NUR 209 FINAL EXAM REVIEWED BY GOLD LEVEL EXPERT. DOWNLOAD TO SCORE A

NUR 209 Final Exam Review. Final Exam Review Safety (9/5) ⟶ Defines as the state of being free from harm or danger ⟶ Multiple healthcare settings have different safety concerns ⟶ Nurse must assess the patient, their equipment, and the environment and plan to maintain safety ⟶ Perform a risk assessment o Falls o Malnutrition o Bed sores Risk Assessment Screening Tools ⟶ Braden Scale for Bed Sore Risk o 0-23 o 23: Low risk o <9: High risk ⟶ Hendrich II Fall Risk o >5: High risk ⟶ Glasgow Coma Scale: Consciousness o 15: Fully alert ⟶ MMSE: Cognition o 30: Max o 27: Average o <24: No cognition Factors Affecting Safety ⟶ Musculoskeletal: Arthritis ⟶ Neurological & Sensory: Seizures, confusion ⟶ Cardiovascular & Respiratory: Shortness of breath, heart failure, blood pressure ⟶ Immune: Autoimmune disorders or immunocompromised patients ⟶ Integumentary: Open wounds, risk for bed sores Risk Assessment ⟶ Unsteady gait ⟶ Medications o Pain medication o Blood pressure medication ⟶ Blood pressure changes ⟶ Altered mental status o Dementia o Confusion ⟶ Sensory impairment o Sight, smell, taste, touch, hearing ⟶ Prolonged bed rest o Leads to depression, atrophy, contractures, bed sores, respiratory impairment ⟶ Incontinence/lack of toileting schedule ⟶ Environment o Hospital Factors Affecting Safety ⟶ Environmental o Workplace ▪ HAI’s o Other ▪ Fire ▪ Pollution ▪ Radiation ▪ Terrorism ⟶ Equipment o Call bell o Oxygen o IV o Monitors o Urinary catheters o Tubes Mechanisms for Quality & Safety Improvement 1. Mistake-proofing 2. Checklists 3. Redundancy 4. Communication Tools for Quality & Safety Improvement ⟶ TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety ⟶ SBAR (Change in status) o Situation o Background o Assessment o Recommendation ⟶ IPASS the BATON (Change in shift) o Identify self o Patient identification o Assessment o Situation o Safety o Background o Action o Timing o Ownership o Next steps ⟶ Huddles (Pre-conference) ⟶ Debriefing (Post-conference or post-event) Alternative to Restraints ⟶ Education ⟶ Comfort measures ⟶ Toileting schedule ⟶ Re-orienting ⟶ Pain Relief ⟶ Relaxation techniques ⟶ Decreased sensory overload ⟶ Activity/Exercise ⟶ Sleep hygiene ⟶ One-to-one *Restraints need to be re-ordered every 24 hours *Non-violent restraints to have a face-to-face assessment every 24 hours and violent restraints need to have a face-to-face assessment every 4 hours Infection Control (9/5) ⟶ Sepsis: Infection in tissue ⟶ Septicemia: Infection in blood ⟶ Infection disease: Transmissible Chain of Infection ⟶ Infectious agent o Bacteria o Fungi o Virus o Parasite o Prion ⟶ Source o Humans o Animals o Inanimate objects ⟶ Portal of exit o Sputum o Blood o Stool o Emesis ⟶ Mode of transmission o Contact o Droplet o Airborne ⟶ Portal of entry o Mucous membranes o Nonintact skin o GI tract o GU tract o Respiratory tract ⟶ Susceptible host o Immunocompromised patients o Elderly patients o Chronically ill patients o Trauma patients o Surgical patients Isolation Systems ⟶ Standard precautions ⟶ Transmission based precautions (negative pressure) o Airborne (Measles, TB) o Droplet (Flu) o Contact (MRSA, C. diff) ⟶ Protective isolation (positive pressure) o Immunosuppressed patients Communication: Nurse-Patient Relationship (9/12) Types of Communication ⟶ Written ⟶ Verbal ⟶ Non-verbal ⟶ Metacommunication Communication Relationships ⟶ Congruent ⟶ Incongruent Communication Process ⟶ Sender ⟶ Encoding ⟶ Decoding ⟶ Receiver ⟶ Feedback Nurse-Patient Relationship ⟶ Phases o Orientation o Working o Termination ⟶ Contract setting ⟶ Advocacy ⟶ Circle of confidentiality Definitions ⟶ Fidelity: Fulfill promises ⟶ Justice: Fairness ⟶ Nonmaleficence: Do no harm ⟶ Beneficence: Do good without self-interest ⟶ Veracity: Honesty Techniques to Facilitate Communication/Help Patients Get Started ⟶ Open ended questions ⟶ Opening remarks ⟶ Active listening ⟶ Restatement ⟶ Reflection Therapeutic Communication Techniques* ⟶ See separate handout from class Hygiene & Self-Care (9/5) ⟶ Hygiene, or the practice of hygiene, means to adhere to the general rules or self-care ⟶ Self-care refers to one’s ability to independently attend to their own primary care in the areas of bathing and grooming, toileting, feeding, and dressing Factors Affecting Self-Care ⟶ Environment o Homelessness ⟶ Motivation ⟶ Mental health ⟶ Cognitive abilities ⟶ Energy o Lack of sleep ⟶ Acute illness & surgery ⟶ Pain o Underlying causes ⟶ Neuromuscular function o Fine and gross motor control ⟶ Sensory deficits o Visual deficits ⟶ Immobility ⟶ Incontinence Mobility (9/5) ⟶ Mobility: Ability to move freely, essential to functioning and defines independence Body Mechanics ⟶ Using alignment, posture, and balance in coordinated effort to perform activities such as lifting, bending, and moving ⟶ Principles of Body Mechanics o Assess situation o Use large muscle groups of legs o Perform work at appropriate height for body Types of Gaits ⟶ Ataxic: Staggering and unsteadiness ⟶ Spastic: Walking appears stiff and toes appear to catch and drag ⟶ Waddling: Walking with feet wide apart in a duck like fashion ⟶ Hemiplegic: When one leg is paralyzed ⟶ Festinating: Walking on tip toes as if being pushed (Parkinson's) Risk Factors for Mobility ⟶ History of previous falls ⟶ Use of an ambulatory aid such as a walker or cane ⟶ IV access with pole ⟶ Altered gait ⟶ Confusion/disorientation ⟶ Depression ⟶ Altered elimination ⟶ History of dizziness or postural hypotension ⟶ Certain medications Types of Crutch Gaits *See handout from class *Crutches and canes should be used in the hand opposite of the weaker leg ⟶ 2-point ⟶ 3-point ⟶ 4-point ⟶ Swing to ⟶ Swing through Introduction to Patient Assessment (9/12) Health History (Subjective) A. Biographical Data B. Reason for Seeking Care C. HPI o Eight critical characteristics D. PMH E. Family History F. ROS G. Functional Assessment o Gordon’s functional health patterns Eight Critical Characteristics 1. Location 2. Character or Quality 3. Quantity or Severity 4. Timing 5. Setting 6. Aggravating or Relieving Factors 7. Associated Factors 8. Patient’s Perception Gordon’s Functional Health Patterns 1. Self-Esteem/Self-Concept 2. Activity/Exercise 3. Sleep/Rest 4. Nutrition/Elimination 5. Roles/Relationships 6. Spiritual Resources 7. Coping and Stress Management 8. Personal Habits 9. Environmental Hazards 10. Intimate Partner Violence 11. Occupational Health Physical Examination (Objective) A. Inspection B. Palpation ⟶ Light palpation o Fingertips are used when we are trying to assess a pulse o Used to check for tenderness o Only go 1-2 cm ⟶ Deep palpation o Used to size an organ o Usually only used in the abdomen o Go deep as 4-8 inches C. Percussion ⟶ Direct: 1 hand ⟶ Indirect: 2 hand ⟶ Hollow o Tympany or resonance o Lungs and abdomen ⟶ Solid o Liver and spleen o Dull sound D. Auscultation ⟶ Bell: Used for vessels/vascular sound such as carotid and aorta ⟶ Diaphragm: Used for bowel sounds and heart sounds Musculoskeletal Assessment (9/12) Functions of Musculoskeletal System ⟶ Provides support and movement of the body ⟶ Protection of vital organs ⟶ Produces blood cells/hematopoiesis ⟶ Provides storage for minerals Components ⟶ Bones ⟶ Joints o Nonsynovial vs. Synovial o Cartilage o Ligaments: o Bursa ⟶ Muscles o Tendons: Parts of the Body 1. Cervical spine 2. Glenohumeral joint 3. Elbow 4. Radiocarpal, carpel, and phalangeal 5. Hip and knee 6. Tibiotalar, tarsals, and phalangeal Grading Scale for Muscle Strength ⟶ 0: No detectable muscle contraction ⟶ 1: Barely detectable contraction ⟶ 2: Complete ROM or active body part movement with gravity eliminated ⟶ 3: Complete ROM or active movement against gravity ⟶ 4: Complete ROM or active movement against gravity and some resistance ⟶ 5: Complete ROM or active movement against gravity and full resistance Normal vs. Arthritic Joint ⟶ Osteoarthritis o From overuse o Increased pain with movement o Decreased pain with rest o Unilateral or bilateral ⟶ Rheumatoid Arthritis o Autoimmune o Unilateral only o Decreased pain with movement Spine Curvatures ⟶ Kyphosis: Hunchback ⟶ Lordosis: Swayback Definitions ⟶ Ipsilateral: Same side pain ⟶ Contralateral: Opposite side pain ⟶ Paresis: Weakness ⟶ Paralysis: No movement Mental Status (9/12) Mental Disorders ⟶ Organic: Known etiology ⟶ Psychiatric Mental Illness: Unknown etiology ⟶ Delirium: Acute state of confusion