Final Exam 226 Fundamentals UMass Boston
Chapter 30 Perioperative Nursing Immediate PACU Nursing Care
#1 Respiratory status - airway patency & oxygenation •Endotracheal tube/airway is not removed until gag reflexes return •Respiratory obstruction most common emergency •wheezing, crowing sounds, increased effort Interventions •Assessments every 10-15 minutes, ongoing documentation •Positioning, administering humified oxygen, deep breaths and suctioning
Chapter 35: Pain Management PCA/ Pt controlled Analgesia
*Intravenous administration (morphine, fentanyl, hydromorphone) *Programmable pump -Basal rates and "on-demand" doses programmed -Locked settings -Check at change of shifts - proper documentation *Used for acute and temporary pain management -Post-operative or post-procedure -Requires patient participation
Chapter 40 Fluid, Electrolytes, and Acid-Base balances Nursing Process for Fluid and Electrolyte Balance: I & O, Daily weights & Labs
*Weight- any changes, need for daily weight, same time each day *Fluid intake? Look at I & O balance over 24 hour period •CBC- increased HCT •BUN & creatinine- can be elevated with dehydration and also kidney disease •Close assessment of electrolyte lab values
Chapter 27 Safety Significant Risk Factors
-Developmental considerations-children and adolescent -Lifestyle- occupation, risk takers -Environment-high crime areas -Mobility -Sensory perception alterations -Knowledge-awareness of safety -Ability to communicate -Physical health state -Psychosocial state-stress, depression
Chapter 30 Perioperative Nursing Preventing Complications: CV
-Hemorrhage & Shock Interventions }Notify surgeon & medical team }Establish airway }Patient in flat position w/ legs elevated }IV line }Administer oxygen & medications }Monitor VS, labs, ABGs }Monitor urine output -Hemorrhage and Shock •Hemorrhage: restlessness, anxiety, hypotension, tachycardia, cool extremities, decrease urine output •Shock: same symptoms as hemorrhage. •Hemorrhage & Shock: Priority Actions Stop Bleeding and replace volume
Chapter 8 Communicator Levels of Communication
-Intrapersonal •Self-talk; communication within a person -Interpersonal •Occurs between two or more people with a goal to exchange messages -Group •Small-group •Organizational communication •Group dynamics
Chapter 30 Perioperative Nursing Preventing Complications: Respiratory 2
-Pneumonia - infection -Findings: fever, chills, productive cough, crackles, wheezes, dyspnea, chest pain 1st priority - treat infection •Oxygen •Admin meds •Ambulating •IS •Position: Semi or high Fowler's •Oral hygieneOxygen •Admin meds •Ambulating •IS •Position: Semi or high Fowler's •Oral hygiene -Atelectasis -}Findings: decreased breath sounds, dyspnea, crackles 1st priority - oxygenation & expand involved lung tissues •Incentive Spirometer •Cough & Deep Breath •O2 •OOB & Ambulate
Chapter 30 Perioperative Nursing PreOp physical preparation
-Pre-op Physical Preparation: Hygiene & Skin •Hygiene & Skin Integrity •Reduce risk of infections •Skin preparation - surgery specific - may include shower with antibacterial soap •Hair removal - only if required - clipper or shaver (not a razor because nicks are portals for infection) -Pre-op Physical Preparation: Elimination •Void prior to Surgery •Evaluate last BM date •May require enema •Surgery can cause absence of peristalsis for 24-48 hours •May have indwelling urinary catheter inserted in OR depending on surgery -Pre-op Physical Preparation: Nutrition and Fluids •NPO (length of time depends on the surgery) •Previous standard was 8 hours NPO •May be able to have clear liquids up to 2 hours before surgery -MD order •Communicate NPO status to patient so they do not eat or drink prior to surgery •IVF to maintain hydration •Diet advanced slowly: clear, full, soft, house. Depends on surgery
Chapter 30 Perioperative Nursing Preventing Complications: CV 2
-Thrombophlebitis Findings: calf or limb pain site redness, swelling, warmth, increased size 1st Priority: Prevent dislodgement leading to pulmonary embolus •Bed rest * want to prevent clot from moving. -Intervention •Notify surgeon •Administer meds (anticoagulants, anti-inflammatory, analgesics) •Measure site, warm packs, compression stockings •Teach patient not to massage legs
Chapter 1 Nursing Today Nursing National Patient Safety Goals
1. Identify patients correctly-Need 2 identifiers 2. Improve staff communication-Timely - with labs 3. Use medications safely-Labeled, procedures, anticoagulants 4.Use alarms safely-Equipment alarms are heard & responded to 5. Prevent infections-Hand hygiene, procedures to prevent HAI 6. Identify patient safety risks-Suicide 7. Prevents mistakes in surgery-Correct patient, procedure & pause before surgery starts
Chapter 7 Legal Four Elements of Liability: Malpractice Elements
1.Duty: You have an obligation to use due care. This is what a reasonable and prudent nurse would have done in the same circumstances. Defined by standard of care. 2.Breach of Duty- failure to meet the standard of care 3.Causation -need to prove that failure to meet the standard of care (breach of duty) caused harm or the injury. 4.Damages: Is the actual harm or injury that occurred to the patient Good documentation usually makes proof impossible.
Chapter 18 Evaluating Actions based on patient response to care plan
Actions Based on Patient Response to Care Plan •Terminate the care plan when each expected outcome is achieved. •Modify the care plan if there are difficulties achieving the outcomes. •Continue the care plan if more time is needed to achieve the outcomes.
Chapter 7 Legal HIPAA - Invasion of Privacy
All information is confidential •Reminders: Breaches ▫Discussing information in public areas ▫Leaving information in public areas ▫Copying data - written or hard copy - except as required by job responsibilities ▫Improperly accessing information Social networks
Chapter 43: Loss, Grief, Dying Clinical Signs of Impending Death
Clinical Signs of Impending Death Difficulty talking or swallowing Nausea, flatus, abdominal distention Urinary and/or bowel incontinence or constipation Loss of movement, sensation, and reflexes Decreasing body temperature, with cold or clammy skin Weak, slow, or irregular pulse Decreasing blood pressure Noisy, irregular, or Cheyne-Stokes respirations Restlessness and/or agitation Cooling, mottling, and cyanosis of the extremities and dependent areas
Chapter 25 Vital Signs Assessing Temperature
Assessing Temperature Oral: Normal Range: 97.7-99.5 Tympanic: Normal Range: 98.2-100 Temporal Artery 98.7-100.5 Axillary 96.7-98.5 Rectal 98.7-100.5
Chapter 5 Culture What is Cultural Competency in Healthcare?
Awareness of One's own cultural values, beliefs and behaviors Awareness and Acceptance of cultural differences Recognition that people of different cultures have different ways of communicating, behaving, interpreting, and problem-solving Recognition that cultural beliefs impact patient's health beliefs, help seeking behavior, interactions with health professionals, health care practices, and health outcomes An ability and willingness to adapt the way one works to fit the patient's cultural preferences in order to provide optimal care for that individual
Chapter 13 Blended Competencies, Clinical Reasoning
BLENDED Competencies for Nursing A. Developing Cognitive Competencies B. Critical thinking C. Nurses need to independent thinkers •Developing •Technical competencies •Developing •Interpersonal competencies •Enjoying the rewards of mutual exchange •Developing •Ethical/legal competencies
Chapter 35: Pain Management Pain Responses
Behavioral •Moving away from painful stimuli •Grimacing, moaning, crying •Restlessness •Protecting the painful area, not moving Affective •Exaggerated weeping and restlessness •Withdrawal •Anxiety •Depression •Hopelessness •Powerlessness •Endurance of pain or without complaint
Chapter 25 Vital Signs Procedure for BP & BP assessment
Blood Pressure Assessment •Systolic <120 Ventricular Contraction •Diastolic <80 rest between beats •Based on at least 2 readings - taken on 2 different occasions •Correct position -Seated for at least 5 minutes -Back supported -Feet on floor -Arm supported - horizontal -BP cuff at heart level
Chapter 33: Activity Effects of immobility
Body System Selected details Cardiovascular 1) Orthostatic hypotension; (2) ↑cardiac workload and (3) thrombus formation Respiratory Atelectasis; ↓effectiveness of cough; ↓ respiratory depth, pooling secretions, pneumonia Musculoskeletal ↓muscle mass can lead to atrophy; contractures and osteoporosis; Metabolic ↓metabolic rate; ↓appetite; Gastrointestinal ↓ GI peristalsis; leading to constipation (fecal impaction); Urinary Urinary stasis; ↑risk of UTI and renal calculi; ↓bladder tone Skin Breakdown due to immobility Psychosocial Sensory deprivation; altered sleep patterns; ↑anxiety and/or depression
Chapter 38: Bowel Elimination Bowel Diversion
Bowel Diversion •Opening into the abdominal wall for fecal elimination: Stoma •Temporary or permanent •Ileostomy: liquid fecal content from the ileum of small intestine •Colostomy: formed feces from the colon
Chapter 40 Fluid, Electrolytes, and Acid-Base balances Calcium Imbalances: Normal 8.6-10.2 mg/dL
Calcium Imbalances: Normal 8.6-10.2 mg/dL HYPOCALCEMIA < 8.5 mg/dL Manifestations: Chevostek & Trousseau's sign, numbness and tingling fingers, mouth, feet, muscle cramps, seizures, pathological fractures Treatment: Calcium, seizure precautions if severe, educate about nicotine and alcohol HYPERCALCEMIA > 10.1 mg/dLManifestations: N/V, constipation, excessive urination, thirst, confusion, lethargy, slurred speech, bone pain Severe (>17)=cardiac arrest Treatment: fluids, diuretics, restrict intake of calcium, *risk of digitalis toxicity
Chapter 30 Perioperative Nursing Immediate PACU Nursing Care 2
Cardiovascular - Compare to pre-op baseline •Transient hypertension •Hypotension r/t to anesthesia, meds, blood loss •Hypothermia-warm blankets •Assess peripheral pulses Central Nervous System - Return of consciousness •From unconscious à responds to touch & sounds à drowsy à awake but not oriented à awake & oriented •Fluid Status - Skin turgor, vital signs, urine output, IV fluids and blood
Chapter 44: Sensory Caring for Visually Impaired Patients
Caring for Visually Impaired Patients ◦Teach patient self-care behaviors to maintain vision and prevent blindness. ◦Acknowledge your presence in the patient's room. ◦Speak in a normal tone of voice. ◦Explain the reason for touching the patient before doing so. ◦Keep the call light within reach. ◦Orient the patient to sounds in the environment. ◦Orient the patient to the room arrangement and furnishings. ◦Assist with ambulation by walking slightly ahead of the patient. ◦Stay in the patient's field of vision if he or she has partial vision. ◦Provide diversion using other senses. ◦Indicate conversation has ended when leaving room.
Chapter 37: Urinary Elimination Common Urinary Problems Older Adult
Common Urinary Problems Older Adult •Nocturia, frequency and urgency •Urinary incontinence *Common but doesn't happen to all adults *Types: Transient, stress, overflow, functional •Urinary tract infection (UTI) *Most common HAI & responsible for over 7 million health care visits Causes: Catheterization, poor hygiene, female anatomy, urinary retention •Urinary Retention *Pressure *Small amounts of urine voided *Assess for distention *Post-void residuals (PVR) Bladder scan or catheterization *Normal PVR<50ml PVR > 100ml may need to catheterize
Chapter 1 Nursing Today Quality & Safety Education for Nurses (QSEN)
Competencies are: •Patient-centered care •Teamwork and collaboration •Evidence-based practice •Quality improvement •Safety •Informatics •These concepts are used to organize the clinical evaluation tool
Chapter 40 Fluid, Electrolytes, and Acid-Base balances Complications of IV
Complications of IV * Swelling, pallor, coolness, pain *Discontinue, raise extremity, wrap in moist towel *Insert new site Complication Key Points -Venous Access Device Infection Erythema, edema, drainage, fever, chills. Notify primary provider immediately, culture (per protocol) -Thrombus Similar to phlebitis, stop infusion, Do not massage or rub the site, apply compress (as ordered), restart IV -Fluid Overload Dyspnea, distended neck veins, ↑ BP, slow rate, and call primary provider -Air Embolus Air enters circulation (break in system). Pinch catheter, call for help immediately
Chapter 40 Fluid, Electrolytes, and Acid-Base balances Complications of IV Phlebitis
Complications of IV Phlebitis *Redness, acute tenderness, warmth over vein *Discontinue infusion, remove IV and insert in new vein *Apply warm moist heat compress *Peripheral IV sites should be changed every 72-96 hours (CDC recommendations)
Chapter 44: Sensory Effects of sensory deprivation
Effects of sensory deprivation ◦Perceptual disturbances ◦Cognitive disturbances ◦Emotional disturbances
Chapter 16 Outcome Identification and planning Establishing Priority
Establishing Priorities* •High •Medium- •Low •Basic human needs •Patient preferences Maslow's Hierarchy of Human Needs 5. Self Actualization 4. Self Esteem 3. Love and Belonging 2. Safety and Security 1. Physiologic needs
Chapter 36: Nutrition Factors affecting BMR/ Basal Metabolic Rate
Factors affecting BMR/ Basal Metabolic Rate *Gender-Males have a higher BMR due to larger muscle mass compared to adipose tissue *Body size: the larger the body the greater the metabolism rate , as more energy is required to move a larger heavier mass *Lean body tissue: greater lean body tissue(compared to fat) increases your metabolism rate as it is active tissue that burns kilojoules at a faster rate *Hormones: Certain hormonal conditions affect basal metabolic rate people with an overactive thyroid have a greater metabolic rate *Infection and Illness: increase basal metabolic rate as the body works harder to fight the infection *Fasting: Decreases BMR as the body conserves energy to keep vital organs functioning *Certain Drugs: caffeine and nicotine increase BMR whilst others decrease it such as Anti-depressents , social and prescription drugs *Climate: cold climates increase BMR as the body uses kilojoules to maintain a stable body temperature *Age: later years often see a decline in BMR due to less activity and reduced lean muscle tissue *Exercise: BMR is increased during any exercise and it remains high for several hours after intense and prolonged exercise. the more exercise a person does the greater lean active body tissue and increased BMR Factors that increase BMR -Lean muscle Mass Factors that decrease BMR -Fat tissue
Chapter 36: Nutrition Feeding clients with dysphagia
Feeding clients with dysphagia •Rest •High Fowlers •Chin position •Pace feeding & placing food •Viscosity •Liquid types: thin, nectar-like, honey-like and spoon-thick
Chapter 19 & 20 Documentation & Informatics Change of shift report/Hand off report
Hand-offs should: Include accurate, relevant patient information •Use a standardized approach A change-of-shift report or handoff is given by a primary nurse to the nurse replacing him or her, or by the charge nurse to the nurse who assumes responsibility for continuing care of the patient. The change-of-shift report may be given in written form or orally in a meeting, or it may be audio- or videotaped. The trend today is toward a standardized, streamlined shift report system at the bedside—the bedside report. Vital elements of the bedside report include the oncoming and outgoing nurse seeing the patient together, reviewing medication records and the health care provider's and nursing orders, and establishing patient goals for the shift.
Chapter 24 Asepsis & Infection Control Health Care Associated Infection
Healthcare Associated Infections Nosocomial - Taking place in hospital Majority of HAI include •Catheter-associated urinary tract infection (CAUTI) •Surgical site infection (SSI) •Central-line associated bloodstream infection (CLABSI) •Ventilator-associated pneumonia (VAP) https://www.mass.gov/lists/healthcare-associated-infections-reports
Chapter 43: Loss, Grief, Dying How Does Palliative Care Differ From Hospice?
How Does Palliative Care Differ From Hospice? HOSPICE CARE Patient considered "terminal" with less than 6 months to live Patient/family chooses NOT to receive aggressive, curative care Focuses on "care" versus "cure" Expenses are covered by Medicare, Medicaid, and most private health insurers A philosophy & model for the care Can occur in many settings Client and family centered Interdisciplinary approach ¡Doctors, Nurse Practitioners, Nurses, Case, Managers, Nurses Aids, SW, PT, Minister, Pastor, Rabbi..... Trained Volunteers Medical and nursing care available 24/7 Bereavement Follow up PALLATIVE CARE Goal to enhance quality of life Ideally begins at the time of diagnosis of a serious illness No life expectancy requirement Expenses are covered by philanthropy, fee-for-service, direct hospital support For pediatric patients, care is provided through mandates from the Affordable Care Act What Palliative Care Can Provide Provide interdisciplinary care to address and manage symptoms (shortness of breath, fatigue, anxiety related to PTSD, etc.) Social work consult to assist in caring for spouse Discuss the urgent need for an advanced directive, along with his goals of care Explore the following: -Commitment to assist with care? -Is it safe to send Arthur back home? -Are there any Veterans benefits for which Arthur could qualify regarding further/future care? (From ELNEC)
Chapter 14 Assessing Identify the Cues
Identify the Cues "Making the case" that the specific problem exists. Nurses now use the language of cues and inferences to describe the early analysis of data. The subjective and objective data you identify ("the patient does not respond when I speak to him on his left side") is a cue that something may be wrong.
Chapter 17 Implementing Interventions related to nursing diagnosis
Implementing Guidelines •Partner with patient and family •Reassess before implementation •Check that interventions are consistent with practice standards (ethical and legal)
Chapter 19 & 20 Documentation & Informatics SBAR reporting
In the interest of Patient Safety and to ensure nursing is giving complete, accurate information to the physician, use the following acronym to communicate to the physician: •S (the current S i t u a t i o n or problem) Identify self, pt, room, problem, when and how severe. •B (a little about the patient's Background) Admitting dx and date, meds, allergies, iv, labs, vitals, code •A (your Assessment of the patient) Nurse assessment •R (your Recommendation of what is needed from the physician) Pt needs to been seen now, Order change
Chapter 37: Urinary Elimination Indwelling catheter care
Indwelling catheter care •Hand hygiene •Perineal Care •Fluid intake •Secure catheter to thigh to decrease "pulling" and irritation •Patient education •Collection bag should be below bladder
Chapter 40 Fluid, Electrolytes, and Acid-Base balance Intervention: Transfusion Reaction
Intervention: Transfusion Reaction -Stop transfusion -Keep IV line open with 0.9% NS -Notify physician -Remain with client & take vital signs every 5 mins -Urine will be obtained and blood & set up sent to lab, do not throw away! -Incident report
Chapter 43: Loss, Grief, Dying Kübler-Ross's Five Stages of Grief
Kübler-Ross's Five Stages of Grief Denial and isolation Anger Bargaining Depression Acceptance
Chapter 5 Culture Learn Model Use LEARN to guide respectful, patient-centered cross-cultural communication
L: Listen actively to what patients say with empathy and understanding, without imposing your own values and beliefs. E: Explain your perception of the problem and express your understanding that perceptions of illness vary by culture. A: Acknowledge and discuss the differences and similarities in perspectives. Be careful not to devalue the pt's perspective and privilege yours. R: Recommend nursing care that respects pt preference and integrate aspects of cultural health beliefs (herbal med, traditional healers, cultural rituals) N: Negotiate agreement as authentic partners (not as superior authority figure) in developing, implementing, and evaluating the plan of care.
Chapter 43: Loss, Grief, Dying Legal & Advanced Care Planning Issues
Legal & Advanced Care Planning Issues Advanced Directives -Durable power of attorney for healthcare -indicates who will make decisions for the patient in case the patient is unable -Indicate the kind of medical treatment the patient wants or doesn't want. -POLST Physician Order for life sustaining treatment) or MOLST( Medical orders for life sustaining treatment) -Allow Natural Death, Do-not-resuscitate (DNR) or No-Code orders •Resuscitation is not done if patient stops breathing and or whose heart stops beating •Standard of care à provide resuscitation if there is not an order
Chapter 40 Fluid, Electrolytes, and Acid-Base balances Magnesium Imbalances (Normal 1.5-2.3 mEq/L)
Magnesium Imbalances (Normal 1.5-2.3 mEq/L) •HYPOMAGNESEMIA <1.5 mEq/L •Manifestations: Muscular weakness & tremors, tetany, seizures, hyperactive Deep Tendon Reflexes (DTRs), mental status changes, cardiac dysrhythmias, respiratory paralysis. •Treatment: replacement of magnesium. Foods rich in magnesium (dark leafy greens, nuts, seeds, fish, beans, whole grains, avocados, yogurt, bananas, dried fruit, dark chocolate). Seizure precautions, airway support •HYPERMAGNESEMIA > 2.5 mEq •Manifestations: Early signs include flushing, and sense of skin warmth, N/V, loss of DTRs, respiratory depression, lethargy progressing to coma, cardiac arrest •Treatment: calcium gluconate, furosemide; hemodialysis in severe cases.
Chapter 30 Perioperative Nursing Risk Assessment
Medical History •Cardiovascular •Respiratory -decreased cough & chest expansion •Kidney and liver Disease •Endocrine Disease Other Risk Factors •Previous surgical complications DVT •Medications e.g. anticoagulants, diuretics, tranquilizers, steroids, antibiotics in mycin group •Poor nutrition or obesity •Smoking, alcohol or substance use/abuse
Chapter 23 The Aging Adult Mental Impairment in Older Adult
Mental Impairment in Older Adults -Dementia -Alzheimer disease -Sundowning syndrome-confusion & agitation after dark -Cascade iatrogenesis -Dementia is progressive and usually develops gradually. It involves a group of symptoms that affects mental cognitive tasks such as memory and reasoning. Dementia is an umbrella term that Alzheimer's disease can fall under
Chapter 35: Pain Management Pain Responses: Physiological
Moderate & Superficial -Increased BP, RR & P -Dilated pupils -Pallor -Increased adrenaline & blood glucose -Muscle Tension Severe -Nausea and vomiting -Decreased BP & P -Rapid, irregular RR -Fainting
Chapter 24 Asepsis & Infection Control Multi-Drug Resistant Organism/ Transmission Based Precautions for different types of infections
Multi-Drug Resistant Organisms (MDRO) •Seen in the clinical setting •Methicillin resistant staph aureus (MRSA) •Vancomyocin includes: •Intermediate resistant (VISA); Staph aureus (VRSA); Enterococci (VRE) •Clostridium difficile (known as C diff)
Chapter 38: Bowel Elimination NG Tube
NG Tube •Used to decompress or drain the stomach •Treatment for paralytic ileus or intestinal obstruction •May be used for "bowel rest before or after surgery •Salem Sump(picture) Levine single lumen-A nasogastric (NG) tube is a flexible tube of rubber or plastic that is passed through the nose, down through the esophagus, and into the stomach.
Chapter 39: Oxygenation Nursing Care for Acute Patients
Nursing Care for Acute Patients •Positioning •Adequate Fluid Intake •Humidified Air
Chapter 44: Sensory Nursing Diagnosis
Nursing Diagnosis •Disturbed Sensory Perception Other potential nursing diagnosis could include: •Acute Confusion •Chronic Confusion •Impaired memory
Chapter 31: Hygiene General hygiene care & principles: oral care, bed bath, peri care
Nursing Knowledge Base •Many factors influence personal hygiene. •Use communication skills to promote the therapeutic relationship. •Hygiene care is never routine. •During hygiene, assess: •Emotional status •Health promotion practices •Health care education needs Considerations: Oral Care •Oral care in increasingly important to prevent infections •Encourage independence with oral care or any personal care •Tooth-brushing is the gold standard •Denture care •Make sure the mouth is moist •Proper positioning Bed Baths •Rinse cloths frequently •Change water as needed-dirty, cold •Do NOT use community items (e.g. razor) • Making Beds •Do NOT shake linen •Do NOT put linen on the floor Perineal and Vaginal Care •Perform perineal care in matter-of-fact and dignified manner according to procedure. •Cleanse vaginal area with plain soap and water. •Foley care important to prevent infection!
Chapter 38: Bowel Elimination Nursing Measures for the Patient with Diarrhea
Nursing Measures for the Patient with Diarrhea •Diarrhea: more than three loose stools a day •Assess & Document: -Frequency -Consistency -Color •Answer call bells immediately •Remove the cause of diarrhea whenever possible (e.g., medication). •Assess for fecal impaction. •Skin care •Assess for dehydration-young & old
Chapter 36: Nutrition Nursing care for clients receiving tube feedings
Nursing care for clients receiving tube feedings 1.Check tube placement and or gastric residuals ●Before feedings or every 4-6 hours/policy ●Flush tubes afterwards 2.Withholding feedings ●Residual > 200 mL/ or agency policy 3.Assess abdomen & check bowel sounds 4.Pt in upright position- 30 degrees, one hour after feeding 5.Prevent contamination ●Expiration dates, replace open system 24H & closed system 48H 6.Medications cannot be mixed with formula
Chapter 29: Medications Oral medication administration
Oral Medication Administration •The Oral route is the most common, least expensive and most convenient route. Drugs given orally are intended for absorption in the stomach and small intestine. PO, the common shorthand for oral administration. Drug action has a slower onset and a more prolonged, but less potent, effect with oral administration of drugs compared to administration via other routes. There are certain situations in which oral medications should not be administered, such as when the patient has difficulty swallowing, is unconscious, is to receive nothing by mouth, or is vomiting. •What do you need to administer oral medications? A cup, Pt. has a good swallow. Medication order is needed before administering any medication. Does the medication need to be put in apples sauce, crushed? Let Dr. know this after assessment •Capsule - Powder or gel form in a gelatinous container •Tablet -Small, solid dose of medication, may be any color, size, or shape Enteric-coated tablets are coated that is insoluble in gastric acids to reduce gastric irritation by the drug •Extended Release-Allows for slow and continuous release over a predetermined period •Elixir: Medication in a clear liquid containing water, alcohol, sweeteners, and flavor •Suspension: Finely divided, undissolved particles in a liquid medium; should be shaken before use •When do you need to wear gloves?? Always were gloves if handing the medication to client or put in cut with clean hands. If you have to put in the patients mouth or touch the patient wear gloves Injection or topical
Chapter 35: Pain Management Pain assessment tools 2 for Dementia
PAINAD (Pain Assessment In Advanced Dementia Scale) 0 1 2 Behavior Score Breathing Independent of vocalization • 0- Normal • 1- Occasional labored breathing • Short period of hyperventilation • 2-Noisy labored breathing • Long period of hyperventilation • Cheyne-Stokes respirations Negative vocalization • 0- None • 1- Occasional moan or groan • Low-level speech with a negative or disapproving quality • 2- Repeated troubled calling out • Loud moaning or groaning • Crying Facial expression • 0- Smiling or inexpressive • 1- Sad • Frightened • Frown • 2- Facial grimacing Body language • 0-Relaxed • 1-Tense • Distressed pacing • Fidgeting • 2-Rigid • Fists clenched • Knees pulled up • Pulling or pushing away • Striking out Consolability • 0-No need to console • 1-Distracted or reassured by voice or touch • 2-Unable to console, distract, or reassure TOTAL SCORE
Chapter 40 Fluid, Electrolytes, and Acid-Base balances POTASSIUM: 3.5-5 mEq/L
POTASSIUM: 3.5-5 mEq/L *Is major intracellular electrolyte: primary function is to stimulate nerve cells & muscle function *Cardiac Conduction *Imbalances can occur rather quickly, small shifts can have significant clinical impact *Client should have telemetry monitoring with any K+ imbalances Hypokalemia < 3.5 mEq/L Manifestations: •Muscular weakness, leg cramps, paresthesia's (numb, tingling) •Dysrhythmias, irregular pulse. • Hypokalemia potentiates digitalis toxicity ¨ Treatment: Replace K+, IV irritates veins, mixed by pharmacy, never give IV push (policy) up to 40mEq in 1 liter IV bag. Hyperkalemia: >5 mEq/L Manifestations: •Cardiac dysrhythmias-LETHAL •Muscle weakness and paralysis, Treatment: Mild (< 6 mEq/L): Stopping K intake or K-sparing medications 1.Severe: IV & medications: Na+ bicarb, insulin, hypertonic dextrose, sodium polystyrene sulfonate (Kayexalate) oral or enema. Dialysis last resort
Chapter 29: Medications Routes of parental medications
Parental medication routes: •IV •Injection intramuscular, subcutaneous, intravenous, and intradermal injection.
Chapter 36: Nutrition Parenteral vs enteral nutrition
Parenteral vs enteral nutrition Parenteral Delivery of nutrients that bypasses GI tract. If intestinal function is inadequate -IV(fluid dextrose) -TPN Enteral Delivery of nutrients through GI tract when GI tract is functional -Tube enters stomach -J tube -NG tube
Chapter 33: Activity Safe patient handling
Patient assessment of: •Ability to assist •Ability to comprehend instructions Use proper assistive device such as: •Gait belts •Lateral assistive devices (e.g. to reduce friction) this is a slide board •Mechanical assistive devices: Powered full body sling lifts, powered stand-assist lifts
Chapter 29: Medications Pharmacokinetics: Absorption
Pharmacokinetics: Absorption What we eat and kidney or liver damage effects absorption •Route-Oral(absorbed through GI tract) vs injectable(quicker absorbed)(iv-blood stream) or Topical(slowest) •Blood flow(vascular area has greater absorption) •Local Conditions at Site of Administration (stomach location with food will alter absorption take longer with food) •Drug dosage- Loading doses (higher dose initially) vs. maintenance doses (ordered dose to maintain drug in blood stream)
Chapter 27 Safety Physical restraint standards/nursing care of client with restraints
Physical Restraint Policies -Least restrictive should be the first option -Never applied for staff convenience -Long-term care - must involve family before applying them -Require an written order from physician or licensed independent practitioner and includes: ◦Type of restraint ◦Justification ◦Criteria for removal ◦Never a PRN
Chapter 30 Perioperative Nursing Informed Consent Information
Physician should describe: procedure/treatment, underlying disease process, alternative therapies, risks, explain pt. has right to refuse treatment or withdraw consent, expected outcome, name and qualifications of person performing procedure •Protect patient, physician and healthcare institution •Nurse may witness signature - indicating patient alert, aware of act and no coercion. •Not legal if...patient is confused, sedated, mentally incompetent or a minor (as determined by state laws)
Chapter 30 Perioperative Nursing Pre-op physical preparation
Pre-Operative Nursing Care: Key Aspects 1.Assessing 2.Client teaching 3.Informed consent 4.Preparation for OR
Chapter 32: Skin Integrity and Wound Care Pressure injury risk factors
Pressure injury risk factors •External Pressure- 1-2 hours •Friction and Shear •Immobility •Nutrition & Hydration •Moisture •Mental Status
Chapter 27 Safety Fall prevention strategies
Preventing Falls: Clinical Facilities -Hourly Patient Rounding -Complete a risk assessment and communicate if patient at risk (door and chart) -Keep bed in low position & locked -Call bell and needed items within reach -Eliminate physical obstacles -Non-skid footwear -Cognitive assessment-report any changes
Chapter 24 Asepsis & Infection Control Principles of Sterile Technique
Principles of Surgical Asepsis/ Sterile Technique 1.Sterile- Sterile 2.Out of sight /below waist level 3.Contaminated with prolonged exposure to air
Chapter 37: Urinary Elimination Promoting Normal Urination
Promoting Normal Urination •What is the client's normal voiding habits? •Fluid intake •Strengthening exercises •Stimulating urination •Assist with toileting
Chapter 30 Perioperative Nursing Preventing Respiratory Complications
Pulmonary Embolism •Findings: dyspnea, chest pain, cough, cyanosis, ↑RR, ↑HR & anxiety •Life threatening/ call physician •1st priority: Stabilize CV and respiratory function
Chapter 40 Fluid, Electrolytes, and Acid-Base balances ELECTROLYTE IMBALANCES SODIUM (135-145 mEq/L) HYPONATREMIA <135
SODIUM (135-145 mEq/L) HYPONATREMIA <135 Related to: •Severe vomiting, diarrhea, excessive sweating •Drinking to much water •Diuretics Manifestations: •Confusion, hypotension •N/V, muscle weakness & cramps. •Less than 115 signs of CNS -Lethargy, muscle twitching, hemiparesis* Seizures and permanent neuro damage Treatment: Encourage foods with Na+, Na+ replacement, monitor Na+ level and specific gravity, Hypertonic IV fluids, H2O restriction, seizure precautions if severeConfusion, hypotension
Chapter 14 Assessing Step:1 What involves nursing assessment/what is done in the phase
STEP 1: Assessment •Identify nursing and medical concerns •Checking for accuracy and recognizing missing information •Analyze data •Document data
Chapter 15 Diagnosing Step 2: identify PED statement and How to Identify a Clients Nursing Diagnosis
STEP 2: Diagnosing •Identify a Nursing Diagnosis •Components of Nursing Diagnosis: •P: The Problem= Nursing Diagnosis •E: Etiology = Cause of the problem •D: Defining characteristics or Signs and Symptoms HOW TO IDENTIFY A CLIENT'S NURSING DIAGNOSIS •Recognizing significant data •Recognize Patterns or Clusters •Identify patient strengths and problems •Identify potential complications • • •Reaching conclusions Nursing Diagnosis -Problems nursing can treat independently Medical Diagnosis -Identification of diseases Know the difference
Chapter 38: Bowel Elimination Selected Medications
Selected Medications Effect on GI: Opioids-Constipation Antacids (aluminum)-Constipation Antibiotics-Diarrhea (e.g. C-diff) Antacids (magnesium)-Diarrhea NSAIDs or aspirin-Increase gastric irritation à at risk for bleeding Iron-Causes black stools, nausea, vomiting, diarrhea (less common) and abdominal cramps Laxatives & cathartics-Soften stool &/or promotes peristalsis Anti-diarrhea-Lowers GI motility
Chapter 44: Sensory Sensory Overload
Sensory Overload ◦The patient experiences to much sensory stimuli ◦The patient feels out of control ◦Exhibits manifestations observed in sensory deprivation. ◦Nursing care focuses on reducing distressing stimuli .
Chapter 23 The Aging Adult Delirium
Significance of Detecting Delirium -Delirium is a reversible condition, it is temporary state of confusion -Common reasons: medications - especially if new one, infection or dehydration -For hospitalized patients with dementia, 32% developed delirium -Stayed 4 days longer than patients without delirium -Reduced level of physical and mental activity at hospital discharge and a month later -They were more likely to die a month after discharge
Chapter 43: Loss, Grief, Dying Spiritual Nursing Care
Spiritual Nursing Care Suggestions for Spiritual Assessment* •Are there any religious or spiritual practices that would be helpful to you while you're here? •Would you like to see a chaplain? •Who or what provides you hope? •Do you use prayer in your life? •How does faith help you cope with illness?
Chapter 17 Implementing Step 4 of the Nursing Process
Step 4: Implementation Assist patients to achieve outcomes •In this step nursing actions are carried out •Reassess the patient plan and review plan of care •Situations change! •Know Skills and scope of practice * Safety •Nursing actions should be individualized to the patient's preferences. Organization is key to implementing care -Patient and visitors-is patient prepared for intervention? Do visitors need to leave? -Equipment & Supplies-what equipment/supplies do you need? -Environment-privacy -Personnel -Do I need assistance? -Anticipate unexpected outcomes and situations
Chapter 18 Evaluating Summarizing the findings
Summarizing the findings •Outcome met •Outcome partially met •Outcome not met
Chapter 43: Loss, Grief, Dying Terms of Grief and loss
Terms of Grief and loss -Grief: Internal emotional reaction to loss -Mourning: actions and expressions of grief - outward expressions -Bereavement: the state of grieving
Chapter 9 Teaching and Counseling 3 Learning Domains
Three Learning Domains •Cognitive: storing and recalling of new knowledge in the brain •Psychomotor: learning a physical skill •Affective: changing attitudes, values, and feelings
Chapter 32: Skin Integrity and Wound Care Wound Debridement
Three types: • Mechanical - wet to dry/damp dressings • Autolytic - Uses the body's own processes (enzymes and moisture) to break down eschar and slough. •Wound base dry - use dsg to add moisture •Wound base wet - use dsg to absorb moisture •Surgical debridement •Quickest method
Chapter 7 Legal Unintentional Tors vs Intentional Torts (know the different types of torts)
Torts: wrongful act Intentional •Assault = threat •Battery = actual contact •Defamation of character •Invasion of privacy •False imprisonment •Fraud Unintentional •Negligence: Below the standard of care, "reasonably prudent person" •Malpractice ▫Failure to carry out a duty that caused injury
Chapter 40 Fluid, Electrolytes, and Acid-Base balances Transfusion Order
Transfusion Order Prescriber order: *Type of Blood *Date and rate Type and Cross: persons blood type and the compatibility of blood specimens * PRBCs usual = transfusion over 2 hrs *May be lengthened to 4 hrs if client at risk for FVE (> 4 hours risk of contamination) * IV push Furosemide may be prescribed before or between PRBCs to prevent fluid overload
Chapter 24 Asepsis & Infection Control Means of Transmission
Transmission-Based Precautions Airborne -For TB, chicken pox, measles, COVID -Private room with NEGATIVE pressure - vented outside -Door closed -Respirator (N-95) mask (special mask - fit to individuals) -Transport only when needed Droplet -Influenza, rubella, mumps -Private room -Door may be open -PPE (Incl. mask & door)& visitors to be 3 feet away -Transport only when needed Contact -Multidrug resistant organisms, diarrhea -Private room -Can be open -PPE (gloves & gowns) -Limit movement out of room
Chapter 35: Pain Management Treating cancer pain
Treating cancer pain -Orally if possible -Around the clock rather than prn -Maximum benefits with minimal side effects -Allow patient to have as much control as possible
Chapter 40 Fluid, Electrolytes, and Acid-Base balances Types of transfusion reactions
Types of transfusion reactions -Allergic -Itching, hives, * Anaphylaxis -Febrile -Fevers, chills, headache -Hemolytic: (Incompatibility) -Fevers, chills, headache, low back pain shock -Overload: dyspnea, dry cough
Chapter 35: Pain Management Pain assessment tools
Verbal Descriptor scale •"please rate your pain from "no pain" to "mild" "severe" or "as bad as it could be" Numerical Rating Scale /NRS •0-10 Numeric pain scale, 0 being no pain, 5 being moderate pain and 10 being worse pain FLACC = 0,1,2 •Pain rating scale for infants to 7 yrs -F: Face, 0-No particular expression or smile, 1-Occasional grimace or frown withdrawn, disinterested, 2-Frequent/constant quiver chin, clenched jaw -L: Legs, 0-Normal position, relaxed, 1-Uneasy, restless, tense, 2-Kicking or legs drawn up -A: Activity, 0-Lying quietly, normal position, moves easily, 1-Squirming, shifting back and forth, tense, 2- Arched, rigid or jerking -C: Cry, 0-No cry(awake or asleep) occasional complaint, 1- Moans or whimpers; sobs; frequent complaint, 2- Crying steadily, screams -C: Consolability, 0- content, relaxed, 1- reassured by occasional touching, hugging or being talked to distractible, 2-Difficult to console or comfort Face Pain Scale-Wong/Baker -0,2,4,6,8,10 Faces: happy face being no pain, 4 no smile/ hurts little more, 10 crying face
Chapter 8 Communicator Therapeutic Communication Responses
With therapeutic communication, nurses often use open-ended statements and questions, repeat information, or use silence to prompt patients to work through problems on their own. Interviewing techniques: Open-ended questions-tell me how you take your medication at home? Closed questions- Do you take aspirin daily? Validating questions -What I heard you saying was.. Clarifying questions -Could you explain what you mean Reflective questions-Repeating back..You are worried about the surgery. Sequencing questions -when did this occur? Directing questions -need to obtain more information. You mentioned earlier... * See text for examples of each technique
Chapter 30 Perioperative Nursing Immediate PACU Nursing Care 3
Wound Status •Most surgical wounds have a dressing, may have drain in place •If large amount of drainage, reinforce dressing and call surgeon(shock=restlessness, cool moist skin, decrease BP, elevated pulse & RR) •Surgeon change 1st dressing Pain Assessment •Will probably be medicated in PACU Hand off Report for Inpatient Essential content of report or Anesthesia and procedure completed •IVF and estimated blood loss (EBL)à look for signs (↓ BP) •Special concerns to be alert for (e.g. hemorrhage) •Surgical complications •Intra-operative positioning
Chapter 16 Outcome Identification and planning Writing outcomes (Be able to identify patient-centered, measurable outcomes/goal)
Writing Outcomes Component: *Client-centered- ex. "Patient will" *Observable & measureable-Patient will report decrease pain as measured by 3/10 (one behavior = singular) *Time- limited - need a specific time frame-Patient will report decrease pain as measured by 3/10 within 8 hours *Realistic-Needs to be attainable *Mutually agreed upon by client-Including client is key to success
Chapter 25 Vital Signs Know baseline vital signs in order to Interpret them/acceptable ranges for adults, what are priority in assessing
You need to know the normal ranges for adults •Oral temperature—98.6°F •Pulse rate—60 to 100 (80 average) •Respirations—12 to 20 breaths/min •Blood pressure—120/80
Chapter 30 Perioperative Nursing Surgery Classification
•Based on Urgency -Elective - pre planned -Not urgent •Based on Risk -Urgent -Done within short time period •Based on Purpose diagnostic, ablative, palliative, reconstructive, transplantation, constructive -Emergency -Must be done now
Chapter 32: Skin Integrity and Wound Care Wound Culture
•Clean wound with normal saline •Sterile swab used to obtain culture in wound bed. 32-6 skill
Chapter 39: Oxygenation Promote Proper Breathing
•Deep Breathing -Oxygenation •Semi-Fowlers position •Ask patient to: •Exhale completely •Inhale through the nose •Hold 3-5 seconds •Exhale thru pursed lips •Repeat •Done every 1-2 hours Cough and Deep Breathing -Clears secretions •Semi-Fowlers position & a splint pillow •Ask patient to: •Inhale & exhale deeply slowly thru nose •Take deep breath & hold 3 secs. •Cough deeply 1-2 times •Done every 2 hours while awake •Incentive spirometer -Lung expansion -Atelectasis •Pursed-lip breathing COPD -"inhale, one, two." Pucker, or "purse" your lips as if you were going to whistle or gently blow out a candle. And then breathe out, or exhale, all of the air in your lungs through your mouth slowly and gently through pursed lips. -Moves oxygen into your lungs and carbon dioxide out of your lungs •Diaphragmatic breathing COPD -Diaphragmatic breathing (also called "abdominal breathing" or "belly breathing") encourages full oxygen exchange -Sit comfortably, with your knees bent and your shoulders, head and neck relaxed. Place one hand on your upper chest and the other just below your rib cage. This will allow you to feel your diaphragm move as you breathe. Breathe in slowly through your nose so that your stomach moves out against your hand. •Leg Exercises -Venus return
Chapter 9 Teaching and Counseling Teaching Methods & Instructional Materials
•Discussion- may be one to one in healthcare •Demonstration •Written Materials •AV /Web based instruction
Chapter 40 Fluid, Electrolytes, and Acid-Base balances Nursing Process for Fluid and Electrolyte Balance: History & Physical Assessment
•Hypovolemia: GI losses, burns or hemorrhage, fever, diuretics, decreased oral intake Manifestations: •Poor skin turgor; dry mucous membranes •Postural hypotension, tachycardia, weak pulse •Oliguria (<30ml/hr) •Increased hematocrit •Hypervolemia: CHF, renal failure, excessive Na+ intake, cirrhosis Manifestations: •Rapid weight gain, edema, crackles in lungs, neck vein distention, polyuria, increased BP, bounding pulse, decreased hematocrit
Chapter 33: Activity Preventing DVT
•Leg, foot, and ankle exercises; regularly providing fluids; position changes; and patient teaching need to begin when the patient becomes immobile. •Heparin therapy for DVT prophylaxis( next slide •Sequential Compression Device(SCDs) and intermittent pneumatic compression (IPC) are used to prevent blot clots in the lower extremities. •Elastic stockings (sometimes called antiembolitic stockings) also aid in maintaining external pressure on the muscles of the lower extremities and thus promote venous return. •Proper positioning reduces the patient's risk of thrombus formation because compression of the leg veins is minimized. •ROM exercises reduce the risk of contractures and aid in preventing thrombi. vIf thrombus suspected à contact physician, elevate the leg & do NOT massage the area
Chapter 7 Legal Invasion of Privacy: HIPAA
•Right to see and copy their health record •Right to request an amendment to their medical record and or request correction of any mistakes •Right to obtain a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations •Right to request a restriction on certain uses or disclosures •Right to choose how to receive health information
