hesi pn fundamentals

Hesi Pn Fundamentals 2021 Handwashing - The single most effective way to stop the spread of infection Medical Asepsis - Reducing the number of organisms in an environment (ex. cleaning the tub with disinfectant before giving a patient a bath) Sterilization - Breaks the chain of infection at its various links of reservoir and the portal exit (removes all organisms) Standard Precautions are? - The principle of infection control that considers every client's blood and body fluid infectious When should you wash your hands? - Between patients and foaming in and out of patient's rooms Why should you hold your hands lower than your forearms while handwashing? - Water flows from the least contaminated to the most contaminated Hand hygiene - Breaks the chain of infection Nosocomial infections - Hospital-acquired infections What are the phases of infection? - Pathogen, reservoir, portal of exit, means of transmission, portal of entry, new host When is a patient most contagious? - Within the first 24 hours and 24 hours after starting medication Wear gown, gloves, and educate the family when? - Caring for a contagious person (ex. C-diff) Standard Precautions - Group of safety measures performed to prevent the transmission of pathogens found in the blood and body fluids (ex. performing hand hygiene, wearing appropriate protective equipment if exposure is possible, and using cough etiquette) Transmission-Based Precautions - Used to prevent the spread of known infection to patients or health care staff and are used when a patient has a communicable illness that can be spread through contact, respiratory droplets, or the air. (Wearing gowns, gloves, masks, eye protection, and possibly head covers are used to prevent transmission of pathogens) Isolation Precautions - Placing an infectious patient in a private room with a private toilet and equipment breaks the chain of infection the portal of exit. All equipment taken into the rooms for use must be left in the room for this patient's use only and sterilized before used for any other patients. Droplet Precautions - Use when in close contact with respiratory or mucous membrane secretions Proper way to remove a gown? - Grasp the neckline to remove Always use what to clean areas that are used by multiple patients? - A disinfectant (ex. bathtub, bedside tables) How often should person cares be done? - A minimum of every morning and evening Morning routine cares include? - Assisting with bath, toileting, oral care, hair care, dressing, bedding HS (Night Cares) include? - Assist to prepare for sleep, assist with toileting, offer fluids if allowed, straighten room, dim lights, back massage How often should oral cares and repositioning be done on an unresponsive patient? - Every 2 hours. When and why should back rubs be given? - Backrubs should be done during skin care to improve venous circulation and promote relaxation (also done before bed and during a bed bath, remember dying patients also) Ted stockings are also called what? - Thromboembolic (antiembolism) stockings What are Ted stockings for? - Prevention of blood clots, reduce swelling, and edema How do Ted stockings work? - They work by providing venous circulation to the heart. Difference between an open and closed bed? - An open bed has sheets turned down and ready to be occupied where a closed bed is fully dressed A bed that has fan-folded sheets to the far side of the bed is for? - Post-operative beds What is the purpose of a footboard? - To prevent foot drop What can we do to reduce friction and shearing in our patients? - Pad and protect bony prominences and other vulnerable areas Abdominal binders are used for what? - Support a patient’s abdomen and sutures after asurgery. Fowlers Position - semi-sitting with various degrees of head elevations (45-60 degrees) Sims Position - left side semi-prone, right leg drawn up to chest, left arm alone patient back (side lying) Prone Position - on stomach with head to side Supine Position - lying on back, arms at side What is the best position for Orthopnea? - Fowler’s position- usually over a bed side table Sheet burns from friction and sheer can be caused when? - When patients are boosted up in bed frequently Best method for applying a pillow case? - Inverting the pillowcase over your hand and pulling down the sides Patients should bear the weight of their body on their hands when using crutches to prevent what? - Brachial Palsy Stair climbing with assistive devices using a 3-point cane or crutch the patient is done safely by? - Stepping up with the good foot and down with the bad foot Always walk on a patient’s side when assisting? - Affected side Always ensure proper alignment of patient body for? - Patients who are bed-ridden when making an occupied bed. What is the difference between passive and active range of motion? - Active range of motion is the patient moving on their own, passive range of motion is someone else moving the part for you Flexion - Movement that decreases the angle between two body parts. Extension - Movement that increases the angle between two body parts. Adduction - Movement towards the midline of the body Pronation - Rotation of the hand and forearm so that the palm faces backwards or downwards. Difference between proximal and distal? - Proximal is closer to the center of the body, distal is further away from the center of the body. When applying a roller bandage, always access what? - Color, warmth, movement, and sensation before and after 15 minutes to asses if too tight. How often should you remove a roller bandage? - Every 4 hours and inspect the skin again for color, warmth, movement, and sensation. Wrap ace bandages starting most distal to the heart to reduce what? - Edema Moisture under a bandage may cause what? - Maceration Maceration - Skin breakdown from moisture If your patient reports anything unusual regarding their dressing or status of wound, what should you do? - Assess the skin True or False? An order is ALWAYS needed for a restraint? - True Serosanguinous - Drainage that is bright red mixed with clear Serous - Bright red drainage Sanguineous - Clear drainage Purulent - Thick yellow or green drainage What type of dressings are often ordered to help debride the wound? - Wet-to-dry dressings Palpation - Uses the sense of touch to evaluate physical signs Percussion - Uses the sense of touch and hearing as examiner taps on an individual body to evaluate location and density of underlying structures. Inspections - Uses the sense of sight to identify specific characteristics of the individual Auscultation - Uses the sense of hearing to listen to body sounds Invasive Procedure - A procedure in which the skin is broken Non-Invasive Procedure - A procedure leaving the skin intact and non-broken What are vital signs? - Temperature, pulse, respiration, blood pressure, oxygen saturation, and pain Normal range for a blood pressure? - 120/80 but less than 140/90 Normal range for pulse? - 60 to 100 bpm Average respiratory rate? - 12 to 20 breaths per minute Average temperature? - 98.6 degrees Fahrenheit If you have a range that is outside of the normal vitals, always do what? - Recheck and assess for conditions such as pain What is systolic pressure? - When the pressure is highest and the heart is contracting What is diastolic pressure? - When the heart is relaxing Why would you not take a blood pressure on an arm with an IV or a mastectomy side? - False reading Where would you take a blood pressure if neither arm is available? - In the thigh of the patient What pulse do you locate prior to taking a blood pressure? - Brachial pulse Orthostatic Hypotension - A drop in 20 or more points with position changes. If the patient complains of feeling light-headed, dizzy, return them to supine position ASAP Where are the main pulse points located? - Femoral- groin area, Radial- wrist, Poplitealbehind the knee, Pedal- top of foot, Apical- below the nipple, Carotid- neck Why is the apical pulse most accurate and where is it located? - It's most accurate because it's basically like listening to the heart. It's located at 4-5 intercostal space Any irregular reading should be taken for how long? - At least 1 full minute What should be assessed with respiratory rate? - Rate per minute, depth, pattern, rhythm, respiratory effort What are Kushal respiration? - Increased rate and depth An incentive spirometer is used for what? - To encourage patients to take deep breaths to help prevent pneumonia. The best time to collect a sputum sample? - Early morning What ways can a temperature be taken? What way is the most accurate? - Oral, axillary, Rectal (Rectal is the most accurate) When checking a person's ear, you use an to assess the condition of the membrane - An Otoscope How do you assess for edema? - Press the area, check if indentation remains How is edema treated? - Elevation, compression stockings, medications What is included in input? - Anything that is liquid at room temperature (record for shift and 24-hour period) What is included in output? - Urine, emesis, blood from wound, nasogastric tube drainage, liquid stools (record for shift and 24-hour period) Any output less than ml/hour is critical value to be reported to an RN/MD. - 30 ml/hour (oliguria) Polyuria - Excessive urination Dysuria - Painful or difficulty urinating Anuria - Absence of urination- very important to report to MD if patient is having kidney troubles Characteristics of bowel obstruction - Many liquid stools, fecal odor, profuse vomiting If a patient cannot void, attempt simple steps like what to assist them? - Turn on running water to assist them When collecting urine specimens, keep them clean as possible by? - Wiping front to back Proper steps for collecting urine sample - Label container and lid before collecting specimen, use bio hazard bag for transport, ensure lab slip is completed correctly. For a catheter urine sample, cleanse the port that is used to obtain the sample with what before collecting? - Alcohol What are different types of stool samples? - Guaiac test is used to detect fecal occult blood, O&P test is used for ovum and parasites, and C&S is to see what microorganism is infecting the stool and the antibiotics that will kill it Enemas should be between what temperatures to prevent thermal injury? - 100-110 degrees Fahrenheit What position should your patient be placed in for an enema? - Left Sims position What is the most important thing to remember when communicating with patients? - Providing privacy- also remember personal space and cultural differences in eye contact Always speak and regardless of language spoken. - Slowly and clearly What is an open-ended question? - A question for clarification to allow understanding of patient’s comments and needs. What is a closed ended question? - Yes or no question- often used in emergency situations Types of therapeutic communication? - Paraphrasing- open-ended such as broad questions that lead and invite the patient to explore thoughts and feelings. Reflectingcan be used to allow the patient to give more information (ex. "My kids have been a series of disappointments" a nurse response: "You sound as though you are disappointed in your kid’s life choices?" Changing the subject when communicating with your patients is an example of what? - A verbal barrier Who can take a verbal order from a doctor? - A licensed nurse What is objective data? - Information you can obtain and measure such as vital signs What is subjective data? - Information your patient reports such as a stomach ache Maslow's Hierarchy of Needs and the purpose from moving from one level to the next: - Physiological, safety, love/belonging, esteem, self-actualization and one must satisfy lower-level basic needs before reaching the highest level of self-actualization Purpose of health promotion and prevention? - Teaching and assisting patients to manage diseases and risk factors such as diabetes and weight management What is the difference between clinical and biological death? - Clinical death is the stoppage of heartbeat, pulse, and breathing and biological death is caused by degeneration of tissues in the brain and other parts. Who can pronounce someone dead? - RN's and Doctors Fixed and dilated pupils are indicative of what? - Being brain dead When would an autopsy need to be performed? - When the reason for death may be an undiagnosed medical condition, questions about an unexpected death due to natural causes, concerns of genetic diseases or conditions, when death occurs unexpectedly during a medical procedure, when the cause of death could affect legal matters, and when death occurs during an experimental treatment What is Hospice Care? - For patients in final 6 months of life, patient and family have a voice in directing care, provide patient and family support, doesn't cure or stop terminal illness, patient comfort and dignity, prevent needless suffering, assist to live life to the fullest, relieve fear and anxiety as death nears What is Palliative Care? - Physician ordered, prognosis may be more than 6 months, incorporates comfort measures and other therapy to decrease symptoms, may include aggressive interventions such as chemo, surgery, radiation- not curative purposes but relieves unpleasant symptoms Detachment - Final stages of dying What are advanced directives? - End of life decisions such as wishes about care and treatment if they become terminally ill. What are resuscitation orders and when should they be checked? - A patient may have a DNR order in place to not resuscitate them. They should be checked when a patient has a change in respiratory status Who is responsible for checking a DNR order? - The nurse A DNR order should definitely be checked when a patient appears to be failing such as? - Breathing with Cheyenne Stokes The most important role of a nurse is? - Honesty with patients and their family and ensuring patient dignity Oral cares should be done on an unresponsive patient how often? - Every time the patient is re-positioned (about every 2 hours) What are the stages of grief according to Kubler-Ross? - Bargaining, denial, anger, depression, acceptance Modifiable risks of cardiovascular disease? - High blood pressure, physical inactivity, smoking, diabetes, high blood cholesterol, being overweight Non-Modifiable risks of cardiovascular disease? - Age, ethnic background, family historyof heart disease What are sources of health promotion and disease prevention? - Immunizations Mortality - the amount of death rates Morbidity - How many contracts a disease (ex. influenza) If you rip a glove, what should you do? - Put a new pair of gloves on When assisting a patient to clean blood on their body, this is an opportunity to assess for additional injuries. True or False? - True What are the three kinds of blood vessels? - Capillaries, arteries, and veins What does MSDS stand for and what are they for? - Material safety data sheets and they have information on the chemical contents in containers Secondary Exposure of hazardous materials - Secondary exposure is when you are exposed to the contamination What is poison control? - A special information center set up to inform people about how to respond to potential poisoning. Where will you find the hotline number on most chemicals or medications? - In the Facts/Information section of the bottle or box ABC's - Airway, breathing, circulation (most life-threatening injuries) What does RICE stand for? - Rest, ice, compression, elevation What is the purpose of splinting? - Keep broken or injured bones from moving so they can heal properly, they also support the muscles of injured limbs to help reduce pain and swelling What is the nursing priority for a patient that has fallen? - Assess and stabilize a possible fracture prior to moving What does PERLA stand for? - Pupils equal, reactive to light and accommodation What are signs of ICP? (Increased intracranial pressure) - headache, nausea, vomiting, increased blood pressure, decreased mental abilities, confusion of time and location, double vision, pupils unresponsive to light, shallow breathing, seizures, loss of consciousness, and coma What should you do first when a patient is in shock? - Check ABC's because a patient in shock may have a decrease in circulation Three levels of burns - First degree- red, non-blistered skin Second degree- blisters and some thickening of skin Third degree- widespread thickness with a white, leathery appearance When in an emergency, assess for what? - Breathing or respiratory concerns (ABC's) as well as burn injuries What is the patient safety goal we talked about on our last lecture day? - Establishing a policy for medication safety and reconciliation- Part of JCAHO which is the accrediting agency for healthcare organizations What is the safety goal JCAHO is monitoring regarding infection control in healthcare? - Hospital acquired infections related to indwelling catheters (UTI's) True or False? Never leave pills with a patient unattended or with a staff member that does not have a license - True Who can take an order from an MD? - Verbal orders can only be taken by a licensed nurse When giving your patients medication, always stay with them until when? - They have taken their medication What are the 6 rights to medications? - Right patient, right medication, right does, right time, right route, right documentation How many checks should you do before administer a medication to a patient - 3checks When should you chart your medications? - After it has been given What should you do if you forgot to document a medication you gave? - Call and notify the facility, if a student you must tell your instructor, and return to the facility to complete your documentation If you accidentally give a medication at the wrong time, is it considered a medication error? yes, or no? - Yes True or False? Never give a medication that was set up by someone else - True- always recheck using the 6 rights and 3 checks What do you do if you drop a medication on the floor? - Discard the medication How do you dispose of sharps? Can you recap? - Dispose of sharps in the sharp container. NEVER recap your needles (except for walking down the hall to the patients room prior to administering) What can you do to make sure you have the right patient? - Use two patient identifiers such as name and date of birth When giving an intradermal injection, do you point the bevel of the needle up or down? - Point the bevel of the needle up Adults vs. Children medications and dosages - Adults often take pills and children often take medicine in liquid form. Dosages in adults are higher than in children. (ALL OTC medicines have the same kind of labels) How do you administer ear drops to an infant? - Pull pinna downward and backward to open ear canal How do you administer ear drops to an adult? - Pull the upper ear upward and backward Incubation Stage - Silent stage because often it is not known when the pathogen gains entry to the host and starts replicating. The length of incubation period depends on the disease and the stage ends when the first signs and symptoms of the disease appear. Prodromal Stage - First onset of signs and symptoms occur (malaise, runny nose, itchy and dry eyes). This stage lasts about one or two days and is considered to be the time when symptoms show that a disease process is taking place. Acute Stage - The disease reaches its highest point of development (severe aches, chills, vomiting) and the symptoms can help determine one disease from another. Declining Stage - The symptoms start to subside. The infection is still present, but the patient's health starts to return to normal. In Maslow's Hierarchy of Needs, Physiological is: - Breathing, food, water, sex, sleep, homeostasis, excretion In Maslow's Hierarchy of Needs, Safety is: - Security of body, of employment, of resources, of morality, of the family, of health, of property In Maslow's Hierarchy of Needs, Love and Belonging is: - Friendship, family, sexual intimacy In Maslow's Hierarchy of Needs, Esteem is: - Self-esteem, confidence, achievement, respect of others, respect by others In Maslow's Hierarchy of Needs, Self-Actualization is: - Morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts