Nurse Think Fundamentals CJSim Free Trail Patient Ellen Thomas
What are the correct steps for inserting a straight catheter?
1. Explain the procedure to the client. 2. Perform hand hygiene and don clean gloves. 3. Help to dorsal recumbent position, with thighs externally rotated hip joints. 4. Perform hand hygiene. 5. Open catheterization kit using sterile technique. Apply sterile gloves, drape perineum, keeping gloves and working surface of drape sterile. 6. Apply sterile gloves. 7. Gently separate labia with fingers of the non-dominant hand to fully expose urethral meatus. 8. Cleanse the urethral meatus from top to bottom, keeping the non-dominant hand in place. 9. Hold catheter 3-4 inches from the tip. 10. Insert catheter 2-3 inches until urine flows out the end of the catheter. Release labia but maintain a secure hold of the catheter. 11. Collect urine in the appropriate receptacle.
Considering the same patient with the same lab results, what other conditions might the nurse be concerned with? Cerebral vascular accident Hypernatremia Constipation Renal failure Dehydration Depression Myocardial infarction Dementia Anemia Diabetes
Answer: Hypernatremia, depression, and dehydration. Debriefing: The client shows signs of dehydration, hypernatremia, and depression, as noted by low blood pressure, tachycardia, headache, serum sodium level, elevated BUN, elevated hemoglobin, and hematocrit, and statements of depression, and refusal to eat and drink. There are no clinical signs the client has diabetes, constipation, anemia, stroke, heart attack, renal failure, or dementia. Consider: 1. What clinical cues would the nurse identify if the client is experiencing hyper or hypoglycemia? 2. What clinical cues would the nurse identify if the client is experiencing a CVA or MI? 3. What clinical cues would the nurse identify if the client is experiencing anemia, constipation, or renal failure? The correct answers are: Dehydration Hypernatremia Depression
Which lab results are most concerning? Lab Result 11/1 at 0930 Sodium 136-145 mEq/L ...149 H Potassium 3.5-5.0 mEq/L ...3.7 Chloride 98-106 mEq/L ...109 H BUN 8-20 mg/dL ...38 H Creatinine 0.7-1.3 mg/dL ...1.1 Glucose 70-100 mg/dL ...81 WBC 4,000-10,000 mm³ ... 10,200 H Hemoglobin 12-17 g/dL ... 16 Hematocrit 36-51% ...49 Platelets 150,000-350,000 mm³... 250,000 Albumin 3.5-5.0 g/dL 2.9 L Temperature 98.9 BP 98/78 MAP 71 HR 108 Headaches - frequent in the past 3 days Mood - is cooperative, sad though
BP BUN Temperature Sodium Heart Rate Headache Debriefing: The nurse should identify normal versus abnormal findings to recognize areas for concern. White blood cells, temperature, and creatinine are all within normal limits. Abnormal findings include the BUN, heart rate, and sodium level. When an abnormal result is discovered, the nurse needs to explore possible causes. The headache as the presenting symptom is concerning due to its consistency over several days. The nurse should be concerned that the client has been feeling depressed lately as it can be a symptom of something worse. Consider: 1. What will cause an elevation of the BUN but not the creatinine? Is this a problem of renal function? 2. Based on the client's BMI, what considerations should the nurse make when assessing the vital signs? 3. What concerns should the nurse have related to perfusion while caring for this client?
Of the doctor's orders, which ones are appropriate for this patient? 1. Consult neurologist2. Insert peripheral IV3. Infuse NaCl 0.09 % @ 125 mL/hr4. Obtain urinalysis via straight catheter 5. Vital signs: orthostatic vital signs now and daily6. Monitor intake and output 7. Encourage oral intake 8. Activity: Out of bed for all meals 9. Consult dietitian, physical, and occupational therapy10. Diet: Low sodium 11. Acetaminophen 650 mg by mouth q6h PRN for headache12. Furosemide 10 mg IVP now13. Continue home medications ASA 81 mg daily by mouth Omeprazole 40 mg by mouth daily Simvastatin 20 mg by mouth daily Citalopram 20 mg by mouth daily ............................................................................ Furosemide Strict intake and output Consultation of OT Neurology consultation Need for straight cath UA Continuation of home medications Low sodium diet IV fluids
Furosemide and continuing home medications should be questioned and of concern with the nurse. Debriefing: For the client with dehydration (as evidenced by the low BP, high sodium level, high H/H, high BUN, and tenting skin), appropriate prescription includes IV fluids, I/O, and a urinalysis. Since the client "cannot void," it is suitable for the nurse to perform a straight catheterization to obtain this. A low sodium diet is appropriate for an older adult with CAD. Her home medications include treatment for CAD, depression, and GERD and are appropriate to continue. Furosemide is a diuretic and should be questioned. There is no justification for a neurological consultation since no tests have been done that suggest a problem. The confusion has resolved and could be attributed to the dehydration. A consultation for the dietitian and physical therapist is appropriate for her poor dietary intake and movement. Occupational therapy consultation is not indicated. Consider: 1. How are PT, OT, and dietary different in the services they offer? 2. How should the nurse approach the HCP when questioning an order? 3. Can a nurse "ignore" an order once written if they disagree with it? What actions should the nurse take?
Before answering this question, review the client's health information in the EHR. As the unlicensed assistive personnel (UAP) and the licensed practical/vocational nurse (LPN/LVN) are getting the client out of bed, her knees buckle, and she falls to the floor, hitting her head on the nightstand and pulling out her IV, both of which are bleeding. The RN is quickly called to the bedside. Identify each action by the team as appropriate or inappropriate. Select one option for each row. Appropriate Inappropriate Notification of the family by the UAP Application of pressure to the bleeding head wound by the UAP Call to the health care provider by the LPN Neuro assessment by the RN Vital sign assessment by the UAP IV restarted by the LPN/LVN Completion of the adverse event report by the charge nurse
Notification of the family by the UAP - inappropriate Application of pressure to the bleeding head wound by the UAP - appropriate Call to the health care provider by the LPN - inappropriate Neuro assessment by the RN - appropriate Vital sign assessment by the UAP - inappropriate IV restarted by the LPN/LVN - inappropriate Completion of the adverse event report by the charge nurse - appropriate . Debriefing: When an acute event occurs, such as a fall, the RN must be notified immediately to perform an assessment. Priority assessments by the RN should include neurological assessment, vital sign assessment, and assessment of any injuries. Since the client is unstable, the RN must not delegate these initial assessments. The RN should also restart the IV (once the client is stable), notify the family, call the health care provider, and complete an adverse event report. The RN can delegate the report's completion to a charge nurse since they are also an RN. The UAP can be asked to hold pressure on a bleeding wound, but the RN must assess and document the injury. Consider: 1. What is the RN's role when someone experiences a fall with broken bones? 2. List ways in which this fall could have been prevented. 3. What could be the long-term client outcome of this event?
Can the UAP compare urine output or obtain orthostatic blood pressures with the RN? Can they discuss food preferences? Who can the RN delegate an intermittent urinary catheter to?
UAP can obtain orthostatic readings LVN, LPN can do the straight catheter procedure. . Debriefing: When the RN delegates, it is crucial to consider the 5 Rights of delegation, including the right task, circumstance, person, supervision, and communication. When considering the functions of the UAP, they can obtain orthostatic readings with the interpretation of those readings becoming completed by the RN. If the RN feels the client is unstable or unsafe, it would be an inappropriate delegation. Discussing food preferences would be an assessment, as would performing a bladder scan and comparing the intake and output. These would need to be completed by the LPN/LVN or RN. The LPN/LVN can complete an intermittent catheterization but not a medication reconciliation, place an IV, or complete a skin care plan.