PN1 Final Exam Review Module One & Two (FULL REVISED EXAM REVIEW).

PN1 Final Exam Review Module One & Two (FULL REVISED EXAM REVIEW). The nurse is responsible for all tasks that are delegated. 5 rights of delegation: • Right task: The task is within the UAP's scope of practice and competence. • Right circumstances: The patient care setting and resources are appropriate for the delegation. • Right person: The UAP is competent to perform the delegated task or activity. • Right communication: The nurse provides a clear and concise explanation of the task or activity, including limits and expectations. • Right supervision: The nurse appropriately monitors, evaluates, intervenes, and provides feedback on the delegation process as needed. Do not delegate what you can EAT: Evaluate Assess Teach Know the 6 ethical principals that nurses should use and examples of them: 1. Autonomy – self management (person suffers an accident and doesn’t want extra measures) 2. Beneficence – doing good for the patient (nurse & patient decide on post op care together) 3. Nonmaleficence – avoiding things that may cause harm 4. Fidelity – keeping the nurses promise to give care 5. Veracity – telling the truth (telling the truth when one makes an error) 6. Justice – ensuring the equal and fair treatment of all patients (If someone lies about an error) RESCUE ALARM CONFINE EXTINGUISH PULL PIN AIM HOSE SQUEEZE SWEEP SBAR Communication: Situation Background Assessment Recommendation Team STEPPS • CUS words: State “I’m concerned; I’m uncomfortable; I don’t feel safe” • Check backs: Restate what a person said to verify understanding by everyone. • Call outs: Shout out important information for all team members to hear at one time. • Two-challenge rule: State a concern twice; if ignored follow facilities chain of command. Mass Casualty Triage • RED – Emergent needing immediate attention (Class I) • YELLOW – Can wait short time for care (Class II) • GREEN – Non-urgent or “walking wounded” (Class III) • BLACK – Expected to die or are dead (Class IV) Common Complications of Decreased Mobility: Physiological - Pressure ulcers - Osteoporosis - Constipation - Weight loss/gain - Muscle atrophy - Atelectasis Psychological - Depression - Changes in sleep/wake cycle - Sensory deprivation Osteoarthritis: Progressive deterioration and loss of cartilage and bone in one or more joints *Most common arthritis and major cause of impaired mobility and disability Disease Process: Affects weight bearing joints, hands, spine S&S: pain, stiffness, immobility, enlarges nodular joints, Risk factors: (Primary) Aging, possible genetics, weight baring joints Secondary) obesity, trauma, occupation, metabolic diseases, blood disorders Diagnostics: ESR labs, Xrays, MRI, CT Interventions: NSAIDS, Muscle relaxants, opioids (tramadol), rest, exercise, hot/cold application, weight control, joint replacement surgery Gout: a systematic disease in which urate crystals deposit in the joints, causing inflammation S&S: swollen, painful joints Risk factors: (Primary) most common; purine metabolism errors, Xlinked trait (Secondary) Hyperuricemia; uric acid in the blood; caused by another risk factor such as renal failure Diagnostics: Serum Uric Acid Level (above 6.5 indicates gout) Interventions: (acute) Colchichine, NSAIDS (chronic) Allopurinol, Febuxostat Low purine diet (meat, shellfish) Avoid aspirin and diuretics Decrease stress Lyme’s Disease: systemic infectious disease caused by spirochete borrelia burgdorferi, results from a bite from a deer tick S&S: (stage 1) flu like, bulls’ eye lesion (stage 2) cardiac issues, dizziness (stage 3) chronic complications; arthritis Risk factors: Situations where a tick bite is likely; heavily wooded areas Diagnostics: ELISA and Western blot test Interventions: antibiotic therapy; doxycycline or amoxicillin Fibromyalgia: chronic pain syndrome S&S: fatigue, sleep disturbances, numbness/tingling, odor sensitivity, headaches, jaw pain Risk factors: most commonly seen in women ages 30-50 Interventions: regular sleep pattern, limit caffeine and alcohol, anticonvulsants, SNRI’s, Tricyclic antidepressants, Tramadol, NSAIDS, physical and integrative therapy Scoliosis: lateral spinal deformity S&S: uneven pant/shirt length, pain Diagnostics: Adam’s bending forward test Interventions: Milwaukee Brace, surgery Kyphosis: posterior curvature of the thoracic spine S&S: hunchback Interventions: brace, spinal infusion Osteoporosis: chronic bone loss diseases S&S: back pain, constipation, heigh decrease, humped back, fractures Risk factors: Alcohol Corticosteroid use Calcium low Estrogen low Smoking Sedentary lifestyle Diagnostics: DEXA Interventions: exercise, diet high in calcium Vitamin D Fiber and Protein, avoid alcohol and smoking, avoid fall risks, Biphosphates *40mg daily for 3 months, EMPTY stomach with 6-8oz water, no food 30 min after, do not lie down for 30 min Osteomyelitis: bone infection S&S: fever, malaise, swelling, purulent drainage, tachycardia Risk factors: Malnourished, elderly, overweight, injection drug use Diagnostics: bone culture, CBC, needle aspiration Interventions: IV antibiotic therapy, immobilize body part Piaget’s Disease: increased bone absorption leading to compensation by remodeling, leading to deformities S&S: hip pain, deep arching, warm to the touch Diagnostics: increase in ALP, x ray, bone scan Interventions: limiting complications Osteomalacia: metabolic disease causing poor and delated mineralization of bone cells S&S: generalized skeletal pain, waddling gait Risk factors: low vitamin D, malabsorption, biliary system disease Diagnostics: serum calcium, phosphate, vitamin D, BUN Interventions: sunlight exposure, Vitamin D supplements, ergocalciferol Assessing mobility: - Past medical history - Family history - Current medications Lifestyle behaviors/occupation Preventing decreased mobility: - AROM exercises every two hours - Help pump activites - Adequate fluids - Evaluation for need of ambulatory aids Interventions for decreased mobility: - PROM - Turn & reposition every 2 hours - Keep skin clean and dry - Adequate nutrition and fluid intake - Ambulate with aides - Encourage deep breathing - Educate the patient and their family A nurse is performing a neurovascular assessment. What should the nurse include in this assessment? Capillary refill, movement, pulses, & warmth The nurse is teaching a client about the risk factors for developing osteoporosis. What is the MOST important information for the nurse to include? Inadequate dietary intake of calcium Family history Smoking The nurse is teaching the client about the cause of primary osteoporosis. What is the MOST accurate answer for the nurse to provide? Hormonal imbalance A 70-year-old female client who reports back pack is diagnosed with osteoporosis. The nurse is aware that this client is MOST at risk for: Fracture The nurse is teaching a class on primary prevention of osteoporosis. What is the MOST important information for the nurse to provide? Maintain optimal calcium intake A client has been diagnosed with gout. Which foods should the nurse instruct the client to eat in moderation? Sardines Liver Shrimp What are the causes of primary osteoarthritis? Overuse of joints, aging, and obesity Assess first - Don’t answer evaluate Decreased mobility results in atrophy, edema, depression, muscle weakness Acute gout attack: Colchicine Daily gout preventative: Allopurinol Instructions for MRI: pacemaker, no metal Instructions for CAT scan: iodine and shellfish allergies Osteoarthritis causes: aging, obesity, overuse of joints Mediations for osteoarthritis: Anti-inflammatory If given NSAIDS, teach full stomach, bleeding, no alcohol, blood thinner interactions Non phrenological intervention for osteoarthritis: heat or cool therapy, resting periods, warm bath in the morning, Tens unit Gout diagnosis: uric acid levels Diet for gout: no Purine – no liver, shrimp, sardines Lyme’s disease comes from: ticks and is indicated by a bullseye rash (Target disease) Lyme’s disease medication: antibiotic, Doxycycline, Amoxicillin Preventing limes disease: avoid tick bites (heavily wooded, long sleeved clothing, check pets, insect repellent, bathing) Diagnosing limes disease: Elisa western blot test Fibromyalgia: chronic idiopathic pain or nerve pain Fibromyalgia treatment: anti-depressants, NSAIDS, physical therapy (walk, swim, bike), regular sleep pattern, acupuncture, Thai chi, avoid caffeine or other stimulants Scoliosis: spine curvature If curve is felt: x rays Depending on curve: may have a Milwaukee brace, worn 23/24 hours, only a thin shirt under it to prevent skin breakdown, may have rod surgery if patient is done growing Kyphosis: humpback, in geriatric patients, impacts breathing, potential cardiac or lung issues Osteoporosis risk: (ACCESS: Alcohol, caffeine, calcium, estrogen, smoking, and sedentary) women, hysterectomy, Alcohol, steroid, calcium, estrogen, smoking, sedentary Osteoporosis diagnosis: DEXA scan Osteoporosis treatment: Fosamax (pyrophosphates), calcium, vitamin d, estrogen (careful, may cause cancer), bisphosphonate Fosamax: Remain upright, no food, a lot of water (6-8 0z) Osteomyelitis: bone infection Osteomyelitis treatment: antibiotics IV, 6-8 weeks at home, teach patient Osteomalacia: bone loss Caused by lack of vitamin D, need sunlight! Perioperative care: from the time the client finds out they are having surgery until they enter the OR. Nursing Diagnosis: Anxiety Pre-operative check list: - Consent (the nurse’s purpose is to verify that the signature is indeed from the patient) - Prep (Fasting, Shave, Enema, etc.) Allergies o Latex (bananas) o Iodine (shellfish) o Antibiotics o Anesthesia o Pain medication Assessment o Vitals (pain) o LOC o Lung sounds o Heart sounds Labs o CBC/HCH/WBC/platelet o Blood type o PTT, PT/INR (Clotting) *Heparin = PTT, Coumadin= PT* o BMP, basic metabolic panel (potassium) o U/A (pregnancy test) o BUN/CR (Kidneys filter out anesthesia) Diagnostics o EKG o Chest Xray Medications o Blood thinners (stop 4- 7 days prior) o Herbal supplements o Steroids (raises glucose and decreases immune system) o BP Meds o Insulin IV: 18 Gauge (in case they need a blood transfusion) Skin Marking: Nurse must make sure it has been done, but the DR marks it .