West Coast University: NURS 100Funds Midterm Study Guide Review 2,100% CORRECT

West Coast University: NURS 100Funds Midterm Study Guide Review 2 Funds Lecture Midterm Study Guide Fall Prevention - Complete a fall­risk assessment for each patient conducted on admission and routinely until patients discharge. o Many health care organizations are implementing hourly rounding. - Apply yellow­colored wristband to patients to communicate that patient is at risk of falling. - Be sure patient knows how to use call light and that it is in reach - Provide regular toileting and orientation of clients who have cognitive impairments - Placement of a fall pad on the floor alongside the bed - Use of bed safety alarms and motion detectors - Provide adequate lighting - Be sure patients knows how to use all assistive devices o Canes, crutches, or walker o Remember to check condition of aids - Place patients at risk for falling near nurses’ station - Keep important/ frequently used items within reach - Remove excess furniture and equipment - Make sure patients wear rubber­soled shoes, slippers, or socks - Keep bed at lowest positions and lock wheels of bed and wheelchair - Keep side rails up for patients who are unconscious or sedated - Use gait belts when moving patient - Keep floor clean, dry, and free of clutter - Educate patient and family of safety risks - Chair/bed sensors for patients at risk for getting up without assistance - Report and document all incidents Fecal Occult Blood Testing - Measures microscopic amounts of blood in feces - Diagnostic screening tool for colon cancer - Test must be repeated 3 times from 3 different stools, while patients refrains from ingesting foods (raw veggies, red meat, poultry, fish) and medications (Vit. C, aspirin, NSAIDS) Black stool indications: - Iron ingestion - Upper GI bleeding or injury Sleep Disorders Insomnia - Chronic difficulty sleeping (chronic) - May be caused by stressful situations (acute) - Signals underlying physical or psychological disorder - Associated with poor sleep hygiene Sleep Apnea: lack of airflow through nose and mouth for periods of 10 seconds or longer during sleep - Central Sleep Apnea: CNS dysfunction – brain fails to trigger breathing during sleep - Obstructive Sleep Apnea: structures in throat and mouth relax during sleep and occlude upper airway  low oxy sat levels - Patients frequently experience excessive daytime sleepiness and fatigue - Rarely achieve deep sleep Narcolepsy: person falls asleep uncontrollably at inappropriate times - Excessive daytime sleepiness is the most common complaint - REM occurs within 15 minutes of falling asleep - Brief daytime naps no longer than 20 minutes help reduce sleepiness - Regular exercise and healthy sleeping habits also help Nursing diagnosis for sleep disorders: - Anxiety - Ineffective breathing pattern - Acute confusion - Ineffective coping - Insomnia - Fatigue - Disturbed sleep pattern - obstruction - Sleep deprivation - Readiness for enhanced sleep Physical Assessment - Inspection, palpation, auscultation, percussion - Abdomen­ inspect, auscultate, palpate Vital Signs – Normal ranges - Blood Pressure: 120/80 mmHg - Pulse: 60­100 beats per minute - Respirations: 12­20 breaths per minute - Temperature: 96.8 – 100.4 F o Oral/Tympanic = 98.6 F o Rectal = 99.5 F o Axillary = 97.7 F - Oxygen saturation level: 95­100 - Pain o Provoke – What caused it? What triggers it? o Quality – What does it feel like? o Region/Radiating – Where? o Severity – 0­10 scale o Timing – How long? How often? When? Apical Pulse - Nurse checks apical pulse when radial is abnormal - Check for one minute Pain Management Administering Analgesics - Know patient’s previous response to analgesics o Med allergies o Whether patient is at risk - Select proper meds when more than one is ordered - Know accurate dosage - Assess right time and interval for administration - When they say they have severe pain - Other measures have already been taken such as: distraction, music 3 Types of Analgesics - Nonopioids: Acetaminophen (Tylenol) & NSAIDS o Provide relief for mild­to­moderate acute intermittent pain - Opioids (narcotics): Oxycodone, Vicodin, Tramadol o Prescribed for moderate­to­severe pain - Adjuvants Communication Levels of Communication - Intrapersonal: occurs within an individual  self­talk - Interpersonal: one­on­one interaction between a nurse and another person - Transpersonal: interaction that occurs within one’s spiritual domain (prayer/meditation) - Small­group: occurs when a small number of persons meet – goal directed - Public: interaction with an audience - Electronic: use of technology Zones of Personal Space - Intimate Zone (0­18in) o Holding crying infant o Physical assessment o Bathing, grooming, dressing, feeding o Changing patient’s dressing - Personal Zone (18in­4ft) o Sitting at bedside o Taking patient’s history o Teaching o Exchanging information at end of shift - Social Zone (4­12ft) o Making rounds with physician o Teaching a class for patients o Support group - Public Zone (>12ft) o Speaking at community forum o Lecturing class of students Phases of Helping Relationship - Preinteraction Phase – before meeting a patient o Review available data (medical/nursing history) o Talk to caregivers who have information on patient o Anticipate health issues that arise o Plan for initial interaction - Orientation Phase – when nurse and patient meet o Set the tone for the relationship o Closely observe patient o Assess patient’s health status o Prioritize patient’s problems and identify their goals - Working Phase – nurse and patient work together to solve problems and accomplish goals o Encourage patient to express feelings about health o Provide information needed to understand and change behavior o Encourage and help patient set goals o Use therapeutic communication - Termination Phase o Evaluate goal achievement with patient o Reminisce about relationship with patient Therapeutic Communication Techniques - Active listening o Sit facing patient o Open posture o Lean toward patient o Establish and maintain eye contact o Relax - Sharing observations - Empathy - Sharing feelings - Using touch - Using silence - Providing relevant information Non­therapeutic Communication Techniques - Hinder or damage professional relationships - Cause recipients to activate defenses to avoid being hurt or negatively affected - Discourage further expression of feelings - Asking personal questions­ being nosey and invasive - Giving personal opinions­ takes decision making away from the patient - Changing the subject­ rude and shows lack of empathy Assertive communication techniques - Allows you to express feelings and ideas without judging or hurting others. - Assertive behavior includes: o Intermittent eye contact o Nonverbal communication that reflects interest, honesty, and active listening o Spontaneous verbal responses with a confident voice o Culturally sensitive use of touch and space - Increases self­esteem, confidence, and goal attainment - Assertive individuals make decisions and control their lives more effectively than others Administration of Enema - Sterile technique is unnecessary but wear gloves - Explain procedure - Position: patient laying on left side with knees drawn to abdomen - Cleansing enema should be retained for 5­10 minutes - Retention enema should be retained for at least 30 minutes - If patient is unable to hold the solution, place bed pan under patient - Insert tube 7.5­10cm - Stop completely if patient is experience pain and/or bleeding Signs and Symptoms of infection - Swelling - Warm to touch - Fever - Increased heart rate - Elevated WBC’s - LOC altered­ confusion with high fever - Ear infection: o Observe for color, discharge, scaling, lesions, foreign bodies, and cerumen o Normal cerumen is dry (light brown gray and flaky) or moist (dark yellow or brown) and sticky o A reddened canal with discharge is a sign of infection Bedpan Steps 2 types of bed pans: - Fractured pan: for supine clients or clients in body casts or leg casts - Regular pan: for seated clients Steps: 1. Lower head of bed flat and help patient roll onto one side (back towards nurse) 2. Apply small amount of powder to back and buttocks to prevent skin from sticking to pan 3. Place bedpan firmly against buttocks, down into the mattress with the open rim toward the patient’s feet 4. Keeping one hand against bedpan, place the other around the patient’s fore hip. Ask the patient to roll back onto the pan, flat in bed. 5. With the patient positioned comfortably, raise head of bed 30 degrees 6. Place a rolled towel or small pillow under the lumbar curve of patient’s back for added comfort 7. Raise the knee or ask patient to bend the knees to assume a squatting position. Physical Assessment Findings for heart and lung disease Heart Disease - Chest pain/discomfort - Palpitations - Excess fatigue - Dsypnea - Leg pain/cramps - Edema of feet - Cyanosis - Fainting - Orthopnea - Digital clubbing: change in angle between nail and nail base (larger than 180 degrees); nail bed softening with nail flattening; often enlargement of fingertips. Lung Disease - Persistent cough - Sputum streaked with blood - Voice change - Chest pain - Shortness of breath - Orthopnea - Dyspnea during exertion or at rest - Poor activity tolerance - Recurrent attacks for pneumonia or bronchitis - Digital clubbing­ Digital clubbing: change in angle between nail and nail base (larger than 180 degrees); nail bed softening with nail flattening; often enlargement of fingertips. Normal nail: approx. 160­degree angle between nail plate and nail Beau’s lines - transverse depressions in nails indicating temporary disturbance of nail growth - causes: systemic illness such as severe infection; nail injury Paronychia - inflammation of skin at base of nail - causes: local infection; trauma Subjective Data ­ Symptoms - Patient’s verbal descriptions - Only patients provide subjective data - Feelings - Perceptions Objective Data – Signs - Observations or measurements of patient’s status - Known characteristics of behaviors Personal Hygiene Practices are influenced by: - Social practices - Personal preferences - Body image - Socioeconomic status - Health beliefs and motivation - Cultural variables - Developmental stage - Physical condition PPE Airborne (measles, varicella, pulmonary or laryngeal tuberculosis) - Mask and respiratory precautions - Private room - N95 or HEPA respirator if client is known or suspected to have TB - If splashing/spraying possible use eyes, nose, and mouth protections Droplet (streptococcal pharyngitis or pneumonia, haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps…) - Masks - A private room or a room with other clients with the same disease Contact (herpes, wound infections, shigella, scabies, multidrug-resistant organisms) - Gloves - Gowns - A private room or room with other clients with same disease Use gloves and gown when visibly soiled and/or in contact with any blood or bodily fluids Purpose of Physical Assessment - To create plan of care Principles of Sterile Technique - 1 in. margins - Above the waist - Sterile to sterile only Dietary Plan for Health Bowel Elimination Diet - Fluids - Fiber o Whole grains o Fresh fruits o Vegetables - Gas-producing foods o Onions o Cauliflower/Broccoli o Beans Medications - Laxatives- stimulates/ facilitates evacuation of the bowel (relieves constipation) - Cathartics (causes emptying of bowel) softens feces/accelerates defecation (in contrast to a laxative) - Possible for substance to be both Sensory Deficit for Stroke Patients - Incoordination & imbalance - Loss of sensation - Loss of motor function - Difficulty with speech - aphasia (stroke affecting left hemisphere) - Loss of half of visual field (stroke affecting right hemisphere) - Ask if they have a hearing aid or device; same for visually impaired Handwashing and infection control Handwashing: #1 prevention of infection - Wash hands with soap and warm water - Rub hands together vigorously and rinse under water - Wash for at least 15 seconds or up to 2 minutes if hands are more soiled - Dry with clean paper towel - Use clean, dry paper towel to turn off faucet if there are no foot or knee pedals Patient Teaching on Narcotics - Instead of teaching them that they cause constipation, inform them to increase fluid and fiber intake, and exercise. Physiological Factors Influencing Pain in Older Patients and how they respond to narcotics - Muscle mass decreases - Body fat increases - Frequency of eating poorly – low serum albumin levels - Decline of liver and renal function - Skin- thinning and loss of elasticity - Fatigue - Response: o Lethargic o Constipation o Confusions o drowsy What are Activities of Daily Living (ADLs)? - Activities usually performed throughout a normal day - Ambulation, Eating, Dressing, Bathing, Oral Hygiene, Grooming Nursing Diagnosis for Patients with Communication Problems - Language barrier - Knowledge deficit How to Communicate with a Patient with Aphasia - Listen attentively, be patient, and do not interrupt - Ask simple “yes” or “no” questions - Allow time for understanding and response - Use visual cues (words, pictures, objects) when needed - Allow one person to speak at a time - Encourage patient to converse - Do not shout or speak loudly Why Acrylic Nails Are Discouraged in Health Care Facilities - They harbor bacteria leading to infection - May puncture gloves Assessment Findings for a Patient Who Develops Atelectasis (collapsed lungs) - Collapse of alveoli - Decreased oxygen - Patient in discomfort - Hypoventilation - Collapsed lung - Low lung sounds when auscultating - Sounds: diminished breath sounds Aphasia Expressive: motor type; inability to name common objects or express simple ideas in words or writing Receptive: sensory type; unable to understand written or spoken language Simple assessment techniques: - Point to a familiar object and ask the patient to name it - Ask patient to respond to simple verbal and written commands such as “stand up” or “sit down” - Ask patient to read simple sentences out loud - Ask questions that require “yes” or “no” answers or blinking of the eyes - Offer pictures or a communication board so patient can point - Speak slowly and give patient time to understand and speak Pain Assessment Provoke Quality Region/Radiating Severity Timing Best time to teach about other treatments? When there is no more pain. Adventitious Breath Sounds Crackles - High pitched - Fine, short, interrupted crackling heard during end of inspiration Rhonchi (Sonorous Wheeze) - Loud, low pitched, rumbling course sounds heard during inspiration or expiration Wheezes (Sibilant Wheeze) - High pitched - Continuous musical sounds are squeak-like, heard continuously during inspiration or expiration (louder) Pleural Friction Rub - Dry, rubbing, or grating quality is heard during inspiration or expiration Isotonic Exercises - Cause muscle contraction and change in muscle length - Enhance circulatory and respiratory functioning - Increases muscle mass, tone, and strength - Walking, swimming, jogging Isometric Exercises - Involve tightening or tensing of muscles without moving body parts - Ideal for patients who are immobilized in a bed - Examples: quadriceps sets and contraction of gluteal muscles Resistive Isometric Exercises - Individual contracts muscle while pushing against a stationary object - Increases muscle strength and endurance - Push-ups ROM - Done hourly while awake - Procedure: Instruct clients to perform the following o Ankle pumps: point the toes towards the head and then away from the bed o Foot circles: rotate the feet in circles at the ankles o Knee flexion: flex and extend the legs at the knees Orthostatic Hypotension aka postural hypotension - When a normotensive person develops symptoms and low BP when rising to an upright position - Decreased pulse pressure - Low BP - Symptoms: o Dizziness o Light-headedness o Nausea o Tachycardia- increased pulse rate o Pallor o Fainting Prehypertension Systolic = 120-139 Diastolic = 80-89 - Patient must be rechecked in 1 year - Patient should get advice on lifestyle modifications SBAR Communication - Standard communication Situation - now Background - history Assessment – vitals/physical assessment Recommendation – labs/testing Wound Dehiscence vs. Evisceration Dehiscence – partial or total separation of wound layers - Patient at risk for poor wound healing is at risk for this Evisceration – protrusion of visceral organs through a wound opening - Emergency and requires surgical repair Manifestations: - A significant increase in the flow of serosanguineous fluid on the wound dressing - Immediate history of sudden straining (coughing, sneezing, vomiting) - Client reports a change or “popping” or “giving way” in the wound area - Visualization of viscera Prevention: - Thin, folded blanket or small pillow over surgical wounds when client coughs to support the wound Risk factors: - Chronic disease - Advanced age - Obesity - Vomiting - Invasive abdominal cancer - Excessive straining - Dehydration, malnutrition - Ineffective suturing - Abdominal surgery - infection Negative Effects of Immobility on All Systems Integumentary - Increased pressure on skin - Decreased circulation to tissue causing ischemia, which may lead to pressure ulcers Respiratory - Decreased respiratory movement resulting in decreased oxygenation and co2 exchange - Decreased cough response Cardiovascular - Orthostatic hypotension - Less fluid volume in circulatory system - Stasis of blood in legs - Decreased cardiac output leading to poor cardiac effectiveness, which results in increases cardiac workload - Increased risk of thrombus development - Increased oxygenation requirement Metabolic - Decreased basal metabolic rate - Changes in protein, carbs, and fat metabolism - Decreased appetite with altered nutritional intake - Negative nitrogen balance - Alterations in calcium, fluid, and electrolytes - Resorption of calcium from bones - Loss of muscle - Weight loss - Decreased urinary elimination of calcium resulting in hypercalcemia Genitourinary - Urinary stasis - Change in calcium metabolism with hypercalcemia resulting in renal calculi - Decreases fluid intake, poor perineal care, urinary tract infections Gastrointestinal - Decreased peristalsis - Decreased fluid intake - Constipation, then impaction, then diarrhea Musculoskeletal - Decreased muscle endurance, strength - Impaired balance - Atrophy of muscles - Decreased stability - Osteoporosis - Foot drop Neurological - Altered sensory perception - Ineffective coping Restraints Patient Assessment - Confused - Disoriented - Repeatedly fall - Try to remove medical devices When? - After doctor’s order How? - Never too tight - Two fingers should fit - Take them off and assess the skin every 2 hours o Book says to check every 15 minutes Pressure Ulcers Stages: I: Nonblanchable Erythema - Intact skin with area of persistent, nonblanchable redness - Swollen tissue II: Partial Thickness - Involves epidermis and the dermis - Ulcer is visible with reddish-pinkish bed without slough or bruising III: Full-Thickness Skin Loss - Damage to or necrosis of subcutaneous tissue - Ulcer appears as deep crater IV: Full-Thickness Tissue Loss - Destruction - Tissue necrosis - Damage to muscle, bone, or supporting structures - Deep pockets of infection, tunneling, slough Prevention - Avoid skin trauma o Keep skin clean, dry, and intact o Firm wrinkle-free foundation with wrinkle-free linens o Reposition client in bed every 2 hours, and every 1 hour if in a chair o Keep HOB elevated at 30 degrees to relieve pressure on buttocks, sacrum, and heels o Raise heels off bed o Ambulate patient o Instruct patients who are mobile to shift weight every 15 min o Keep clients from sliding down & lift rather than pull - Provide supportive devices o Pressure-reducing surfaces and devices (overlays; replacement mattresses; specialty beds; kinetic therapy; foam, gel, or air cushions) - Maintain skin hygiene o Inspect skin frequently o Clean skin with mild cleansing agent- pat it dry o Bathe with tepid water and avoid scrubbing o Apply moisture barrier creams or alcohol-free barrier creams o NO powder or cornstarch o Implement active and passive exercises o Do not massage bony prominences - Encourage proper nutrition o Adequate hydration and meet protein and calorie needs o Note is serum albumin level are low o Provide nutritional support- vitamins and mineral supplements o Monitor lymphocyte count Treatment - Suspected deep tissue and stage 1: o Relieve pressure o Encourage frequent turning and repositioning o Use pressure relieving devices- such as air-fluidized bed o Implement pressure reduction o Keep client dry, clean, well nourished, and hydrated - Stage 2: o Maintain moist healing environment (saline dressing) o Promote natural healing while preventing the formation of scar tissue o Provide nutritional supplements o Administer analgesics - Stage 3: o Clean and/ or debride the following: □ Prescribed dressing □ Surgical intervention □ Proteolytic enzymes o Provide nutritional supplements o Administer analgesics o Administer antimicrobials (topical and/ or systemic) - Stage 4: o Clean and/ or debride the following: □ Prescribed dressing □ Surgical intervention □ Proteolytic enzymes o Perform non-adherent dressing changes every 12 hours o Treatment can include skin grafts or specialized therapy such as hyperbaric oxygen o Provide nutritional supplements o Administer analgesics o Administer antimicrobials (topical and/ or systemic) Braden Scale – infection risk assessment tool for pressure ulcers Abdomen - inspect, auscultation Low pitched - rhonchi (2) Pt understands, doesn't talk - give him picture board (2) Doesn't want to cough, scared it will open up - put pillow Diabetic comes in - explain the dressing change Difference between dehiscent and evisceration High pitched - wheezing Ausc- diminished breath sounds Something is on fire - quality Vivid dreams - REM Pt can't talk - impaired verbal communication Restrains - takes out ng tube Confused but no anxiety - turn on bed alarm Pt falling - slide down ...assess the weight and what assistance is needed What do you monitor for pt with obstructive sleep apnea - respiratory Vital signs normal, O2 - 79% - assess that one first Vital signs are normal, later oral temperature was higher - did you drink something hot within 30 minutes? Uap with acrylic nails - bacteria Stockings - venous return to the heart Occult blood test - guaiac test Takes vicodin - plenty of water and fiber Adolescent with irregular pulse - apical for 1 minute After two times enema - do it with finger Cardiopulmonic smth - clubbing Bleeding while enema - stop and check the vitals Hip fracture, bedpan - raise the head Transmission the bacteria - hand washing During physical assessment, when the nurse should intervene - effectiveness of medical.. GI bleeding (select all that apply) - aspirin and nsaids