MCCN 205 Final Exam

making an unoccupied bed

* Loosens soiled linen on both sides of bed and rolls it from head to foot of bed. Removes one piece at a time. Avoids contact with skin or clothes. Places it in a hamper or bag. Linens should not touch hospital floor.

admitting a patient

- a general routine includes initial greeting, proper identification - patient assessment - complete the chart review and note any abnormalities or changes -question the patient concerning valuables, prostheses, and last intake of food and fluid - confirm that the correct drugs were given

factors affecting mobility

- alterations in muscles - injury to the musculoskeletal system - poor posture - impaired central nervous system - health status and age

Enteral feeding complications

- diarrhea - N/V - gas/bloating - constipation - aspiration pneumonia - tube obstruction - hyperglycemia - dehydration

IV therapy complications

- infiltration - phlebitis - cellulitis - thrombosis - local hematoma - sepsis - pulmonary thromboembolus - air bolus - catheter fragment embolus

Nutrition Nursing Diagnoses

-Risk for aspiration -Diarrhea -Deficient knowledge -Readiness for enhanced nutrition -Feeding self-care deficit -Impaired swallowing -Imbalanced Nutrition: -Less than body requirements -More than body requirements Risk for... -outcomes individualized, mutual, address R/T and AEB's ex: emotional stress

standard precautions are

-Wear gloves when collecting and handling blood, bodily fluids or tissue specimen. -Wear face shields when there is is a danger for splashing on mucous membranes. -Dispose of all needles and sharp objects in puncture-proof containers without recapping.

Transferring a patient

-preparation: explain transfer to patient and family, discuss the patients condition and plan of care with the staff of the receiving unit or facility, arrangements for transportation -obtain a set of vital signs, assessment and give report to the person accepting the patient

intermittent parenteral fluid therapy

10-12 hour feeds

IV gauge colors

16g - Gray 18g - Green 20g - Pink 22g - Blue 24g - Yellow 26g - purple (rarely used 16g, 24g, 26g) think: I'd turn green if somebody came at me with an 18g, twenty TWO rhymes with blue, and pink is just the other one

back massage

3-5min helps improve relaxation, comfort, and sleep

sterile field

A work area free of all pathogens and non-pathogens (including spores)

hygiene nursing interventions

ADL help - assist, setup, do it entirely figure out root of self care deficit

nursing process

ADPIE Assessment Diagnosis Planning Implementation Evaluation

independent interventions

Activities that nurses are licensed to initiate on the basis of their knowledge and skills

Carbohydrates

Broken down to glucose to provide energy.

standard precautions

CDC precautions used in the care of all patients regardless of their diagnosis or possible infection status; this category combines universal and body substance precautions

chlorhexidine bath

CHG kills germs reduces spread of infection pre-op helpful in ICU

vitamins

Compounds found in food that help regulate many body processes

minerals

Elements found in food that are used by the body

Airway management

Essential nursing skills that maintain natural or artificial airways for compromised clients

Oxygenation: Children

Eustachian tubes, bronchi, and bronchioles are elongated and less angular

Stages of infection

Incubation period Prodromal stage Full stage of illness Convalescent period

topical medications

Lotions, creams, and ointments that are applied to the surface of the skin and affect only that area; a medication delivery route.

multidrug-resistant organisms (MDROs)

MRSA VRE

subcutaneous medication

Medication injected into the subcutaneous layer, or fatty tissue, of the skin.

Intramuscular medication administration

Needle penetrates through the dermis and subcutaneous tissue and into the muscle layer Allows larger volume of medication Potential to damage nerves

fats

Nutrients that promote normal growth, give you energy, and keep your skin healthy.

proteins

Nutrients the body uses to build and maintain its cells and tissues

PPE

Personal Protective Equipment i.e. gloves, mask, safety glasses and clinical attire

supplemental oxygen therapy

Providing a patient with additional concentration of oxygen to improve oxygen levels in the bloodstream. Oxygen may be provided by a mask or nasal cannula.

Making an Occupied Bed

Raise side rail opposite working side of the bed. Raise second side rail opposite working side of the bed and assist the resident to roll over the bottom linen, preventing trauma and avoid pain to resident.

allergic reaction symptoms

Rash, itching, swelling, SOB due to airway swelling

SBAR

Situation Background Assessment Recommendation

Oral Medications

Solid form: tablets, capsules, pills Liquid form: elixirs, spirits, suspensions, syrups

IV therapy

The delivery of medication directly into a vein.

Medication Order Components

The patient's full name, date of the order, name of the drug preceded by the abbreviation Rx, dosage, route of administration, time and frequency, prescriber's signature (without which the medication order is not legal), number of refills and quantity (preceded by the word repetatur), and the prescriber's DEA number on all prescriptions for controlled substances.

oxygenation

The process of delivering oxygen to the blood by diffusion from the alveoli following inhalation into the lungs.

Perfusion

The supply of oxygen to and removal of wastes from the cells and tissues of the body as a result of the flow of blood through the capillaries.

collaborative interventions

Therapies that require the knowledge, skill, and expertise of multiple health care professionals.

opthalmic medications

a drug given into the eye, in the form of either eye drops or ointment

Otic medications

administered into the ear

isolation precautions

airborne, droplet, contact, and protective environment

enteral nutrition

alternate form of feeding that involves passing a tube into the gastrointestinal tract to allow instillation of the appropriate formula

critical thinking and patient safety

always consider plan of action before dealing with patient adjust plans based on patient response

Healthcare-associated infection (HAI)

an infection acquired within a healthcare setting during the delivery of medical care

chemical restraint

any drug used for discipline or convenience and not required to treat medical symptoms

physical restraint

any method, device, material, or equipment that restricts a person's freedom of movement

Safe Medication Administration

assessment prior and post 3 med checks 6 rights follow policy drug indications, contraindications, and dosing knowledge

discharging a patient

begins at admission proper follow up and medications

6 classes of nutrients

carbohydrates, fats, proteins, vitamins, minerals, water

oral care

care of mouth, teeth and gums. Cleaning the teeth, gums, tongue, inside of mouth and dentures, if used

practices that promote patient safety

checking allergies medication checks, rights patient identifiers environmental survery

medical asepsis

clean technique

Perineal care (peri-care)

cleaning of the perineum and anus, as well as the vulva and the penis

Skin Assessment

color, moisture, temperature, texture, turgor, vascularity, edema, lesions

hair assessment

color, texture, distribution

Principles of Documentation

confidential accurate concise complete objective organized/timely include pt narrative

communicating with patient and family

do not provide false reassurance empathetic, answer questions narrative

Priorities of Scheduled Hygiene Care

early morning care am care - bed bath, oral care, breakfast pm care - bed bath, hair washing, shaving, etc PRN care- perineal care, after meals hs care - relaxation, oral care depends on patient needs/wants, status, and cultural preferences

rectal medications

enema, suppository

water (nutrition)

essential for life, transport substances, maintain body temp, maintains blood volume

personal hygiene assessment

general appearance self reports/ view of self smell greasy hair or skin brushed/not brushed teeth hair done/combed dress appropriate

Droplet precautions ppe

gloves, gown, mask

contact precautions ppe

gown and gloves

Break the chain of infection

hand hygiene!! isolation precautions ppe sanitizing/cleaning

Oxygenation: Older Adults

increased risk for pneumonia, diaphragm moves less efficiently

chain of infection

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

IV infusion

introduction of fluid into a vein

IV intermittent infusion

iv provided during dose and stopped when finished till next dose

KNOD

knock name occupation description

airborne precautions ppe

mask

Medication documentation should include:

medication given must be recorded on the patient's record, along with dose, time, route, location, and any side effects or reactions to the medication

intradermal medication

medication inserted just beneath the epidermis using a syringe and needle

inhaled medications

medications delivered directly to the respiratory tract

patient safety factors

mobility infection mental status HCP compliance and education negligence organizational policies limitations of HCP

factors affecting personal hygiene

mobility mental status

incident reports

never go into patient chart

Reporting unsafe practices

nurses may need to report nursing colleagues or other health professionals for practices that endanger the health and safety of clients chain of command

accessing patient records

only access patient you are caring for

transdermal medications

patches

Types of restraints

physical, chemical, seclusion

Oral cavity assessment

pink, blanched presence of lesions or blood moist, dry

aseptic technique

precautions taken to prevent contamination

Risk for injury

pressure ulcers/skin tears falls substance abuse

nutritional goals

prevention of nutrient deficiencies prevention of infection preventions of complications associated w/enteral or parenteral feedings fluid and electrolyte balance decreased overall morbidity and mortality

Drug Legislation

protects the consumer from false claims made by the drug manufacturer

restraints

require prescription

seclusion restraint

safety checks and documentation every 30min to 1 hr can be requested should last for the shortest duration possible

Hygiene Nursing Diagnosis

self-care deficit

nail assessment

shape and contour, consistency, color, capillary refill

infection nursing dianosis

skin integrity hygiene tissue integrity

bedside report

sometimes known as "walking rounds", allows you to observe patient. Outgoing nurse can introduce you to client and it gives patient opportunity to participate in the report.

surgical asepsis

sterile technique

vaginal medications

suppositories, creams, aerosol, foams, tablets

patient safety

the avoidance and prevention of patient injuries or adverse events resulting from the processes of health care delivery.

venous return

the flow of blood back to the heart pro to mobility and ambulation use gait belt, mobility aids, assists

critical thinking

the objective analysis and evaluation of an issue in order to form a judgment.

problem solving

the process of finding solutions to difficult or complex issues

bed bath

washing with a basin of water at the bedside using wipes hair care assist, total assist, set up, refused