NURS 360- FINAL EXAM (FULL & REVISED) STUDY GUIDE A+GUARANTEED.

NURS 360- FINAL EXAM (FULL & REVISED) STUDY GUIDE A+GUARANTEED. Fundamentals test taking things to remember when answering: - Assess ABC’s - Maslow’s hierarchy of needs o Safety - ADPIE - If smoking is an option, then it is the answer. 1. Techniques & Best Ways To Prevent HAIs CH. 26 is what HAI’s are. Health Acquired Infections (HAIs) = AKA nosocomial infections patient retracts this during their treatment for other conditions in a healthcare facility CH. 25 for the most part Prevention of HAI = - Nurse plays the key role by considering routes of transmission; - standard precautions with *all* patients in avoiding all bodily fluids - primary precautions and the best way (one exam 1) ishand hygiene before and after seeing patients. - Donning PPE as appropriate and indicated. - isolation precautions. o TB, measles, rubella is airborne. VTM = airbone ‘em! Need N95 mask not a surgical mask. o Flu is droplet so surgical mask is fine. o Primary precautions = hand washing/gelling/foaming in and before going out between patients. Gel in, gel out. - Staying sterile as indicated during a procedure can avoid risk for infections such as UTI caused by nonsterile indwelling catheter insertion. 2. Assessment Of The Patient Who Does Not Speak English - Main idea: always use an interpreter if the patient speaks a different language. The use of written material is good to enforce and refer back to the information (exam 2 question); considered to be essential to culturally competent care. o Keep the communication simple: ▪ Do not use humor, slang, jargon, abbreviations; anything that the patient would not understand. ▪ Ask questions one at a time and look at the patient not the interpreter when you are talking to them. - Important to make sure the patient understands the information because they can just keep nodding their head but not really understand you. CH. 36 - Assessing pain for non-native English speakers/anyone who cannot communicate: o Look for signs and symptoms of pain o Assessing their vital signs o The Universal Pain Assessment Tool, which has the Verbal Descriptor Scale, Wong-Baker Facial Grimace Scale, and Activity Tolerance Scale as this is available in other languages and used world-wide. o If it is an option, use an interpreter. 3. Immediate (As In The First) Actions For A Seizure CH. 25 - Precautions for seizure patients: Have oxygen and suction ready at bedside and the bed railing should be padded with something appropriate/covered with blankets already (exam 1 asks what should be at the patient’s bedside). 1. Protect the patients head by padding or putting them on a soft surface under their head to prevent further damage 2. Turn their head or whole body to the side to prevent aspiration, maintain a patent airway, and do not stick anything in their mouth. 3. Safety: Move anything sharp or hard out of the way of the patient while they are seizing. - Think about your ABC’s and safety come after. ATI says: 1. Stay with the client, and call for help. 2. Lower the patient/do not restrict/make sure there is nothing that can harm the patent/maintain airway patency and suction PRN. - Do not to restrain the client during a seizure but to lower him to the floor or bed, protect his head, remove nearby furniture, provide privacy, put him on his side with his head flexed slightly forward if possible, and loosen his clothing. - Do not put anything in their mouth such as a tongue blade. 4. Restraint Use. When Do We Use?/ Interventions To Do BEFORE Restraint Application CH. 25 - Physical restrains are usually made for either or both reasons: for medical necessity, behavioral or mental health issues. - Common reasons would be to immobilize the patient, to prevent harmful behavior and to allow for treatments to continue without the patient’s interference such as patient pulling out IV treatments. - Restraints are the last resort. We should use alternatives to physical or chemical restraints: o Orient the patient to their surroundings to decrease anxiety. o Relocate the patient closer to the nurse’s station. o Bed alarms to detect when the patient gets out from bed.Make sure alarms works and batteries are changed. o Family should spend time with the patient. o Environmental stimuli should be decreased that can startle or aggravate the patient. o Distractions such as TV. o Relaxation techniques such as massages. o CAM therapy like aromatherapy or music. o Sitter with the patient 24/5. o Tubing and drains wrapped in clothing, so the patient doesn’t feel anxious about them. o Mitts to prevent the patient from pulling anything or grasping on to stuff. - If all else fails and collaboration with other healthcare staff have no other ideas, get an order from their doctor unless they are combative or doing harm to themselves, order would be needed within the next hour. 5. Patient and Family Discharge Education Ch. 8 - Planning for discharge starts at the admission of the patient. - Collaboration is important with family and the patient as they are caring for the patient andprioritizing what is important to the patient makes their planning and adherence more effective. - Education about their medications and knowing how often to take them, what they are for, having a scale to use is important. DISCHARGE EDUCATION from ATI - The nurse discusses the discharge instructions with the client and provides a printed copy. - Instructions should use clear, concise language that the client will understand. - The nurse should verify understanding of the instructions by the client. Standards for discharge education - Identifying safety concerns at home and making alterations as necessary such as raised toilet seats or grab bars. - Reviewing symptoms of potential complications and when to contact emergency care or the provider - Providing the phone number of the provider - Providing names and phone numbers of community resources that give care at the client’s residence - Step‐by‐step instructions for performing continuing treatments, such as dressing changes - Dietary restrictions and guidelines, including those that pertain to medication administration - Amount and frequency of therapies to perform to support continued independence at home like nubulizer or continuing incentive spirometry. - Directions how to take medications, potential interactions, and why adherence is important. 6. Discharge Education And Communication To The Confused Patient (And Family Involvement) CH. 3 - Communication can be established with someone who is partially anesthetized by observing nonverbal ques such as grimacing by assessing them and their cognitive impairment. - Assess the patient to see if and what they understood. - Intellectually impaired patients need to have a caregiver and the family involvement is important is addressing what needs to be done to continue the nursing interventions. Do not confront the patient since there are demented or even attempt to argue with their erroneous way of thinking. CH. 31 - Other healthcare providers are contacted in the community as well to make sure the patient receives continuous and maximum care. - These patients may need to be put in a day-care and need caregivers to prevent burnout. 7. Incentive Spirometry. Indications. How To Use. CH. 37 - A nurse uses a variety of teaching strategies to show a patient how to use an incentive spirometer. o Use of this is to prevent pneumonia and atelectasis, maintaining lung expansion after surgery/post-op but should be taught before the patient goes in for surgery to encourage deep breathing on inhalation to open up those alveoli. o Good lung hygiene to prevent the growth of bacteria from staying immobile or recovering from post-op (ATI). o You How to use: 1. Patient should be in an upright position in Semi-Fowler or Fowler’s position to allow for more lung expansion. 2. Goal is to maintain inhalation for at least 3-5 seconds and keeping the thing afloat at the goal for the day. 3. Exhale slowly. 4. Instruct a patient to use an IS 5-12 times a day every 1-2 hour depending on provider’s order for postoperative care. 5. Encourage the patient to cough to get the mucous out and deep breathing (similar to IS but without the IS) o Patient can use a split to protect surgical cuts. o Need to cough at least 2-3 times without inhaling every hour. 8. Maslow’s Hierarchy Of Needs CH. 1/CH. 8 (examples) - The base of the pyramid is met first which is the physiological needs to be able to live such as health, pain, comfort, sex, oxygen, food, etc. before safety and security. Needs according to what is NEEDED/BASE of the pyramid: 1. Physiological needs: food, water, elimination, oxygen, comfort/temperature control, sex, movement, rest. Everything you need to be able to live.