NR 226 Final exam Questions and Answers

NR 226 Final exam Questions and Answers Critical Thinking -Continuous process characterized by open-mindedness, continual inquiry, and perseverance -Recognizing that an issue exists, analyzing information, evaluating information, and making conclusions using a systematic apprach Critical thinking skills Interpretation Analysis Inference Evaluation Explanation Self-regulation A critical thinker considers what things? What is important in each clinical situation Imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients Aspects of critical thinking Reflection Language Intuition Levels of critical thinking Commitment (level 3),- results from an expert level of knowledge, experience, developed intuition, and reflective flexible attitudes Complex (level 2)- expresses autonomy by analyzing and examining data to determine best alternatives Basic (level 1)- results from limited knowledge and experience Components of critical thinking Knowledge base Experience Competence Attitudes Standards ADPIE Assessment- what you see, hear, feel, touch and smell Diagnosis- NANDA Planning- set realistic goals, and outcomes and identify appropriate nursing actions Implementation- perform the nursing actions identified in planning Evaluation- determine if goals and expected outcomes were achieved How do you know if you delegate vs not delegate task?` Your ongoing assessments of your patients, the priorities of each, following delegation guidelines and only delegating interventions within the delegates training and ability What is concept mapping and how is it helpful? A visual representation of patient problems and interventions that shows their relationships to one another -primary purpose of concept mapping is to better synthesize relevant data about a patient, including assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures How can reflective journaling be helpful to a nurse? A tool used to clarify concepts through reflection by thinking back or recalling situation -Gives the chance to define and express clinical experiences in own words HIPPA Privacy Rule Give patients new rights to access their medical records, restrict access by others, request changes, and learn how they're accessed Restrict most disclosures of protected health information (PHI) to minimum needed for health care treatment and business operations All patients are formally notified of covered entities' privacy practices Enable patients to decide who they include in disclosure of their PHI for uses other than treatment or health care business operations Establish new criminal and civil sanctions for improper use or disclosure of PHI Establish new requirements for access to records by researchers and others Establish business associate agreements with business partners who safeguard their use and disclosure of PHI In regards to HIPPA in the workplace what is important to remember to help protect your patients privacy? -Only share information with who patient gives permission too. If patient has altered LOC use best judgement -Do not display patients’ identifying information (name, social security number, address, telephone number) in public places -Computer workstations should be password protected agency can track who is accessing patients’ records -Be sure to sign off from your workstation each time you leave the console so that others do not use your password -Keep computer workstations shielded from others view -Shred unkept medical records so privacy of PHI is maintained -Communicate orally quietly those not involved in patient’s care cant hear you -When transferring PHI via fax or computer, follow your agency’s policies and procedures. -Communicate by telephone using a private line, and verify identity of person or agency receiving information PQRSTU *PQRSTU* stands for *P*rovocative or palliative, *Q*uality or quantity, *R*egion or radiation, *S*everity scale, *T*iming, and *U*nderstanding the patient's perception of the problem. Communicable disease Infectious disease transmitted from one person to another Symptomatic infection vs Asymptomatic infections Symptomatic: -Pathogens multiply and cause clinical signs and symptoms Asymptomatic: -Absent of signs and symptoms Chain of infection Infectious agent or pathogen Reservoir or source for pathogen Portal of exit Mode of transmission Portal of entry Susceptible host Modes of transmission Direct- Person to person Person to source Indirect- Person to inanimate object Droplet- Coughing, sneezing, talking (lg particle only 3ft) Airborne- Droplet nuclei or residue suspended in air carried on dust particles Vehicles- Food, water, drugs, and solutions, blood, fomites Vector- External transfer Internal transmission (parasitic) Mosquito, louse, flea, tick Standard precautions designed to be used for the care of all patients, in all settings, regardless of risk or presumed infection status. -Includes- Use of PPE when the nurse may be exposed to or is handiling blood, blood products, body fluids, secretions/excretions, non-intact skin, or mucous membranes Examples- HIV and AIDS Contact precautions -gloves and gown (wear mask, and or goggles only if needed) -door closed, private room or cohort patients -Direct/Indirect contact with patient and their environment-c-diff, MRSA, herpes, VRE Droplet precautions -Wear mask when within 3 feet of patient -Door-closed private room or cohort patients -Droplets larger than 5 microns - Flu, Strep pharyngitis, pneumonia, meningitis Protective environment Applies to significantly immuno-compromised patients -positive airflow with HEPA filtration for incoming air Airborne precautions - N95 mask -negative air pressure room (HEPA filtered and flows to outside) -Private room with door shut -transmitted by small droplets 5 - TB, measles, varicella Sterile field includes -1 inch margins -Sterile gloves -Never turning your back on the field -Hands above the waist level -Appropriate PPE -Dry surface area Aerobic bacteria VS. Anaerobic bacteria Aerobic: Require oxygen for survival and for multiplication sufficient to cause disease Anaerobic: Thrive where little or no free oxygen is available Bacteriostasis VS. Bactericidal Bacteriostasis: Prevention of growth and reproduction of bacteria Bactericidal: Destructive to bacteria Stages of infectious process Incubation period- Interval between entrance of pathogen into body and appearance of first symptoms Prodromal stage- Interval from onset of nonspecific signs and symptoms Full stage of illness- Interval when patient manifests signs and symptoms specific to type of infection Convalescent period- Interval when acute symptoms of infection disappear The cellular response of the body to injury, infection, or irritation is termed Inflammation - a protective vascular reaction that delivers fluid, blood products, and nutrients to an area of injury What is an HAI? Healthcare-associated infection- They occur as the result of invasive procedures, antibiotic administration, the presence of multidrug-resistant organisms (MDROs), and breaks in infection prevention and control activities. Risk factors for HAIs Multiple illnesses Older adults Poorly nourished Lowered resistance to infection Critical illness Invasive treatment devices Major sites for HAI infection Surgical traumatic wounds Urinary and respiratory tracts Bloodstream Why are older adults more at risk for infections and HAIs? -Age-related functional deterioration in immune system function -Older adults are less capable of producing lymphocytes to combat challenges to immune system -Risks associated with development of infections or HAIs poor nutrition, unintentional weight loss, lack of exercise, poor social support, and low serum albumin levels -Flu and pneumonia vaccinations are recommended -Teach older adults and their families how to reduce risk by using proper hand hygiene practices Defenses against infection Normal flora Body defense mechanisms Inflammation Vascular and cellular responses Inflammatory exudate Tissue repair Factors influencing infection prevention and control Age Nutritional status Stress Disease process Treatments or conditions that compromise the immune response Infection prevention and control to reduce reservoirs of infection Bathing Dressing change Proper disposal of contaminated articles and sharps Cleaning bedside unit Not leaving bottles solutions opened Cleaning surgical wounds Wearing proper PPE Nosocomial infection Health care-associated infection Medical Asepsis Controlling pathogen Hand hygiene, barrier technique, and routine environmental cleaning "Clean procedure" Common in home, ECF, assisted living Standard precautions (CDC) Sterile Asepsis Killing or eliminating pathogen Scrub (surgical) PPE sterile handling Common in hospital Principles of surgical asepsis A sterile object remains sterile only when touched by another sterile object Only sterile objects may be placed on a sterile field A sterile object or field out of range of vision or an object held below a person's waist is contaminated A sterile object or field becomes contaminated by prolonged exposure to air When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action Fluid flows in the direction of gravity The edges of a sterile field or container are considered to be contaminated Cleaning is the removal of.. organic material (blood) or inorganic material (soil) from objects and surfaces --using water, a detergent/disinfectant, and proper mechanical scrubbing Disinfection A process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects Autoclave High level disinfection, which is required for some items such as endoscopes Sterilization The complete elimination or destruction of all microorganisms, including spores --include steam, dry heat, hydrogen peroxide plasma, or ethylene oxide (ETO) What are some skills and procedures that should be performed using clean technique and sterile technique Clean- Food utensils, bed pans, blood pressure cuffs, bed rails, linens, stethoscopes, patient furniture Sterile- Surgical instruments, cardiac or intravascular catheters, urinary catheters, implants High-level disinfected/ sterile- Endoscopes, respiratory and anesthesia equipment, GI endoscopes, diaphragm fitting rings What is the order for removing full PPE? Gloves, eyewear/face shield or goggles, untie waist and neck strings of gown folding inside out, face mask Wash hands Ranges of normal vital signs Pulse= 60-100 regular 2+ regular Respirations= 12-20 bpm Blood pressure= 120/80 mmHg Temperature= 36c- 38c O2 stats= 95-100 What can cause alterations in heart rate? Infection Anxiety Medications Exercise Stress Athletes What can cause alterations in respiratory rate fear, fever, age drugs, or metabolic conditions What can cause alterations in temperature? Medications Drinking Eating Disease process Fever Immobility complications Orthostatic hypotension Atlectasis Pressure ulcers Thrombus Renal calculi Psychosocial effects DVT Muscle atrophy Hypotension Altered self image Constipation Metabolic effects of immobility Slowed wound healing Muscle atrophy Decreased amount of subcutaneous fat Respiratory effects of immobility Decreased O2 sat Crackles/wheezes Dyspnea GI and GU effects of immobility GI: Distended abdomen Decreased bowel sounds Decreased frequency of elimination GU: Dysuria Decreased urinary output Cloudy/concentrated urine Cardiovascular effects of immobility Orthostatis hypotension Increased heart rate Weak peripheral pulses Increase monitor for edema DVT Musculoskeletal effects of immobility Lack of coordination Altered gait Contractures Decreased muscle tone and strength Decreased ROM Psychosocial effects of immobility Hostility, fear and anxiety Confusion Feeling powerless Decreased self esteem Altered coping Sleep-wake alterations Depression What is orthostatic hypotension and how can you help to prevent it Increased pulse rate, decreased pule pressure, and a drop in blood pressure, and can lead to fainting Help prevent it by Implementing interventions that reduce or eliminate the effects-mobilize patient as soon as physical condition allows Could include- taking BP while pt stands, assess their current medications, watching pts. input and output of fluid Strategies to prevent complications of immobility Slowed wound healing, muscular atrophy: Increase protein, and calories start TPN or enteral feedings Urinary complications: Encourage fluids and record I/O Respiratory: Incentive spirometer q 1-2 hours while awake TCDB Abdominal and GI tract: Prevent constipation -Increase fiber -Increase fluids -Increase activity Skin integrity: Reposition every 2 hrs, manage moisture, optimize nutrition/health, minimize pressure Muscle tone: Ambulation, splint, PT, active and passive ROM, repositioning, exercise programs DVT prophylaxis Leg, foot and ankle exercises Dangle lower extremities Fluids Position changes Medications Do not massage legs Initiate DVT prophylaxis Anti-embolic stockings (TED hose) and SCDs - remove to assess skin Range of Motion (ROM) Any body action involving muscles and joints in natural directional movements -Can be performed by PT, RN, or allied staff -Indicated for pts confined to bed for long periods of time Preventing injury when lifting or moving Assess situation carefully Use large muscle groups whenever possible --Pelvic tilt helps protect lower back from injury Work at appropriate height Use mechanical lifts ROM - Support the joint ______ to the one being exercised Distal What should the nurse include in a teaching session to a patient who is using a cane for the first time? Keep cane on the stronger side of body For maximum support when walking place cane forward 15-25 cm (6-10 inches) keeping body weight on both legs, then move weaker leg forward to the cane so weight is evenly distributed, then advance stronger leg past the cane How do you measure a patient for a cane? Cane length is equal to the distance between the greater trochanter and the floor What are the two types of canes and who uses them? Single straight legged cane is more common and used to support and balance a patient with decreased leg strength The quad cane provides the most support and is used when there is partial or complete leg paralysis or some hemiplegia What should a nurse in a teaching session to a patient who is using a walker for the first time? Hold the hand grips on the upper bars, take a step and then move the walker forward before taking another steps How do you measure a walker for a patient? Measure by having patients relax their arms at the side of their body and stand up straight, top of walker should line up with crease on inside of wrist, elbows should be flexed 15-30 degrees when standing inside walker with hands on the handgrips A walker may be prescribed for patients who Are weak or have a problem with balance Walkers with wheels are useful for patients how have difficulty lifting and advancing the walker as they walk What should a nurse include in a teaching session to a patient who is using crutches for the first time? The proper crutch gate they need to use per their injury Used modified 3 point when using stairs What do you teach a patient about going up the stairs on crutches? When ascending stairs advance unaffected leg between crutches to the stairs, then sift weight from crutches to unaffected leg and then align crutches on stairs What do you teach a patient about going down the stairs on crutches? Use a three phase sequence transferring body weight to unaffected leg, then place crutches on stairs and begin to transfer weight to the crutches moving the affected leg forward, finally move the unaffected leg to the stairs with crutches Crutch gaits Four-point - gives stability to the patient but requires weight bearing on both legs, each leg is moved alternately with each opposing crutch so there are three point on floor at all times Three-point- requires patient to bear all weight on one foot, the uninvolved leg , the affected leg does not touch the ground during the early phase Two-point- requires the least partial weight bearing on each foot, move crutch as same time of the opposing leg What are the two types of crutches and how are they used? Double adjustable crutch/forearm crutch has a hand grip and metal band that fits around patients forearm, metal band and handgrip are adjusted to fit patients height Axillary crutch has padded curved surface which fits under the axilla, a hand grip in the form of a cross bar is held at level of palms to support body How are patients measured for crutches? Axillary crutch includes patients height, angle of elbow flexion, and distance between crutch pad and axilla --- ensure that length of crutch is 2-3 finger widths from the axilla and position the tips 2 inch laterally and 4-6 inch anterior to front of patients shoe -elbows should be slightly flexed at 20-25 degrees When assisting a patient to walk what is the point in using a gait belt around the patients waist? To provide support so the patients center of gravity remains midline When assisting a patient using a gait belt, how should you proceed if the patient begins to fall or faint? Assume a wide base of support with one foot infront of the other Extend one leg letting the patient slide against the leg and gently lower them to the floor protecting the head SBAR Situation - What is going on with the patient? Background - What is the clinical background or context? Assessment - What do I think the problem is? Recommendation - What would I recommend? Do you have any questions for me? Types of alarms Telemetry Ventilator Bed alarms IV pumps Contributing factos to misuse of medical alarms Alarm fatigue Improper alarm settings Equipment malfunctions and failures Alarm settings inappropriately turned off Alarm settings not integrated with other medical devices Inadequate staffing Alarms not audible in all necessary clinical areas