MDC Final Exam Review

1. Appropriate nursing actions: Nicole a) When a client falls  1 st priority – check on patient for any injuries Before that, guide the patient to the floor. b) Positioning to reduce injury for bony prominences  Place pillows under areas and elevate  Changes position for 2hrs Elevate calves to protect heels c) Reducing shear injury (med surg pg 447)  Avoid pulling and sliding patient against bed  Keep head of bed at a slight elevation  Make sure sheets and blankets have ripples in them that rub against the patient’s skin  Use others to assist to protect from shearing. d) Reduce urinary tract infection  Proper cleaning of Perineum – front to back e) Reducing pressure ulcers- factors that are contributors (med surg pg 448) Preventing Pressure Injuries Positioning  Pad contact surfaces with foam, silicone gel, air pads, or other materials with pressureredistribution properties.  Do not keep the head of the bed elevated above 30 degrees to prevent shearing.  Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or her.  When positioning a patient on his or her side, position at a 30-degree tilt.  Re-position an immobile patient at a frequency consistent with assessed needs.  Do not place a rubber ring or donut under the patient's sacral area.  When moving an immobile patient from a bed to another surface, use a designated slide board well lubricated with talc or use a mechanical lift.  Place pillows or foam wedges between two bony surfaces.  Keep the patient's skin directly off plastic surfaces.  Keep the patient's heels off the bed surface using bed pillow under ankles or a heelsuspension device. Nutrition  Ensure a fluid intake between 2000 and 3000 mL/day.  Help the patient maintain an adequate intake of protein and calories. Skin Care  Perform a daily inspection of the patient's entire skin  Document and report any manifestations of skin infection.  Use moisturizers daily on dry skin and apply when skin is damp  Keep moisture from prolonged contact with skin:  Dry areas where two skin surfaces touch, such as the axillae and under the breasts.  Place absorbent pads under areas where perspiration collects.  Use moisture barriers on skin areas where wound drainage or incontinence occurs.  Do not massage bony prominences.  Humidify the room. Skin Cleaning  Clean the skin as soon as possible after soiling occurs and at routine intervals.  Use a mild, heavily fatted soap or gentle commercial cleanser for incontinence.  Use tepid rather than hot water.  In the perineal area, use a disposable cleaning cloth that contains a skin-barrier agent.  While cleaning, use the minimum scrubbing force necessary to remove soil.  Gently pat rather than rub the skin dry.  Do not use powders or talc directly on the perineum.  After cleaning, apply a commercial skin barrier to areas in frequent contact with urine or feces. f) For vital signs out of range (i.e low oxygen saturation) (module 1 slide 56-59)  Normal body temperature 96.4 to 99.5 (depending on the site)  Respiration Rate – 12 to20 breaths per minute  BP – 120/80 and below; anything higher is abnormal  Pulse-Oximetry (saturation) – 94 to 100%  Pulse – 60 to 100 BPM g) Appropriate measures in taking an oral temperature (module 1 slides55) h) Vital signs that can indicate post-surgical pain?  Elevated Heart Rate  Breathing rate can be elevated  Elevated BP 2. Describe the following: Nicole a) Complications of amputations and type of pain (module 1 slide 10) Possibility of phantom pain b) Autonomy for a client requiring oral care (funds book pg 594-595)  Brush the teeth twice a day.  Use a soft toothbrush.  Moisturize oral mucosa and lips every 2 to 4 hours.  Use a chlorhexidine gluconate (0.12%) rinse twice a day during the perioperative period for patients who undergo cardiac surgery (adult patients).  Use mouthwash inside the mouth twice a day for adult patients who are on a ventilator.  Give the patients the oral supplies c) Fire safety measures and priorities (module 3 slides 12 &22) o Fires  Home fires are the major cause of death and injuries  Older adults & children < 5y/o have the highest risk.  Most common causes of fires:  Cooking fires  Smoking  Heating Equipment  Home oxygen administration equipment: 75% of home fires involves oxygen, smoking materials are the ignition source  Remove the client from the area o RACE  Rescue – remove patient from danger  Alarm – pull the alarm  Contain - close doors  Extinguish fire (if possible) o PASS  Pull the pin  Aim at the base of the fire  Squeeze the handles  Sweep back and forth d) Infant safety- education for new moms in keeping babies safe.  Don’t Sleep with baby  Car seat faces backwards for 2 years  Baby should sleep in their back  Do not use microwave to heat formula  Do not sleep with mom and dad e) Client orientation to a new room may include what specifics  Ensure they can use call light before you leave  Show them where their personal items are and place them near to them  Show them where all the furniture is at and walk them around it.  Also show them where the bathroom is and how to get to it f) Delegation to an unlicensed assistive personnel (UAP) o Anytime there is concern over a finding from an unlicensed person – assess the patient yourself to confirm the concern o Things that can be delegated to unlicensed personnel  Vital signs on a non-critical patient  Moving/ambulating a patient  Bedside glucose monitoring  Bathing and documenting tasks 3. Describe the following: Casey a) Benefits of bathing for a client Cleans the body, stimulates circulation, provides relaxation, and enhance healing. b) Caring for a patient with dementia, specific nursing interventions promote patient orientation, use simple communication, decrease anxiety, keep the patient safe, and pro- vide continuity of care. (fund book, p. 787). As for assistance with procedures such as indwelling catheters or IV insertions. c) Normal temperatures of clients of all ages (infants, adults, elderly) Infant 97.7- 99.5, Adults 96.4 to 99.5, Elderly 96.8 average (due to loss of subcutaneous fat) d) Main causes of accidental poisoning  Young Children exposure is mainly due to improper storage of household chemicals, medicines, vitamins & cosmetics  Older children and adolescents cause is due to suicide attempt, accidental experiment with recreational or prescription drugs.  Adults poisoning occurs by misuse or abuse or prescription drugs, especially narcotics, tranquilizers and antidepressants ( module 3 , slide 8) e) Main purpose of incident report To give the health care facility and the healthcare professionals the opportunity to address the issue and prevent the occurrence of future incidents. f) Interventions for a patient with a DVT  Patient education  Leg exercises  Early ambulation  Adequate hydration  Graduated compression stockings  Intermittent pneumatic compression, such as sequential compression devices (SCDs)  Venous plexus foot pump  Anticoagulant therapy ( med surg p. 744) g) Different types of nurse/client relationships  Pre-interaction: The student nurse gathers information about the client before having a personal interaction, looking at the client’s medical record to begin data collection.  Orientation: The student nurse introduces themselves, explains their role in the relationship, determines the name the client wishes to be addressed by, and establishes trust and rapport.  Working: Active part of the relationship. The student nurse communicates caring and compassion to the client, encourages the client to express concerns and feelings openly and honestly in an environment, and shows mutual respect and understanding. The professional relationship is competent, courteous, and confidential.  Termination: This marks the end of the relationship, whether at the end of the shift or at discharge. The student nurse summarizes all of the work done during the relationship. This is a good way to end the shift. 4. Communication: Casey what are important aspects in communication? a) Christian Scientist beliefs in the ED Will most likely only encounter these patients following an accident because they do follow Western Medicine as first choice to promote health. Most adults are not likely to accept a blood transfusion. ( funds p. 332) b) Asian cultures and space People stand farther apart and touch less c) Jehovah’s Witness and blood transfusions View accepting blood transfusions or blood products as morally wrong. ( funds p. 332). However, it is vital for the nurse to educate o the client on the reasons why the blood transfusion is needed. d) Hindu clients and bathing Hindus prefer to wash in free-flowing water (e.g., a shower instead of a tub bath). If a shower is not avail- able, provide a jug of water for the person to use in the bath. Women are modest and usually prefer to be treated by female medical staff (funds p. 333) e) Catholics and last rights- who does the nurse communicate to? A Roman Catholic who is seriously ill might wish to receive the sacrament of anointing the sick. This sacrament, once known as the last rites, can be repeated if the person recovers and then be- comes ill at a later time. Only a priest can hear the sacrament of reconciliation (confession), during which God, through the agency of the priest, grants forgiveness for past sins. (funds p. 332)