NCLEX Basic Care & Comfort

NCLEX Basic Care & Comfort Low Fowler's - ANS HEAD OF BED RAISED 15-30 DEGREES - resting/sleeping - reduce pain on lower back - postoperatively - position of comfort Semi-Fowler's - ANS HOB RAISED 30-45 DEGREES - For feeding (risk for reflux & aspiration) - for trouble breathing - further HOB elevated easier it is to breath leads lung more room for expansion Fowler's - ANS HOB RAISED 45-60 DEGREES - promoting lung expansion - NG tube (prevent reflux & aspiration) - start with this position to progress to mobility/walking (dangling legs) - postoperlavitly - risk for foot drop: a complication of immobility (use boots or foot board so don't develop) High Fowler's - ANS HOB ELEVATED 60-90 DEGREES - best position for PT at risk for aspiration while feeding - best position to insert a nasogastric tube - sometimes used for chest x-ray - sit all the way up - better room for lung expansion Orthopneic Position - ANS SITTING UP & LEANING OVER - less common - natural to some PT - position called tripoding - helps obstructive lung disease (COPD, asthma, emphysema) - helps with exhaling - maximum lung expansion Supine - ANS ALL THE WAY FLAT ON THE BACK - general exam or physicals assessment - best comfort - frequently used in surgery - legs can be all the way extended or bent - arms can be up or down supine complications - ANS - off load the boney pyromancies (back of the head: occiput, elbows, heels) - assess skin frequently for breakdown - support PT with aids: pillows especially under head & under lumbar curvature Prone - ANS LAYING ALL THE WAY ON BELLY - only position that allows full extension of the hip & knee joints - helps prevent contractures of the hips & knees - helps drain secretions - helps with aspiration - needs a lot of pillows (position aids) while their in prone - helps with ARDS (not ventilating): helps perfuse base of the lungs so we can get better O2 Prone complications - ANS - to be able to breathe head will need to be turned to one side - contraindicated when they have spinal problems b/c we are having a lot of gravity on the trunk when laying on anterior surface - if placed long- term PT when will need the head to be switch each side Right Lateral Recumbent - ANS LAY ON RIGHT SIDE OF BODY - relieves pressure on the bone promines that the client was laying on in supine - distribute weight on body in different areas - prevents pressure ulcers - promotes gastric emptying: filitates the movement of food from stomach to small intestines - helps with reflux Left Lateral Recumbent - ANS LEFT RIDE LAYING - relieves pressure on the bone promines that the client was laying on in supine - redistributes body weight - recommended to pregnant woman b/c increased blood flow to the placenta Trendelenburg - ANS LOWERING HOB & RAISING FEET - PT arms tucked at their sides - head down feet up - promotion of venous return leads to move blood back to the heart (for hypotension) - provides postural drainage ( drain bases of the lungs) - not for PT having trouble breathing Reverse Trendelenburg - ANS HEAD GOES UP & FEET GO DOWN - helps really severe reflux - helps minimize gastrointestinal problems by promoting gastric emptying - don't put PT in position rapidly, might not tolerate well - do position change slowly (minimize orthostatic hypotension) Sims - ANS SIM- I - PRONE - helps facility drainage (prevents aspiration) - lower pressures on lower part of the body - helps prevent contractures (help complication of immobility) - assess perennial area & clean - may use to administer enema - position of comfort - left side for pregnant patient - use pillows - position used if PT can't tolerate full prone position of Sims - ANS - one arm bent - other behind client - flexion of top knee & top hip PT halfway between R or L lateral and prone position Traction Positioning - ANS - realign bones or dislocated parts of the body Uses a pulling force to realign a bone ● Skeletal ○ Uses screws/pins into the bone ○ 15 - 30 lbs of pulling force ○ Example: Halo Traction ● Skin ○ Decreases muscles spasms ○ 5- 10 lbs of pulling force ○ Example: Buck Traction Traction Nursing Actions - ANS ● Do NOT adjust weights unless specifically ordered to by the PHCP. ● Weights should be free hanging ● Ensure no fraying of ropes/pulleys ● Monitor circulation hourly for the first 24 hours then every 4 hours ● Pin Site Care: ○ Use of Saline/Vaseline Dressings (facility protocol may differ) ○ Done every 8 - 12 hours Signs of Pin Site Infection: - ANS - red hot to touch ○ Loose pins (no traction effective) ○ Purulent drainage from pins (clear is an expected finding) ○ Oder ○ Fever ways to treat pain - ANS ○ Nonpharmacological ○ Non-opioid analgesics ○ Opioid analgesics Nonpharmacological: body - ANS ● Massage ● Reiki ● Acupuncture ● Acupressure ● Progressive muscle relaxation ● Biofeedback: transcutaneous electrical stimulant - apply heat or cold Nonpharmacological: mind - ANS ● Meditation ● Prayer ● Guided imagery ● Hypnosis ● Mind/Body exercises ● Distraction ● Deep breathing: effective, actives vagus nerve & turns on parasympathetic nervous system Mobility assessment - ANS ● Many different tools available ● You may score your client with a tool, which determines the amount of assistance they need. ● Common methods of assessing ○ Sit and shake ■ How is their trunk strength, seated balance, and cognition? ○ Stretch and point ■ How is their lower extremity stability and strength? ○ Stand ■ Can they stand? Strength from sitting to standing? ○ Walk ■ How is their standing balance? Assess their gait while walking. Complications of immobility - ANS ● Skin breakdown ○ Pressure ulcers ● Contractures (high or semi fowlers) ● Muscular weakness ● Muscular atrophy (waste away) ● Loss of calcium from the bones ● Atelectasis (collapsed alveoli) ○ Pneumonia, respiratory infections ● Venous stasis ○ DVT -- Can lead to a clot anywhere in the body! - red, warm signs a clot dislodged anywhere in the body is an emergency Loss of calcium from the bones - ANS ○ Osteoporosis (weak, brittle bone) ○ Hypercalcemia (increase calcium in blood) ○ Renal calculi (kidney stone) - risk for fractures - hypercoagulable: clotting a lot develop blood clot Skin breakdown - ANS ● Always assess your client's skin! ● Use a risk score ○ Ex - Braden scale (adult) ● Open sores can lead to infection - sacral pressure ulcer and wears a diaper with fecal incontinences leads to bloodstream then leads to sepsis high fowler & semi fowlers leads to - ANS cutting off blood flow -- tissue hypoxia --- skin breakdown Ways to reduce pressure - ANS ● Assess the source of the pressure + reduce it!! ● Turn (every 2 hrs) ● Reposition (every 2 hrs) ● HOB 30 degrees ● Padding on bony prominences (tuck pillow under calves) ● Float the heels off the bed ● Specialty mattresses ● NO donut-shaped pillow Promoting venous return - ANS ● Venous stasis = blood isn't flowing! ● Blood that's not flowing clots. We want to prevent that! ● Devices that promote venous return ○ Ted hose ○ Compression stockings - squeeze calves, get blood back to heart ○ Sequential compression devices (SCDs): inflated balloons around calves that inflates and deflates to push blood back to the heart Range of Motion - ANS ● Prolonged immobility caused decreased range of motion ● Totally immoble? ○ Help your client with passive range of motion activities? ● Able to do some movement? ○ Teach them about active range of motion activities? Contractures - ANS - Permanent tightening of the muscles, tendons, skin, and tissue causes a joint to become really stiff & shorten ● Foot drop ○ Plantar flexion contracture ○ Prevent with boots! or foot board - supine Nutrition Assessment - ANS ● Any unintentional weight loss ○ If present in the past three months, client at risk for deficit ● How is their appetite ○ Reduced dietary intake in the last week puts the client at risk ● Body Mass Index ○ 18.5 is underweight ● Elderly clients at higher risk ● Assess skin turgor and mucous membranes - are they hydrated? ● What is their appearance? ● Energy level Calculating BMI - ANS BMI = weight (kg) / height squared X (m squared) BMI - ANS 18.5 - Underweight 18.5-24.9 - Normal weight 25.0-29.9 - Overweight 30 - Obese - doesn't account for muscle or bone density Interventions for nutrition - ANS ● Oral nutrition ○ High calories ○ High protein (heal & rebuild body) ● Enteral nutrition (into gut) ○ Feeding delivered via a nasogastric tube ● Parenteral nutrition (around gut, into veins) ○ Feeding delivered intravenously. - monitor fluid & electrolytes - daily weights - input & output What is a nasogastric tube? - ANS ● Tube inserted in the nare that terminates in the stomach ● Uses: ( put in or take out) ○ Enteral nutrition ○ Decompression ○ Medication administration ○ Removal of stomach contents after an overdose - Out: overdose, blockage - in: nutrition Insertion a nasogastric tube? - ANS 1. Perform hand hygiene 2. Explain the procedure to the client 3. Measure from the earlobe of the client to the nose, then to the xiphoid process. This is how deep you will insert the NG tube. 4. Mark the depth of insertion on the NG tube 5. Lubricate the tip of the tube. 6. Insert the tube to the nasopharynx, and ask the client to swallow and tuck their chin to their chest. 7. Continue advancing the tube to the predetermined depth. 8. Secure the tube. 9. Verify placement of the NG tube. Placement verification of a nasogastric tube? - ANS ● Gold standard - x-ray visualization*** ● Aspiration of gastric contents (check pH) ● Auscultation of air over the epigastrium - hear in belly ● Residuals (syringe + pull back to assess digestion): ○ The amount of feeding that remains in the stomach at the time of your assessment ○ Typically checked as you are preparing to start the next feed ○ If it is greater than 500 mL, the feed should be held. Elimination Assessment - ANS ● Assess your client for alterations in elimination (too little or too much) ○ Bowel ○ Bladder ● Incontinence (can't control) ○ May need intervention to promote elimination ○ At high risk of skin breakdown - altered LOC or sedated, development delays, elderly, infection (UTI) At risk clients - ANS ● Altered level of consciousness ● Developmental level ● Advanced age ● Poor muscular tone ● Urinary tract infection Interventions - ANS ● Maintain skin integrity ○ Keep skin clean and dry (top priority) ○ Check and change bedding/pad/diaper etc. often ● Medications ○ Diuretics → Promote urinary elimination ○ Laxatives/stool softeners → Promote bowel elimination ○ Enemas ● Colostomy or ileostomy (surgery) ● Urinary catheter Colostomy & Ileostomy - ANS ● Colostomy ○ Opening in the large intestine brought to the surface ○ Stool will be formed (normal) ● Ileostomy ○ Opening created in the small intestine brought to the surface ○ Higher risk for dehydration, electrolyte & fluid imbalance ○ Stool will be liquidy (not reabsorbed) Monitor their fluid & electrolytes closely!! Nursing Care of the Ostomy - ANS ● Empty the pouch when ⅓-½ full ● Change pouch every 3-5 days ● Keep stoma clean and dry ● Assess peristomal skin closely for breakdown - wound care Enemas - ANS ● Supplies needed: enema bag and solution, lubricant, gloves, clamp, towel/bed pads (a lot) ● Ideal position for the client - left side with knees drawn up or Sims position ● Always warm the solution administration steps for enemas - ANS ● Smart to put a towel or pads under the client first! ● Administration steps: 1. Fill enema bag, prime, and clamp tubing 2. Lubricate the tip of the enema applicator. 3. Insert into client's rectum (just until you meet resistance) 4. Release clamp 5. Remove applicator after solution has infused (all solution) - in as long as they can usually about 10 minutes What is a foley catheter? - ANS ● Catheter placed into the urethra and up to the client's bladder ● Foley catheters are 'indwelling' or left for an extended period of time ● Urine drains into a drainage bag - high risk for UTI (catheter associated) Inserting a foley catheter - ANS 1. Wash your hands and don sterile gloves 2. Place the tip of the catheter in lubricant 3. Clean with betadine a. Females: Use the non-dominant hand to spread the labia. Use three swabs: one on the left, one on the right, and the last one down the middle. - through each swab away using sterile hand b. Male: Clean the peri-urethral opening with three swabs. 4. Using the dominant hand, insert the catheter into the urethral opening 5. Once urine is observed, advance the catheter another one to two inches 6. Attach the pre-filled syringe to the port and inflate the balloon 7. Connect the drainage system to the catheter and secure per facility protocol. Nursing Must Know - ANS ● There should never be dependent loops in the tubing. (kinking tube) This can lead to urine backing up in the bladder. ● Inserting a foley catheter requires sterile technique to prevent infection. ● CAUTIS (catheter acquired urinary tract infections) are UTIs caused by a catheter. The hospital is not reimbursed for these infections, so there is a lot of emphasis on preventing them. ○ Most facilities use a bundle to prevent CAUTIS ■ Always remove as soon as possible - can get up & void on own ■ Daily cleaning and care ● You can collect a urine sample directly from the port on the foley! (only RN allowed to do) Collecting a urine sample - ANS 1. Collect supplies. 2. Wash hands, put on gloves. 3. Wipe genitals with a towelette 4. Allow urine for flow for two seconds, then place sterile container to collect sample. 5. Client can finish urinating. 6. Replace lid on specimen container and label according to policy. Place in a specimen bag. 7. Remove gloves, wash hands.