound headache)
- Almotriptan, Rizatriptan
- Beta blocker, calcium channel blocker, or antiepileptic may also be used
158
Gout
Systemic disease in which uric acid deposits in joints and other body tissues, causing inflammation and pain, usually the metatarsophalangeal joint of the great toe.
159
6 lifestyle recommendations for gout
1. Low-purine diet
2. Avoid foods as organ meats, shellfish, and oily fish with bones (ex. sardines)
3. Avoid excessive alcohol intake and fad “starvation” diets
4. Avoid aspirin and diuretics
5. Avoid excessive physical or emotional stress
6. Drink plenty of fluids (unless contraindicated)
160
Pharmacology for managing gout (acute and chronic)
* Acute management:
- combo of colchicine (anti-gout agent) and an NSAID
- IV colchicine works with 12 hours
* Chronic management:
- Uric acid reducers and excretion
- Allopurinol, febuxostat, or probenecid
161
Advancing Diets
Generally NPO-> clear liquid -> full liquid
As tolerated it is up to the nurse to know when the patient is able to advance, which diet would be next, when to go back and so forth. Do not allow foods from previous diet until it is proven that new diet is tolerated
162
3 labs that are low in malnutrition
- Hemoglobin (also low with Anemia)
- Albumin & protein (Low->malnutrition (prealbumin is preferred for acute changes; albumin best for long-term; High-> dehydration)
- Iron (ferritin) levels
163
NG tube (4)
Nose to stomach
Put in by nurse
Check for placement and residual (gold standard for placement is x-ray; pH strip also acceptable)
Unavailable for gastric ileus
164
6 Tips for Enteral Feeding
1. Start slow and increase as patient tolerates every 8-12 hours (you know patient is tolerating if no or low residual or aspiration)
2. Need free water
3. Always check placement before feeding
4. Hold Feedings over 500 mL
5. Measure Gastric Residual Volume (GRV) every 4-6 hrs if receiving continuous feedings or immediately before bolus feeding
6. Keep head of bed at 30-45 degrees during feeding and 30-60 minutes post feeding
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8 precautions for Aspiration
1. Observe during mealtimes
2. Ask client about difficulties with foods
3. Add thickener to thin liquids, pureed foods (Thicker liquids are easier to swallow)
4. Encourage to swallow twice
5. Observe for coughing/choking. Suction and orthopneic position as needed.
6. Provide rest periods and allow time to slowly swallow food
7. Observe mouth for pockets of food
8. Need Barrow Swallow Study to confirm Dysphagia
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Clear liquid diet (3)
- Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles
- Easily digestible with no residue
- Seen post surgery
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Bland Diet (4)
- Avoid stomach acidity and pain such as caffeine, decaffeinated coffee, frequent milk intake, citric acid juices, and spicy seasonings
- BRAT
- Discourage smoking, alcohol, aspirin, and NSAIDs
- Used with GI diseases
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Dysphagia/Pureed Diet (2)
- As for clear and full liquid, with addition of scrambled eggs; pureed meats, vegetables, and fruits; mashed potatoes and gravy
- Seen after Cerebral Vascular incident, stroke, cancer, elderly
169
Who are the interprofessional team members for Nutrition? (3)
- Need RD who prescribes the patient’s diet and is consulted on calorie requirement
- UAP often feeds patients who are not NPO
- LPN may do tube feedings
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Full liquid (3)
- Same as clear liquid, with addition of smooth-textured dairy products (e.g., ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt
- Anything that melts In the mouth
- Seen in advanced post-surgical
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Aphasia definition (Difference b/w Expressive and Receptive)
Aphasia: inability to speak, interpret or understand language
Expressive Aphasia: motor type of aphasia where the patient has the inability to name common objects or express simple ideas in words or writing. The patient understands the question but doesn’t have the ability to answer.
Receptive Aphasia: inability to understand written or spoken language. A patient can express words but is unable to understand questions or comments of others. This is extremely traumatic to the individual
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6 Interventions for Aphasia
1. Assess for alternate communication methods (blinking, notepads, computers, communication board)
2. Do not shout or speak loudly
3. Do not patronize or speak in childish phrases
4. Use short, simple questions if patient has problem comprehending
5. Assess for anxiety
6. Determine from family or previous shift if they have developed a way of communication with patient (ie sign language, winks, hand grasps)
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7 Interventions for Patient with Sensory Overload
1. Remove unnecessary equipment
2. Consistently reorient the patient
3. Turn down lights in room
4. Turn down alarms in room
5. Keep talking in room to patient a minimum
6. Keep conversations quiet outside the patient’s room and nursing station
7. Institute quiet hours in your unit
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7 Nursing interventions for sensory deprivation
1. Provide reading material and crossword puzzles
2. Turn on fan
3. Turn on television to something patient wants to watch
4. AM and PM hygiene care
5. Plan time to talk with your patient
6. Keep their cellphone charged and available
7. Encourage family visits
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6 tips for Caring for a Hearing Aid
1. Clean accessible and functional
2. Do not submerge in water
3. When removed from patient, place in cup and write “hearing aid”
4. Clean with soft cloth
5. Keep extra batteries
6. Assist patient in how to turn it up and down when it is new
176
Interventions for Patient with Auditory deficit (5)
1. Make sure patient has their hearing aids clean and in place
2. Ask patient how bad is their hearing impairment (good, bad, average)
3. Put on whiteboard or wall that patient is hard of hearing
4. Let patient see your lips moving
5. Use communication board
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Interventions for patient with Visual deficit (5)
1. Put patient’s glasses on them
2. Need well-lit entrances and exits
3. Stand close to patient so they can see you
4. Put on whiteboard or put on wall that patient is blind so others know they need to announce their presence
5. Ask patient how bad is their vision impairment (good, bad, average)
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Home Safety for patient with Tactile deficit (5)
1. Check skin regularly for breakdown
2. Get a bath thermometer or have family member check temp of bath/shower water
3. Discourage use of heating pads, hot water bottles
4. Have faucets labeled “hot” and “cold”
5. Temperature of hot water heater should be no higher than 120 degrees F-Ideal is 110
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10 things to assess in physical exam for gas exchange
* Respiratory rate, depth, effort (Dyspnea, Pursed lip breathing)
* Oxygen saturation (<95%)
* Use of accessory muscles
* Nasal flaring
* Cough
* Auscultation of lung sounds: wheezes, Rhonchi, crackles, stridor
* Color – cyanosis, pallor
* Level of consciousness
* Nails-clubbing
* Shape of chest- barrel shape with COPD
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6 Early signs of Hypoxemia
* Tachypnea
* Tachycardia
* Restlessness, anxiety, confusion
* Pale skin, mucus membranes
* Hypertension unless from shock
* Use of accessory muscles, nasal flaring, adventitious breath sounds
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7 Late signs of Hypoxemia
* Stupor
* Cyanotic skin, mucus membranes
* Clubbing seen in cystic fibrosis, Congenital heart defect
* Bradypnea
* Bradycardia
* Hypotension
* Cardiac dysrhythmias
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2 types of Chest Physiotherapy
-percussion (with nurse’s hand)
-vibration (with tool i.e., vest)
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Postural drainage
Drainage, positioning, and turning to improve secretion clearance and oxygenation
-position depends on which lobe is drained; position so side that needs draining is up
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Aerosol Mask-breathing treatment i.e nebulizer
Flow rate
FiO2
3 notes
* Flow rates at least 10 L/min
* FiO2 24-100%
* Provides high humidification with O2 delivery
* Medication delivery
* Put it back on the oxygen flow amount and device after treatment -IMPORTANT
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How to use incentive Spirometer (5)
How often to use?
1. Set up yellow marker
2. Patient exhales completely
3. Patient seals mouth and inhales slowly and deeply
4. Patient should inhale until they cannot anymore then hold for 6 seconds
5. Then takes mouth off and exhales
*At least 4 times a day, 10 times an hour each time; no order needed*
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4 tips on Positioning for gas exchange
* Elevate HOB- Position (45-degree semi-Fowler’s)
* Change positions often and prevent sliding down bed
* If lung collapse, put good lung down
* If abscess or hemorrhage, put bad lung down
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7 Tips for oxygen therapy
- Use humidification if above 4 L to avoid drying out nose
- Need order since therapeutic gas (device, number of liters of oxygen and/or sat to maintain)--
- Monitor respiratory rate and pattern, LOC, SpO2, ABGs and notify provider as necessary
- Provide oxygen therapy at the lowest liter flow rate that manages hypoxia
- Takes 5 minutes for change in O2 sat to be noticed
- Decrease the FiO2 as the client’s SpO2 improves
- Can delegate nasal cannula or face mask but nurse still assess response
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What does a complete oxygen order include ? (2)
Must have
- the device
- number of Liters of oxygen and/or O2 sat to maintain
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5 Adverse effects of oxygen
- Nonproductive cough
- Sternal pain
- Nasal stuffiness
- Sore throat
- Hypoventilation
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Ambu Bag
3 purposes
- CPR (Chest compression, Earl defibrillation, Establish airway and rescue breathing)
- Rescue Breathing
- Manual Ventilation
191
Face Tent
Flow rate
FiO2
Purpose
2 notes
- Flow rate 8-12 L/min
- FiO2: highly variable; 28% - 100%
- Purpose: controlled concentration of oxygen and increase moisture for patients who have facial burn or broken nose, or who are claustrophobic
- Notes: Covers the nose and mouth; Does not create a seal around the nose
192
Simple Face Mask
Flow rate
FiO2
Purpose
4 disadvantages
- Flow rate 6-12 L/min; Minimum flow 5 L/min
- FiO2 35-50%
- Purpose: short-term use
- Disadvantages: Therapy interrupted with eating and drinking; Increased risk of aspiration, Comfortable unless claustrophobic, contraindicated for pts who retain CO2
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Nasal Cannula
Flow rate
FiO2
Main concern (3 tips to address)
3 Advantages
- Most common
- Low flow O2 (1-6 L/min)
- FiO2 24-44%
- Concern: Skin
- 3 tips to address concern: Pad pressure points; Lubricate nares; Humidify > 4 L/min
- Advantages: safe, simple, does not impede talking or eating
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Non-rebreathing mask
Flow rate
FiO2
Purpose of valve
2 advantages
3 disadvantages
- Flow rates 10-15 L/min to keep the reservoir bag 2/3 full during inspiration and expiration
- FiO2 60-90%
- Valve between mask and reservoir bag-prevents mixing of exhaled air with oxygen administered
- Advantages: Useful for short period, does not dry mucous membranes
- Disadvantages: Contraindicated for COPD, may irritate skin; hot, confining
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Venturi mask
Flow rate
FiO2
3 Advantages
- Flow rates 4-12 L/min
- FiO2 24-50%
- Benefits: High-flow delivery system; Delivers the most precise oxygen concentration; Good for COPD who need low, constant O2
196
Pathophysiology of Pneumonia (2)
* Inflammation of terminal bronchioles and alveoli is triggered by infectious organisms and inhalation of irritating agents
* Reduces GAS EXCHANGE and leads to hypoxemia (need blood culture)
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Management for Health Care-acquired pneumonia (4)
- Provide adequate hydration
- use postural drainage to drain secretions
- Hand hygiene
- Provide vigorous oral care
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Who are the interprofessional team members for gas exchange? (2)
- Pulmonologist
- Respiratory Therapist (gives breathing treatments; SBAR with them; do assessments before calling them)
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What is Atelectasis? (3 notes)
- Collapse of alveolar lung tissue which prevents normal exchange of O2 and CO2
- Incomplete expansion of a lung or portion of the lung
- manage with incentive spirometer
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Maslow’s Hierarchy of Needs
Lower-level needs must be met before attempting to address higher-level needs.
* Self-actualization
* Self-esteem/ego
* Social / love and belonging
* Security (comfort)
* Physiological (pain, food, hydration)
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Overflow Urinary Incontinence Nursing Interventions (4)
1. Timed void
2. double void
3. monitor post void residual
4. intermittent catheterization if severe retention
202
Stress Urinary Incontinence Nursing Intervention
Instruct patient to do pelvic floor exercises (Kegel exercises)- squeeze anus as if to hold in gas
203
Overflow urinary incontinence (2 causes and 3 symptoms)
Caused by overdistended bladder which may happen with urinary retention OR poor bladder emptying due to pelvic floor weakness, weak bladder contractions
Symptoms: distended bladder, high postvoid residual, nocturia
204
Stress Urinary Incontinence (3 causes, one note)
Small volumes of urine loss due to increased intraabdominal pressures, trauma after childbirth, weakness of urinary structures.
Usually does not happen at night
205
Process for Clean-voided or midstream urine test (6)
- Always use a sterile specimen cup.
- Patient performs perineal care first (females hold labia open)
- Patient urinates a bit into toilet
- Patient then urinates in cup
- Remove cup before urine stops and before releasing labia
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7 Nursing Considerations for Timed specimen for culture and sensitivity urine test
- The timed period begins after the patient urinates and ends with a final voiding at the end of the time period.
- In most 24-hour specimen collections, discard the first voided specimen and then start collecting urine.
- Patient voids into a clean receptacle, and the urine is transferred to the special collection container, which often contains special preservatives.
- Depending on the test, the urine container may need to be kept cool by setting it in a container of ice.
- Each specimen must be free of feces and toilet tissue.
- Missed specimens make the whole collection inaccurate.
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Nocturia and 6 common causes
Awakened from sleep because of urge to void
- Excess intake of fluids (especially coffee or alcohol before bedtime)—avoid 2 hours before bedtime
- Bladder outlet obstruction (e.g., prostate enlargement)
- Overactive bladder
- Medications (e.g., diuretic taken in the evening)
- Cardiovascular disease (e.g., hypertension)
- Urinary tract infection
208
Best way to get someone to use a bedpan (2)
- raise the head
- provide privacy, and give them the call light
209
Analgesics and Elimination
Conditions that cause pain with elimination (6)
Main drug
Precaution for analgesics (2)
Conditions: UTI, kidney stones, cystitis, bladder spasms, hemorrhoids, rectal fissures
Main: phenazopyridine (changes urine orange, for dysuria)
Precaution: hypnotics and sedatives may reduce ability to recognize urge to void; opioids may lead to constipation
210
Intake and Output
Normal Amount
Minimum Amount (if less what 3 things may it indicate)
Normal timing (what if longer?)
Normal Amount: 2300 mL in 24 hrs
Minimum Amount: 30 mL/ hr (if less, may be sign of impending death, bladder or kidney dysfunction, or fluid imbalance)
Normal timing: every 3-6 hours; if longer urinary retention
211
5 Interventions for Urinary Retention
- Do bladder scan before calling HCP (put above mons pubis to see how much urine is in bladder)
- Maintain normal voiding
- Cholinergic medication (Bethanechol chloride to stimulate bladder contraction)
- Crede’s method
- Catheterization if high postvoid residuals
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Enemas
What is it?
How it works?
When used? (3)
Example of order: Soap Sud Enema 500 mL now until clear
Enemas: instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis.
It works by breaking up the fecal mass, stretching the rectal wall, and initiating the defecation reflex
- Used for immediate relief of constipation, emptying the bowel before diagnostic tests or surgery, and beginning a program of bowel training. (ALWAYS check for impaction first)
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Cleansing Enemas (and 4 types)
promote the complete evacuation of feces from the colon by stimulating peristalsis through the infusion of a large volume of solution or through local irritation of the mucosa of the colon; patient should hold as long as they can
Types: tap water, normal saline, soapsuds solution, and low-volume hypertonic saline.
214
Tap Water Enemas (2)
- hypotonic and exerts an osmotic pressure lower than fluid in interstitial space so after infusion it escapes from bowel lumen to interstitial spaces
- Use caution if ordered to repeat tap-water enemas because water toxicity or circulatory overload develops if the body absorbs large amounts of water.
215
Normal Saline Enema (2)
- Safest because same osmotic pressure as fluid in interstitial spaces so no fluid shift
- Only enema allowed for infants and children
216
Hypertonic Solution Enema (3)
- osmotic pressure that pulls fluids out of interstitial spaces, so colon fills with fluid, and the resultant distention promotes defecation
- Best for patients unable to tolerate large volumes of fluid benefit (120-180 mL effective usually)
- Contraindicated for patients who are dehydrated and young infants.
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Soap Sud Enema (3)
- add soapsuds to tap water or saline to create the effect of intestinal irritation to stimulate peristalsis
- Use only pure castile soap that comes in a liquid form
- Use with caution in pregnant women and older adults because they could cause electrolyte imbalance or damage to the intestinal mucosa.
218
Oil Retention enema (3)
Ex. Fleet's enema
-lubricates feces in rectum and sigmoid colon
-feces absorb oil and become softer and easier to pass
-patient should try to retain for several hours
219
Carminative Enema (2)
-relief from gaseous distention
- ex is MGW solution with 30 mL magnesium, 60 mL glycerin, and 90 mL water
220
Fecal occult blood test
-What is it
-Amount of stool needed
-Patient education points (3)
- Measures amount of blood in feces; screens for colon cancer; positive tests followed up with colonoscopy or flexible sigmoidoscopy
- Only need 3 cm of formed stool or 15-30 mL of liquid stool but 3 different samples
Patient education
- instruct patient to avoid meat 3 days before test b-c can cause false positive
- avoid aspirin, ibuprofen, naproxen and other NSAIDs for 7 days b-c can cause false positive
- Avoid vitamin C supplements and citrus fruits and juices for 3 days before test because can cause false negative
221
Who are the interprofessional Team members for elimination? (4)
- urologist
- gastroenterologist
- dietitian
- UAP
222
Fecal Impaction
When it happens?
6 Signs
- Most likely in patients who are debilitated, confused, or unconscious who are dehydrated, too weak or unaware of the need to defecate, and the stool becomes too hard and dry to pass.
- Signs: inability to pass a stool for 3 days; continuous oozing of liquid stool (liquid stool from higher in colon seeps around mass), loss of appetite (anorexia), nausea and/or vomiting, abdominal distention and cramping, and rectal pain
223
Chain of Infection
Infectious agent (bacteria, virus, fungi, protozoa)
Reservoir (location where microorganisms survive; chosen based on presence of nutrients, pH, light, temp; includes humans, animals, water, objects, etc.)
Portal of Exit (reason for precautions; may be respiratory, GI, GU, blood, skin)
Portal of Entry (may be same as exit)
Modes of Transmission
Susceptible host (degree of resistance i.e. age, nutrition, immunity, pregnancy)
224
Modes of Transmission (3)
Contact (indirect, direct, droplet (within 3 feet), airborne (suspended in air))
Vehicle (non-living; contaminated items i.e .sharps, drugs, solutions, blood, water, food)
Vectors (living; flies, mosquitos, ticks)
225
Direct vs Indirect contact transmission
Direct: person-to-person via physical contact; unwashed hands
Indirect: contact with contaminated object of susceptible host (needles, sharps, dressings, soiled linen, environment)
226
5 Signs of Localized infection
* Skin or mucous membrane breakdown such as surgical and traumatic wounds, pressure ulcers, and oral lesions, and abscesses.
* Redness, warmth, swelling, pain, loss of function caused by inflammation
* Infections may be yellow, green or brown
* Drainage from open wounds
* Tenderness and pain at site
227
9 signs of Systemic infection
* Fever, fatigue, nausea/vomiting, anorexia, and malaise
* Enlarged, swollen, and tender lymph nodes
* ↑ heart rate
* ↑ respiratory rate
* ↓ blood pressure
Specific symptoms (UTI has pain and foul smelling urine; pulmonary has cough, sputum, dyspnea, adventitious breath sounds)
228
Medical Asepsis
-Technique type?
-Purpose
-What does it include? (4)
-When used? (3)
Clean technique
Purpose: reduce number, growth, and spread of microorganisms
Includes: hand hygiene, clean environment, isolation, PPE (gown, gloves, mask, face shields)
Used: oral medications, NG tubes, personal hygiene
229
Standard precautions (7 tips)
* Use with ALL clients EVERYTIME!!!
* Wear clean gloves when touching blood, body fluids, secretions, and contaminated items
* Wear a mask, eye protection, or a face shield if splashes or sprays are expected
* Wear a clean, non-sterile gown if sprays or splashes or contact with blood or body fluids are expected
* Clean soiled equipment carefully
* Wrap soiled linen clean side out and handle as little as possible (not on floor)
* Place sharps in appropriate containers. DO NOT recap needles!
230
Contact Precautions
How spread?
Precautions (4)
Diseases (7)
Spread: Direct client or environmental contact (indirect contact with intermediate object such as equipment or hands)
Precautions: Private room, gown and gloves, Use disposable or dedicated equipment on single client
Diseases: MRSA, VRE, C. diff, major wound infections, scabies, herpes simplex, RSV
231
Droplet Precautions
How spread?
Precautions (3)
Diseases (9)
Spread: Focuses on large droplets ( >5um) that are expelled into the air 3-6 feet
Precautions: Private room (or cohort), surgical mask or respirator, Dedicated-care equipment
Diseases: influenza, adenovirus, group A streptococcus, pertussis, pneumonia, RSV, rubella, mumps, diphtheria
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Airborne Precautions
How spread?
Precautions (2)
Diseases (4)
Spread: smaller droplets (<5um) that remain in the air for long periods of time
Precautions: Negative air flow and air exhausted to the outside (airborne infection isolation room), N-95 mask required
Diseases: measles, chickenpox, TB, rubeola
233
Clostridium difficile
What is it?
Mode of transmission
* It is a bacteria that causes symptoms ranging from diarrhea to inflammation of the colon (large intestine) which can lead to colon dysfunction and cell death from sepsis
* Spread by indirect contact with inanimate objects (i.e. medical equipment and commodes)
234
4 preventive/interventions for C. Diff care
* Hand-washing-Use soap and warm water not alcohol-based hand sanitizers
* Contact precautions
* Thorough cleaning with chlorine bleach to disinfect surfaces since sporicidal
* Monitor for hypernatremia and hyperkalemia (may indicate dehydration)
235
Influenza
What is it?
When contagious?
Major Complication
Highly contagious acute viral respiratory infection that can occur at any age caused by several virus categories: A, B, and C.
Contagious for 24 hrs before symptoms and 5 days after symptoms
Major complications: pneumonia or death; may people treated at home
236
Varicella
What is it?
When contagious?
4 main complications
Highly contagious disease caused by varicella-zoster virus spread by direct contact, inhalation of aerosols from vesicle fluid of skin lesions
Contagious 1-2 days before development of rash until all lesions crusted
5 main complications: brain infection, bacterial infections of skin and soft tissues for children, pneumonia, sepsis,
237
1 Primary and 3 Secondary Prevention for Varicella
Primary: Chickenpox vaccine (safe and effective and prevents almost all severe illness)
Secondary: blood test/culture, lesion samples; airborne/contact precautions
238
Protective/Reverse Isolation
Purpose
Precautions (3)
Purpose: for protection of immunocompromised patients (cancer, transplant, HIV, iatrogenic (glucocorticoids, antineoplastic))
Precautions: positive air flow filtered with HEPA room, no dried or fresh flowers or potted plants, take off PPE after leaving room
239
Health-Care Associated Infections (HAIs)
Causes (4)
Main types (4)
Main populations at risk (4)
Cause: Invasive procedures (bypass body defenses), antibiotic administration, the presence of multi-drug resistant organisms (MDROs i.e VRE or MRSA), Breaks in infection prevention and control activities
Major sites for HAIs: surgical or traumatic wounds, urinary (UTI most common site-CAUTI) and respiratory tracts, and the bloodstream.
At risk population: older adults, patients with multiple illnesses, poorly nourished, immunocompromised
240
Order to Don PPE and order to doff PPE
Don: gown, mask, goggles, gloves
Doff: gloves, goggles, gown, mask
241
PUMPS Assessment for Central and Peripheral Perfusion
Pulses- bilateral equal pulses, heart sounds
Urine output- >30 mL/hr, I& O, daily weights
Moist-crackle lung sounds, assess O2, peripheral edema, tachypnea
Pain-chest, leg pain
Skin color-pale or pink, cool or warm, capillary refil
242
Electrical conductivity of Heart
Normal Sinus Rhythm is from SA node (automaticity, pacemaker) to AV node to bundle of His to Purkinje Fibers
242
Difference between:
- sinus arrhythmia
- sinus bradycardia
- sinus tachycardia
Sinus arrhythmia- Sinus beat within 60-100, but not regular
Sinus bradycardia- < 60
Sinus tachycardia- <100
243
How can you tell a rhythm is a normal sinus rhythm? (2)
it is between 60-100 bpm
P wave: QRS complex ratio is 1:1 and in the right range
244
EKG Wave (what do they represent)
P wave
QRS Complex
T wave
- P Wave- atrial contraction (depolarization); deformity = problem with atrium
- QRS Complex- ventricular contraction (depolarization); deformity = problem with ventricles
- T Wave- ventricular repolarization
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EKG normal ranges and/or location)
PR interval
QRS complex
QT interval
R to R
- PR Interval = 0.12-0.20 seconds (start of P to start of Q)
- QRS complex = 0.08-0.12 seconds (start of Q to end of S; w shaped)
- QT interval = less than 0.44 seconds (start of Q to end of T)
- R to R interval (Heart rate) is 60-100 (sharp, count number on 6s strip and multiply by 10)
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REM sleep (6)
- Vivid, full-color dreaming occurs.
- tissue restoration
- Typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased or fluctuating blood pressure.
- Loss of skeletal muscle tone occurs.
- Gastric secretions increase.
- important for cognition, memory and early brain development-increased blood flow to areas of brain is important for memory storage and learning.
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Narcolepsy
What is it?
Most common complaints (2)
Big Problem
- Dysfunction of mechanism that regulate sleep and wake states were person feels overwhelming wave of sleepiness and REM sleep in 15 minutes of falling asleep
- EDS and sleep paralysis are most common complaints
- Big problem: Falls asleep at inappropriate times and may be mistaken for laziness, drunkenness, disinterest
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Pharmacological Treatment for Narcolepsy (5)
-stimulants (Modafinil (Provigil), armodafinil, methylphenidate, sodium oxybate)
-Antidepressants (suppress cataplexy
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Nonpharmacological Treatment for Narcolepsy (5)
- Brief daytime naps no longer than 20 minutes to reduce subjective feelings of sleepiness
- Regular exercise and good sleeping habits
- Chewing gum and vitamins
- Deep breathing
- Avoid situations that increase drowsiness (alcohol, heavy meals, heavy exercise, long periods of sitting)
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Polysomnogram (PSG)-2
-most important sleep test by registered tech
-EEG-type electrodes to monitor sleep patterns, stages, muscle activity, respiratory effort belt, pulse oximetry, nasal and oral airflow
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Epworth Sleep Scale
What is it?
Scale
Ranges (3)
Eight questions on likeliness of patient being sleepy during daytime activities (watching tv, reading, sitting inactive, sitting and talking with someone, as passenger in car, rest in afternoon) over time
- Scale of 0 (never doze or sleep) to 3 (high chance of doze or sleep)
- 0-5 = lower normal daytime sleepiness (4.4 -4.6 is average)
- 6 to 10 higher than normal daytime sleepiness
- If over 10, refer to sleep specialist, neurologists, or pulmonologist (11 or 12 mild EDS, 13-15 moderate EDS, 16-24 severe EDS)
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Sleep hygiene (what is it and 6 factors)
What is optimal? (5)
-practices that patient associates with sleep
-Consider ventilation, noise, light, temp, alone or with someone (whichever is typical), size, firmness, position of bed (consider bedding and blankets)
- comfortable, well ventilated, quiet (turn alarms down), and as dark as possible, slightly cool temp
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Patient Teaching for Sleep Hygiene (7)
-exercise daily in morning or afternoon, no exercise within 2 hrs of bedtime
-avoid long hours of sleep on weekends and holidays to prevent disturbance of cycle
-only use bedroom for sleep and sex (get out of bed if can’t sleep within 30 minutes)
-More than 1-2 alcoholic drinks disrupt sleep
-avoid electronics 30 minutes before bedtime
-small snack prior to sleep
-use sound machine or fan
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7 Physiological symptoms of Sleep Deprivation
-Ptosis, blurred vision
-Fine motor Clumsiness
-decreased reflexes
-slowed response time
-decreased reasoning and judgment
-decreased auditory and visual alertness
-cardiac arrythmias
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6 Psychological symptoms of Sleep Deprivation
-confused/disoriented
-increased pain sensitivity
-withdrawn, apathetic
-agitated, irritable
-hyperactive
-decreased motivation
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Sleep Apnea
What is it?
Main symptoms (3)
What to ensure patient has at hospital? (2)
-Disorder where individual unable to breathe and sleep at same time; lack of airflow through nose and mouth for 10 seconds to 1-2 minutes
Main symptoms: EDS, insomnia, snoring
If patient has sleep apnea, need to bring CPAP to hospital and receive ventilator support in post-op period b-c increased respiratory complication risk
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How to check for and remove impaction? (8)
1. need gloves, water soluble lubricant, absorbent pad, bed pan
2. lie person on left side with right leg flexed
3. monitor vital signs (want to see heart rate to avoid vagal response)
4. lubricate gloved index finger
5. Put full finger and feel for impaction; if there is impaction; you need order to remove
6. Digitally remove impaction by pushing against bowel wall to loosen stool and put in bedpan
7. Ask patient to take deep breath each time you go in
8. Stop if you see blood, patient says they feel light headed, heart rate drops
*no need for order to check for impaction but you need order to remove it*
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Medicated Enemas
-Sodium polystyrene sulfonate (Kayexalate)
-Neomycin solution
-Cortisone
Sodium polystyrene sulfonate (Kayexalate): used to treat patients with dangerously high serum potassium levels.
Neomycin solution: an antibiotic used to reduce bacteria in the colon before bowel surgery.
Cortisone: An enema containing steroid medication may be used for acute inflammation in the lower colon.
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Progression of Oxygen
Room air -> face mask - venturi - nonrebreather - ambu
No face mask for COPD
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Who are the interprofessional partners for Sleep? (3)
- Polysomnographist
- pulmonologist
- neurologist
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Erikson’s Psychosocial Theory
What are the 8 stages and corresponding ages?
Trust vs. mistrust - infancy (0-18m)
Autonomy vs. shame & doubt – toddler (18m-3 yr)
Initiative vs. guilt – preschool (3-6)
Industry vs. inferiority - school age (6-12)
Identity vs. role confusion - adolescence
Intimacy vs. isolation - young adult
Generativity vs. stagnation – middle adult
Integrity vs. despair – older adult.
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Erikson’s Psychosocial Theory
What is the young adult stage?
2 notes
* Intimacy vs. isolation - young adult
* Deepen capacity to love and care for others through intimate relationships
* Isolation if unsuccessful leading to fear of rejection and disappointment
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Erikson’s Psychosocial Theory
What is the middle adult stage?
2 notes
* Generativity vs. stagnation – middle adult
* Expand one’s personal and social involvement in parenthood, teaching, mentoring, community (caring for others)
* Stagnation if unable to play role in development of next gen
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Erikson’s Psychosocial Theory
What is the older adult stage?
2 notes
* Integrity vs. despair – older adult.
* Reflect on lives as meaningful or regretful
* Enhance integrity with reflection of meaningful relationships can create growth and basic strength
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Metabolic Hazards of immobility (4)
- Negative nitrogen balance (due to increased protein catabolism and inadequate protein intake)
- tissue catabolism
- disrupts normal functioning of metabolism
- calcium resorption from bones (hypercalcemia)
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Respiratory Hazards of immobility (2)
- atelectasis (collapse of alveoli)
- hypostatic pneumonia (pooling of secretions)
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Cardiovascular Hazards of immobility (3)
- orthostatic hypotension
- increased cardiac workload
- thrombus (clot) formation (Virchow triad for thrombi: damage to vessel, blood flow stasis (obesity, long travel), hypercoagulability (fever, dehydration))
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Musculoskeletal Hazards of immobility (5)
- permanent or temporary loss of range of motion
- muscle wasting or disuse atrophy
- osteoporosis
- joint contracture (fixation of joint due to stronger flexor muscles)
- footdrop (foot permanently in plantar flexion-increased risk with nerve injury)
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Urinary Hazards of immobility (4)
- urinary stasis (increased UTI risk)
- reflux of urine
- renal calculi (due to hypercalcemia)
- reduced urine output (5-6th day of immobilization)
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GI Hazards of immobility (3)
- Constipation
- Impaction and pseudodiarrhea
- Decreased appetite
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Integumentary Hazards of immobility (4)
- pressure ulcer
- dehydration
- edema
- increased rate of skin breakdown
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Psychosocial Hazards of immobility (5)
- Depression
- Withdrawal
- delirium,
- sleep deprivation (restlessness, agitation, insomnia)
- sensorimotor dysfunction
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Osteoporosis
2 notes on pathophysiology
What does person need?
- calcium leaks out of bones and into blood stream
- old bone resorbed faster than new bone placed
- person needs weight bearing exercises
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Role of Occupational therapist
Help with little muscles, fine motor skill (feed or dress self, ADL, adaptive devices)
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Role of Physical therapist
Help with big muscles, gross motor (walk, get out of bed, specific exercises)
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Three steps to achieve balance and alignment
1. Widen your base of support by separating the feet to a comfortable distance.
2. Bring the center of gravity closer to your base of support to increase balance. (line of gravity should past through base of support)
3. Bend your knees and flex the hips until squatting and maintain proper back alignment to keep the trunk erect.
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7 principles of body mechanics
1. Ask for help
2. Maintain erect posture (wide base of support & low center of gravity for stability)
3. Use strong arm/leg muscles for power not back
4. Maintain internal girdle to support abdomen (hold abdomen in but not breath)
5. Work close to an object
6. Push> pull > lift
7. Avoid twisting by facing direction of movement
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High Fowler
Position
Uses (4)
Position: HOB 60-90 degrees
Use: 1st 2 hours post feeding, toileting, dyspnea, medications
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Mid or Semi Fowler
Position
Uses (2)
Position: HOB 45 degrees
Use: > 2 hours post feeding, comfort
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Low Fowler
Position
Use
Position: HOB 30 degrees
Use: comfort
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Supine (dorsal recumbent)
Position
Uses (2)
Position: HOB flat or slightly elevated; patient on their back
Use: preferred position, CPR
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Prone
Position
Uses (4)
Use: HOB flat, patient lies face or chest down; head often turned to the side
Use: COVID-19, ARDS, pneumonia, spinal tap
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Trendelenburg
Position
Uses (2)
Position: feet up, head down
Uses: moving patients up bed, severe hypotension
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Reverse Trendelenburg
Position
Position: feet down, head up
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Left Lateral Sims
Position
Uses (3)
Position: side-lying on left with knees flexed
Uses: rectal exam, enema, Nausea or vomiting recovery position
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Lithotomy
Position
Uses (3)
Position: head down, legs up for females
Uses: vaginal exam, birth, foley catheter insertion
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Trochanter Roll (3)
* Used for post-hip surgery
* prevents external rotation of the hips when the patient is in a supine position.
* When the hip is aligned correctly, the patella faces directly upward.
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Hand roll (3)
* maintain the thumb in slight adduction and in opposition to the fingers, which maintain a functional position.
* often used in paralyzed arms or unconscious
* do not use rolled wash cloths
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Trapeze bar (2)
* allows the patient to pull with the upper extremities to raise the trunk off the bed, assist in transfer from bed to wheelchair, or perform upper arm exercises.
* decreases the shearing action from sliding across or up and down in bed.
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How to break a patient's fall? (4)
1. Assume wide base of support with one foot in front of the other to support patient’s body weight
2. Extend one leg
3. Let patient slide to floor
4. Bend your knees to lower your body as patient slides to floor
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When to use single leg cane?
mild balance or strength impairments
292
When to use quad leg cane?
unilateral weakness for neurological disease or event (more support)—hemiplegia or partial or complete leg paralysis
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3 general tips for using Canes
- Height equal to length of greater trochanter to floor
- 15-30 degree of elbow flexion.
- Always have two points of support on the floor at a time (both feet or foot and cane)
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How to walk with cane? (5)
1. Cane on strong side (nurse on weaker side)
2. Place cane 6-10 inches ahead with body weight on both legs
3. Move affected leg up toward cane
4. Put weight on affected leg and cane
5. Move unaffected leg ahead of cane
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Who should use walker? (2)
* lower weakness or who has problems with balance.
* Patient should have at least one weight bearing leg and arm
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4 general tips for using walker
- upper bar of walker should be slightly below the client’s waist with arms flexed 15-30 degree
- do not lean on or walk behind walker
- do not use walker on steps
- weight should be on arms and partially on affected leg
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How to walk with walker? (4)
1. nurse behind and slightly to side of patient
2. patient has feet in the middle
3. move walker forward 6-8 inches
4. take a step and repeat
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How to stand up from chair with walker? (3)
1. have walker in front of seat
2. push off chair arms ( do not pull up on walker)
3. move hands to walker one at a time
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How to sit with walker? (4)
1. back up to chair
2. reach back with one arm to grasp arm of chair
3. grab other arm of chair
4. lower into chair
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Tripod position (2)
-basic crutch stance with feet parallel
- When standing tip of crutch rests 4-6 inches in front & 4-6 inches to side of foot.
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4 General tips for crutches
- crutches should be 2-3 finger widths under axilla
- elbows slightly flexed with handgrips at wrist-level
- weight on hands, not armpits
- nurse behind and to the side of patient
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Who should use crutches? (2)
- Temporary loss of weight bearing on one leg due to ligament damage
- Permanently for paralysis of lower extremities
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4-point crutch gait (5 steps)
1. Patient begins in tripod position with weightbearing on both legs
2. Move R crutch 4-6 inches
3. Move L foot parallel R crutch
4. Move L crutch 4-6 inches forward
5. Move R foot parallel R crutch
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3 Notes on 4 point gait
- Most stable crutch walk
- weight on both legs
- used for muscular weakness
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Swing through gait
Same as three point gait without weight bearing on affected leg
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3-point crutch gait (3 steps)
1. patient begins in tripod position weight-bearing only on unaffected leg
2. Move crutches and affected leg
3. Move unaffected leg
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2-point crutch gait (3 steps)
1. Patient begins in tripod position with partial weight bearing on both feet
2. Move R crutch and L leg
3. Move L crutch and R leg
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Swing-to crutch gait (4 steps)
1. Patient begins in tripod position with partial weightbearing on both feet
2. Extend crutches out a comfortable distances
3. Place full weight on crutches
4. Swing body to crutches
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How to walk up stairs with crutches? (4)
1. Place weight on crutches
2. Step up with unaffected leg
3. Straighten knee of uninjured leg and lift up with body weight
4. Bring up crutches and injured leg
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How to walk down stairs with crutches? (5)
1. Place weight on crutches
2. Lower crutch down step
3. Move down affected leg
4. Move down strong leg
5. Bring down other crutch
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Health care disparities (2 notes)
* inequality or difference between the health status of a disadvantaged group and an advantaged group
* Members of the disadvantaged group bear a burden of disease, injury, and violence that is out of proportion to the size of the group
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What are nursing-sensitive outcomes?
Definition
5 examples
* Patient outcomes and nursing workforce characteristics that are directly related to nursing care
* Examples: changes in patients' physical or psychological symptoms, safety, RN job satisfaction, total nursing hours per patient day, and costs
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Primary/ Preventive Care (5 notes)
Examples: prenatal and well-baby care, nutritional counseling, family planning, exercise, yoga and meditation classes
- Focus on reducing risk
- lowers overall costs
- Reduces incidence of disease
- Minimizes complications
- Reduces the need for more expensive resources
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Secondary/Acute Care (2 notes)
Examples: acute medical-surgical care; ambulatory care, outpatient surgery, hospital, radiological procedures
* Focus: Diagnosis and treatment of illness; screening
* Used when the nature or severity of a condition makes primary care insufficient.
315
Tertiary Care (2 notes)
Examples: intensive care unit (ICU), inpatient psychiatric facilities
* Highly Specialized consultative care, usually provided on referral from secondary medical personnel
* For disease management
316
Restorative Care (2 notes)
Ex: Home care (nursing, OT, PT, SLP, nutrition, Durable medical equipment)
* Focus: intermediate follow-up for restoring health
* Helps individuals regain maximal function and enhance quality of life though promotion of independence and self-care
317
Who are the interprofessional team members for spirituality (2)
- Chaplains
- Social worker
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What is hope? (2 definitions and 2 notes)
- Beliefs, wishes, or actions taken in situations of uncertainty
- Energizing source that has an orientation to future goals
- Faith brings hope
- If care is not possible, hope can be a saving grace to give someone the strength to continue
319
What is compassion?
Suffering together after witnessing another person suffer
320
FICA tool
* Faith/belief- what do you believe? Do you consider yourself spiritual? What things do you believe give meaning to life?
* Importance and influence- how important is faith to you? How has your illness impacted your personal beliefs?
* Community- Is there a community you’re connected to? Is there someone that supports you during stress?
* Address- What can I do for you? What support can health care provide to support your spiritual beliefs?
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Functional/Team Nursing (3 notes)
- Includes RNs, practical nurses, and assistive personnel (APs)
- Each person contributes to the team within their own scope of practice
- RN is in charge and can delegate but task is still RN’s responsibility
322
5 Tips for UAP delegation
- Assess knowledge and skills of person you are delegating to
- Do not delegate tasks you dislike
- Communicate clearly (always provide clear directions by describing a task, desired outcome, time within which AP needs to complete the task)
- Listen attentively
- Provide feedback (always give the AP feedback regarding performance regardless of outcome)
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5 rights of delegation
Right task (in the person’s job description)
Right circumstance (do not delegate tasks for unstable patient who needs to be reassessed often)
Right person (in the person’s scope of practice)
Right Directions and communication (Give a clear, concise description of a task, including its objective, limits, and expectations)
Right Supervision and evaluation (evaluate patient outcomes, be available and ready to intervene when appropriate, and ensure appropriate documentation.)
