NURSE 215 EXAM 2
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Questions and Answers

Which factor is least likely to impact a patient's ability to maintain proper hygiene?

  • Well-managed chronic illness (correct)
  • Emotional disturbances
  • Cognitive impairment
  • Sensory deficits

    • What is the primary focus when assisting an immobile patient with hygiene?

  • Minimizing discomfort while bath is given
  • Ensuring hygiene is performed quickly
  • Maximizing the patient's independence (correct)
  • Providing a thorough cleaning regardless of patient needs

    • In providing hair care for an unconscious patient on bedrest, which method is most appropriate?

  • Using a traditional shampoo and a rinse
  • Utilizing a basin and water
  • Applying dry shampoo directly to the hair
  • Using rinse-free shampoo or a basin with water (correct)

    • When questioning a patient about their usual hair care practices, what is the best inquiry?

    <p>How do you usually care for your hair at home?</p> Signup and view all the answers

    What is the most critical action for the nurse when observing white spots on the tongue of an unconscious patient?

    <p>Report the findings to the provider</p> Signup and view all the answers

    In an instance where a patient has inflammation and foul odor in skin folds, what is the best nursing intervention?

    <p>Keep the area clean, dry, and report findings</p> Signup and view all the answers

    Which statement by a patient's daughter indicates a need for further education on hygiene safety for her father with limited mobility?

    <p>I let him bathe alone although he is unsteady.</p> Signup and view all the answers

    What type of bath would be most suitable for areas that are hard to reach?

    <p>Assist bath</p> Signup and view all the answers

    Which of the following is an appropriate nonpharmacological intervention for acute pain management in patients?

    <p>Acupuncture</p> Signup and view all the answers

    What is a common misconception about pain management goals?

    <p>They should always aim for complete pain elimination.</p> Signup and view all the answers

    Which statement correctly represents the concept of referred pain?

    <p>Pain experienced in an area different from the injury's origin.</p> Signup and view all the answers

    Which risk factor is associated with sensory overload in patients?

    <p>Isolation</p> Signup and view all the answers

    What is NOT a permissible action for a UAP regarding patient care?

    <p>Performing a pain assessment</p> Signup and view all the answers

    In which stage of infection do symptoms first present themselves?

    <p>Illness</p> Signup and view all the answers

    Which of the following defines a systemic infection?

    <p>Infection that spreads via blood or lymph.</p> Signup and view all the answers

    What might a foul odor and reddened skin between a patient's toes indicate in a patient with a cast?

    <p>Bacterial infection or moisture issues</p> Signup and view all the answers

    What is a significant concern for patients with diabetic neuropathy?

    <p>Risk of burns due to reduced sensation.</p> Signup and view all the answers

    What is an ineffective response to a patient experiencing sensory deprivation?

    <p>Encouraging isolation.</p> Signup and view all the answers

    Which statement indicates a need for further education regarding denture care?

    <p>I never take my dentures out even when I am asleep.</p> Signup and view all the answers

    What is the most appropriate action when repositioning a patient in a chair to prevent skin breakdown?

    <p>Limit sitting time to 1 hour and shift weight every 15 minutes.</p> Signup and view all the answers

    What characterizes the prodromal stage of infection?

    <p>Initial vague symptoms beginning to appear.</p> Signup and view all the answers

    Which intervention is NOT appropriate for a patient at risk for immobility-related complications?

    <p>Implementing a sitting position for meals only</p> Signup and view all the answers

    When scoring the Braden Scale, which score indicates the least risk for skin breakdown?

    <p>23</p> Signup and view all the answers

    What is the correct sequence for using crutches when navigating stairs?

    <p>Lead with the unaffected leg and maintain weight on crutches</p> Signup and view all the answers

    Which nursing action should be avoided when practicing proper body mechanics?

    <p>Bending and twisting your neck and back.</p> Signup and view all the answers

    How should a nurse respond to a patient who feels uncomfortable waiting for a same-sex staff member for personal hygiene care?

    <p>Respect the patient's wishes and reschedule the care accordingly.</p> Signup and view all the answers

    Which of the following is the most appropriate method for delivering therapeutic communication with a patient?

    <p>Ask open-ended questions to encourage conversation.</p> Signup and view all the answers

    Which of the following is a risk factor most associated with immobility?

    <p>Muscle weakness and atrophy</p> Signup and view all the answers

    When calculating medication dosage based on an order, what is the correct amount to give if the order is for 100mcg and the medication is supplied as 0.1mg/tablet?

    <p>1 tablet</p> Signup and view all the answers

    What classification of pain is characterized by its origin from deep internal organs?

    <p>Visceral pain</p> Signup and view all the answers

    When assessing pain in a patient with dementia, which method is most appropriate?

    <p>Observing nonverbal cues and expressions</p> Signup and view all the answers

    Which of the following measures is an appropriate nursing intervention for a patient exhibiting pressure injuries?

    <p>Increase the frequency of patient repositioning</p> Signup and view all the answers

    What is the purpose of the Braden Scale in patient assessment?

    <p>To evaluate the risk of pressure ulcer development</p> Signup and view all the answers

    What indicates a systemic infection in patients with increased WBC count?

    <p>Leukocytosis, fever/chills, and positive blood cultures</p> Signup and view all the answers

    What is a potential sign of tinea pedis that requires notifying the provider?

    <p>Redness and itching between toes</p> Signup and view all the answers

    Which factor is primarily related to increasing the risk of skin infections?

    <p>Maintaining long fingernails</p> Signup and view all the answers

    What precautions should be taken for someone with a droplet-transmissible infection?

    <p>Standard surgical mask and eye protection when within three feet</p> Signup and view all the answers

    What is the best practice to prevent the spread of infection among staff and patients?

    <p>Frequent hand washing</p> Signup and view all the answers

    What is the correct response if a patient begins to fall?

    <p>Assist the patient down to the ground gently</p> Signup and view all the answers

    What is the most relevant method to confirm patient identity prior to treatment?

    <p>Asking the patient for two identifiers, like name and date of birth</p> Signup and view all the answers

    What is the best practice for caring for a patient at risk of DVT?

    <p>Use compression stockings and ambulate if possible</p> Signup and view all the answers

    What type of infection arises from the patient's normal flora due to treatment?

    <p>Endogenous infections</p> Signup and view all the answers

    What indicates that a patient is at high risk for aspiration?

    <p>History of stroke and decreased level of consciousness</p> Signup and view all the answers

    Which score on the Braden Scale indicates the highest risk for skin breakdown?

    <p>10</p> Signup and view all the answers

    What is the correct action a nurse should take to minimize back strain when providing patient care?

    <p>Maintain a wide base of support and keep the back straight.</p> Signup and view all the answers

    When calculating medication dosage for a patient, what does an order for 250mg PO QID convert to in grams per day?

    <p>0.25 grams/day</p> Signup and view all the answers

    Which statement best describes the role of therapeutic communication in patient care?

    <p>Assessing patient feelings without making assumptions.</p> Signup and view all the answers

    What common mistake should be avoided when assessing a patient's pain according to NCLEX standards?

    <p>Relying solely on physiological signs of pain.</p> Signup and view all the answers

    Which action should be prioritized when providing oral care for an unconscious patient?

    <p>Use a moistened mouth swab that is attached to suction.</p> Signup and view all the answers

    What is the most effective intervention for preventing skin breakdown in an immobile patient?

    <p>Rotate float heels off the bed regularly.</p> Signup and view all the answers

    When assessing a patient's skin, which condition should a nurse report to the healthcare provider?

    <p>White spots on the tongue.</p> Signup and view all the answers

    Which statement best reflects the needs of a patient who is unsteady and uses an assistive device during bathing?

    <p>Offer assistance with washing hard-to-reach areas during his bath.</p> Signup and view all the answers

    In what scenario should the nurse utilize a therapeutic bath?

    <p>To provide relief from skin irritation or rashes.</p> Signup and view all the answers

    What is the appropriate way for a nurse to manage skin folds that are inflamed and show signs of infection?

    <p>Keep the area clean and dry and report findings to the provider.</p> Signup and view all the answers

    What is the key consideration when planning hygiene care for a patient with cognitive impairment?

    <p>Adapt hygiene practices to incorporate familiar routines.</p> Signup and view all the answers

    How should a nurse respond to a patient's complaint of burning and itching in skin folds?

    <p>Keep the area clean and dry and report findings to the provider.</p> Signup and view all the answers

    Which of the following factors can significantly influence a patient's perception of pain?

    <p>Emotional state</p> Signup and view all the answers

    What is the primary concern when using cold therapy for pain management?

    <p>It should not cause erythema or blisters.</p> Signup and view all the answers

    Which nursing intervention is inappropriate when managing sensory overload in a patient?

    <p>Encouraging visitors to stay longer for comfort</p> Signup and view all the answers

    In the context of the chain of infection, what does the portal of exit refer to?

    <p>The routes by which the infectious agent leaves the reservoir</p> Signup and view all the answers

    Which type of infection is characterized by vague and non-specific symptoms without decisive clinical signs?

    <p>Prodromal infection</p> Signup and view all the answers

    What should a nurse consider while assessing a patient who exhibits sensory deprivation?

    <p>The patient’s access to sensory stimulation devices</p> Signup and view all the answers

    In which stage of infection does the body show signs of recovery and tissue repair?

    <p>Convalescence stage</p> Signup and view all the answers

    What is a common misconception regarding nonpharmacological interventions for pain management?

    <p>They are always effective for all patients.</p> Signup and view all the answers

    Which nursing action is crucial when caring for a patient with diabetes to prevent complications of peripheral neuropathy?

    <p>Examining feet daily for skin breakdown</p> Signup and view all the answers

    What is the most important nursing intervention for managing a patient with increased risk of skin breakdown due to immobility?

    <p>Turn and reposition the patient regularly</p> Signup and view all the answers

    Which classification of pain is most closely associated with psychological factors rather than physical injury?

    <p>Psychogenic pain</p> Signup and view all the answers

    What factor can significantly increase the risk of skin breakdown in obese patients?

    <p>Presence of skin folds that retain moisture</p> Signup and view all the answers

    According to the Braden Scale, which score indicates the highest risk for pressure ulcers?

    <p>Less than 12</p> Signup and view all the answers

    What should a nurse prioritize when assessing a confused client experiencing pain?

    <p>Observe for changes in behavior or vital signs</p> Signup and view all the answers

    In terms of pain management, what is a primary consideration for nursing care in patients with chronic pain?

    <p>Effective communication about pain levels is vital</p> Signup and view all the answers

    What is the correct action for a nurse when a patient with a cast has reddened skin and odor between their toes?

    <p>Inquire about itching or burning sensations</p> Signup and view all the answers

    Which patient-centered care practice respects individual cultural preferences in hygiene?

    <p>Allowing same-sex staff to assist with hygiene</p> Signup and view all the answers

    What should be emphasized when creating an effective oral hygiene plan for older adults with dentures?

    <p>Advocate for removal before bedtime</p> Signup and view all the answers

    Which of the following conditions could potentially lead to urinary stasis in an immobile patient?

    <p>Prolonged bed rest and decreased activity</p> Signup and view all the answers

    What is the primary characteristic of purulent drainage?

    <p>Pus-filled, yellow or green appearance</p> Signup and view all the answers

    Which of the following is the best action to prevent skin breakdown in patients with high risk factors?

    <p>Keep skin moisturized and check frequently</p> Signup and view all the answers

    What constitutes an exogenous infection?

    <p>Infection originating from the environment outside the body</p> Signup and view all the answers

    Under what condition must the nurse implement protective isolation for a patient?

    <p>Patient is immune compromised</p> Signup and view all the answers

    What is a common mechanism of pathogen transmission listed as a vector?

    <p>Mosquito bites</p> Signup and view all the answers

    Which action is least effective in infection control within a healthcare environment?

    <p>Leaving long fingernails natural</p> Signup and view all the answers

    When should the nurse consider using compression stockings?

    <p>Immediately after surgery to prevent DVT</p> Signup and view all the answers

    What is the preferred method for confirming a patient's identity before treatment?

    <p>Have the patient confirm using two identifiers</p> Signup and view all the answers

    Why should nurses avoid using lotion between fingers?

    <p>It can lead to skin breakdown due to moisture retention</p> Signup and view all the answers

    What is the primary goal of implementing medical asepsis in a healthcare setting?

    <p>To control infection through cleanliness</p> Signup and view all the answers

    What is the maximum score on the Braden Scale indicating the least risk for skin breakdown?

    <p>23</p> Signup and view all the answers

    When calculating the medication dosage, how many tablets should be given for an order of 7.5mg if the medication comes in 5mg scored tablets?

    <p>1.5 tablets</p> Signup and view all the answers

    Which of the following actions is NOT recommended when practicing proper body mechanics during patient care?

    <p>Bending at the waist to lift patients</p> Signup and view all the answers

    What is a primary consideration when offloading pressure to prevent skin breakdown in a patient who is immobile?

    <p>Repositioning the patient every 2 hours while in bed</p> Signup and view all the answers

    What is the most appropriate action to take when a patient reports severe pain rated at 8 out of 10?

    <p>Request the physician's order for additional medication immediately</p> Signup and view all the answers

    What is the primary consideration when working with an immobile patient to provide hygiene care?

    <p>To promote their independence with activities of daily living (ADLs) as much as possible</p> Signup and view all the answers

    What is the most appropriate nursing intervention for a patient with signs of skin inflammation and a foul odor in skin folds?

    <p>Keep the area clean and dry, and report findings to the provider</p> Signup and view all the answers

    Which method is considered appropriate for hair washing in an unconscious patient who is bedbound?

    <p>Use a rinse-free shampoo or a basin with water in bed</p> Signup and view all the answers

    When assessing a patient's hygiene needs, which factor is likely to have the least effect?

    <p>Patient's shoe size</p> Signup and view all the answers

    In what way should a nurse position an unconscious patient during oral care?

    <p>On their side with the head of the bed lowered</p> Signup and view all the answers

    Which statement by a caregiver indicates a need for further education regarding safe hygiene practices for a patient with limited mobility?

    <p>He prefers to bathe on his own despite being unsteady.</p> Signup and view all the answers

    What is the preferred method for assessing an older patient's mobility during a hygiene assessment?

    <p>Ask if they need a sponge bath or shower chair</p> Signup and view all the answers

    How often should a nurse reassess a patient's skin condition who is at risk for skin breakdown?

    <p>Every shift and as needed based on changes</p> Signup and view all the answers

    What is the primary objective when setting pain management goals for a post-operative patient?

    <p>Achieve a tolerable pain level as per patient’s input</p> Signup and view all the answers

    Which of the following is NOT a characteristic of sensory overload?

    <p>Increased stimulation in a quiet environment</p> Signup and view all the answers

    During which stage of infection can a person still transmit the infection despite not showing discernible symptoms?

    <p>Incubation stage</p> Signup and view all the answers

    Which of the following describes a common misconception about nonpharmacological interventions for pain management?

    <p>They should be the sole method of pain relief.</p> Signup and view all the answers

    Which of the following correctly describes a type of drainage associated with injury?

    <p>Fluid mixed with blood but not completely bloody</p> Signup and view all the answers

    What is an essential nursing action for a patient with sensory deprivation?

    <p>Provide stimulating activities to engage their senses</p> Signup and view all the answers

    What is the primary reason for using protective isolation for patients?

    <p>To safeguard immune-compromised patients from pathogens</p> Signup and view all the answers

    Which of the following choices best represents the modes of transmission in the chain of infection?

    <p>Airborne, contact, droplets, vector-borne</p> Signup and view all the answers

    What best describes the pathway a pathogen takes when it exits the body?

    <p>Portal of exit through body fluids like saliva or respiratory droplets</p> Signup and view all the answers

    What implication does the Glasgow Coma Scale have in clinical practice?

    <p>It correlates with a patient's consciousness and alertness levels.</p> Signup and view all the answers

    Which factor is least considered when planning care for a patient at risk of sensory deficits?

    <p>Current medication regimen</p> Signup and view all the answers

    In what scenario would a nurse prioritize assessing the risk for DVT in a patient?

    <p>When the patient has limited mobility or prolonged bed rest</p> Signup and view all the answers

    Which of the following nursing interventions is appropriate for a patient demonstrating signs of sensory overload?

    <p>Minimize environmental stimuli and disruptions</p> Signup and view all the answers

    What practice should be avoided to decrease the risk of skin infections?

    <p>Applying lotion between the toes regularly</p> Signup and view all the answers

    Which factor is least likely to be controlled by healthcare providers to manage infection transmission?

    <p>Vector</p> Signup and view all the answers

    What is the primary method to prevent the spread of healthcare-related infections?

    <p>Frequent handwashing by staff</p> Signup and view all the answers

    Which identification method is considered safest to confirm a patient’s identity?

    <p>Only confirming identity if the patient is alert and oriented</p> Signup and view all the answers

    Which of the following is a key sign that a patient may be experiencing a suprainfection?

    <p>Development of a yeast infection after antibiotic use</p> Signup and view all the answers

    Which assessment is most critical for a patient with a foul odor and reddened skin between their toes?

    <p>Ask about any itching or burning between the toes.</p> Signup and view all the answers

    Which practice should be included in a culturally congruent plan for a patient requiring hygiene care?

    <p>Providing the option for male caregivers for male patients.</p> Signup and view all the answers

    What is the primary reason for performing passive range of motion (ROM) exercises?

    <p>To prevent skin breakdown and improve mobility.</p> Signup and view all the answers

    Which intervention is essential for a patient at risk for skin breakdown due to immobility?

    <p>Turning and repositioning the patient frequently.</p> Signup and view all the answers

    What assessment tool would be appropriate for evaluating a patient’s risk for pressure ulcers?

    <p>Braden Scale.</p> Signup and view all the answers

    Which classification of pain involves the sensation that continues even after an injury has healed?

    <p>Phantom pain.</p> Signup and view all the answers

    What is a defining characteristic of the Norton Scale in patient assessment?

    <p>It evaluates the risk of pressure ulcers based on mental state and mobility.</p> Signup and view all the answers

    Why is the Numeric Pain Scale not suitable for patients with dementia or delirium?

    <p>They have difficulty understanding numerical concepts.</p> Signup and view all the answers

    Which action is most beneficial when using a walker to ensure patient safety?

    <p>Encouraging the patient to lift the walker before taking a step.</p> Signup and view all the answers

    What is the priority nursing intervention when performing oral care for an unconscious patient?

    <p>Use suction equipment to prevent aspiration.</p> Signup and view all the answers

    Which of the following factors is least likely to directly influence the hygiene practices of a patient?

    <p>Room temperature</p> Signup and view all the answers

    When assessing an older patient who walks with an assistive device, which hygiene consideration is most critical?

    <p>Understanding their usual hygiene routines and preferences</p> Signup and view all the answers

    For a patient who is unable to assist with hygiene due to immobility, which method is most appropriate for hair washing?

    <p>Using a rinse-free shampoo cap</p> Signup and view all the answers

    What is the most appropriate nursing action when observing a patient with skin folds that are inflamed and have a foul odor?

    <p>Keep the area clean and dry and notify the healthcare provider</p> Signup and view all the answers

    In the context of providing oral care for an unconscious patient, which action should a nurse prioritize?

    <p>Using a moistened mouth swab attached to suction</p> Signup and view all the answers

    When planning a therapeutic bath for a patient with dry skin, which type of bath would be the most beneficial?

    <p>An oatmeal therapeutic bath</p> Signup and view all the answers

    Which statement by a patient's daughter suggests a misunderstanding regarding safe hygiene practices for a father with limited mobility?

    <p>Since he won't let me help, I just let him do it by himself.</p> Signup and view all the answers

    Which approach is essential for enhancing a patient's independence in activities of daily living (ADLs) during hygiene care?

    <p>Encouraging participation to the best of their ability</p> Signup and view all the answers

    What is the primary consideration when calculating the volume to administer if the medication order is 1,000 mcg and the concentration is 2 mg/mL?

    <p>You will administer 0.5 mL per dose</p> Signup and view all the answers

    Which strategy is the least effective for preventing skin breakdown in a patient with limited mobility?

    <p>Allow the patient to remain in the same position for extended periods</p> Signup and view all the answers

    When conducting an assessment to determine the safest method for assisting a patient with personal care, what is the most appropriate initial step?

    <p>Evaluate the patient's preferences, wants, and needs</p> Signup and view all the answers

    What is a key component of therapeutic communication that should be avoided to foster an open dialogue with the patient?

    <p>Inquiring 'why' a patient feels a certain way</p> Signup and view all the answers

    Which of the following statements reflects a correct understanding of body mechanics when providing patient care?

    <p>Maintaining a wide base of support decreases your risk of injury</p> Signup and view all the answers

    What is the primary aim when setting pain management goals for a post-operative patient?

    <p>To work with the patient to establish a tolerable pain level</p> Signup and view all the answers

    Which nonpharmacological intervention is contraindicated for acute injuries with inflammation present?

    <p>Heat therapy</p> Signup and view all the answers

    What is the most appropriate nursing action for a patient who reports experiencing both itching and burning between the toes under a cast?

    <p>Assess for signs of infection and skin breakdown.</p> Signup and view all the answers

    Which statement regarding denture care is incorrect and requires further education?

    <p>Denture maintenance is not important for oral hygiene.</p> Signup and view all the answers

    What stage of infection involves the appearance of vague symptoms without a discernible illness?

    <p>Prodromal stage</p> Signup and view all the answers

    Which factor does NOT influence a patient's experience of pain?

    <p>Type of medication administered</p> Signup and view all the answers

    When developing a care plan for a patient with cultural considerations, which factor is essential to respect?

    <p>Promoting open dialogue about hair or body grooming.</p> Signup and view all the answers

    What is the primary goal of nursing interventions for immobile patients?

    <p>To maintain safety while encouraging optimal mobility.</p> Signup and view all the answers

    How frequently should cold therapy applications be assessed to ensure safety?

    <p>Every 15 minutes</p> Signup and view all the answers

    Which statement accurately describes a systemic infection?

    <p>Spread via blood or lymphatic system</p> Signup and view all the answers

    Which risk factor is most commonly associated with immobility in hospitalized patients?

    <p>Limited opportunity for ambulation.</p> Signup and view all the answers

    What is a key characteristic of referred pain?

    <p>Pain experienced in an area other than the source</p> Signup and view all the answers

    Which of the following assessments is crucial in identifying patient pain when using the Wong-Baker FACES scale?

    <p>Nonverbal cues and changes in behavior.</p> Signup and view all the answers

    Which patient demographic is most at risk for sensory overload?

    <p>Elderly individuals with mobility limitations</p> Signup and view all the answers

    What can be concluded if a patient scores below 18 on the Braden Scale?

    <p>The patient is at risk for developing pressure ulcers.</p> Signup and view all the answers

    What type of infection persists without identifiable symptoms, characterizing a latent infection?

    <p>Chronic infection</p> Signup and view all the answers

    In patients with mobility impairments, which intervention is least effective in preventing skin breakdown?

    <p>Restricting movement to limit risk.</p> Signup and view all the answers

    For a patient experiencing phantom pain post-amputation, which type of pain is being described?

    <p>Neuropathic pain.</p> Signup and view all the answers

    Which nursing intervention should NOT be delegated to UAPs?

    <p>Administering prescribed medications</p> Signup and view all the answers

    What is the most effective way for nurses to assess pain in a patient who cannot verbalize their experience?

    <p>Observing for changes in vital signs and behaviors.</p> Signup and view all the answers

    What type of drainage is described as clear or straw-colored fluid?

    <p>Serous</p> Signup and view all the answers

    Which transmission precaution requires the use of a positive airflow room and an N-95 mask?

    <p>Airborne precautions</p> Signup and view all the answers

    What is the purpose of protective isolation?

    <p>To safeguard those with compromised immune systems</p> Signup and view all the answers

    In what scenario is it advised to avoid using lotion between the toes?

    <p>To reduce fungal infection risk</p> Signup and view all the answers

    Which of the following is NOT a recognized risk factor for skin breakdown?

    <p>Regular physical activity</p> Signup and view all the answers

    What is the correct method to confirm a patient's identity before treatment?

    <p>Only the patient should confirm their identity</p> Signup and view all the answers

    What is the primary factor contributing to the increased risk for aspiration in patients?

    <p>Diminished alertness or consciousness</p> Signup and view all the answers

    Which type of infection occurs due to the overgrowth of a patient's normal flora following treatment?

    <p>Suprainfection</p> Signup and view all the answers

    What is a recommended action when the nurse discovers a patient has fallen?

    <p>Call for assistance before moving the patient</p> Signup and view all the answers

    Which of the following represents a transmission factor where pathogens can survive and multiply?

    <p>Reservoir</p> Signup and view all the answers

    What is the primary reason for promoting independence in activities of daily living (ADLs) for patients?

    <p>To enhance the patient's self-esteem and comfort</p> Signup and view all the answers

    Which type of bed bath is most appropriate for a patient who is unable to wash themselves but can still assist with certain areas?

    <p>Partial bath</p> Signup and view all the answers

    When providing oral care to an unconscious patient, which of the following is NOT an appropriate action?

    <p>Placing the patient on their back to manage secretions</p> Signup and view all the answers

    In assessing the hygiene needs of a patient with cognitive impairment, which approach is most effective?

    <p>Ask about their preferences for personal care</p> Signup and view all the answers

    What is a key consideration when providing a therapeutic bath, such as an oatmeal bath, to a patient?

    <p>To check for any allergies to the bath additives before administration</p> Signup and view all the answers

    During a follow-up home visit, which statement from a patient's caregiver suggests additional education is needed regarding safe hygiene practices?

    <p>I let him bathe alone, as he prefers privacy.</p> Signup and view all the answers

    Which factor is most likely to hinder a patient's ability to maintain their hygiene?

    <p>Experiencing pain or discomfort</p> Signup and view all the answers

    When assessing for skin breakdown, which action should a nurse prioritize?

    <p>Rotate the patient every two hours</p> Signup and view all the answers

    What is the ideal approach when setting pain management goals for a post-operative patient?

    <p>Collaborate with the patient to set a tolerable goal, such as 3/10.</p> Signup and view all the answers

    In the context of sensory perception, what does 'reception' refer to?

    <p>The process of receiving stimuli through nerve endings.</p> Signup and view all the answers

    Which of the following is a nursing intervention for addressing sensory overload in a patient?

    <p>Closing blinds and dimming lights to minimize stimuli.</p> Signup and view all the answers

    What characteristic primarily differentiates a latent infection from acute and chronic infections?

    <p>It remains asymptomatic despite the presence of pathogens.</p> Signup and view all the answers

    Which nursing action is essential when caring for patients with peripheral neuropathy to prevent injuries?

    <p>Advising daily foot examinations for signs of skin breakdown.</p> Signup and view all the answers

    What is the correct sequence of the stages of infection from the initial exposure to recovery?

    <p>Incubation, prodromal, illness, decline, convalescence.</p> Signup and view all the answers

    What role do 'portals of exit' play in the chain of infection?

    <p>They allow the infectious agent to leave the reservoir.</p> Signup and view all the answers

    Which of the following best describes what 'negative' effects sensory deprivation can have on patients?

    <p>Deterioration in cognitive and emotional health.</p> Signup and view all the answers

    What is the main factor that differentiates a local infection from a systemic infection?

    <p>Presence of fever indicates a systemic infection.</p> Signup and view all the answers

    Which nursing intervention is most effective in preventing pressure injuries in an immobile patient?

    <p>Reposition the patient every 2 hours</p> Signup and view all the answers

    In assessing a patient with evidence of skin breakdown, which should the nurse prioritize?

    <p>Evaluating the patient’s nutritional status</p> Signup and view all the answers

    What is the most crucial factor a nurse must monitor to prevent complications related to immobility in patients?

    <p>Monitoring for signs of deep vein thrombosis (DVT)</p> Signup and view all the answers

    When caring for a patient with dentures, which approach is considered inappropriate?

    <p>Brushing dentures with antibacterial soap</p> Signup and view all the answers

    Which of the following indicates an accurate application of the Braden Scale in assessing skin breakdown risk?

    <p>Scores should consider both mobility and sensory perception</p> Signup and view all the answers

    For a patient experiencing phantom pain, which classification of pain is most appropriate?

    <p>Neuropathic</p> Signup and view all the answers

    When assessing an older adult's statement regarding denture care, what indicates a need for further education?

    <p>I never take my dentures out even when I am asleep</p> Signup and view all the answers

    Which method is considered the safest for transferring a patient from bed to a chair?

    <p>Use a slide board for assistance</p> Signup and view all the answers

    What is an essential consideration for a nurse when using crutches to prevent patient falls?

    <p>Position the crutches 1 foot in front before moving</p> Signup and view all the answers

    Which statement best reflects the understanding of mobility limitations and hygiene practices?

    <p>Patient preferences should influence hygiene choices</p> Signup and view all the answers

    What is the most effective strategy to minimize the risk of skin breakdown for a patient in a sitting position?

    <p>Use a pressure-relieving cushion and encourage shifting every 15 minutes.</p> Signup and view all the answers

    Which calculation method is appropriate for determining the correct dosage of a medication that is ordered for 1,200 micrograms, given that the medication is supplied as 0.2mg/tablet?

    <p>You will give 6 tablets.</p> Signup and view all the answers

    When evaluating the Braden Scale score for a patient, which of the following scores indicates a moderate risk for skin breakdown?

    <p>15</p> Signup and view all the answers

    In which situation should a nurse contact a physician regarding a patient's pain management plan?

    <p>If the patient exhibits lethargy with a respiratory rate of 10.</p> Signup and view all the answers

    Which statement reflects an understanding of using therapeutic communication effectively with patients?

    <p>Encouraging the patient to express their feelings without judgment enhances open dialogue.</p> Signup and view all the answers

    What clinical sign may indicate a need for immediate notification of the healthcare provider?

    <p>White spots on the tongue</p> Signup and view all the answers

    What type of drainage is characterized by a mix of serous fluid and blood?

    <p>Serosanguinous</p> Signup and view all the answers

    Which factor is considered a portal of exit for pathogens?

    <p>Sneezing</p> Signup and view all the answers

    What precaution is essential for a patient suspected of having an airborne infection?

    <p>Wearing an N-95 mask and using positive airflow</p> Signup and view all the answers

    What is a significant risk factor for skin breakdown in patients?

    <p>Poor nutrition</p> Signup and view all the answers

    Which of these conditions could lead to an endogenous infection?

    <p>Overuse of antibiotics</p> Signup and view all the answers

    What should a nurse prioritize when caring for a patient at high risk of falls?

    <p>Utilizing a gait belt during ambulation</p> Signup and view all the answers

    Which is a necessary action before verifying a patient’s identity?

    <p>Ask the patient to provide two identifiers</p> Signup and view all the answers

    What strategy is effective for preventing deep vein thrombosis (DVT) during a patient's hospitalization?

    <p>Prophylactic heparin injections</p> Signup and view all the answers

    How often should a primary care provider renew the order for restraints on a hospitalized patient?

    <p>Every 24 hours</p> Signup and view all the answers

    Study Notes

    Hygiene

    • Provide hygiene care based on a patient’s ability and mobility, promoting independence as much as possible.
    • For immobile patients, a bed bath and rinse-free shampoo cap are recommended.
    • Skin turgor is affected by hydration and nutritional status.
    • Obesity and conditions like diabetes can increase the risk for skin breakdown.
    • To prevent skin breakdown, rotate a patient's heels off the bed frequently.
    • When providing oral care for an unconscious patient, place them on their side with the head of the bed lowered.
    • Consider the patient's cultural preferences and preferences for a same-sex UAP/nurse.
    • For denture care, cleanse dentures with warm water and toothpaste or denture cleaner. Remove dentures before bedtime.
    • Encourage regular dental visits, two times per year, for health promotion.
    • Warm, damp towels can be used before shaving.
    • Shave in the direction of hair growth and pull the skin taut.
    • Avoid razors if the patient has a bleeding disorder.
    • Do not cut or shave hair without prior discussion with the patient or their family.

    ### Mobility

    • Maintain proper posture to avoid arching shoulders forward when sitting.
    • The Braden Scale assesses six aspects of a patient’s risk for skin breakdown. A score less than 18 indicates high risk.
    • The Norton Scale assesses five elements related to a patient's risk for pressure ulcers.
    • Complications of immobility include pressure injuries, pneumonia, weakness, muscle atrophy, contractures, urinary stasis, constipation, and deep vein thrombosis (DVT).
    • The ONLY patients who should NOT be ambulating are those with a BEDREST order.
    • Active ROM exercises are performed by the patient without assistance.
    • Passive ROM exercises are performed by the nurse while the patient relaxes.
    • For proper crutch use, the uninjured leg should bear all weight along with hands on the crutches. Do not bear weight on the armpits.
    • When using a walker, elbows should be bent at 30 degrees. Adjust the walker's height accordingly.
    • When using a cane, it should have a rubber tip for safety and be used on the patient's strong side.
    • Do NOT pull a patient up in bed by grabbing under their armpits. Use a draw sheet.
    • Use a slide board to transfer a patient from a stretcher to a bed.
    • When transferring patients from a bed to a bedside commode or chair, the bed should be down all the way to prevent falls.
    • Use a gait belt to stand and pivot a patient if they are weak, positioning the chair or commode on the patient's strong side.
    • Do NOT let a patient grab you near your neck during a transfer.

    Pain

    • Pain assessment and management are crucial for healing.
    • Use nonverbal cues to assess pain in patients with cognitive impairments or dementia.
    • Patients who cannot ambulate due to pain must have their pain managed better.
    • Non-pharmacological pain interventions include distraction techniques, cold therapy, heat therapy, acupuncture, acupressure, TENS, and PENS. Heat therapy is not appropriate for acute injuries.
    • Remove cold therapy after 15 minutes and assess for redness or blistering frequently.
    • Referred pain is felt in an area far away from the origin or source.
    • Proprioceptors are responsible for the body's sense of position and movement.
    • The Glasgow Coma Scale score helps plan care for patients with altered levels of consciousness.
    • Peripheral neuropathy, often associated with diabetes, can cause numbness.

    Sensory Perception

    • Sensory perception involves stimulus, reception, and perception.
    • Sensory deprivation occurs when there is a lack of stimulation, while sensory overload is caused by overstimulation.
    • Patients with sensory impairments may require modifications to their environment, such as increased lighting or decreased noise.

    Infection

    • The chain of infection includes infectious agents, reservoirs, portal of exit, modes of transmission, portal of entry, and susceptible hosts.
    • Infections are classified as local or systemic, as well as acute, chronic, or latent.
    • Leukocytosis indicates increased WBC count and may signal a systemic infection.
    • Drainage can be serous, sanguineous, serosanguinous, or purulent.
    • Factors that increase the risk of skin infections include diabetes, burns, wounds, and immobility.
    • Hand washing is the best way to prevent the spread of infection.
    • Medical asepsis involves clean environment techniques, while surgical asepsis is used for sterile environments.
    • Transmission precautions include contact, droplet, and airborne precautions.
    • Contact precautions require gown and gloves and are used for MRSA and C-diff. Droplet precautions involve surgical mask, goggles, gown, and gloves and apply to respiratory viruses like influenza and chickenpox. Airborne precautions require positive airflow, N-95 mask, gown, goggles, and gloves and are used for tuberculosis and varicella.
    • Healthcare-related infections can be exogenous or endogenous.
    • Surgical asepsis involves sterile environments.

    Safety and Prevention

    • Focus on driver's education when educating adolescents.
    • Restraints can only be used with a healthcare provider's order that is renewed every 24 hours.
    • If a patient is found on the floor, assess for injury before moving them.
    • Patients with history of stroke require assessment of swallow.
    • Patients with decreased level of consciousness are at high risk for aspiration.
    • Use swabs hooked up to suction for oral care if a patient is unconscious and avoid performing oral care while the patient is supine.
    • Avoid petroleum-based lip moisturizers and use water-based ones instead.
    • DVT prevention includes ambulation, compression stockings, sequential compression devices, and prophylactic heparin injections.
    • If a patient begins to fall, assist them down to the ground.
    • Fall risk factors include older adults, sensory impairments, weakness, neurological problems, dizziness, orthostatic hypotension, history of falls, confusion, and urinary frequency or diarrhea.
    • Implement fall prevention measures such as benches in the shower, gait belts, lowering the bed, and ensuring high-risk patients can use the call light.
    • For patient identification, use two identifiers such as name and date of birth.
    • Skin breakdown and pressure injuries most often occur on bony prominences.
    • Avoid heat on bony prominences and monitor for risk factors like diabetes, excess moisture, malnutrition, immobility, and impaired circulation.

    Delegation

    • Do NOT delegate med pass, teaching, or assessment (e.g., pain assessment) to UAPs.
    • UAPs can collect vitals and assist with ADLs (repositioning, hygiene, toileting, ear cleaning, hearing aid care etc.).
    • UAPs can provide food/water, ice packs, and back rubs.

    Pressure Ulcer Prevention

    • Offloading Pressure: Reposition patients every two hours when in bed. Encourage patients to reposition themselves frequently. When sitting in a chair, limit sitting time to one hour, shift weight every 15 minutes, and provide a cushion.
    • Additional Preventive Measures: Ensure adequate hydration and protein intake for patients.
    • Braden Scale: Assess risk for skin breakdown using the Braden Scale.
      • A score of 23 indicates the lowest risk.
      • Factors assessed include sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
    • Proper Body Mechanics: Avoid bending forward by raising the patient's bed. Limit bending and twisting your neck and back. Maintain a wide base of support. Use proper equipment like mechanical lifts when necessary.

    Therapeutic Communication

    • Avoid asking "why” questions.
    • Use open-ended questions. For example, ask "Can you tell me about your pain?" instead of "Isn't your pain better now?".
    • Assess patient needs and don't make assumptions.

    Medication Calculations

    • Milligrams/Milliliters (mg/mL): Convert micrograms (mcg) to milligrams (mg) for accurate medication dosage. For example, if an order is for 1,000 mcg and the medication comes in 2 mg/mL, administer 0.5 mL/dose.
    • Capsules/Tablets/Dose: Calculate the number of capsules/tablets per dose based on the medication's strength. For example, if the order is for 7.5 mg and the medication comes in 5 mg scored tablets, administer 1.5 tablets/dose.
    • Grams/Day: Calculate the total grams per day of medication. For example, if the order is for 250 mg PO QID (four times a day), administer 1 gram/day.

    Nursing Process

    • Prioritize assessment before determining interventions.
    • Optimize hygiene and mobility, prioritizing safe and appropriate methods.
    • Start by assessing a patient's preferences, needs, and wishes.
    • Many tasks are nursing interventions and may not require physician consultation.
    • Inpatient pain management relies heavily on self-report. If a patient reports severe pain (7 or higher out of 10), further medication may be needed unless there are signs of respiratory suppression (RR < 12, lethargy, etc.).

    Hygiene

    • Hygiene promotes comfort, improves self-image, and decreases infection and disease
    • Provide hygiene care appropriate to the patient’s mobility, promoting independence as much as possible.
    • For immobile patients, provide bed baths and wash hair with rinse-free shampoo caps.
    • Skin turgor (hydration) and nutritional status affect skin health and increase the risk of skin breakdown.
    • Rotate heels off the bed to prevent pressure ulcers.
    • When providing oral care for unconscious patients, position them on their side with the head of the bed lowered.
    • Plan hygiene care around patient needs, considering factors like pain, limited mobility, sensory deficits, cognitive impairment, and emotional or mental health disturbances.
    • Common types of bed baths include assist, complete, partial, towel bath, bag or packaged bath, and therapeutic baths.
    • Keep skin dry to prevent breakdown, particularly in folds where odor may indicate moisture or fungus.
    • Obese patients are at higher risk for skin breakdown due to folds.
    • For denture care, cleanse with warm water and toothpaste or denture cleaner and remove before bedtime.
    • Promote patient dignity and preferences during hygiene care, such as showering every other day or requesting same-sex care providers.
    • Develop culturally congruent care plans for hygiene care, considering personal preferences.
    • Shave with warm, damp towels, pull skin taut, and shave in the direction of hair growth; avoid razors for patients with bleeding disorders.
    • Do not cut or shave hair without prior discussion with the patient and family.

    Mobility

    • Maintain safety while encouraging and optimizing safe mobility.
    • Mobility limitations may preclude showering independently if unsafe.
    • Proper posture involves avoiding arching shoulders forward when sitting.
    • Increased pressure, shearing, and friction can lead to skin breakdown.
    • Dehydration affects skin turgor, and moisture leads to maceration (softening of skin).
    • Use the Braden Scale (score less than 18 indicates risk) and Norton Scale to assess pressure ulcer risk factors.
    • Common positions include Fowler's (45-60 degrees), semi-Fowler's (30 degrees), high-Fowler's (90 degrees), lateral, prone, Sims', and supine.
    • Immobility increases the risk of falls, fractures, pressure ulcers, pneumonia, constipation, decreased urination, blood clots, and muscle contractures.
    • Nursing interventions for immobility include turning, repositioning, ambulation, floating heels, and protecting elbows.
    • Complications of immobility include pressure injuries, pneumonia, weakness, muscle atrophy, contractures, urinary stasis, constipation, and deep vein thrombosis (DVT).
    • The ONLY patients who should NOT be ambulating are those with a BEDREST order, usually only ordered immediately after an injury or awaiting surgery.
    • Look for active or passive range of motion (ROM) orders.
    • Active ROM involves the patient performing exercises without assistance, while passive ROM involves the nurse performing the exercises for the patient.
    • Crutches are used with a three-point gait, with weight borne on the uninjured leg and hands on the crutches; do not bear weight on armpits. When going up stairs, lead with the unaffected leg. Keep elbows slightly flexed.
    • Walkers should have elbows bent at 30 degrees; adjust walker height accordingly. The patient lifts the walker forward ~6 inches before taking a step. When ambulating a patient with a gait belt, walk slightly behind the patient. Walkers with seats are helpful for individuals with fatigue or dyspnea.
    • Canes should have a rubber tip for safety. Use the cane on the strong side, moving it forward 2 feet while taking a step with the weaker foot. Then take a larger step with the strong foot.
    • When boosting and repositioning patients, do NOT pull them up in bed by grabbing under their armpits; use a draw sheet instead.
    • For transfers from a stretcher to bed, use a slide board.
    • When transferring from bed to a bedside commode or chair and back, lower the bed fully to prevent falls. Use a gait belt to stand and pivot weak patients. Place the chair/commode on the patient’s strong side before pivoting. Do NOT let the patient grab you near your neck during transfers.

    Pain

    • Pain classifications include:
      • Cutaneous/Superficial: Skin surface
      • Deep somatic: Deeper tissues, bones, joints, muscles
      • Visceral: Organs
      • Radiating/referred: Pain felt in an area away from the source
      • Phantom: Perceived pain in an amputated limb
      • Psychogenic: Pain with a psychological origin
      • Nociceptive: Pain caused by damage to tissues
      • Neuropathic: Pain caused by damage to nerves
      • Acute: Short-term pain
      • Chronic: Long-term pain (longer than 6 months)
      • Intractable: Unrelieved pain, often resistant to treatment
    • Pain characteristics include quality, periodicity, and intensity.
    • Understanding pain classifications is crucial for developing effective pain management plans.
    • Assess nonverbal cues of pain, such as grimacing, restlessness, clenching, etc., particularly in dementia or delirium patients. Use the Pain-AD scale or Wong-Baker FACES scale for these patients.
    • It is not acceptable for a post-op patient to be unable to ambulate due to pain. If this happens, the nurse must improve pain management.
    • Pain goals/outcomes should be SMART (Specific, Measurable, Achievable, Relevant, Time-bound). Eliminate pain altogether is not a realistic goal. Work with the patient to determine a tolerable pain level.
    • Nonpharmacological pain interventions include distraction, relaxation techniques, heat therapy (not for acute injuries with inflammation), cold therapy (remove after 15 minutes, do not apply directly to skin, monitor for redness/blistering), acupuncture, acupressure, transcutaneous electrical nerve stimulation (TENS), and percutaneous electrical nerve stimulation (PENS).
    • Referred pain is felt in an area far from the origin or source, e.g., shoulder pain related to gallbladder issues.
    • Factors influencing pain include emotions, past experiences, developmental stage, sociocultural factors, communication skills, and cognitive impairments.

    Sensory Perception

    • Sensory perception involves:
      • Stimulus: Triggers that stimulate receptors
      • Reception: Receiving stimuli from nerve endings through receptors (thermoreceptors, proprioceptors, photoreceptors)
      • Perception: Interpreting sensory impulses and giving meaning to them
    • Sensory deprivation refers to a lack of sensory input, while sensory overload refers to excessive stimulation.
    • Sensory deficits involve loss of senses, impacting a patient’s ability to respond to stimuli.
    • The Glasgow Coma Scale score helps assess a patient's level of consciousness and guides care.
    • Arousal is a combination of consciousness and alertness.
    • Patients with diabetes are susceptible to peripheral neuropathy (numbness), increasing the risk of burns. Use a thermometer to test bath water temperatures. Avoid soaking in hot water, examine feet daily for skin breakdown, wear gloves in cold weather, and avoid open-toed shoes.
    • Always assess the patient’s preferred communication method.
    • Make sure hearing aids, glasses, etc. are easily accessible and ready for use.
    • Sensory overload is common in the elderly, individuals with mobility limitations, sensory impairments, or isolation. Implement measures to minimize stimuli, such as dimming lights, turning off alarms, limiting visitors, and creating a calming environment.
    • Sensory deprivation is also a concern in elderly individuals with limited mobility, sensory impairments, or isolation.

    Delegation

    • Do NOT delegate medication administration, teaching, or assessments (e.g., pain assessment) to UAPs.
    • UAPs can collect vital signs and assist with ADLs, including repositioning, hygiene, toileting, ear cleaning, and hearing aid care.
    • UAPs can also provide food/water, ice packs, and back rubs.

    Infection

    • The chain of infection includes infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.
    • Infectious agents: Microorganisms capable of causing disease or illness (bacteria, fungi, parasites, prions).
    • Reservoirs: Places where infectious agents live, grow, and reproduce (people, water, food).
    • Portals of Exit: Ways infectious agents leave the reservoir (blood, secretions, excretions, skin, coughing, sneezing, diarrhea, seeping wounds, tubes, IV lines, bandaging a MRSA wound).
    • Modes of Transmission: Ways in which infectious agents are spread from reservoir to susceptible host (physical contact, droplets, airborne).
    • Portals of Entry: Ways infectious agents enter the susceptible host (mucous membrane, respiratory system, digestive system, broken skin, vagina, mouth, bite from a bug).
    • Susceptible Host: Individuals who have traits affecting their susceptibility and severity of disease (immune deficiency, diabetes, burns, surgery, age).
    • The five stages of infection include incubation, prodromal, illness, decline, and convalescence.
    • Infections can be classified by location (local or systemic) or duration (acute, chronic, latent).
    • Local infection occurs in a limited region, while systemic infection spreads via blood or lymph.
    • Monitor WBC count for leukocytosis (elevated WBC count), which may indicate systemic infection.
    • Signs and symptoms of infection include white spots on the tongue (thrush), odor, redness, and itching/burning between toes (tinea pedis).
    • Drainage can be serous (clear), sanguineous (bloody), serosanguinous (serous and blood), or purulent (pus-filled).
    • Factors increasing skin infection risk include diabetes, burns, wounds, etc.
    • Nursing interventions for infection control include maintaining short fingernails, frequent hand washing, inspecting hands for sores or cuts, keeping skin moisturized, cleaning equipment after use, avoiding invasive lines and catheters, and practicing medical asepsis (clean techniques).
    • Transmission factors include portal of exit, vector, pathogen, reservoir, and susceptible host.
    • Transmission precautions include:
      • Contact precautions: Gown and gloves (MRSA & C-diff).
      • Droplet precautions: Surgical mask, goggles, gown, gloves (influenza, chicken pox, COVID).
      • Airborne precautions: Positive airflow, N-95 mask, gown, goggles, gloves (tuberculosis, varicella).
    • Healthcare-related infections can be exogenous (acquired from the healthcare environment) or endogenous (arising from the patient’s normal flora).
    • Implementing surgical asepsis (sterile techniques) requires an autoclave for sterilization.

    Safety/Prevention

    • When meeting the safety needs of adolescents, focus teaching on driver’s education.
    • Restraint orders should be renewed by the primary care provider every 24 hours.
    • If a patient is found on the floor, assess for injury but do NOT move the patient.
    • Aspiration risks are high in patients with a history of stroke or a decreased level of consciousness. Always assess swallow ability. Ensure suction is available for these patients.
    • Use swabs hooked up to suction for oral care if unconscious, avoiding oral care while the patient is supine.
    • Avoid petroleum-based lip moisturizers (water-based is best).
    • DVT prevention strategies include ambulation (if possible), compression stockings, sequential compression devices, and prophylactic heparin injections.
    • If a patient begins to fall, assist them to the ground.
    • Fall risk factors include older adults, sensory impairments, weakness, neurological problems, dizziness, orthostatic hypotension, history of falls, confusion, and urinary frequency/diarrhea.
    • Fall prevention measures include benches and rails in the bath or shower, use of gait belts, making sure beds are low and locked, prohibiting independent ambulation for dizzy patients, ensuring high-risk patients can use the call light, using night lights, keeping frequently used items within reach, hourly rounding, educating patients to avoid getting up too quickly, and keeping siderails up for patients with multiple sensory deficits.
    • Patient identification should involve two identifiers (name and date of birth) and confirmation by the patient if alert and oriented.
    • Skin breakdown and pressure injuries often occur on bony prominences, so avoid heat application on these areas. Risk factors include diabetes, excess moisture, malnutrition, immobility, impaired circulation, etc.

    Skin Breakdown Prevention

    • To prevent skin breakdown, offload pressure by repositioning patients every two hours while in bed.
    • If patients are sitting in a chair, limit their time to one hour at a time, shift their weight every 15 minutes, and provide a cushion for them to sit on.
    • Other prevention measures include ensuring adequate hydration and protein intake.
    • The Braden Scale assesses the risk for skin breakdown.
      • A score of 23 indicates the lowest risk, while a lower score reflects a higher risk.
      • For example, a patient with rarely moist skin, slight mobility limitations, slight sensory impairment, excellent food intake, and no friction or shear problems would score 20 on the Braden Scale.
    • When providing care, use proper body mechanics to prevent injury to yourself.
      • Raise the patient’s bed to avoid bending forward.
      • Limit bending and twisting of your neck and back.
      • Maintain a wide base of support.
      • Do not attempt to lift or turn heavy or immobile patients without assistance.
      • Use proper equipment, such as a mechanical lift, when necessary.

    Therapeutic Communication

    • Avoid asking “why” questions.
    • Use open-ended questions.
    • Avoid asking questions like “don’t you do this?” or “don’t you like this?”
    • Assess before assuming.

    Medication Math

    • To calculate the volume of medication to administer based on a prescribed dose, convert micrograms (mcg) to milligrams (mg) and use the concentration of the medication in mg/mL.
      • For example, if the order is for 1,000 mcg and the medication comes in 2 mg/mL, you will administer 0.5 mL/dose.
    • To calculate the number of capsules or tablets to administer, consider the desired dose and the strength of the medication.
      • For example, if the order is for 7.5 mg and the medication comes in 5 mg tablets, you will administer 1.5 tablets/dose.
    • To calculate the daily dose of medication in grams, multiply the individual dose by the number of times the medication is administered per day.
      • For example, if the order is for 250 mg four times daily (QID), you will administer 0.25 grams/day.

    General Nursing Principles

    • Follow the nursing process: assess before determining an intervention.
    • Optimize hygiene and mobility by prioritizing the safest and most appropriate methods.
      • First, assess the patient’s preferences, wants, and needs.
    • Most care tasks are nursing interventions, and it is often unnecessary to contact the physician.
    • In a clinical setting, the gold standard for pain is self-report.
      • If a patient reports severe pain (7 or higher out of 10), they need more medication, unless there are signs of respiratory suppression (respiratory rate less than 12, lethargy, etc.).

    Hygiene

    • Promote independence: Encourage patients to participate in their hygiene care as much as possible.
    • Bed Baths: Use appropriate types of bed baths based on the patient's mobility (assist, complete, partial, towel, bag, therapeutic).
    • Factors Affecting Hygiene: Be aware of factors like pain, limited mobility, sensory deficits, cognitive impairment, and emotional/mental health disturbances that can impact hygiene.
    • Skin Care: Maintain skin integrity by keeping it clean and dry.
    • Oral Care: Provide oral care for unconscious patients in a side-lying position with the head of the bed lowered, using a suctioned oral swab.
    • Denture Care: Clean dentures with warm water and toothpaste or denture cleaner, and remove them before bedtime.
    • Shaving: Use a warm, damp towel on the skin before shaving. Shave in the direction of hair growth. Avoid razors if the patient has a bleeding disorder.
    • Cultural Sensitivity: Respect patient's cultural preferences and avoid cutting or shaving hair without prior discussion.

    Mobility

    • Maintain Safety: Prioritize safety while optimizing mobility. Consider mobility limitations when planning hygiene care.
    • Posture: Avoid arching shoulders forward when sitting to maintain proper posture.
    • Risk Factors for Immobility: Understand risks associated with immobility, including falls, fractures, pressure ulcers, pneumonia, constipation, decreased urination, blood clots, muscle contractors.
    • Nursing Interventions: Implement turning, repositioning, ambulation, floating heels, and positioning to prevent immobility complications.
    • Braden & Norton Scales: Use these scales to assess patients' risk for skin breakdown.
    • Positions: Familiarize yourself with various patient positioning techniques: Fowler's, Semi-Fowler's, High Fowler's, Lateral, Prone, Sims, Supine.
    • Complications of Immobility: Be alert for potential complications of immobility: pressure injuries, pneumonia, weakness, muscle atrophy, contractures, urinary stasis, constipation, deep vein thrombosis (DVT).
    • Ambulation: Ambulate patients unless a bedrest order is in place.
    • Range of Motion (ROM): Understand the difference between active and passive ROM and provide appropriate ROM exercises.
    • Crutches: Teach patients using crutches the proper three-point gait technique. Ensure they bear weight on legs and hands, not armpits.
    • Walkers: Teach patients using walkers the proper walking technique, adjusting the walker's height to ensure elbow flexion of 30 degrees.
    • Canes: Instruct patients using canes on the proper technique, using the cane on the stronger side and moving it forward before taking a step with the weaker leg.
    • Boosting and Repositioning: Use a draw sheet to pull patients up in bed, avoiding grabbing under the armpits. Utilize a slide board for transferring from a stretcher to a bed.
    • Bedside Commode/Chair Transfers: Ensure the bed is lowered and the chair/commode is positioned on the patient's strong side. Use a gait belt for support during transfers.

    Pain

    • Pain Classification: Understand different pain classifications: cutaneous/superficial, deep somatic, visceral, radiating/referred, phantom, psychogenic, nociceptive, neuropathic, acute, chronic, intractable.
    • Assessment and Management: Prioritize accurate pain assessment and management for optimal patient recovery and pain management plan development.
    • Assessment Tools: Utilize appropriate pain scales for different patient populations.
    • Non-pharmacological Interventions: Implement distraction, relaxation techniques, heat therapy (avoid acute injuries), cold therapy, acupuncture, acupressure, TENS, PENS.
    • Referred Pain: Understand that pain can be felt in areas away from its origin.
    • Factors Influencing Pain: Recognize factors influencing pain: emotions, past experiences, developmental stage, sociocultural factors, communication skills, cognitive impairments.

    Sensory Perception

    • Stimulus, Reception, Perception: Understand the process of sensory perception, including stimulus, reception, and perception.
    • Sensory Deprivation & Overload: Recognize risk factors and nursing interventions for sensory deprivation and sensory overload.

    Infection

    • Chain of Infection: Understand the components of the chain of infection: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host.
    • Types of Infectious Agents: Recognize the different types of infectious agents: bacteria, fungi, parasites, prions.
    • Reservoirs: Understand where infectious agents live and reproduce.
    • Transmission Modes: Be familiar with the various modes of transmission: physical contact, droplets, airborne.
    • Portals of Exit and Entry: Know how infectious agents leave and enter the body.
    • Susceptible Hosts: Identify factors that make individuals more vulnerable to infection.
    • Stages of Infection: Understand the five stages of infection: incubation, prodromal, illness, decline, convalescence.
    • Classifications of Infections: Understand the different classifications of infections: local, systemic, acute, chronic, latent.
    • Signs of Infection: Monitor patients for signs of infection, including elevated WBC count, fever/chills, positive blood cultures, drainage types (serous, sanguineous, serosanguinous, purulent), white spots on the tongue, odor, redness, and itching/burning between toes.
    • Risk Factors for Skin Infections: Be aware of risk factors for skin infections, such as diabetes, burns, wounds.
    • Infection Control: Practice good infection control measures: hand washing, proper nail care, equipment cleaning, limiting invasive lines.
    • Asepsis: Differentiate between medical asepsis (clean technique) and surgical asepsis (sterile technique).

    Safety/Prevention

    • Adolescent Safety: Focus teaching on topics relevant to adolescents, such as driver's education.
    • Restraints: Ensure restraints are used appropriately with proper orders and monitoring.
    • Injuries: Assess for injuries if a patient is found on the floor. Do not move the patient until assessed.
    • Aspiration: Assess patients' swallowing abilities who have a history of stroke. Ensure suction equipment is readily available for patients with decreased level of consciousness. Avoid oral care while patients are supine and use water-based lip moisturizers.
    • DVT Prevention: Implement measures to prevent DVT: ambulation, compression stockings, sequential compression devices, prophylactic heparin injections.
    • Falls: Assist patients to the ground if they begin to fall. Be aware of fall risk factors and implement preventative measures.
    • Patient Identification: Use two identifiers (name and date of birth) to ensure patient safety.
    • Skin Breakdown and Pressure Injuries: Recognize risk factors and preventative measures for skin breakdown and pressure injuries, particularly on bony prominences. Avoid heat application to bony prominences.
    • Preventing Heat Injuries: Monitor patients with diabetes and peripheral neuropathy for burns, especially when using hot water baths.

    Pressure Ulcer Prevention

    • Reposition patients frequently to reduce pressure: every two hours for bedridden patients and every fifteen minutes for those sitting.
    • Use appropriate support to avoid skin shearing and friction.
    • Adequate hydration and protein intake are crucial for skin health.

    Braden Scale

    • The Braden Scale measures the risk of skin breakdown.
    • A higher score indicates lower risk.
    • The highest possible score is 23.

    Safe Patient Handling

    • Use proper body mechanics to avoid injury to yourself and the patient.
    • Raise the bed to a comfortable height.
    • Avoid twisting and bending.
    • Use assistive devices like mechanical lifts for heavy or immobile patients.

    Therapeutic Communication

    • Avoid closed-ended questions and "why" questions.
    • Use open-ended questions to encourage patient participation.
    • Focus on assessing rather than assuming.

    Medication Math

    • Convert micrograms (mcg) to milligrams (mg).
    • Calculate the number of tablets or capsules per dose based on the ordered dose and available medication strength.
    • Determine daily medication dosage in grams.

    Nursing Process

    • Prioritize patient assessment before intervention.
    • Focus on optimizing patient hygiene and mobility while ensuring safety.
    • Consider patient preferences, wants, and needs.
    • Most interventions are within the scope of nursing practice and do not require physician orders.

    Pain Management

    • Self-reported pain is the gold standard for pain assessment.
    • Pain scores of 7 or higher out of 10 require further pain management interventions.
    • Monitor for respiratory suppression if medication is administered for pain management.

    Hygiene

    • Promote independence in ADLs as much as possible.
    • Provide hygiene appropriate for patient mobility.
    • Skin tinting and hydration are indicative of a patient’s nutritional status.
    • Patients with poor nutritional status are at higher risk for skin breakdown.
    • When providing oral care for an unconscious patient, position them on their side with the head of the bed lowered.
    • Factors that affect hygiene include: pain, limited mobility, sensory deficits, cognitive impairment, and emotional or mental health disturbances.
    • Common types of bed baths include: assist, complete, partial, towel bath, bag, and packaged baths.
    • Therapeutic baths are used for specific conditions, such as oatmeal baths to soothe eczema.
    • Keep skin dry to prevent breakdown and odor.
    • Obese patients are at higher risk for skin breakdown due to folds.
    • Promote dignity by providing choices and consider patient’s preferences regarding hygiene care.
    • Develop culturally congruent care plans for hygiene care.
    • Clean dentures with warm water, toothpaste or denture cleaner, and remove them before bedtime.
    • Twice yearly dental visits are a health promotion recommendation.
    • Shave with warm, damp towels. Pull skin tight and shave in the direction of hair growth.
    • Avoid razors if the patient has a bleeding disorder.
    • Do not cut or shave hair without prior discussion with the patient or family.

    Mobility

    • Promote safety while encouraging and optimizing mobility.
    • Maintain proper posture by avoiding arching shoulders forward when sitting.
    • Increased pressure, shearing, and friction can lead to skin breakdown.
    • Dehydration can lead to poor turgor.
    • Moisture leads to maceration (softening of the skin).
    • The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction or shear. A score less than 18 indicates a risk for pressure injuries.
    • The Norton Scale assesses physical condition, mental state, activity, mobility, and incontinence.
    • Positioning includes: Fowler’s, Semi-Fowler’s, High Fowler’s, Lateral, Prone, Sims, and Supine.
    • Risk factors for immobility include falls, fractures, pressure ulcers, pneumonia, constipation, decreased urination, blood clots, and muscle contractures.
    • Nursing interventions for immobility include turning, repositioning, ambulating, floating heels, and elbow positioning.
    • Complications of immobility include pressure injuries, pneumonia, weakness, muscle atrophy and contractures, urinary stasis, constipation, and Deep Vein Thrombosis (DVT).
    • Only patients with a bedrest order should NOT ambulate.
    • Bedrest is usually ordered immediately after an injury or in preparation for surgery.
    • Range of motion (ROM) exercises can be active or passive.
    • Active ROM: Patient performs exercise without assistance.
    • Passive ROM: Nurse performs ROM exercise.
    • Crutches require a three-point gait, with weight on uninjured leg and hands on crutches.
    • Crutch usage should not put weight on armpits.
    • Walkers require elbows to be bent at 30 degrees, adjusted based on walker height.
    • When ambulating a patient with a gait belt, walk slightly behind the patient.
    • Walkers with seats can be used for those with fatigue or dyspnea.
    • Canes should have rubber tips for safety.
    • Use cane on the strong side, move cane forward about 2 feet while taking a step with the weaker foot, then take a larger step with the strong foot.
    • When boosting or repositioning, do NOT pull the patient up in bed by grabbing under their armpits.
    • Use a draw sheet to assist with boosting and repositioning patients.
    • Use a slide board when transferring a patient from a stretcher to a bed.
    • Ensure the bed is down all the way to prevent falls when transferring patients.
    • Use a gait belt to stand and pivot patients if they are weak.
    • Place a chair or bedside commode on the patient’s strong side before pivoting.
    • Do NOT let the patient grab you near your neck during transfers.

    Pain

    • Pain classification includes: cutaneous/superficial, deep somatic, visceral, radiating/referred, phantom, psychogenic, nociceptive, neuropathic, acute, chronic, and intractable.
    • Appropriate assessment and management of pain are crucial for healing.
    • The numeric (0-10) pain scale is not appropriate for dementia or delirium patients.
    • Assess nonverbal cues and use the Pain-AD scale or Wong-Baker FACES scale for patients with cognitive impairments.
    • A post-op patient who cannot ambulate due to pain is NOT acceptable.
    • Set SMART goals for pain management.
    • Eliminating pain altogether is not a realistic goal.
    • Non-pharmacological pain interventions include distraction, relaxation techniques, heat therapy, cold therapy, acupuncture, acupressure, TENS, and PENS.
    • Referred pain is felt in an area far away from the origin or source of pain.
    • Factors that influence pain include emotions, past experience, developmental stage, sociocultural factors, communication skills, and cognitive impairments.
    • Stimulus: A trigger that stimulates a receptor (e.g., a loud noise, bright light, sour fruit).
    • Reception: Receiving stimuli from nerve endings through receptors (e.g., thermoreceptors, proprioceptors, photoreceptors).
    • Perception: The ability to interpret sensory impulses and give meaning to those impulses.
    • Sensory deprivation: Missing a sensory cue (e.g., stepping on something without knowing because you have diminished sensation).
    • Sensory overload: Overstimulation (e.g., ADHD).
    • Sensory deficits: Loss of a sense (e.g., loss of taste or smell).
    • The Glasgow Coma Scale correlates with the client’s ability to function.
    • Arousal: A combination of consciousness and alertness.
    • Patients with diabetes often have peripheral neuropathy.
    • Use a thermometer to test bath water for patients with peripheral neuropathy.
    • Do NOT soak or bathe in hot water for patients with peripheral neuropathy.
    • Examine feet daily for patients with peripheral neuropathy.
    • Wear gloves in cold weather to prevent frostbite.
    • Avoid open-toed shoes for patients with peripheral neuropathy.
    • Nursing interventions for patients with sensory impairments include assessing the patient’s preferred method of communication and ensuring they have access to assistive devices.
    • Sensory overload (overstimulation) risk factors include: elderly, mobility limitations, sensory impairments, and isolation.
    • Sensory overload interventions include minimizing stimuli by turning off alarms, TV, lights, and limiting visitors.
    • Sensory deprivation is an increased risk for elderly patients, those with mobility limitations, sensory impairments, and isolation.

    Delegation

    • Do NOT delegate medication administration, teaching, or assessment (e.g., pain assessment) to UAPs.
    • UAPs can collect vital signs and assist with ADLs (repositioning, hygiene, toileting, ear cleaning, hearing aid care, etc.).
    • UAPs can provide food, water, ice packs, and back rubs.

    Infection

    • The Chain of Infection: Infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host.
    • Infectious agent (bacteria, fungi, parasites, prions) are microorganisms capable of causing disease or illness.
    • Reservoirs (people, water, food) are places where infectious agents live, grow, and reproduce.
    • Portals of exit (blood, secretions, excretions, skin, coughing, sneezing, diarrhea, seeping wounds, tubes, IV lines, bandaging a MRSA wound) are ways infectious agents leave the reservoir.
    • Modes of transmission (physical contact, droplets, airborne) are ways in which infectious agents are spread from the reservoir to the susceptible host.
    • Portals of entry (mucous membranes, respiratory system, digestive system broken skin, vagina, mouth, insect bites ) are ways in which infectious agents enter the susceptible host.
    • Susceptible hosts (immune deficiency, diabetes, burns, surgery, age) have traits that affect their susceptibility and severity of disease.
    • Five stages of infection: Incubation, Prodromal, Illness, Decline, Convalescence.
    • Classification of infections: Local, Systemic, Acute, Chronic, and Latent.
    • Local infection occurs in a limited region of the body.
    • Systemic infection spreads via blood or lymph.
    • Acute infection has rapid onset and short duration.
    • Chronic infection develops slowly and has long duration.
    • Latent infection is present with no discernible symptoms.
    • Monitor WBC count for leukocytosis (increased WBC count), fever/chills, and (+) blood cultures to indicate systemic infection.
    • White spots on the tongue may indicate thrush – notify the provider.
    • Odor, redness, and itching/burning between toes may indicate tinea pedis.
    • Avoid lotion between the toes to prevent fungal infection.
    • Drainage types: Serous, Sanguineous, Serosanguinous, Purulent.
    • Factors that increase risk for skin infections include diabetes, burns, wounds, etc.
    • Nursing considerations for infection control:
      • Keep fingernails short.
      • Hand washing is the best way to prevent the spread of infection.
      • Inspect skin for open sores or cuts frequently.
      • Keep skin moisturized.
      • Clean all equipment after each use between patients.
      • Avoid invasive lines and catheters if not necessary.
      • Medical asepsis: Clean environment techniques are used.
    • Transmission factors:
      • Portal of exit: How the pathogen leaves the body.
      • Vector: How the pathogen is transported.
      • Pathogen: Type of microorganism.
      • Reservoir: Environments where the pathogen lives.
      • Susceptible host: Individual at risk for infection.
    • Transmission precautions:
      • Contact: Gown and gloves.
      • Droplet: Surgical mask, goggles, gown, gloves.
      • Airborne: Positive airflow, N95 mask, gown, goggles, gloves.
    • Health-care related infections: Exogenous and Endogenous.
    • Exogenous infections are acquired from the healthcare environment.
    • Endogenous infections are caused by a patient’s normal flora multiplying due to treatment.
    • Suprainfection: A secondary infection that occurs as a result of treatment, such as a yeast infection after antibiotic use.
    • Implementing surgical asepsis (sterile technique).
    • Autoclave: Sterilization method used to kill microorganisms.

    Safety/Prevention

    • Focus on driver’s education when meeting the safety needs of an adolescent client.
    • Ensure primary care provider renews restraints orders every 24 hours.
    • If a patient is found on the floor, assess for injury before moving them.
    • Always assess swallowing for patients with a history of stroke.
    • Patients with decreased level of consciousness (LOC) are at high risk of aspiration.
    • Set up suction equipment for patients at risk of aspiration.
    • Use moistened mouth swabs hooked up to suction for oral care if the patient is unconscious.
    • Do not perform oral care while the patient is supine.
    • Avoid petroleum-based lip moisturizers; water-based is best.
    • DVT prevention methods include ambulation, compression stockings, sequential compression devices, and prophylactic heparin injections.
    • If a patient begins to fall, assist them down to the ground.
    • Fall risk factors include older adults, sensory impairments, weakness or neurological problems, dizziness, orthostatic hypotension, history of falls, confusion, urinary frequency, and diarrhea.
    • Fall prevention methods include: Benches and rails in the bath or shower, gait belts, ensuring the bed is low and locked, educating patients to avoid getting up too fast, making sure high-risk patients can use the call light, keeping a night light on, keeping the call light, items, and bedside table within reach, hourly rounding, leaving siderails up for patients with multiple sensory deficits.
    • Patient identification:
      • Ask for two identifiers (name and date of birth), comparing them to the wristband.
    • Confirm patient identity only with the patient if they are alert and oriented; family members and other staff members should not be involved.
    • Scanning a wristband without confirming identity is NOT adequate or safe.
    • Skin breakdown and pressure injuries most often occur on bony prominences.
    • Avoid heat on bony prominences.
    • Risk factors for skin breakdown include diabetes, excess moisture, malnutrition, immobility, impaired circulation, etc.

    Preventing Skin Breakdown

    • Repositioning is crucial to prevent pressure ulcers.
    • Frequency: Reposition every 2 hours while in bed and limit sitting to 1 hour at a time.
    • Sitting: Change weight distribution every 15 minutes and use cushions for support.
    • Braden Scale: Assesses risk of skin breakdown.
      • Score of 23 indicates the lowest risk.
      • Factors considered include moisture levels, mobility, sensory perception, nutrition, and friction/shear.
    • Hydration and Protein: Adequate intake is essential for skin health.

    Body Mechanics

    • Lifting: Lift patients using proper equipment (mechanical lift) when necessary.
    • Bed Height: Raise the bed to minimize bending and strain.
    • Limiting Motions: Avoid bending, twisting, and improper lifting.
    • Support: Maintain a wide base of support when providing care.

    Therapeutic Communication

    • Avoid "Why" Questions: Encourage open-ended questions instead.
    • Avoid Assumptions: Assess the patient’s needs and preferences.

    Medication Calculations

    • mcg to mg: Convert mcg to mg before calculating dosage.
    • Grams/Day: Calculate total daily dose for medications administered multiple times per day.
    • Capsule or Tablet Dosage: Calculate total number of capsules or tablets needed per dose.
    • mL per Dose: Calculate the volume of medication in mL per dose.

    Nursing Process

    • Assessment: Prioritize assessment before determining intervention.
    • Patient Preferences: Prioritize patient needs and preferences.
    • Goal: Optimize hygiene and mobility in the safest and most appropriate way.
    • Pain Management: Prioritize pain control through self-report, especially for patients experiencing severe pain (7/10).
    • Respiratory Monitoring: Monitor for signs of respiratory depression (RR < 12, lethargy) when providing pain medication.

    Hygiene

    • Hygiene promotes comfort, improves self-image, and decreases infection and disease.
    • Work with patients to provide hygiene appropriate to their mobility and promote independence with ADLs as much as possible.
    • Immobile patients require bed baths and washing hair with rinse-free shampoo caps.
    • Hydration is crucial for skin health.
    • Nutritional status affects skin health, and undernourished individuals are at risk of skin breakdown.
    • Rotate heels off the bed to prevent pressure ulcers.
    • Unconscious patients need oral care with moistened mouth swabs attached to suction and should be positioned on their side with the head of the bed lowered.
    • Pain, limited mobility, sensory deficits, cognitive impairment, and emotional or mental health disturbances can affect hygiene.
    • Common types of bed baths include assist, complete, partial, towel, bag, and therapeutic (e.g., oatmeal bath).
    • Denture care involves cleansing with warm water and toothpaste or denture cleaner and removing them before bedtime.
    • Shaving requires using a warm, damp towel on the skin first, pulling skin back tightly, shaving in the direction of hair growth, and avoiding razors for patients with bleeding disorders.
    • Culture and patient preferences should always be considered when providing hygiene care; for example, allowing patients to choose showering frequency or requesting same-sex UAPs/nurses.

    Mobility

    • Mobility goals focus on maintaining safety while encouraging and optimizing safe mobility.
    • Mobility limitations may preclude showering independently if unsafe.
    • Proper posture requires avoiding arching shoulders forward when sitting.
    • Mobility status is important due to the increased risk of pressure, shearing, and friction leading to skin breakdown.
    • Dehydration results in poor skin turgor.
    • Moisture can lead to maceration (softening of the skin).
    • Braden and Norton Scales assess a patient's risk for skin breakdown based on various factors such as sensory perception, moisture, activity, mobility, nutrition, friction, shear, physical condition, mental state, activity, mobility, and incontinence.
    • Common positions include Fowler's, Semi-Fowler's, High Fowler's, Lateral, Prone, Sims', and Supine.
    • Risk factors for immobility include falls, fractures, pressure ulcers, pneumonia, constipation, decreased urination, blood clots, and muscle contractures.
    • Nursing interventions for immobility include turning, repositioning, ambulation, floating heels, and protecting elbows.
    • Complications of immobility include pressure injuries, pneumonia, weakness, muscle atrophy and contractures, urinary stasis, constipation, and deep vein thrombosis (DVT).
    • Only patients on bedrest should not ambulate; this order is typically only given immediately after an injury or before surgery.
    • Range of motion (ROM) is the maximum movement possible at a joint; it can be active (patient-performed) or passive (nurse-performed).
    • Crutches require the uninjured leg to bear all weight along with hands on the crutches, with a three-point gait.
    • Walkers require the elbows to be bent 30 degrees (adjust height accordingly), and patients should lift the walker forward before taking a step.
    • Canes should have a rubber tip for safety, be used on the strong side, and moved forward before taking a step with the weaker foot, followed by a larger step with the strong foot.
    • Boosting and repositioning patients in bed should be done using a draw sheet, not by grabbing under the armpits.
    • Transferring from stretcher to bed requires a slide board.
    • Transferring from bed to bedside commode or chair requires the bed to be lowered completely, use of a gait belt (if necessary), and positioning the chair/commode on the patient's strong side.

    Pain

    • Pain classification includes cutaneous/superficial, deep somatic, visceral, radiating/referred, phantom, psychogenic, nociceptive, and neuropathic.
    • Pain can be acute (short-term) or chronic (longer than 6 months). Intractable pain, such as that from compression fractures, does not respond to treatment.
    • Pain quality can be described as dull, burning, or achy.
    • Pain periodicity can be intermittent or constant.
    • Pain intensity is measured on a scale from mild to moderate to severe.
    • Appropriate pain assessment and management are crucial for healing.
    • Numeric (0-10) pain scales are not suitable for dementia/delirium patients; nonverbal cues should be observed, and Pain-AD or Wong-Baker FACES scales can be used.
    • Non-pharmacological interventions include distraction, relaxation techniques, heat therapy (not for acute inflammation), cold therapy (apply for 15 minutes, remove, and assess for redness/blistering), acupuncture, acupressure, TENS, and PENS.
    • Referred pain is felt in an area far away from its source.
    • Factors influencing pain include emotions, past experiences, developmental stage, sociocultural factors, communication skills, and cognitive impairments.

    Sensory Perception

    • Stimulus triggers nerve endings (e.g., loud noises, bright lights, sour fruits).
    • Reception is the process of receiving stimuli through receptors such as thermoreceptors, proprioceptors, and photoreceptors.
    • Perception interprets sensory impulses; it is the ability to give meaning to the stimuli.
    • Sensory deprivation occurs when the brain does not receive enough sensory input; for example, stepping on something without noticing.
    • Sensory overload occurs when the brain is overwhelmed by sensory input; for example, ADHD.
    • Sensory deficits involve a loss of senses, such as taste or smell.
    • ** Glasgow Coma Scale** correlates to a patient's ability to function and helps guide nursing care.
    • Arousal is composed of consciousness and alertness.
    • Peripheral neuropathy (numbness) in patients with diabetes increases the risk of burns.
    • Nursing interventions for patients with sensory impairments include assessing preferred communication methods, verifying the availability and functionality of assistive devices (e.g., hearing aids, glasses), and providing individualized care.
    • Sensory overload can be reduced by minimizing stimuli such as noise, light, and visitors.
    • Sensory deprivation can be addressed by providing stimulating activities, social interaction, and sensory stimulation.

    Infection

    • Chain of infection involves the infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.
    • Infectious agent includes bacteria, fungi, parasites, and prions.
    • Reservoir is where infectious agents live, grow, and reproduce (e.g., people, water, food).
    • Portal of exit is how infectious agents leave the reservoir (e.g., coughing, sneezing, wounds).
    • Modes of transmission include physical contact, droplets, and airborne.
    • Portal of entry is how infectious agents enter the susceptible host (e.g., mucous membranes, broken skin).
    • Susceptible host are individuals at risk due to factors like immune deficiency, diabetes, burns, surgery, or age.
    • Stages of infection include incubation, prodromal, illness, decline, and convalescence.
    • Types of infections include local, systemic, acute, chronic, and latent.
    • Monitor WBC count for leukocytosis (increased WBC count) which indicates systemic infection.
    • Possible signs of infection include white spots on the tongue, odor, redness, and itching/burning between toes.
    • Drainage can be serous, sanguineous, serosanguinous, or purulent.
    • Factors increasing skin infection risk include diabetes, burns, wounds, and decreased mobility.
    • Nursing considerations for infection control include maintaining short fingernails, frequent hand washing, skin inspection, moisturizing skin, cleaning equipment, limiting invasive lines and catheters, and practicing medical asepsis.
    • Transmission factors impacting infection spread include portal of exit, vector, pathogen, reservoir, and susceptible host.
    • Transmission precautions include contact, droplet, and airborne.
    • Contact precautions require gown and gloves for infections like MRSA and C-diff.
    • Droplet precautions require surgical mask, goggles, gown, and gloves for respiratory viruses like influenza and chicken pox.
    • Airborne precautions require positive airflow, N-95 mask, gown, goggles, and gloves for infections like tuberculosis and varicella.
    • Healthcare-related infections can be exogenous (acquired from the healthcare environment) or endogenous (arising from the patient's normal flora).
    • Surgical asepsis involves sterile techniques and equipment sterilization using an autoclave.

    Safety / Prevention

    • Adolescent safety education should focus on driving education.
    • Restraints require a renewed order from the primary care provider every 24 hours.
    • If a patient is found on the floor, assess for injury before moving them.
    • Aspiration risk is high in patients with a history of stroke, decreased level of consciousness, or impaired swallowing; use suction, modified oral care, and water-based lip moisturizers.
    • DVT prevention includes ambulation (if possible), compression stockings, sequential compression devices, and prophylactic heparin injections.
    • Falls require assisting the patient to the ground if they begin to fall.
    • Fall risk factors include age, sensory impairments, weakness, neurological problems, dizziness, orthostatic hypotension, history of falls, confusion, and urinary frequency or diarrhea.
    • Fall prevention measures include benches and rails in the shower, gait belts during ambulation, low and locked beds, education about getting up slowly, nighttime lights, easy access to call lights and necessities, hourly rounding, and using siderails for patients with multiple sensory deficits.
    • Patient identification involves using two identifiers (name and date of birth) and comparing them to the wristband; patients who are alert and oriented should confirm their own identity.
    • Skin breakdown and pressure injuries occur on bony prominences and are associated with diabetes, excess moisture, malnutrition, immobility, impaired circulation, etc.
    • Avoid heat on bony prominences to prevent skin breakdown.

    Delegation

    • Do not delegate medication administration, teaching, or assessment tasks to unlicensed assistive personnel (UAPs).
    • UAPs can collect vital signs and assist with ADLs such as repositioning, hygiene, toileting, ear cleaning, and hearing aid care.
    • UAPs can provide food/water, ice packs, and back rubs.

    Preventing Skin Breakdown

    • Offload Pressure: Reposition patients every two hours while in bed, and every 15 minutes while sitting in a chair. Limit sitting to one hour at a time.
    • Braden Scale: Used to assess risk of skin breakdown. The highest score, 23, indicates the lowest risk.
    • Other Prevention Measures: Adequate hydration and protein intake, proper body mechanics.
      • Body Mechanics: Use mechanical lifts to move heavy or immobile patients. Avoid bending forward or twisting your back.

    Therapeutic Communication

    • Ask Open-Ended Questions: Avoid "why" questions and questions that assume (e.g., "Don't you...").
    • Rule of Thumb: Assess, don't assume.

    Medication Calculations

    • Calculating mL/Dose: If the order is in mcg and the medication is in mg/mL, convert mcg to mg.
    • Calculating # Capsules/Tablets/Dose: If the order is in mg and the medication is in mg per capsule/tablet, calculate the necessary dosage.
    • Calculating Grams/Day: If the order is for a specific dose multiple times a day, calculate the total daily dosage in grams.

    Nursing Process

    • Assess Before Intervening: Determine the safest and most appropriate intervention for the patient. Consider their preferences, wants, and needs.
    • Optimizing Hygiene and Mobility: Focus on safety and appropriateness.
    • Pain Management: The gold standard for pain assessment is self-report. For pain scores of 7 or higher, consider additional pain medication.
    • Respiratory Suppression: Monitor for signs of respiratory suppression such as low respiratory rate (RR < 12) and lethargy.

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    This quiz covers essential hygiene care practices for patients, focusing on promoting independence and adapting techniques based on the patient's mobility. Explore strategies for handling immobilized patients, oral care for unconscious individuals, and the importance of considering cultural preferences in hygiene practices.

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