1323 Final Exam Review

Name different types of splints indications for their use?

- Molded: rigid; used for chronic injuries w/inflammation carpal tunnel - Cervical collars: foam or rigid; used for trauma or neck injuries - Inflatable: limit motion, control bleeding & swelling also called pneumatic splints - Traction: immobilize and pull-on contacted muscles - Immobilizers: limit motion in healing area (knee)

Name three ways in which the integrity of a wound is restored and three different types of healing. (how is it restored)

1. inflammation Second Phase Leukocytes and Macrophages Blood or tissue culture Increased neutrophils and monocytes (indicate inflammatory process and infections Phagocytosis - consumers of pathogens, coagulate blood, and debris Proliferation: 3rd period during which new cells fill and seal a wound it occurs 2 days to 3 weeks after inflammatory phase The integrity of skin and damaged tissue is restored by resolution, regeneration, and scar formation Granulation Tissue Remodeling: Period during which the wound undergoes changes and maturation Lasts 6 months to 2 years During remodeling, the wound contracts and the scar shrinks Collagen is key

Discuss the difference between fever and hyperthermia and nursing considerations andinterventions of each (fever )

A fever (febrile illness) is indicated when body temperature rises above 99.3, But not usually treated until: 102 F or 38-38.5 C

Identify techniques and nursing considerations when assessing blood pressure. (adult cuff size)

Adult Cuff size Cuff Width: 40% of limb's circumference Cuff Length: Bladder at 80% of limb's circumference

List five risk factors and nursing interventions for preventing pressure ulcers

Also known as decubitus ulcers Appear over bony prominences of the sacrum, hips, heals, and places where pressure is unrelieved Risk factors include: Inactivity, immobility, malnutrition, emaciation Diaphoresis, incontinence, sedation Vascular disease, localized edema, dehydration Due to decreased blood supply to the skin, older adults may need position changes every 60 to 90 minutes, instead of every 2 hours. Use special care when moving older adults; avoid friction on the skin. Depression, poor appetite, cognitive impairments, and physical/economic barriers interfering with adequate nutrition may impair wound healing.

List five stages and sign and symptoms in the course of an infectious disease (chain of infection)

An infectious agent (bacteria, virus, fungi, etc) A reservoir for growth and reproduction (humans, equipment, water) An exit route from the reservoir (excretions, secretions, skin, droplets) Means of transmission (direct contact, ingestion, surfaces, airborne) Portal of entry (mucous membranes- respiratory tract, GI, GU, broken skin) A susceptible host

Define infection control measures and techniques. ( Anti-infective Drugs)

Antibacterials: alter metabolic processes of bacteria can sometimes affect normal nonpathogenic bacteria DO NOT WORK ON VIRUSES Antivirals: control viral replication; do not kill viruses limit viral load or stimulates immune system to interfere ex. Acyclovir for Herpes, Harvoni for Hepatitis C

Describe techniques in caring for and preventing damage to dentures.

Artificial teeth • Removal with gauze and gloves • Inspect gums for alterations (how do they fit?) • Dentures are cleaned with toothbrush, denture cleanser or toothpaste and cool/tepid water to prevent drying/shrinkage • Always have cushioned area for removal over sink or basin with wash cloth/paper towels never leave out in open - should be in water

Define specific proper hygiene techniques. (bathing and skin care)

Ask patient if they want special soaps/personal care items avoid regular powders • Wear gloves always • Keep patient covered expose 1 area at a time • Wash clean dirty • Keep open communication about what you are doing • Always PAT dry, never rub avoids risks of infection and skin tears

Define specific proper hygiene techniques. (Bedpan)

Ask patient to raise their buttocks off the bed while the nurse slides the bedpan underneath him • Semi-fowlers position is best for bedpan do not allow patient to sit on side of bed and SIT on the bedpan • If patient is unable to help with positioning -roll to one side (get help if needed) and then reposition over bedpan • Bed pans are huge risk for skin breakdown. Keep call light within reach, give the patient some privacy but DON'T FORGET TO TAKE THEM OFF.

Name four nursing considerations involved in ostomy care.

Bag or collection devise that fits over stoma Attaches to a faceplate - BE VERY PRUDENT IN CHECKING SKIN SITE WHERE THIS ATTACHES!!!! ASSESS STOMA ITSELF - NO YELLOW OR BLOODY DRAINAGE Ileostomy liquid stool Colostomy more formed Disturbed Body Image related to fear of rejection based on altered elimination secondary to a colectomy with ileostomy as evidenced by asking that room freshener be sprayed frequently, applying perfume heavily, and stating, "I hate myself for agreeing to this operation. This 'thing' fills up, it bulges, and it smells. No one will ever want to come near me again."

Define specific proper hygiene techniques. (Medicated Baths)

Bathing in mixture of water + substances such as oatmeal, cornstarch or baking soda, and Epsom salts • Used for relief of itching and/or rash • Helps with dermatological pain from rashes such as psoriasis plaques • Water should be tepid (not too hot, will dry skin further)

Name three considerations for oral hygiene and how to prevent the chief hazard whenproviding oral hygiene to an unconscious client

Brushing and Flossing • Encourage independence • Soft bristles only With Unconscious Clients • Less salivation = oral care more frequently • Sordes - dried crusts containing mucus, microorganisms, and epithelial cells shed from mucous membranes • Suction at bedside - aspiration risk • Patient's head/body turned to side if possible

Identify techniques and nursing considerations when assessing blood pressure. (factors that affect)

Cardiac Output- amount of blood ejected from the heart per contraction Blood Volume- adult has about 5-6 liters of circulating blood Elasticity of arterial walls- yields with systole, retracts upon diastole Age Emotions Exercise Drugs Environment

Define specific proper hygiene techniques. (Perineal Care with a Catheter)

Catheter Care • Urinary meatus = urethra opening • Always clean away from the meatus to prevent moving bacteria inward • Nurse performs perineal care for patients with catheters every 8 hours PRN (when soiled) per facility/hospital policy

Name different types of slings and braces and indications for their use? (slings)

Cloth device used to elevate, cradle and support - most commonly applied to arms, leg or pelvis

Identify considerations for applying heat and cold.

Consideration to extreme temperatures to skin Consider those who can't voice discomfort- Who are they? Never directly to skin

List five common alterations in bowel elimination and nursing considerations of each.

Constipation Impaction - STILL CAN OOZE LIQUID STOOL AROUND IMPACTION Diarrhea Incontinence Flatulence Hemorrhoids - TYPE?

List four temperature assessment sites and nursing considerations of each site. (core and surface temp)

Core Temperature Measured through tympanic and rectal routes Surface Temperature Measured through oral and axillary routes

Identify considerations for applying heat and cold. (Ice Bag and Collar)

Crushed ice, frozen peas Tonsillectomy, vasectomy, strains and sprains Usual left in place for 20-30 minutes Need breaks of applications for same time CAUTION on mottled skin

Name different types of slings and braces and indications for their use? (braces)

Customized to patient Prophylactic - prevent or reduce joint injury Functional - provide stability to unstable joint Rehabilitative - allow protected motion of postop joint Always assess bony prominences and ensure devices fit well

Define infection control measures and techniques. ( Antimicrobial Agents)

Destroy or suppress growth of infectious microorganisms Antiseptics Bacteriostatic - inhibit growth but DO NOT KILL microorganisms Ex: alcohol (rubbing alcohol) Disinfectant Germicides and bactericides destroy active microorganisms; not spores Ex. Household bleach, phenol

Define infection control measures and techniques. ( Personal Protective Equipment(PPE))

Different Types: •Gloves: barrier against bodily fluids and nonintact skin; protects nurse and patient •Scrub suit: sterilized uniforms to prevent contamination of environment. Used in OR, nursery, delivery room. • Gowns: prevents contamination of uniform; change after every use • Masks: prevent droplet transmission of microorganisms • Respirators: N95, particulate air filter (Tuberculosis, COVID) • Protective eyewear: prevent splash of bodily fluids into eyes • Hair/shoe covers: reduce transmission of pathogens on hair/shoes

Identify considerations for applying heat and cold (Safety Measures "DO's)

Do explain to the patient sensations to be felt during the procedure Do instruct the patient to report changes in sensation or discomfort immediately Do provide a timer, clock, or watch so that the patient can help the nurse time the application Do keep the call light within the patients reach Do refer to the agency's policy and procedure manual for safe temperatures

Identify considerations for applying heat and cold (Safety Measures "DO nots)

Do not allow the patient to adjust the temperature Do not allow the patient to move an application Do not place the patient in a position that prevents movement away from the temperature source Do not leave unattended a patient who is unable to sense temperature changes or move from the temperature source

Identify three characteristics noted when assessing a client's pulse and respirations and nursing considerations of each (respirations sounds)

Dyspnea Difficulty Breathing Wheezing Narrowing of airways, causing whistling or sighing sounds Stridor High pitched sounds heard on inspiration. Crackles occur if the small air sacs in the lungs fill with fluid and there's any air movement in the sacs Rales and Rhonchi Sound made by air passing thru airways narrowed by fluids, edema, muscle spasms-heard during exhalation ADVENTITIOUS ANY ABORMAL SOUND

Define specific proper hygiene techniques. ( Shaving guidelines)

Electric razors should not be used in rooms with oxygen in use Electric razors should not be used around a water source Check blades for chips or rust Dispose of used razor blades (one time use only in facility) Supervise the use of razors for safe and correct handling before allowing individual to shave themselves Encourage as much self independence as safely possible

Discuss several five techniques for promoting sleep and relaxation.

Environment Room - cleanliness/ window/ birthing room • Climate/ temperature • Furniture/ bed • Privacy • Noise level Light • Circadian Rhythm • Correlates with light • Melatonin is secreted with dark environment Activity • Exercise encourages fatigue • Lack of exercise can also cause fatigue • Sleep rituals - snack before bed, reading, hygiene • Special blanket Emotion and Mood • Depression, Anger, Anxiety • Excitement Food and Beverages • Alcohol (not always good for REM), caffeine • Excessive carbs/ sugar • Trytophan??? • Medical research indicates that taking 1 g L-tryptophan before bedtime can induce sleepiness and delay wake times. Researchers think L-tryptophan brings on sleep by raising levels of serotonin, a body chemical that promotes relaxation. However, consumers should take this supplement with caution as it may adversely interact with certain antidepressants

Identify three characteristics noted when assessing a client's pulse and respirations and nursing considerations of each (respirations terminology)

Eupena Normal, effortless Tachypnea RR > 24 BPM Bradypnea RR< 10 bpm Apnea Absence of breathing Hyperpnea Deeper with normal rate Cheyne Stokes Faster, deeper, slower, periods of apnea (close to death) Kussmaul's Faster and deeper without pauses, -panting Apneustic Prolonged gasping followed by short exhalation

Name three ways in which the integrity of a wound is restored and three different types of healing. (three different typers of healing)

First-Intention Healing Reparative process in which wound edges are directly next to each other Primary Intention - minor skin tears and abrasions Edges are narrow Surgical Wounds - should be "well approximated" Second-Intention Healing wound edges are widely separated; time-consuming, complex reparative process Types of wound healing: healing occurs from the inside out, through granulation. Great chance of infection Third-Intention Healing Deep wound edges brought together with some type of closure material, resulting in a broad, deep scar INTENTIONALLY LEFT OPEN Types of wound healing a grossly contaminated wound is purposely left open to heal by granulation until inflammation subsides wound is closed with sutures increased risk for infection, drainage, larger scar.

Discuss techniques and situations for using airborne, droplet, and contact precautions.. (Droplet Precautions)

For patients known or suspected to be infection with pathogens transmitted by respiratory droplets (coughing, sneezing or talking) • Put a mask on the patient • Ensure placement in single room if possible • Use appropriate PPE - don mask upon entry to patient room • Limit transport/movement of patients if necessary - patient + nurse must wear mask

Define specific proper hygiene techniques. (Bed bath, towel bath, bag bath )

For patients who cannot take a tub bath or shower independently, there are 3 options ü Bed Bath washing w/basin of water & soap at bedside üTowel Bath using non-rinse liquid cleanser microorganism transfer in basins? faster ü Bag Bath premoistened wipes - no rinse required hydrating to skin - better skin integrity promotes self- care: easy to use

Identify techniques and nursing considerations when assessing blood pressure.

Force of the blood against the arterial walls Measured in millimeters of mercury (mmHg) Systole- the highest pressure Diastole- the lowest pressure

Define specific proper hygiene techniques (Visual and Hearing )

Glasses •Part of nursing assessment • Store in case or rest on frame when not in use •Hold glasses by nose or ear braces Contacts - lens applied directly to cornea - ordered by ophthalmologist Eye Prosthesis - cosmetic replacement for natural eye •Depress lower lid to remove •Do not remove with resistance •Irrigate eye socket with water/saline before reinserting

Define specific proper hygiene techniques (hair)

Grooming • Respect client's wishes/preferences • Brush slowly in direction of growth to prevent tangles/snags • Inspect - scalp/skull disorders and parasites (tinea capitus, pediculosis capitus) Shampooing • Weekly is sufficient for most • Dry shampoo • Shampoo kits/caps

Define infection control measures and techniques. ( Handwashing vs. Surgical Hand Antisepsis)

Handwashing: o may keep jewelry on o wash for minimum of 20 seconds o hands dried with paper towel use paper towel to turn off faucet Surgical Hand Antisepsis Aka surgery scrub o ALL jewelry is removed o washing lasts 2-6 minutes o hands are dried with sterile towels o sterile gloves are donned immediately after drying

Technique of BP measurement

If you immediatelyhear sound, pump upan additional 30mmHg and repeat If the BP is surprisingly high or low, repeat the measurement towards the end of your exam (Repeated blood pressure measurement can be uncomfortable and give false readings) White coat hypertension" may occur if the medical visit itself produces extreme anxiety

List five stages and sign and symptoms in the course of an infectious disease

Incubation - time interval between entry of infectious agent into host and onset of symptoms Prodromal - onset of nonspecific symptoms to specific symptoms of illness Illness - period of specific signs and symptoms of infection Convalescence - disappearance of acute symptoms until client returns to previous state of health

Identify five signs and symptoms classically associated with the inflammatory response.

Inflammation: physiologic defense occurring immediately after tissue injury, lasting 2 to 5 days Purpose: limit local damage, remove injured cells/debris, prepare wound for healing Signs and Symptoms of Inflammation: 1-swelling, 2-redness, 3-warmth, 4-pain, and 5-decreased function

Define specific proper hygiene techniques (nail care )

Keep fingernails/toenails trimmed and clean. Trimming • Podiatrist •Diabetes •Vascular insufficiencies •Thickened nails •Nail care if not needed by podiatrist à •Soak nails in warm water •Loosen debris/clean under nails •Cut straight across nail - file in one direction •Avoid sharp nail edges •Protect against ingrown nails by avoiding tight shoes, very high heels Never, never, never trim nails on a diabetic patient

Identify characteristics of good posture in a standing, sitting, or lying position and listexamples of correct body mechanics

Keeps muscular tone Helps with spine alignment Proper gravity distribution Reduces risk for muscle spasms and pain Goals: Prevention of falls and fractures Prevention of repetitive strains and sprains

Identify techniques and nursing considerations when assessing blood pressure. (accuracy)

Let patient rest for a minimum of 5 minutes for routine assessment Should not have ingested caffeine or nicotine 30 minutes before Delay assessing if patient is in pain , upset or just exercised.

Name nursing activities and considerations involved in managing the care of clients who arebeing tube-fed

Maintain tube patency (unobstructed). Providing adequate hydration. Clearing obstructions. Preparing for home-care. Handling miscellaneous problems that may come up (tears in tubing, etc.).

Name several principles that apply to maintaining effective traction

Manual - relocation of joint - physical pulling by physician or certified personnel Skin - belts and wraps - Buck's and Russel's traction Skeletal -wires, pins or tongs directly inserted into bones - continuous

Identify considerations for applying heat and cold (rebound phenomonen cold)

Maximum vasoconstriction occurs when the skin temperature reaches 150 or in about 30 minutes to one hour. Vasodilation begins as a protective device to prevent the body tissue from freezing Recovery time of one hour is best before reapplication.

Discuss different types of transmission of disease and list examples of each.

Means of transmission (direct contact, ingestion, surfaces,airborne) Enteric- c.diff Droplet via coughing,sneezing, or talking Airborne- tuberculosis (Tb). measels, chickenbox, disseminated herpes zoster , COVID

Name types of urine specimens that nurses commonly collect and nursing considerations. (midstream)

Midstream (clean-catch) urine collection is the most common method of obtaining urine specimens from adults, particularly men. This method allows a specimen, which is not contaminated from external sources to be obtained without catheterization. DOCTOR'S ORDER!!! Supplies and Equipment. (1) Sterile specimen cup. (2) Zephiran, a soap solution, or three antiseptic towelettes. (3) Three cotton balls (to use with zephiran or soap solution). (4) Laboratory request form. uInstruct the patient to clean the urethral area thoroughly. This will prevent external bacteria from entering the specimen. The female should wipe from front to back to avoid contaminating the vaginal and urethral area from the anal area. She should clean each side with a separate cotton ball or towelette, then use the last one for the urethral area itself. The male should cleanse the penis, using the first cotton ball or towelette for the urethral meatus, the next cotton ball to clean the end of the penis, and the last to cleanse the urethral opening. u(2) Instruct the patient to void a small amount of urine into the toilet to rinse out the urethra, void the midstream urine into the specimen cup, and the last of the stream into the toilet. The midstream urine is considered to be bladder and kidney washings; the portion that the physician wants tested. u(3) Complete the laboratory request form, label the specimen container with patient identifying information, and send to the lab immediately. A delay in examining the specimen may cause a false result when bacterial determinations are to be made. u(4) Wash your hands and instruct the patient to do likewise. u(5) Record that the specimen was collected. Note any difficulties the patient had or if the urine had an abnormal appearance.

Identify techniques and nursing considerations when assessing blood pressure. (cuff size)

Minimum Cuff Width: 2/3 length of upper arm Minimum Cuff length: Bladder nearly encircles arm

Identify considerations for applying heat and cold (contraindications)

Neuro-sensory impairment Impaired mental status Impaired circulation Immediately after surgery or injury Hemorrhage

Define infection control measures and techniques. (Breaking the Chain of Infection handwashing)

Nurses should: o Perform proper handwashing wash in, wash out soap and water when available, sanitizing gel o Wear gloves whenever necessary (ALWAYS change between patients) o Follow all isolation precautions (no exceptions) o Proper disposal of contaminated items o Proper cleaning of equipment as necessary

Identify three characteristics noted when assessing a client's pulse and respirations and nursing considerations of each (Respiratory Rate)

Observe the rise and fall of the chest while you appear to be taking their pulse, so you do not affect their attempts to take more or less breaths per minute They should be counted for at least 30 seconds. 15 second period is rather small and any miscounting can result in rather large errors when multiplied by 4.

Identify considerations for applying heat and cold (rebound phenomonen heat)

Occurs at the time that maximum therapeutic effect of hot or cold application is achieved Heat produces maximum vasodilation in 20-30 minutes. Continuation beyond 30-45 minutes causes tissue congestion, the blood vessels constrict

Name three ways in which the integrity of a wound is compromised or restored.

Open Wounds Skin or mucous membranes are not intact Intentional Accidental Closed Blunt trauma Surgically closed Excessive Tension/Wound dehiscence Malnutrition Impaired immune or inflammatory process Medications such as corticosteroid Assessment Redness Swelling Warmth Drainage Undermining erode the base or foundation Soughing Dead tissue Moist, stringy, yellow, green Necrotic Tissue Dry Black Evisceration Wound separated and strangulated organs From surgery or disruption in tissue wall Too much pressure on incision Weakness in tissue/ previous scar Obesity Place moistened STERILE gauze with STERILE normal saline and notify

List four temperature assessment sites and nursing considerations of each site. (oral)

Oral- most frequently used. CONTRAINDICATIONS: Infants and very young children Patients with oral surgery Unconscious or irrational patients Seizure-prone patients Mouth breathers an patient's with oxygen Recent hot or cold foods/smoking •Oral=98.6 NO MERCURY Done for 3 minutes Must wait if patient has eaten or drunk cold fluids-20 minutes

Identify four general types of gastrointestinal tubes and nursing considerations of each type.

Orogastric tube Nasogastric tube Nasointestinal tube Transabdominal tube

Define infection control measures and techniques. ( Sterilization )

Physical or chemical techniques that destroy all microorganisms Physical sterilization: destroyed via radiation, high heat, boiling water, free-flowing steam, dry heat Steam under pressure - autoclave is most dependable and preferred Special packaging with indicators are used to ensure sterility Chemical sterilization: gas or liquid agents used to destroy microorganisms

Identify techniques and nursing considerations when assessing blood pressure. (pulse pressure)

Pulse Pressure - difference between the systole and diastole Normal is 30-50 Wide or narrow If healthy - arterial walls are elastic and recoil easily to accommodate increased blood volume Reflects ability of arteries to stretch, the volume of circulating blood, and amount of resistance the heart needs to overcome to pump blood through arteries

Identify three characteristics noted when assessing a client's pulse and respirations and nursing considerations of each (respirations)

Rate -Number of Breaths per minute (30-60 for babies and 14-20 for adults) Rhythm- regularity of respirations, inhalation and exhalation are evenly spaced Depth- assed by watching the movement of the ches

Identify considerations for applying heat and cold. ( Therapeutic Baths)

Reduce fever Treat skin disorders - psoriasis plaques Loosen sore muscles Sitz baths -episiotomies, hemorrhoids

Identify three characteristics noted when assessing a client's pulse and respirations and nursing considerations of each (pulse)

Rhythm - pattern of regularity of beats and interval between each beat Volume/ amplitude- amount of blood pumped with each heartbeat Cardiac Output - 5-6 liters of blood is forced out of the left ventricle per minute Pulse Deficit- difference between the apical pulse and radial Counts are taken at the same time. Fever - Pulse may be increased if fever is present Pulse: Quantity Measure the rate of the pulse (recorded in beats per minute). Count for 30 seconds and multiply by 2 If the rate is particularly slow, fast, or irregular it is probably best to measure for a full 60 seconds in order to minimize the error. Tachycardia Above 100 Bradycardia Below 60 Pulse:Regularity Is the time between beats constant? Irregular rhythms, (arrhythmias) are quite common. Do Apical pulse for one full minute if detected

Identify techniques and nursing considerations when assessing blood pressure. (Stethoscope)

Single Lumen The shorter, the better Two Parts Bell for low pitched sounds especially with abnormal heart sounds Diaphragm - used more commonly

Identify considerations for applying heat and cold. (Soaks and Moist Packs)

Soaks Warmth or medication - Epsom salt soak Temperature needs to stay constant Packs Longer than soaks Heat more intense - used by PT and Chiropracters

List at least five signs of inadequate oxygenation and list nursing considerations and interventions.

Tachypnea - > 35 breaths/minute Bradypnea - < 10 breaths/minute Apnea - No movement of air for 15 seconds or longer Nasal Cannula Simple, comfortable method, cannula in nares Flow rate from 1-6L/min Rates > 4L/min rarely used r/t drying. Assess skin in nares, on ears Positioning Semi to high Fowler's Tripod Orthopneic Breathing Techniques Deep breathing exercises Incentive spirometer Goal driven and measurable Pursed lip Improves gas exchange with expiration uComplaint of chest pain uComplaint of shortness of breath uDeterioration of patient's vital signs uOxygen saturation that drops below 90% or below prescribed value COPD patients are an exception to most rules about oxygen therapy. COPD patients commonly have asthma, emphysema, chronic bronchitis, or bronchiectasis End stage COPD patients cannot tolerate high amounts of oxygen - they will deteriorate before becoming apneic It is common for COPD patients to have saturations that range from 85-90% - this is considered a normal range for them. If you are caring for a COPD patient who is complaining of shortness of breath or who appear to be having trouble breathing contact the RT - they may require a breathing treatment.

Discuss the difference between fever and hyperthermia and nursing considerations andinterventions of each (hyperthermia)

Temp above 105. 8 F/ 40.6 C May lead to brain damage, or death AKA- heat stroke Antipyretics if above 101.5 F- (will vary by MD and facility)

Discuss how and why range-of-motion exercises are performed.

Therapeutic activities that move the joints - assess joint flexibility - MAINTAIN joint mobility and flexibility in inactive clients - prevent permanent loss of joint mobility - stretch joints before strenuous activity Can be continuous, active or passive Nurse assists with joints that are compromised

Name four types of crutch-walking gaits as well as nursing considerations and teaching techniques

They are the "Four-Point Gait," the "Partial Weight-Bearing Three-Point Gait" and the "Three Point "Swing Through Gait.

Discuss four types of transfer devices and rationale for using each type.

Transfer board for bedbound patients Hoyer lift, Sarah steady Transfer belt

Describe six common client positions and rationales and examples for each type

Trendelenburg Position •Used for some lower abdominal surgeries and pelvic surgeries (allows greater access to organs) and central venous catheters •Is used system wide in healthcare for hypotension and shock however many studies are underwhelming as far as true benefits of this position •CAUTION - this can rapidly increase intracranial pressure Dorsal recumbent position - used primarily for obstetrics, perineal care and foley catheter insertion Lithotomy Originally used to retrieve kidney stones but is now most used position for childbirth Prone, supine, fowlers, semi fowlers, lateral , sims , trendelenburg

List five common bowel alterations (cont)

Urinary retention Urinary tract infections Urinary incontinence Urinary diversions urostomies

Discuss techniques and situations for using airborne, droplet, and contact precautions. (Contact Precautions)

Used for known/suspected infections that represent risk for contact transmission • Use single-patient room • Gloves and gown (dispose after use) • Limit transport/movement • Use disposable PPE + patient care equipment • Prioritize cleaning/disinfection of rooms (especially touched surfaces)

Discuss techniques and situations for using airborne, droplet, and contact precautions.. (Enteric Precautions)

Used for patients infected with clostridium difficile infections. • Same guidelines as contact precautions except: • YOU MUST wash hand with soap and water following contact with these patients • C. Diff spores are not killed by regular hand sanitizers • Clean with facility approved spore-killing disinfectant (bleach) -standard disinfectant wipes do not kill C. Diff spores either

Discuss techniques and situations for using airborne, droplet, and contact precautions.. (Airborne Precautions)

Used for patients known or suspected to infected with pathogens transmitted by airborne route (tuberculosis (Tb), measles, chickenpox, disseminated herpes zoster, COVID) • Place mask on patient • Ensure placement in airborne infection isolation room (AIIR) or negative pressure room • Restrict susceptible healthcare personnel • Use fit-tested N95 mask or higher level respirator • Limit transport/movement if necessary, pt + nurse wear mask; any open lesions covered prior to movement • Immunize susceptible persons ASAP following unprotected contact

Identify considerations for applying heat and cold (cold)

Vasoconstriction Decrease capillary permeability Decreased local cellular metabolism Decreased nerve conduction Decreased blood flow to an area Decreased lymph flow Decreased muscle tone

Identify considerations for applying heat and cold (heat)

Vasodilation Increase capillary permeability Increase local cellular metabolism Increase blood flow to an area Increase lymph flow Increase muscle tone

Define specific proper hygiene techniques (Visual and Hearing cont hearing aids )

Wash ears daily with washcloth - don't forget behind ears! inspect behind ears every shift when patients are wearing nasal cannula tubing for oxygen DO NOT USE QTIPS IN EARS - they push wax/debris farther into ear canal Hearing Aids Very expensive - do not submerge in water EVER Clean with soft cloth Never yell when speaking with patient Make eye contact Provide visual as well as verbal communication Inspect ears for ulcerations or drainage that may affect fit of hearing aids

Name types of urine specimens that nurses commonly collect and nursing considerations. (INDWELLING CATHETER)

When an indwelling or retention catheter is inserted, the nurse is responsible for the daily care required to maintain proper drainage and reduce the possibility of an infection occurring. Always have a confident, reassuring, and professional attitude when maintaining the catheter so that the patient will not feel embarrassed. a. Wash your hands before and after caring for the patient and wear gloves when handling an indwelling catheter. b. Clean the perineal area with soap and water every 8 hours and after each bowel movement, especially around the meatus. Use a separate area of the cloth for each stroke. c. In some cases, an antiseptic may be used for perineal care. Povidone iodine (Betadine) is most commonly recommended. d. Avoid use of lotions or powder in the perineal area.

List four temperature assessment sites and nursing considerations of each site. (Rectal)

accurate, but invasive and uncomfortable to patient-subtract a degree CONTRAINDICATIONS: Rectal abnormalities Diarrhea Certain heart conditions Immunosuppressed •Rectal-99.5 (subtract degree

Compare and contrast aseptic, disinfection and sterile technique.

aspectic o Confine or reduce numbers of microorganisms o Clean technique o Examples: performing hand hygiene using antimicrobial agents wearing personal protective equipment (PPE disinfection Germicides and bactericides destroy active microorganisms; not spores Ex. Household bleach, pheno sterile technique Physical or chemical techniques that destroy all microorganisms Physical sterilization: destroyed via radiation, high heat, boiling water, free-flowing steam, dry heat Steam under pressure - autoclave is most dependable and preferred Special packaging with indicators are used to ensure sterility Chemical sterilization: gas or liquid agents used to destroy microorganisms

Describe urinary elimination alternative devices and nursing considerations of each. (bed pan

bed pan

Identify techniques and nursing considerations when assessing blood pressure. (pulse pressure phases)

faint tapping, swishing, loud knocking, muffled, silence Newborn 80-180 bpm Adults 60 - 100 bpm Elderly 60-100 bpm +4 Bounding +3 Normal +2 Weak +1 Feeble/thready 0 Absent

Discuss the different physiologic data that can be inferred from a blood pressure assessment.

hypertension HIGH BLOOD PRESSURE GREATER THAN 139/89 hypotension Postural or Orthostatic HYPOtension Temporary drop Rising from supine and/ or sitting Dehydration Geriatric population Diuretics other medications Confirmed by a fall in >20 mm Hg when rising Nursing considerations for falls

Identify considerations for applying heat and cold. (checmical packs/compresses)

limited time one time use moist, warm or cool always check for desired temps very hot - 105 -115 very cold <50 Aquathermia pad -electrical heat or cold

Provide at least three teaching suggestions for preventing infections.

medical aspesis proper PPE Antimicrobial Agents

Define infection control measures and techniques. ( Medical Asepsis cont ex )

o Confine or reduce numbers of microorganisms o Clean technique o Examples: performing hand hygiene using antimicrobial agents wearing personal protective equipment (PPE)

Define infection control measures and techniques. (Medical Asepsis)

o Practices that decrease or eliminate infectious agents, their reservoirs and means of transmission o Major method for preventing and controlling infection o Health care providers use medical and surgical asepsis to prevent spread of infection

Define infection control measures and techniques. ( Hand Hygiene)

o When hands are visibly dirty o When hands are contaminated with proteinaceous material o When hands are soiled with blood or other bodily fluids o Before eating and after using the restroom o If exposure to spore-forming pathogens is suspected or proven

Define infection control measures and techniques. (Breaking the Chain of Infection)

oInfectious agent - antibiotic administration, careful handwashing/sanitization o Reservoir - disposal of contaminated dressings, bodily fluids, outdated IV fluids/medications, proper spill cleanup, not wearing jewelry or artificial fingernails o Portal of exit - clean dressings on all wounds, cover mouth/nose when sneezing/coughing o Means of transmission - correct use of PPE, appropriate disposal of contaminated items o Port of entry - protective isolation, cleaning from clean to dirty, correct sterile techniques

Name types of urine specimens that nurses commonly collect and nursing considerations. (24 hour urine )

uA 24-hour urine protein test is given if you have symptoms of glomerulonephritis, a type of kidney disease, or other conditions that affect the kidneys, such as: uuncontrolled diabetes uhigh blood pressure ulupus (an autoimmune disease) uurinary tract infections (UTIs) uRenal disease uA 24-hour urine collection always begins with an empty bladder so that the urine collected is not "left over" from previous hours. EMPTY BLADDER FIRST IN THE MORNING. This specimen shows the total amounts of wastes the kidneys are eliminating and the amount of each. ua. Supplies and Equipment. u(1) Large, clean bottle with cap or stopper. u(2) Measuring graduate. u(3) Bedpan or urinal. u(4) Refrigerated storage area or pan with ice u(5) Gloves. u1) Label the bottle with patient identifying information, the date, and time the collection begins and ends. u(2) Instruct the patient to void all urine into a sterile cup. Measure each specimen of urine voided and pour into the refrigerated bottle. Wash your hands before and after each collection. Record each amount on the intake and output (I&O) sheet. u(3) Exactly 24-hours after beginning the collection, ask the patient to void. This will complete the specimen collection. u(4) Send the bottle and laboratory request form to the lab.

List four temperature assessment sites and nursing considerations of each site. (axillary)

uAxillary temperatures can be taken under the arm. Temperatures taken by this route tend to be 0.3 to 0.4° (Fahrenheit) lower than those temperatures taken by mouth. •Axillary-97.5 (add degree) Typically, we add 1 degree F.

List common oxygen delivery devices and nursing considerations with each.

uNasal Cannula uSimple, comfortable method, cannula in nares uFlow rate from 1-6L/min uRates > 4L/min rarely used r/t drying. Assess skin in nares, on ears

Name types of urine specimens that nurses commonly collect and nursing considerations. (INFANT URINE COLLECTION)

uTo collect a urine sample from an infant: uPreform perineal care. uObtain special bag to collect the urine (U bag). It will be a plastic bag with a sticky strip on one end, made to fit over baby's genital area. Open this bag and place it on the infant. uFor males, place the entire penis in the bag and attach the adhesive to the skin. uFor females, place the bag over the two folds of skin on either side of the vagina (labia). uPut a diaper on the baby (over the bag). uCheck the infant often, and change the bag after the infant has urinated. (An active infant can cause the bag to move, so it may take more than one try to collect the sample.) uEmpty the urine from the bag into the container. Do not touch the inside of the cup or lid. If at home, place the container in a plastic bag in the refrigerator. When finished, label the container and return it as instructed. uThoroughly wash the area around the urethra.

Describe and demonstrate techniques and nursing considerations for feeding clients andhow to meet the nutritional needs of clients with visual impairment or dementia. (cont)

´* Order & cancel diets ´ * serve and collect meal trays ´ * record amount of food eaten ´ * ensure the correct diet is given ´ Request full liquid or mechanical soft diet for patient with missing teeth or recent oral surgery ´ Small frequent meals ´ Make sure patient has swallowed, before offering another bite ´ Encourage repeated swallowing if needed ´Protein complementation -(combining plant sources of protein) helps a person to acquire all essential amino acids from nonanimal sources ´* Coughing, choking, drooling ´ * asymmetry of mouth ´ * extend tongue, deviation? ´ * Mucus Membranes, Moist or dry ´ * Inspect mouth ´ * results of swallow test

Name four nursing considerations involved in ostomy care. (ostomy care)

´APPLIANCE - ´Bag or collection devise that fits over stoma ´Attaches to a faceplate - BE VERY PRUDENT IN CHECKING SKIN SITE WHERE THIS ATTACHES!!!! ´ASSESS STOMA ITSELF - NO YELLOW OR BLOODY DRAINAGE ´Ileostomy liquid stool ´Colostomy more formed

List five common alterations in bowel elimination and nursing considerations of each. (factors)

´Age ´Diet - FIBER ´Fluid intake ´Physical activity ´Psychological factors ´Personal habits Failure to respond to URGE - IMPACTION' ´Position during defecation ´Pain ´Pregnancy ´Surgery and anesthesia - ILEUS ´Inability of the intestine (bowel) to contract normally and move waste out of the body. ´Medications ´Diagnostic tests - BARIUM ´Turns stools pasty white

identify measures within the scope of nursing practice for treating constipation andpromoting elimination (enemas)

´Cleansing, Prep, or Medicinal ´Types Cleansing: ´tap water/ saline - distends rectum and moistens stool ´ hypertonic - draws water out of colon ´ soapsuds - irritates and stimulates peristalsis ´ oil retention - held for 30 minutes, softens stool

Name types of urine specimens that nurses commonly collect and nursing considerations.

´Common urine tests ´Urinalysis ´Specific gravity ´Culture

Describe urinary elimination alternative devices and nursing considerations of each. (Assessment of the Foley Catheter)

´Ensure catheter is properly secured to the leg to facilitate draining and stabilize catheter to help prevent it being dislodged ´Note size and type of catheter (16 F Foley) (18F Coude) ´Ensure there is an order for f/c to remain

Name four nursing considerations involved in ostomy care. ( Excoriation)

´Excoriation ´Burning from stool around stoma site ´Wash with soap and water and pat dry ´Can apply a barrier cream ´Pouches can be emptied as needed ´Faceplate 3 to 5 days (know your PP)

identify measures within the scope of nursing practice for treating constipation andpromoting elimination

´Impaction ´Can still have liquid stools ´Peristalsis is still happening ´Removing ´Place in Sims ´Remove segments ´Caution on vasovagal response -A sudden drop in heart rate and blood pressure leading to fainting, often in reaction to a stressful trigger.

identify measures within the scope of nursing practice for treating constipation andpromoting elimination (medications)

´Medications ´Laxatives, stool softeners ´Antidiarrheal agents ´Enemas: tap water, saline, hypertonic, soapsuds, oil retention - MUST HAVE DOCTOR'S ORDER ON ALL THE ABOVE

Describe and demonstrate techniques and nursing considerations for feeding clients andhow to meet the nutritional needs of clients with visual impairment or dementia.

´Older adults require fewer calories and, therefore, should be taught to select nutrient-dense foods such as meat, fruits, vegetables, dairy products, and whole-grain breads and cereals. ´30% grains, of which half are preferably whole grains ´30% vegetables ´20% fruits ´20% protein; which are accompanied by low-fat/nonfat milk or other reduced fat dairy products. (USDA, ChooseMyPlate.gov.) ´Regular - unrestricted food selections ´ ´Soft - foods soft in texture, low residue, easily digestible, little spice, fewer fruits, veg., meats ´ ´Mechanical soft - light diet but for patient with chewing difficulty, cooked fruits & veg., with ground meat. ´ALWAYS CHECK THE ORDERS ´CHECK FOR POSSIBLE NPO STATUS!!!! ´Clear liquids - HENCE THE WORD CLEAR ´Grape, apple, cranberry juices ´Strained fruit juices ´Vegetable broth ´Carbonated water ´Clear fruit-flavored drinks, tea, coffee ´Gelatin and ices ´Clear candies ´Popsicles ´Clear broth Full liquids ´Milk and milk beverages ´Yogurt, eggnog, pudding ´Custard and ice cream ´Pureed meats and vegetables in cream soups ´Vegetable juices ´Sweetened plain gelatin ´Cooked refined cereals ´Strained or blended gruel ´All other beverages ´Cream using clock method

Describe urinary elimination alternative devices and nursing considerations of each. (Texas Catheters/condom cath problems)

´Potential problem ´Apply too tightly - Restricting blood flow ´Moisture tends to accumulate and causes skin breakdown ´Tend to leak ´Another type of external urine collecting device ´Pedi U bag

List seven common hospital diets and examples of why they may be prescribed.

´Regular - unrestricted food selections ´Soft - foods soft in texture, low residue, easily digestible, little spice, fewer fruits, veg., meats ´Mechanical soft - light diet but for patient with chewing difficulty, cooked fruits & veg., with ground meat. ´CHECK FOR POSSIBLE NPO STATUS!!!! ´Clear liquids - HENCE THE WORD CLEAR ´Grape, apple, cranberry juices ´Strained fruit juices ´Vegetable broth ´Carbonated water ´Clear fruit-flavored drinks, tea, coffee ´Gelatin and ices ´Clear candies ´Popsicles ´Clear broth Full liquids ´Milk and milk beverages ´Yogurt, eggnog, pudding ´Custard and ice cream ´Pureed meats and vegetables in cream soups ´Vegetable juices ´Sweetened plain gelatin ´Cooked refined cereals ´Strained or blended gruel ´All other beverages ´Cream ´Protein complementation -(combining plant sources of protein) helps a person to acquire all essential amino acids from nonanimal sources

Name four nursing considerations involved in ostomy care. (types)

´STOMA - EXIT POINT ´ILEOSTOMY ´COLOSTOMY ´Kock pouch ´DIFFERENTIATED BY WHERE IT IS PLACED IN THE BOWEL

Define continence training rationale and nursing considerations involved.

´Strengthening pelvic floor muscles ´Bladder retraining ´Habit training ´Self-catheterization ´Maintenance of skin integrity ´Promotion of comfort kegels

Describe urinary elimination alternative devices and nursing considerations of each. (Urethral Catheterization)

´Types - external, straight, and indwelling/retention ´Insertion - men vs women ´ALWAYS sterile technique ´Drainage systems ´Routine care: hygiene, fluids ´Prevention of infection ´Irrigations and instillations

Identify considerations for applying heat and cold (danger)

ØExceeding normal temperature ranges can damage tissues ØRaise heart rate ØLower blood pressure - vasodilation ØCause dizziness ØNOT safe after alcohol

Describe urinary elimination alternative devices and nursing considerations of each. (Texas Catheters/condom cath)

ØUrine collecting device applied to skin ØFlexible sheath that is unrolled over penis ØEnd connects to tubing to collection container

Define specific proper hygiene techniques. (hand hygeine)

• ALWAYS wash hands before and after touching a patient • #1 habit for infection control • Antimicrobial soap and water are best methods soap + water ONLY method for Clostridium difficile infection • May use antiseptic hand wash, alcohol-based hand sanitizer (Purell, Germ-X, etc.), and surgical hand hygiene ONLY WHEN INDICATED • Always wash in & wash out

Define infection control measures and techniques. (sequence for removing PPE)

• Gloves • Goggles/Face Shield • Gown • Mask/Respirator • Wash hands immediately after removing all PPE

Define infection control measures and techniques. (sequence for putting on PPE)

• Gown • Mask/Respirator/N95 • Goggles or Face Shield • Gloves

Name nursing considerations that help to prepare clients for ambulation. (gerontological)

• Maintain mobility • Give extra time and assist when needed encourage independence when it is SAFE • Fear of falling common (especially with hx of frequent falls) • Bone demineralization = increased risk of fractures • Cognitive impairments make following directions hard keep instructions/directions simple and easy • PT/OT consults when needed (usually beneficial if client participates

Define infection control measures and techniques. ( prinicpals Medical Asepsis)

• Microorganisms exist everywhere other than sterilized equipment • Frequent hand hygiene, intact skin are best methods for reducing microorganisms • Blood, body fluids, cells/tissue are major reservoirs of microorganisms • Personal Protective Equipment (gloves, gown, masks, goggles, etc) are barriers to transmission • Clean environment reduces microorganisms • Some areas are more contaminated than others (toilet, floors, etc) • Cleaning should be done from cleaner to dirtie

Define specific proper hygiene techniques. (Perineal care)

• Post surgery • Postpartum • Incontinence • Decubiti When cleaning males - immediately dry and replace foreskin

Describe at least five nursing actions that are appropriate when caring for clients with casts (cast removal)

• Removed with electric cast cutter noisy, but will NOT cut clients • Unexercised muscle is smaller & weaker after removal • Skin may be flaky - do not pick wash with warm soapy water and soft cloth apply lotion or cream to soften scales • May need rehab if severe weakness

Define infection control measures and techniques. (Standard Precautions)

• Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. • Includes: hand hygiene use of appropriate PPE respiratory hygiene/cough etiquette sharps safety (know where to dispose) safe injection practices sterile instruments/devices clean/disinfected environmental services

Describe at least five nursing actions that are appropriate when caring for clients with casts

• Teach patients not to stick ANY items in cast (very itchy but no coat hangers) • Keep limb elevated for first 48 hours • Ice for pain (overcast) and to help with itching • Monitor new casts every 30 minutes for first 2 hours after placement - color (red, purple, pale) - sensation (numbness?) - movement - swelling

Name nursing considerations that help to prepare clients for ambulation.

• Transfer belts (aka gait belts) place chair parallel to bed on patient's stronger side • Hoyer lift movement from bed to chair used for bariatric or very limited mobility clients that need to be up • Non-skid socks • Always KNOW patient's ability beforehand Cognitive vs physical Some clients are unaware of their own limitations - SAFETY always

Define specific proper hygiene techniques. ( Shaving)

• Use personal equipment if available • Disposable safety razors • Electric razors Contraindications for shaving: Anticoagulants or thrombolytics Blood clotting disorders (hemophilia) Rashes/lesions - infection risk Suicidal

Define specific proper hygiene techniques. (Partial Bath)

• Washing specific areas subject to greatest soiling Face -careful around eyes - wipe from inner canthus to outer Hands Axillae Perineum

Discuss four types of position devices and rationale for using each type.

•Adjustable beds specialty: bariatric, cardiac, labor/delivery •Specialty mattresses air mattresses - offloading + bariatric sand beds - redistribute pressure à wound healing •Pillows and wedges •Bed boards - skeletal support •Roller sheets •Trochanter Rolls - prevent legs from turning outward (hip positioning) •Hand Rolls - prevent contractures of the hands and preserve ability to grasp/pick up objects •Footboards, Prevalon Boots, Foot Splints -devices that prevent foot drop and keep feet in functional position •Trapeze -used by clients to position themselves in bed

List four temperature assessment sites and nursing considerations of each site. (temporal)

•Temporal artery-99.4

Explain general guidelines and considerations that apply when transferring clients.

•Transfer belts (aka gait belts) place chair parallel to bed on patient's stronger side •Hoyer lift movement from bed to chair used for bariatric or very limited mobility clients that need to be up •Non-skid socks •Always KNOW patient's ability beforehand Cognitive vs physical Some clients are unaware of their own limitations - SAFETY always

Name advantages and rationales for each of three different pressure-relieving devices (Low-Air Loss Bed)

•Type of specialty air mattress •Regardless of changes in body position, the mattress selectively redistributes the air to maintain low air pressure to ALL skin areas •Commonly used for patients with multiple wounds •One of the most common bed used in hospital

Name advantages and rationales for each of three different pressure-relieving devices (circular beds)

•Used for spinal injury patients •Allows clients to remain passively immobilized during position changes

List four temperature assessment sites and nursing considerations of each site. (tympanic)

•more accurate, less invasive •CONTRAINDICATIONS •Presence of earache or drainage •Scarred tympanic membrane •Sleeping with the head turned on one side •Proper placement is required for accuracy uTympanic thermometers can quickly measure the temperature of the ear drum, which reflects the body's core temperature. u*Adults-pull up and back u*Children 2 yo and below, ear canal too narrow. •Tympanic-99.5