ati review

Disclosure of Confidential Health Information (ch.4)

*Breach of confidentiality - A nurse releases a client's medical diagnosis to a member of the press.*

Caring for a Client Who Has Hearing Loss

Advise clients to not place any objects in the ear, including cotton-tipped swabs. ● Tell clients to have an otologist remove any object lodged in the ear. Use a commercial ceruminolytic (ear drops that soften cerumen) for impactions, and follow with warm-water irrigation. ● Instruct clients to wear ear protection during exposure to high-intensity noise and risk for ear trauma. ● Tell clients to blow the nose gently and with both nostrils unobstructed. ● Advise clients when wearing headphones, keep the volume as low as possible. Patient-Centered Care ◯ Monitor functional ability. ◯ Communication ■ Get the client's attention before speaking. ■ Stand or sit facing the client in a well-lit, quiet room without distractions. ■ Speak clearly and slowly without shouting and without hands or other objects covering the mouth. ■ Arrange for communication assistance (sign language interpreter, closed-captions, phone amplifiers, teletypewriter [TTY] capabilities).heck the hearing of clients receiving ototoxic medications for more than 5 days. Reduced renal function that occurs with aging increases the risk for ototoxicity. Ototoxic medications include the

Therapeutic Communication: Encouraging Verbalization (32)

Basic Communication ● Levels of Basic Communication ◯ Intrapersonal communication - Communication that occurs within an individual. Also identified as "self-talk." This is the internal discussion that takes place when an individual is thinking but not outwardly verbalizing the thoughts. In nursing, intrapersonal communication allows the nurse to assess clients and/or situations and think critically about the clients/situations before communicating verbally. ◯ Interpersonal communication - Communication that occurs between two people. This form of communication is the most common in nursing and requires an exchange of information with an individual or small group. ◯ Public communication - Communication that occurs within large groups of people. In nursing, this commonly occurs during educational endeavors during which the nurse is teaching a large group of individuals, such as in a community setting. ◯ Transpersonal communication - Communication that addresses spiritual needs and provides interventions to meet these needs. ◯ Small group communication - Communication within a group of people, usually working toward a mutual goal.

Trialing Handoff Communication Tools (5)

Change-of-Shift Report ◯ Nurses give this report at the conclusion of each shift to the nurse assuming responsibility for the clients. ◯ Formats include face to face, audiotaping, or presentation during walking rounds in each client's room (unless the client has a roommate or visitors are present). ◯ An effective report should: ■ Include significant objective information about the client's health problems. ■ Proceed in a logical sequence. ■ Include no gossip or personal opinion. ■ Relate recent changes in medications, treatments, procedures, and the discharge plan. ● Telephone reports are useful when contacting the provider or other members of the interprofessional team. ◯ It is important to: ■ Have all the data ready prior to contacting any member of the interprofessional team. ■ Use a professional demeanor. ■ Use exact, relevant, and accurate information. ■ Document the name of the person, the time, content of the message, and the instructions or information received during the report. elephone or Verbal Prescriptions ◯ It is best to avoid these, but they are sometimes necessary during emergencies and at unusual times. ◯ Have a second nurse listen to a telephone prescription. ◯ Repeat it back, making sure to include the medication's name (spell if necessary), dosage, time, and route. ◯ Question any prescription that may seem inappropriate for the client. ◯ Make sure the provider signs the prescription in person within the time frame the facility specifies, typically 24 hr. ● Transfer Reports ◯ These should include demographic information, medical diagnosis, providers, an overview of health status (physical, psychosocial), plan of care, recent progress, any alterations that might become an urgent or emergent situation, directives for any assessments or client care essential within the next few hours, most recent vital signs, medications and last doses, allergies, diet, activity, special equipment or adaptive devices (oxygen, suction, wheelchair), advance directives and resuscitation status, and family involvement in care and health care proxy. ● Incident Reports (Unusual Occurrences) ◯ Incident/variance reports are an important part of a facility's quality improvement plan. ◯ An incident is the occurrence of an accident or an unusual event. Examples of incidents are medication errors, falls, and needlesticks. ◯ Nurses must document the facts without judgment or opinion. ◯ Nurses must not refer to an incident report in the client's medical record. ◯ Incident reports contribute to changes that help improve health care quality.

Grief, Loss, and Palliative Care: Therapeutic Communication with a Client Who Is Grieving (36)

Clarifying - Question clients about specific details in greater depth or directing them toward relevant parts of the history. ☐ Back channeling - Use active listening phrases such as "Go on" and "Tell me more" to convey interest and to prompt disclosure of the entire story. ☐ Probing - Ask more open-ended questions such as "What else would you like to add to that?" to help obtain comprehensive information. ☐ Closed-ended questions - Ask questions that require yes or no answers to clarify information, such as "Do you have any pain when you cannot sleep?" ■ Summarizing - Validate the accuracy of the story. ● Avoid using medical jargon, giving advice, ignoring feelings, and offering false reassurance.Types of Loss NECESSARY LOSS › This is a loss related to a change that is part of the cycle of life that is anticipated but still may be intensely felt. This type of loss can be replaced by something different or better. ACTUAL LOSS › This is any loss of a valued person, item, or status, such as loss of a job. PERCEIVED LOSS › This is any loss defined by the client that is not obvious or verifiable to others. MATURATIONAL OR DEVELOPMENTAL LOSS › This is any loss normally expected due to the developmental processing of life. These losses are associated with normal life transitions and help to develop coping skills. SITUATIONAL LOSS › This is any unanticipated loss caused by an external event. Theories of Grief ● Kübler-Ross: Five Stages of Grief ◯ Denial - The client has difficulty believing a terminal diagnosis or loss. ◯ Anger - The client lashes out at other people or things. ◯ Bargaining - The client negotiates for more time or a cure. ◯ Depression - The client is overwhelmingly saddened over the inability to change the situation. ◯ Acceptance - The client acknowledges what is happening and plans for the future. ◯ Stages may not be experienced in order, and the length of each stage varies from person to person. MANIFESTATIONS OF GRIEF REACTIONS Normal grief › This grief is considered uncomplicated. › Emotions may be negative, such as anger, resentment, withdrawal, hopelessness, and guilt but should change to acceptance with time. › Some acceptance should be evident by 6 months after the loss. › Somatic complaints can include chest pain, palpitations, headaches, nausea, changes in sleep patterns, and fatigue. Anticipatory grief › This grief implies the "letting go" of an object or person before the loss, as in a terminal illness. › Individuals have the opportunity to start the grieving process before the actual loss. Complicated grief (unresolved or chronic grief is a type of complicated grief) › This grief involves difficult progression through the expected stages of grief. › Usually, the work of grief is prolonged, the manifestations of grief are more severe, and they may result in depression or exacerbate a preexisting disorder. › The client may develop suicidal ideation, intense feelings of guilt, and lowered self-esteem. › Somatic complaints persist for an extended period of time. Disenfranchised grief › This grief entails an experienced loss that cannot be publicly shared or is not socially acceptable, such as suicide.

Nasogastric Intubation and Enteral Feedings: Identifying a Complication (54)

Complications ◯ Excoriation of nares and stomach ■ Apply lubricant to the nares as needed. ■ Assess the color of the drainage. Report dark, "coffee-ground," or blood-streaked drainage immediately. ■ Consider switching the tube to the other naris. ◯ Discomfort ■ Rinse the mouth with water for dryness. ■ Throat lozenges may help. ■ Provide oral hygiene frequently. ◯ Occlusion of the NG tube leading to distention ■ Irrigate the tube per facility protocol to unclog blockages. Use tap water with enteral feedings. Have the client change position in case the tube is against the stomach wall. ■ Verify that suction equipment functions properly.

Rest and Sleep: Stress Relief (RM Fundamentals 8.0 Chp 38

Common Sleep Disorders ◯ Insomnia, the most common sleep disorder, is the inability to get an adequate amount of sleep and to feel rested. It might mean difficulty falling asleep, difficulty staying asleep, awakening too early, or not getting refreshing sleep. Acute insomnia lasts a few days and may be due to personal stressors. Chronic insomnia lasts a month or more. Some people have intermittent insomnia, sleeping well for a few days and then having insomnia for a few days. Women and older adults are more prone to insomnia. ◯ Sleep apnea is more than five breathing cessations lasting longer than 10 seconds per hour during sleep, resulting in decreased arterial oxygen saturation levels. Sleep apnea can be a single disorder or a mixture of the following: ■ Central - central nervous system dysfunction that fails to trigger breathing during sleep. ■ Obstructive - structures in the mouth and throat occlude the upper airway. ◯ Narcolepsy - sudden attacks of sleep during waking hours. It often happens at inappropriate times and increases the risk for injury. Nursing Interventions ● Help clients establish and follow a bedtime routine. ● Limit waking clients during the night. ● Help with personal hygiene needs or a back rub prior to sleep to increase comfort. ● Instruct clients to: ◯ Exercise regularly at least 2 hr before bedtime. ◯ Arrange the sleep environment for comfort. ◯ Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime. ◯ Limit fluids 2 to 4 hr before bedtime. ◯ Engage in muscle relaxation if anxious or stressed. ● Instruct clients with narcolepsy to: ◯ Exercise regularly. ◯ Eat small meals that are high in protein. ◯ Avoid activities that increase sleepiness (sitting too long, warm environments, drinking alcohol). ◯ Avoid activities that would cause injury should the client fall asleep (driving, heights). ◯ Take naps when drowsy or when narcoleptic events are likely. ◯ Take stimulants the provider prescribes. ● Consider continuous positive airway pressure (CPAP) devices for clients who have sleep apnea. ● Consult the provider about trying sleep-promoting, over-the-counter products (melatonin, valerian, chamomile). ● As a last resort, suggest that the provider prescribe a pharmacological agent. Medications of choice for insomnia are benzodiazepine-like medications, which include the sedative-hypnotics zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata).

Bowel Elimination: Skin Care for a Client Who Has Incontinence

If you are caring for a patient who is incontinent, provide perineal care frequently to help prevent skin breakdown and infection. The procedure is the same as it is for routine perineal care with one difference: After you have washed, rinsed, and dried the perineal area, apply a cream or ointment on the perineum and surrounding skin as prescribed to act as a barrier that will help protect the patient's skin.

Mobility and Immobility: Application of Antiembolitic Stockings by Assistive Personnel (RM Fundamentals 8.0 Chp 40,

ED hose ◯ Equipment ■ Tape measure ■ TED hose ◯ Procedure ■ Perform hand hygiene. ■ Assess skin and circulation in the legs. ■ Measure the calf and/or thigh circumference and the length of the leg to select the correct size stocking. ■ Turn the stockings inside to the heel. ■ Put the stocking on the foot. ■ Pull the remainder of the stocking over the heel and up the leg. ■ Smooth any creases or wrinkles. ■ Remove the stockings and reapply them at least twice a day. ■ Make sure the stockings are not too tight over the toes. ■ Keep the stockings clean and dry. Clients who are postoperative or have special needs may need a second pair of hose. ■ Document the application and removal of the stockings.

Measures to Relieve Constipation

Encourage exercise and a diet high in fiber (25 g/day for women and 38 g/day for men), and promote adequate fluid intake to help alleviate symptoms. If caused from medication, a change in the medication may be required.

Bowel Elimination: Skin Care for a Client Who Has Incontinence (43) OSTOMY CARE

Equipment › Pouch system (skin barrier and pouch) › Pouch closure clamp › Barrier pastes (optional) › Gloves › Washcloths › Towel › Warm water › Scissors › Pen Procedure › If a wound ostomy continence nurse is not available, educate the client about stoma care. › Perform hand hygiene. › Put on gloves. › Remove the pouch from the stoma. › Inspect the stoma. It should appear moist, shiny, and pink. The peristomal area should be intact, and the skin should appear healthy. › Use mild soap and water to cleanse the skin, then dry it gently and completely. Moisturizing soaps can interfere with adherence of the pouch. › Apply paste if necessary. › Measure and draw where to cut the skin barrier, allowing only the stoma to appear through the opening. › Cut the opening in the skin barrier. › If necessary, apply barrier pastes to creases. › Apply the skin barrier and pouch. › Fold the bottom of the pouch and place the closure clamp on the pouch. › Dispose of the used pouch. Remove the gloves and perform hand hygiene.

Client Safety: Priority Action for Fire (12)

Fire Safety ● Fires in health care facilities are usually due to problems related to electrical or anesthetic equipment. Unauthorized smoking also may be the cause of a fire. ● All staff must be instructed in fire response procedures, which includes the following: ◯ Knowing the location of exits, alarms, fire extinguishers, and oxygen turn-off valves ◯ Ensuring fire doors are not blocked with equipment ◯ Knowing the evacuation plan for the unit and facility ● The fire response in the health care setting always follows this sequence (RACE): ◯ R - Rescue: Rescue and protect clients in close proximity to the fire by evacuating them to a safer location. Ambulatory clients can walk unattended to a safe location. ◯ A - Alarm: Activate the facility alarm system, and then report fire details and location per facility protocol. ◯ C - Contain: Contain the fire by closing doors and windows as well as turning off any sources of oxygen and electrical devices. Clients who are on life support are ventilated with a bag-valve mask. ◯ E - Extinguish: Extinguish the fire if possible using an appropriate fire extinguisher. ■ There are three classes of fire extinguisher: ☐ Class A is for paper, wood, upholstery, rags, or other types of trash fires. ☐ Class B is for flammable liquids and gas fires. ☐ Class C is for electrical fires. ■ To use a fire extinguisher, use the PASS sequence: ☐ P - Pull the pin. ☐ A - Aim at the base of the fire. ☐ S - Squeeze the levers. ☐ S - Sweep the extinguisher from side to side, covering the area of the fire.

Sensory Perception: Caring for a Client Who Has Hearing Loss (45) (459)

Hearing loss is difficulty in hearing or accurately interpreting speech and other sounds due to a problem in the middle or inner ear. ◯ Conductive hearing loss is an alteration in the middle ear that blocks sound waves before they reach the inner ear. ◯ Sensorineural hearing loss is an alteration in the inner ear that involves cranial nerve VIII or cochlear damage. ● Advise clients to not place any objects in the ear, including cotton-tipped swabs. ● Tell clients to have an otologist remove any object lodged in the ear. Use a commercial ceruminolytic (ear drops that soften cerumen) for impactions, and follow with warm-water irrigation. ● Instruct clients to wear ear protection during exposure to high-intensity noise and risk for ear trauma. ● Tell clients to blow the nose gently and with both nostrils unobstructed. ● Advise clients when wearing headphones, keep the volume as low as possible. Patient-Centered Care ● Nursing Care ◯ Monitor functional ability. ◯ Communication ■ Get the client's attention before speaking. ■ Stand or sit facing the client in a well-lit, quiet room without distractions. ■ Speak clearly and slowly without shouting and without hands or other objects covering the mouth. ■ Arrange for communication assistance (sign language interpreter, closed-captions, phone amplifiers, teletypewriter [TTY] capabilities).heck the hearing of clients receiving ototoxic medications for more than 5 days. Reduced renal function that occurs with aging increases the risk for ototoxicity. Ototoxic medications include the following: ■ Multiple antibiotics - gentamicin (Garamycin), amikacin (Amikin), metronidazole (Flagyl) ■ Diuretics - furosemide (Lasix) ■ NSAIDs - aspirin, ibuprofen (Advil) ■ Chemotherapeutic agents - cisplatin (Abiplatin) ● Teamwork and Collaboration ◯ Refer clients with audiometry findings to an audiologist for more sensitive testing. ● Therapeutic Procedures ◯ Hearing aids ■ Hearing aids amplify sounds, but do not help clients interpret what they hear. ■ Amplification of sound in a loud environment can be distracting and disturbing. ◯ Nursing Actions ■ Use the lowest setting that allows hearing without feedback noise. ■ To clean the ear mold, use mild soap and water while keeping the hearing aid dry. ■ When the hearing aid is not in use, make sure to turn it off or remove the batteries to conserve battery power. Keep replacement batteries on hand. ● Surgical Interventions ◯ Tympanoplasty/myringoplasty - conductive hearing loss ■ Tympanoplasty is a surgical reconstruction of the middle ear structures; myringoplasty is an eardrum repair. ■ Nursing Actions ☐ Place sterile ear packing postoperatively. ☐ Position the client flat with the operative ear facing up for 12 hr. ■ Client Education ☐ Tell the client to avoid air travel and forceful straining, coughing, or sneezing with the mouth closed. ☐ Teach the client to cover the ear with a dressing to wash the hair and not to allow water to enter the ear. ☐ Remind the client that hearing will be impaired while packing is in the ear.

Pharmacokinetics and Routes of Administration: Proper Use of a Metered-Dose Inhaler (RM Fundamentals 8.0 Chp 46,

Inhalation - administered through metered dose inhalers (MDI) or dry powder inhalers (DPI) › For an MDI, instruct the client to: » Remove the cap from the inhaler mouthpiece. » Shake the inhaler five or six times. » Hold the inhaler with the mouthpiece at the bottom. » Hold the inhaler with the thumb near the mouthpiece and the index and middle fingers at the top. » Hold the inhaler about 2 to 4 cm (0.8 to 1.6 in) away from the front of the mouth or close the mouth around the mouthpiece of the inhaler with the opening pointing towards the back of the throat. » Take a deep breath and then exhale. » Tilt the head back slightly, press the inhaler, and, at the same time, begin a slow, deep breath. Continue to breathe slowly and deeply for 3 to 5 seconds to facilitate delivery to the air passages. » Hold the breath for 10 seconds to allow the medication to deposit in the airways. » Take the inhaler out of the mouth and slowly exhale through pursed lips. » Resume normal breathing. › A spacer may be used to keep the medication in the device longer thereby increasing the amount of medication delivered to the lungs and decreasing the amount of the medication in the oropharynx. › If a spacer is used: » Remove the covers from the mouthpieces of the inhaler and of the spacer. » Insert the MDI into the end of the spacer. » Shake the inhaler five or six times. » Exhale completely, then close the mouth around the spacer mouthpiece. Continue as with an MDI. › For a DPI: » Do not shake the device. » Take the cover off the mouthpiece. » Follow the directions of the manufacturer for preparing the medication, such as turning the wheel of the inhaler. » Exhale completely. » Place the mouthpiece between lips and take a deep breath through the mouth. » Hold the breath for 5 to 10 seconds » Take the inhaler out of the mouth and slowly exhale through pursed lips. » Resume normal breathing. › If more than one puff is prescribed, instruct the client to wait the length of time directed before administering the second puff. › Instruct the client to remove the canister and rinse the inhaler, cap, and spacer once a day with warm running water and dry it completely before using it again.

Home Safety: Planning Home Safety for an Older Adult Client Who Has Vision Loss (13)

Modifications that can be made to improve home safety include: ☐ Removing items that could cause the client to trip, such as throw rugs and loose carpets. ☐ Placing electrical cords and extension cords that against a wall behind furniture. ☐ Monitoring gait and balance, and providing aids as needed. ☐ Making sure that steps and sidewalks are in good repair. ☐ Placing grab bars near the toilet and in the tub or shower, and installing a stool riser. ☐ Using a nonskid mat in the tub or shower. ☐ Placing a shower chair in the shower and bedside commode if needed. ☐ Ensuring that lighting is adequate both inside and outside of the home. Factors that contribute to loss of vision include presbyopia, cataracts, glaucoma, diabetic retinopathy, macular degeneration, infection, inflammation, injury, and brain tumor. Vision impairment • Call clients by name before approaching to avoid startling them. • Identify yourself. • Stay within the clients' visual field if they have a partial loss. • Give specific information about the location of items or areas of the building. • Explain interventions before touching clients. • Before leaving, inform clients of your departure. • Carefully appraise clothing and suggest changes if soiled or torn. • Make a radio, television, compact disc (CD) player, or digital audio file player available. Describe the arrangement of the food on the tray before leaving the room. clock

Nasogastric Intubation and Enteral Feedings: Priority Action for Nasogastric Tube Insertion watch the video

Nasogastric Intubation ● An NG tube is a hollow, flexible, cylindrical device inserted through the nasopharynx into the stomach. ● Indications ◯ Decompression ■ Removal of gases or stomach contents to relieve distention, nausea, or vomiting ■ Tube types - Salem sump, Miller-Abbott, Levin ◯ Feeding ■ Alternative to oral route for administering nutritional supplements ■ Tube types - Duo, Levin, Dobhoff ◯ Lavage ■ Washing out the stomach to treat active bleeding, ingestion of poison, gastric dilation ■ Tube types - Ewald, Levin, Salem sump ◯ Compression ■ Applied pressure using an internal balloon to prevent hemorrhage ■ Tube type - Sengstaken-Blakemore Nursing Actions ■ The insertion and maintenance of a nasogastric tube is a nursing responsibility, but measuring output, providing comfort, and giving oral care can be delegated. ■ Removal is done wearing clean gloves. ☐ Inform the client of the prescription and process, emphasizing that removal is less stressful than placement. ☐ Measure and record any drainage, assessing it for color, consistency, and odor. ☐ Ensure comfort. ☐ Document all relevant information. X Tubing removal and condition of the tube X Volume and description of the drainage X Abdominal assessment, including inspection, auscultation, percussion X Last and next bowel movement and urine output

Urinary Elimination: Inserting an Indwelling Urinary Catheter for a Female Client (RM Fundamentals 8.0 Chp 44

Nursing Actions ◯ Don the required personal protective equipment. ◯ Assist the client to high-Fowler's or Fowler's position for suctioning if possible. ◯ Encourage the client to breathe deeply and cough in an attempt to clear the secretions without artificial suction. ◯ Obtain baseline breath sounds and vital signs, including SaO2 by pulse oximeter. May monitor SaO2 continually during the procedure. ◯ For oropharyngeal suctioning, use a Yankauer or tonsil-tipped rigid suction catheter and move the catheter around the mouth, gum line, and pharynx. ◯ For nasopharyngeal and nasotracheal suctioning, use a flexible catheter and lubricate the distal 6 to 8 cm (2 to 3 in) with water-soluble lubricant. ◯ For endotracheal suctioning, use a suction catheter with an outer diameter of no more than 1 cm (0.5 in) of the internal diameter of the endotracheal tube. ■ Hyperoxygenate the client using a bag-valve-mask (BVM) or specialized ventilator function with an FiO2 of 100%. ◯ Use medical asepsis for suctioning the mouth. ◯ Use surgical asepsis for all other types of suctioning. ◯ Use suction pressure no higher than 120 to 150 mm Hg. ◯ Limit each suction attempt to no longer than 10 to 15 seconds to avoid hypoxemia and the vagal response. Limit suctioning to two to three attempts. ◯ Additional guidelines for nasopharyngeal and nasotracheal suctioning ■ Insert the catheter into the naris during inhalation. ■ Do not apply suction while inserting the catheter. ■ Follow the natural course of the naris and slightly slant the catheter downward while advancing it. ■ Advance the catheter the approximate distance from the tip of the nose to the base of the earlobe. ■ Apply suction intermittently by covering and releasing the suction port with the thumb for 10 to 15 seconds. ■ Apply suction only while withdrawing the catheter and rotating it with the thumb and forefinger. ■ Do not perform more than two passes with the catheter. Allow at least 1 min between passes for ventilation and oxygenation. ◯ Additional guidelines for endotracheal suctioning ■ Remove the bag or ventilator from the tracheostomy or endotracheal tube and insert the catheter into the lumen of the airway. Advance the catheter until resistance is met. The catheter should reach the level of the carina (location of bifurcation into the mainstem bronchi). ■ Pull the catheter back 1 cm (0.4 in) prior to applying suction to prevent mucosal damage. ■ Apply suction intermittently by covering and releasing the suction port with the thumb for 10 to 15 seconds. ■ Apply suction only while withdrawing the catheter and rotating it with the thumb and forefinger. ■ Reattach the BVM or ventilator and administer 100% oxygen. ■ Do not reuse the suction catheter.

Therapeutic Communication with a Client Who Is Grieving (36)

Nursing Interventions ● Facilitate Mourning ◯ Grant time for the grieving process. ◯ Identify expected grieving behaviors, such as crying, somatic manifestations, and anxiety. ◯ Use therapeutic communication. Name the emotion the client is feeling. For example, the nurse can say, "You sound as though you are angry. Anger is a normal feeling for someone who has lost a loved one. Tell me about how you are feeling." ◯ Avoid communication that inhibits the open expression of feelings, such as offering false reassurance, giving advice, changing the subject, and taking the focus away from the grieving individual. ◯ Assist the grieving individual to accept the reality of the loss. ◯ Support efforts to "move on" in the face of the loss. ◯ Encourage the building of new relationships. ◯ Provide continuing support; encourage the support of family and friends. ◯ Assess for evidence of ineffective coping, such as refusing to leave the home months after the client's spouse died. ◯ Share information about mourning and grieving with the client, who may not realize that feelings, such as anger toward the deceased, are expected. ◯ Encourage attendance at bereavement or grief support groups. Provide information about available community resources. ◯ Initiate referrals for individual psychotherapy for clients who have difficulty resolving grief. ◯ Ask the client whether contacting a spiritual advisor would be acceptable, or encourage the client to do so. ◯ Participate in debriefing provided by professional grief and mental health counselors.

Setting Up a Sterile Field for a Sterile Dressing Change When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse A. keep the sterile field at least 6 ft away from the client's bedside. B. instruct the client to refrain from coughing and sneezing during the dressing change. C. place a mask on the client to limit the spread of micro-organisms into the surgical wound. D. keep a box of facial tissues nearby for the client to use during the dressing change.

Placing a mask on the client prevents contamination of the surgical wound during the dressing change. Pouring the solution (without splashing) onto the dressing or site without touching the bottle to the site. Check that all sterile packages (additional dressings, sterile bowl, sterile gloves, and solution) are dry and have a future expiration date. Any chemical tape must show the appropriate color change.

Medical and Surgical Asepsis: Setting Up a Sterile Field for a Sterile Dressing Change (10)

Practices that Maintain a Sterile Field ● Prolonged exposure to airborne micro-organisms can make sterile items nonsterile. ◯ Avoid coughing, sneezing, and talking directly over a sterile field. ◯ Advise clients to avoid sudden movements, refrain from touching supplies, and avoid coughing, sneezing, or talking over a sterile field. ● Only sterile items may be in a sterile field. ◯ The outer wrappings and 1-inch edges of packaging that contains sterile items are not sterile. The inner surface of the sterile drape or kit, except for that 1-inch border around the edges, is the sterile field to which other sterile items may be added. To position the field on the table surface, grasp the 1-inch border before donning sterile gloves. Discard any object that comes into contact with the 1-inch border. ◯ Touch sterile materials only with sterile gloves. ◯ Consider any object held below the waist or above the chest contaminated. ◯ Sterile materials may touch other sterile surfaces or materials; however, contact with nonsterile materials at any time contaminates a sterile area, no matter how short the contact. ● Microbes can move by gravity from a nonsterile item to a sterile item. ◯ Do not reach across or above a sterile field. ◯ Do not turn your back on a sterile field. ◯ Hold items to add to a sterile field at a minimum of 6 inches above the field. ● Any sterile, nonwaterproof wrapper that comes in contact with moisture becomes nonsterile by a wicking action that allows microbes to travel rapidly from a nonsterile surface to the sterile surface. ◯ Keep all surfaces dry. ◯ Discard any sterile packages that are torn, punctured, or wet. Nursing Interventions ● Equipment ◯ Select a clean area above waist level in the client's environment (a bedside stand) to set up the sterile field. ◯ Check that all sterile packages (additional dressings, sterile bowl, sterile gloves, and solution) are dry and have a future expiration date. Any chemical tape must show the appropriate color change. ◯ Make sure an appropriate waste receptacle is nearby. ● Procedure ◯ Perform hand hygiene. ◯ Open the covering of the package per the manufacturer's directions, slipping the package onto the center of the workspace with the top flap of the wrapper opening away from the body. ◯ Grasp the tip of the top flap of the package, and with arm positioned away from the sterile field, unfold the top flap away from body. ◯ Next, open the side flaps, using the right hand for the right flap and the left hand for the left flap. ◯ Grasp the last flap, and turn it down toward the body. ◯ Additional sterile packages ■ Open next to the sterile field by holding the bottom edge with one hand and pulling back on the top flap with the other hand. Place the packages that will be used last furthest from the sterile field, and open these first. ■ Add them directly to the sterile field. Lift the package from the dry surface, holding it 15 cm (6 in) above the sterile field, pulling the two surfaces apart, and dropping it onto the sterile field. ◯ Pour sterile solutions by: ■ Removing the bottle cap. ■ Placing the bottle cap face up on a clean (nonsterile) surface. ■ Holding the bottle with the label in the palm of the hand so that the solution does not run down the label. ■ First pouring a small amount (1 to 2 mL) of the solution into an available receptacle. ■ Pouring the solution (without splashing) onto the dressing or site without touching the bottle to the site. ◯ Once the sterile field is set up, don sterile gloves. ◯ Sterile gloving includes opening the wrapper and handling only the outside of the wrapper. Don gloves by using the following steps. ■ With the cuff side pointing toward the body, use the nondominant hand and pick up the dominant-hand glove by grasping the folded bottom edge of the cuff and lifting it up and away from the wrapper. ■ While picking up the edge of the cuff, pull the dominant glove onto the hand. ■ With the sterile dominant-gloved hand, place the fingers of the dominant hand inside the cuff of the nondominant glove, lifting it off the wrapper, and put the nondominant hand into it. ■ When both hands are gloved, adjust the fingers. ■ During that time, only a sterile gloved hand may touch the other sterile gloved hand. ■ At the close of the sterile procedure, or if the gloves tear, remove the gloves. Take them off by grasping the outer part of one glove at the wrist, pulling the glove down over the fingers and into the hand that is still gloved. Then, place the ungloved hand inside the soiled glove and pull the glove off so that it is inside out and only the clean inside part is exposed. Discard into an appropriate receptacle.

Therapeutic Communication: Responding to a Client Who Has a Terminal Diagnosis (32)

Silence › Silence allows time for meaningful reflection. Active listening › The nurse is able to hear, observe, and understand what the client communicates and provide feedback. Open-ended questions › This technique facilitates spontaneous responses and interactive discussion. Allows the client to explore feelings and thoughts. Avoids yes/no answers. Clarifying techniques › This technique is used to determine whether the message received was accurate: » Restating - Uses the client's exact words » Reflecting - Directs the focus back to the client in order for the client to examine his feelings » Paraphrasing - Restates the client's feelings and thoughts for the client to confirm what has been communicated » Exploring - Allows the nurse to gather more information regarding important topics mentioned by the client Offering general leads, broad opening statements › This encourages the client to start and to continue talking. Showing acceptance and recognition › This technique acknowledges the nurse's interest and nonjudgmental attitude. Focusing › This technique helps the client concentrate on what is important. Asking questions › Asking questions is a way to seek additional information. Giving information › This technique provides details that the client may need for decision-making. Presenting reality › This technique is used to help the client focus on what is actually happening and to dispel delusions, hallucinations, or faulty beliefs. Summarizing › This technique emphasizes important points and reviews what has been discussed. Offering self › This technique demonstrates a willingness to spend time with the client. Limited personal information may be shared, but the focus should return to the client as soon as possible. Relevant self-disclosure by the nurse allows the client to see that his experience is shared by others and understood. Touch › If appropriate, touch may communicate caring and provide comfort.

Therapeutic Communication: Encouraging a Client to Express Feelings (32)

The nurse uses interactive, purposeful communication skills to ◯ Elicit and attend to the client's thoughts, feelings, concerns, and needs. ◯ Express empathy and genuine concern for the client and the family's issues. ◯ Obtain information and give feedback about the client's condition. ◯ Intervene to promote functional behavior and effective interpersonal relationships. ◯ Evaluate the client's progress toward desired goals and outcomes. ● Children and older adults frequently require altered techniques to enhance communication. ● Use of the nursing process depends on therapeutic communication between the nurse, client/family/ significant other, and the interprofessional health care team. ● Characteristics of Therapeutic Communication ◯ Client-centered - Not social or reciprocal ◯ Purposeful, planned, and goal-directed Essential Components of Therapeutic Communication ◯ Time - Plan for and allow adequate time to communicate with others. ◯ Attentive behaviors or active listening - A means of conveying interest, trust, and acceptance. ◯ Caring attitude - Show concern and facilitate an emotional connection and support between the nurse and the client/family/significant other. ◯ Honesty - Be open, direct, truthful, and sincere. ◯ Trust - Demonstrate to the client/family/significant other that they can rely on the nurse without doubt, question, or judgment. ◯ Empathy - Convey an objective awareness and understanding of the feelings, emotions, and behaviors of the client/family/significant other, including trying to envision what it must be like to be in the client/family/significant other's position. ◯ Nonjudgmental attitude - A display of acceptance of the client/family/significant other will encourage open, honest communication.

Conducting a Client-Centered Interview

Therapeutic communication helps develop rapport with clients. The techniques encourage a trusting relationship, whereby clients feel comfortable telling their stories. Begin with the purpose of the interview, gather information, and then conclude the interview by summarizing the findings. Introduce yourself and the various parts of the assessment. Determine what the client wants you to call them. Allow more time for responses from older adults. Make sure the client is comfortable (room temperature, chair). When possible, start by asking for the health history, performing the general survey, and measuring vital signs to build rapport prior to moving on to more sensitive parts of the examination. Reduce environmental noises (TV, radio, visitors talking) to enhance communication and eliminate distractions. Ensure understanding by obtaining interpretive services for clients who have language or other communication barriers. Use therapeutic communication techniques including: Active listening - Shows clients that they have your undivided attention. Open-ended questions - Use initially to encourage clients to tell their story in their own way. Use terminology clients can understand. Clarifying - Question clients about specific details in greater depth or directing them toward relevant parts of the history. Back channeling - Use active listening phrases such as "Go on" and "Tell me more" to convey interest and to prompt disclosure of the entire story. Probing - Ask more open-ended questions such as "What else would you like to add to that?" to help obtain comprehensive information. Closed-ended questions - Ask questions that require yes or no answers to clarify information, such as "Do you have any pain when you cannot sleep?" Summarizing - Validate the accuracy of the story. Avoid using medical jargon, giving advice, ignoring feelings, and offering false reassurance.

Mobility and Immobility: Positioning a Client for Promotion of Venous Return (10)

Trendelenburg position › The entire bed is tilted with the head of the bed lower than the foot of the bed. › This position is used during postural drainage, and it facilitates venous retur

Sources of Nutrition: Nutrients That Enhance Wound Healing (RM Nutrition 5.0 Chp 1

Water-Soluble Vitamins ◯ Vitamin C (ascorbic acid) aids in tissue building and metabolic reactions (wound and fracture healing, collagen formation, adrenaline production, iron absorption, conversion of folic acid, cellular adhesion). ■ Vitamin C is found in citrus fruits (oranges, lemons), tomatoes, peppers, green leafy vegetables, and strawberries. ■ Stress and illness increase the need for vitamin C. ■ Severe deficiency causes scurvy, a hemorrhagic disease with diffuse tissue bleeding, painful limbs/joints, weak bones, and swollen gums/loose teeth. ◯ B-complex vitamins have many functions in cell metabolism. Each one has a varied duty. Many partner with other B vitamins for metabolic reactions. Most affect energy, metabolism, and neurological function. Sources for B vitamins almost always include green leafy vegetables and unprocessed or enriched grains. ■ Thiamin (B1) is necessary for proper digestion, peristalsis, and providing energy to the smooth muscles, glands, the CNS, and blood vessels. ☐ Deficiency results in beriberi, gastrointestinal findings, and cardiovascular problems. ☐ Food sources are widespread in almost all plant and animal tissues, especially meats, grains, and legumes. ■ Riboflavin (B2) is required for growth and tissue healing. ☐ Deficiency results in cheilosis (manifestations include scales and cracks on lips and mouth), smooth/swollen red tongue, and dermatitis particularly in skin folds. ☐ Dietary sources include milk, meats, and green leafy vegetables.

older Adults (65 Years and Older): Reinforcing Teaching About Walker Use (25)

size: wrists even with hand grips when arms dangling down 1) advance walker 12 inch 2) advance affected leg 3) move unaffected leg 4) repeat

Data Collection and General Survey: Conducting a Client-Centered Interview (26)

• Standardized formats are a framework for obtaining information about clients' physical, developmental, emotional, intellectual, social, and spiritual dimensions. • Therapeutic techniques for health assessment foster communication and create an environment conducive to an optimal health assessment experience. • Therapeutic communication helps develop rapport with clients. The techniques encourage a trusting relationship, whereby clients feel comfortable telling their stories. Begin with the purpose of the interview, gather information, and then conclude the interview by summarizing the findings. • The general survey is a written summary of impressions of overall health. Gather this information from the first encounter with the client and continue to make observations throughout the assessment process.

Nutrition and Oral Hydration: Priority Findings for an Older Adult Client (RM Fundamentals 8.0 Chp 39 do question

› A slower metabolic rate requires fewer calories. › Thirst sensations diminish. › Older adults need the same amount of most vitamins and minerals as younger adults. › Calcium may be necessary and is important for both men and women. › Many older adults require carbohydrates that provide fiber and bulk to enhance gastrointestinal function.

Middle Adults (35 to 65 Years): Evaluating Understanding of Perimenopause (24)

■ Women - Symptoms of menopause can represent a: ☐ Loss of the reproductive role or femininity ☐ New interest in intimacy

Safe Medication Administration and Error Reduction: Refusal of Medication (Chp 47)

● *Medication refusal - Clients have the right to refuse a medication. Determine the reason for refusal, provide information regarding the risk of refusal, notify appropriate health care personnel, and document the refusal and actions taken.*

Airway Management: Measuring Arterial Oxygen Saturation (RM Fundamentals 8.0 Chp 53,

● A pulse oximeter is a device with a sensor probe that attaches securely to the fingertip, toe, bridge of nose, earlobe, or forehead with a clip or band. ● A pulse oximeter measures pulse saturation (SpO2) via a wave of infrared light that measures light absorption by oxygenated and deoxygenated hemoglobin in arterial blood. SpO2 reliably reflects the percent of saturation of hemoglobin (SaO2). ● Oxygen is a tasteless and colorless gas that accounts for 21% of atmospheric air. ● Oxygen flow rates vary to maintain an SpO2 of 95% to 100% using the lowest amount of oxygen to achieve the goal without risking complications. ● The fraction of inspired oxygen (FiO2) is the percentage of oxygen the client receives. Pulse Oximetry ● Noninvasive measurement of the oxygen saturation of the blood for monitoring respiratory status when assessment findings include any of the following: ◯ Increased work of breathing ◯ Wheezing ◯ Coughing ◯ Cyanosis ◯ Changes in respiratory rate or rhythm ◯ Adventitious breath sounds ◯ Restlessness, irritability, confusion

Medication Error Prevention

● Common medication errors -Wrong medication or IV fluid - Incorrect dose or IV rate -Wrong client, route, or time - Administration of known allergic medication -Omission of dose - Incorrect discontinuation of medication or IV fluid

Client Safety: Using Restraints (12)

● In general, seclusion and/or restraints should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient. It is for the physical protection of the client or the protection of other clients or staff. ● A client may voluntarily request temporary seclusion in cases in which the environment is disturbing or seems too stimulating. ● Restraints can be either physical or chemical, such as sedatives and neuroleptic or psychotropic medications to calm the client. ● Seclusion and/or restraint must never be used for the following: ◯ Convenience of the staff ◯ Punishment for the client ◯ Clients who are extremely physically or mentally unstable ◯ Clients who cannot tolerate the decreased stimulation of a seclusion room ● Restraints should ◯ Never interfere with treatment ◯ Restrict movement as little as is necessary to ensure safety ◯ Fit properly and be as discreet as possible ◯ Be easily removed or changed to decrease the chance of injury and to provide for the greatest level of dignity ● When all other less restrictive means have been tried to prevent a client from harming self or others, the following must occur in order for seclusion or restraint to be used: ◯ The treatment must be prescribed by the provider in writing, based on a face-to-face assessment of the client. ■ In an emergency situation in which there is immediate risk to the client or others, the nurse may place a client in restraints. The nurse must obtain a prescription from the provider as soon as possible in accordance with agency policy (usually within 1 hr). ◯ The prescription must include the reason for the restraint, the type of restraint, the location of the restraint, how long the restraint may be used, and the type of behaviors demonstrated by the client that warrant use of the restraint. ◯ The prescription and the renewal are limited to 4 hr for an adult, 2 hr for clients ages 9 to 17, and 1 hr for clients younger than 9 years of age. Prescriptions may be renewed, if needed, with a maximum of 24 consecutive hours. ◯ PRN prescriptions for restraints are not allowed. Nursing responsibilities ■ Assess skin integrity, and provide skin care per facility protocol, usually every 2 hr. ■ Offer food and fluid. ■ Provide with means for hygiene and elimination. ■ Monitor for vital signs. ■ Offer range of motion of extremities. ◯ Always explain the need for the restraint to the client and family, emphasizing that the restraint is needed to ensure the safety of the client and will be used only as long as it is necessary. ◯ Obtain signed consent from client or guardian, if required. ◯ Review the manufacturer's instructions for correct application. ◯ Remove or replace restraints frequently to ensure good circulation to the area and allow for full range of motion to the limb that has been restricted. ◯ Pad bony prominences. ◯ Use a quick-release knot to tie the restraint to the bed frame (loose knots that are easily removed) where it will not tighten when the bed is raised or lowered. ◯ Ensure that the restraint is loose enough for range of motion and with enough room to fit two fingers between the device and the client to prevent injury. ◯ Regularly assess the need for continued use of the restraints to allow for discontinuation of the restraint or limiting the restraint at the earliest possible time while ensuring the client's safety. ◯ Never leave the client unattended without the restraint. ◯ Document ■ Precipitating events and behavior of the client prior to seclusion or restraint ■ Alternative actions taken to avoid seclusion or restraint ■ The time restraints were applied and removed (if discontinued) ■ Type of restraint used and location ■ Client's behavior while restrained ■ Type and frequency of care (range of motion, neurosensory checks, removal, integumentary checks) ■ Condition of the body part being restrained ■ Client's response when the restraint is removed ■ Medication administration ◯ An emergency situation must be present for the nurse to use seclusion or restraints without first obtaining a provider's written prescription. If this treatment is initiated, the nurse must obtain the written prescription within a specified period of time (usually within 1 hr).

Urinary Elimination: Planning Care for a Client Who Has an Iodine Allergy (40)

● Intravenous pyelogram (IVP) - Injecting contrast media (iodine) allows for viewing of ducts, renal pelvis, ureters, bladder, and urethra. Determine whether the client has an allergy to shellfish.

PALLIATIVE CARE (36)

● The nurse serves as an advocate for the client's sense of dignity and self-esteem by providing palliative care at the end of life. ● Palliative care improves the quality of life of clients and their families facing end-of-life issues. ● Palliative care interventions are primarily used when caring for clients who are dying and family members who are grieving. ● Palliative care interventions focus on the relief of physical manifestations such as pain as well as addressing spiritual, emotional, and psychosocial aspects of the client's life. ● Palliative care may be provided by an interprofessional team of physicians, nurses, social workers, physical therapists, massage therapists, occupational therapists, music/art therapists, touch/energy therapists, and chaplains. ● Hospice care is a comprehensive care delivery system implemented when a client is not expected to live longer than 6 months. Further medical care aimed toward a cure is stopped, and the focus becomes enhancing quality of life and supporting the client toward a peaceful and dignified death.

Gastrointestinal Disorders: Measures to Relieve Constipation (15)

◯ Causes include irregular bowel habits, psychogenic factors, inactivity, chronic laxative use or abuse, obstruction, medications, GI disorders such as IBS, pregnancy, or secondary to genital/rectal trauma such sexual abuse or child birth, and inadequate consumption of fiber and fluid. ◯ Encourage exercise and a diet high in fiber (25 g/day for women and 38 g/day for men), and promote adequate fluid intake to help alleviate symptoms. ◯ If caused from medication, a change in the medication may be required. ◯ Nursing Interventions ■ Assess onset and duration of past and present elimination patterns, what is normal for the client, activity levels, occupation, dietary intake, and stress levels. ■ Assess past medical and surgical history, medication use (OTC, herbal supplements, laxatives, enemas, and prescriptions), presence of rectal pressure or fullness, and abdominal pain. ■ Encourage client to gradually increase daily intake of fiber. ■ Advise the client that an increase in fiber intake is the preferred treatment for constipation. Chronic use of laxatives should be avoided.