Rasmussen NUR 2356: Multidimensional Care I / MDC 1 Exam 3 Multidimensional CARE Exam 3 study guide- Complete 2023/2024 solutions

Rasmussen NUR 2356: Multidimensional Care I / MDC 1 Exam 3 Multidimensional CARE Exam 3 study guide- Complete 2023/2024 solutions NUR2356 Study Concept Guide Exam 3 150 questions, worth 300 points, & 225 minutes to take the exam NUR2356 Exam 3 Study Guide Module 1-3 Review Fall priority • Guide the patient to the floor using your leg Assess for injuries of the patient after they have been guided to the floor. Position yourself so you are behind and to the side of the patient, so you are ready to guide them down to the floor. Low platelet teaching • Increased risk for bleeding, try to avoid injuries. Garlic can help with platelet promotion. Review Pain assessment • PQRST, when did it start, does anything make it better or worse, what does the pain feel like, does the pain radiate anywhere, on a scale of 1-10 what would you rate your pain. 1-10 is common scale for adults, FACES is used for pediatrics, CRIES is used for infants • Patient description of pain is the most reliable. Must document pain for what the patient says • Set goals for comfort and function/recovery/quality of life. Ask patients which pain rating would be acceptable or satisfactory, considering the activities required for recovery or for maintaining a satisfactory quality of life. Therapeutic/non-therapeutic communication • Therapeutic communication- Client-centered communication directed to achieve the patients’ goal • 5 key characteristics- Empathy, Respect, Genuineness, Concreteness, Confrontation • Techniques to help with communication- Active listening, Silence, establishing trust, Being assertive, Validating messages, Exploring issues, Summarizing, Process recordings • Non-Therapeutic communication- Not professional or appropriate Priority care/assessment • ABC’s priority Review Risk for fall – Teaching/Interventions • Throw rugs, low lighting, clutter, unsteady gait, mobility issues. Teach patients to walk with assistive devices, ensure the environment is free of clutter, remove any tripped hazards, replace lights that are dim, polypharmacy, confusion lOMoARcPSD| National Patient safety Goal • Joint Commission- Monitors safety goals and quality care, publishes National Safety Goals Vitals/normal vs abnormal/concerning/Priority/interventions • Normal BP- less than 120/80 • RR- 12-20 • HR- 60-100 • Temp: 96.4-99.5 • Concerns and priority are hypoxia, hypotension/hypertension (Depending on how high), hyperthermia, bradycardia/tachycardia. Maslow’s Hierarchy of Needs • Physiological needs, Safety/security, Love and belonging, Self-esteem, Self-actualization Module 4-6 Review Joint movements (extension, circumduction, rotation, flexion, abduction, etc.) • Extension- straightening a limb at a joint • Flexion- Bending a limb at a joint • Circumduction- Moving a limb in a full circle- 360 degrees • Rotation- Moving the head side to side • Abduction- Moving a limb away from the body • Adduction- Moving a limb towards the body ROM, PROM, AROM • ROM is how far a joint or muscle can be stretched • Passive range of motion- done by nurse • Active range of motion- done by client Limited movement/Adaptive devices • Trochanter roll, hand roll, abduction pillow, cradle boots, foot board Review assessment of an immobile client and priority • Turn the client every 2 hours, keep skin dry and clean. Rotate the client to clear muscous in the airway on an immobile client RN interventions to improve respiratory function • Deep breathing exercise, use of a spirometer, promote coughing RN movement to reduce injuries to herself—Movement should be lOMoARcPSD| • Bend at the knees, do not lift with the back, use assistive devices, call for help, movement should be purposeful RN Intervention if she can’t feel the pulses • Use a doppler to check for a pulse Interventions to promote patient independence • Allowing the patient to preform activities themselves if they are capable, allow them to keep their daily routine RN priority for an infected wound • Notify the physician, start the patient on antibiotics, change dressings as needed Risk factors of immobility (GU, Respiratory, Integumentary, GI) • GU- Bladder/kidney infections, UTI, decreased urine output • Respiratory- Atelectasis, pneumonia • Integumentary- skin breakdown, decreased skin integrity, risk for ulcers • GI- Peristalsis, constipation, bowel obstruction • Cardiac- venous stasis, increased cardiac output Positive and negative effects of immobility (Cardio, musculoskeletal, GI, GU, Respiratory) – Immobility Interventions ^^^^^^^^ Mobility devices- equipment – Proper use (patient education, staff safety, which patient will use what device) • Have clients hold a cane on the unaffected side of their body. Two points must always remain on the ground • Walker, move the walker in front of you and then step forward • Patient can use a trapeze bar to assist in moving Bed positioning (Fowler, high-fowler, supine, prone, etc.) • Fowler- 45–60-degree angle • High fowler- 60–90-degree angle • Supine- laying flat on the back • Prone- laying flat on the stomach • Orthopneic- arms rested on a table in front of the client, similar to tripod position, helps with respiratory improvement DVT high risk/s/s • Immobility, surgery, females on oral contraceptives Pressure Ulcer/Interventions/Preventions