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What is the most appropriate action for providing oral care for an unconscious patient?
What is the most appropriate action for providing oral care for an unconscious patient?
Health promotion suggests dental visits should be once a year.
Health promotion suggests dental visits should be once a year.
False
What should you do to prevent skin breakdown in patients?
What should you do to prevent skin breakdown in patients?
Keep the skin dry and reposition the patient regularly.
The patient reported burning and itching with inflamed skin. The most appropriate action is to keep the area ______ and ______.
The patient reported burning and itching with inflamed skin. The most appropriate action is to keep the area ______ and ______.
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Which statement requires additional education regarding oral hygiene for an older adult?
Which statement requires additional education regarding oral hygiene for an older adult?
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Which of the following is a goal of maintaining safety while encouraging mobility?
Which of the following is a goal of maintaining safety while encouraging mobility?
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What should be avoided if a patient has a bleeding disorder?
What should be avoided if a patient has a bleeding disorder?
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Which scale assesses the risk of pressure ulcers?
Which scale assesses the risk of pressure ulcers?
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What are the five stages of infection?
What are the five stages of infection?
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What is the primary action to prevent the spread of infection?
What is the primary action to prevent the spread of infection?
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What is a sign of possible infection indicated by white spots on the tongue?
What is a sign of possible infection indicated by white spots on the tongue?
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What is an exogenous infection?
What is an exogenous infection?
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What is a characteristic of endogenous infections?
What is a characteristic of endogenous infections?
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What does surgical asepsis ensure?
What does surgical asepsis ensure?
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What should be done if a patient is found on the floor?
What should be done if a patient is found on the floor?
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For patients with a history of stroke, always assess ______.
For patients with a history of stroke, always assess ______.
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What is a method of DVT prevention?
What is a method of DVT prevention?
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It is safe to scan wristbands without confirming a patient's identity.
It is safe to scan wristbands without confirming a patient's identity.
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Pressure injuries most often occur on ______.
Pressure injuries most often occur on ______.
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What does the Braden Scale assess?
What does the Braden Scale assess?
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What is the highest score on the Braden Scale indicating the least risk?
What is the highest score on the Braden Scale indicating the least risk?
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When providing care, proper body mechanics include keeping a ______ of support.
When providing care, proper body mechanics include keeping a ______ of support.
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What should the nurse avoid when asking therapeutic questions?
What should the nurse avoid when asking therapeutic questions?
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What is the gold standard for pain assessment in patients?
What is the gold standard for pain assessment in patients?
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Patients with dizziness should not be ______ independently.
Patients with dizziness should not be ______ independently.
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What is an exogenous infection?
What is an exogenous infection?
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What should a nurse focus on when meeting the safety needs of an adolescent client?
What should a nurse focus on when meeting the safety needs of an adolescent client?
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The primary care provider should renew the order for restraints every 24 hours.
The primary care provider should renew the order for restraints every 24 hours.
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To prevent DVT, it's important to ambulate if ______.
To prevent DVT, it's important to ambulate if ______.
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Which of the following is a risk factor for falls in elderly patients?
Which of the following is a risk factor for falls in elderly patients?
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What is the highest score on the Braden Scale indicating the least risk for skin breakdown?
What is the highest score on the Braden Scale indicating the least risk for skin breakdown?
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When caring for a patient, proper body mechanics include which of the following?
When caring for a patient, proper body mechanics include which of the following?
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What should a nurse avoid when communicating therapeutically?
What should a nurse avoid when communicating therapeutically?
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To calculate mL/dose, if the order is for 1,000 mcg and the medication comes in 2 mg/mL, you will give ______ mL/dose.
To calculate mL/dose, if the order is for 1,000 mcg and the medication comes in 2 mg/mL, you will give ______ mL/dose.
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What is the most appropriate question to ask an older patient who ambulates with a device regarding hygiene care?
What is the most appropriate question to ask an older patient who ambulates with a device regarding hygiene care?
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What should be the nurse's action when providing oral care for an unconscious patient?
What should be the nurse's action when providing oral care for an unconscious patient?
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The appropriate method for washing the hair of an unconscious patient in bed is to use ___.
The appropriate method for washing the hair of an unconscious patient in bed is to use ___.
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What actions should be taken for a patient with burning and itching in the folds of the skin?
What actions should be taken for a patient with burning and itching in the folds of the skin?
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Obese patients are at higher risk for skin breakdown due to folds.
Obese patients are at higher risk for skin breakdown due to folds.
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What is one appropriate way for a nurse to promote dignity when providing hygiene care?
What is one appropriate way for a nurse to promote dignity when providing hygiene care?
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What should a nurse do if a patient has a cast and has foul odor and reddened skin between their toes?
What should a nurse do if a patient has a cast and has foul odor and reddened skin between their toes?
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Which of the following statements by an older adult requires additional education regarding oral hygiene and denture care?
Which of the following statements by an older adult requires additional education regarding oral hygiene and denture care?
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Match the following types of baths with their appropriate descriptions:
Match the following types of baths with their appropriate descriptions:
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What is a risk factor for immobility?
What is a risk factor for immobility?
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Nurses should not delegate medication passing, teaching, or assessment.
Nurses should not delegate medication passing, teaching, or assessment.
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What is the chain of infection?
What is the chain of infection?
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Cultures should not be taken before administering antibiotics.
Cultures should not be taken before administering antibiotics.
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What precautions are needed for airborne transmission?
What precautions are needed for airborne transmission?
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Study Notes
Injuries
- If a patient is found on the floor, assess for injury before moving them.
Aspiration
- Always assess swallowing in patients with a history of stroke.
- Patients with decreased level of consciousness are at high risk for aspiration.
- Ensure suction is readily available for patients at risk of aspiration.
- Use swabs connected to suction for oral care in unconscious patients.
- Do not perform oral care while the patient is supine.
- Avoid petroleum-based lip moisturizers; water-based is preferred.
DVT Prevention
- Ambulate patients if possible.
- Use compression stockings.
- Utilize sequential compression devices.
- Administer prophylactic heparin injections.
Falls
- If a patient starts to fall, assist them safely to the ground.
- Identify fall risk factors, such as older age, sensory impairments, weakness, neurological issues, dizziness, orthostatic hypotension, history of falls, and confusion.
- Consider urinary frequency or diarrhea as contributing factors to confusion.
- Implement fall prevention measures, such as:
- Benches and rails in showers and baths
- Use gait belts for high-risk patients during ambulation
- Maintain beds in a low and locked position
- Ensure high-risk patients can access the call light
- Encourage patients to avoid getting up too quickly to prevent orthostatic hypotension.
-# Keep call lights, personal items, and bedside tables within easy reach. - Implement hourly rounding.
- Use siderails for patients with multiple sensory deficits.
- Leave a nightlight on at night.
Identification
- Verify patient identity using two identifiers (name and date of birth), comparing to the wristband.
- Only the alert and oriented patient should confirm their identity.
- Scanning the wristband alone is insufficient for safe identification.
Skin Breakdown and/or Pressure Injuries
- Most occur on bony prominences (heel, sacrum/coccyx, etc.).
- Avoid applying heat to bony prominences.
- Risk Factors: Diabetes, excessive moisture, malnutrition, immobility, impaired circulation.
-
Pressure offloading is key for prevention:
- Assess patient's ability to reposition themselves.
- Reposition patients every two hours while in bed.
- If sitting in a chair, limit sitting time to one hour at a time and shift weight every 15 minutes. Provide a cushion for the patient to sit on.
- Other prevention measures: Adequate hydration and protein intake.
-
Braden Scale: Tool used to assess risk for skin breakdown (be able to calculate score).
- 23 is the highest score, indicating the least risk.
Proper Body Mechanics During Care
- Elevate 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 a heavy or immobile patient without assistance.
- Use proper equipment, such as mechanical lifts, as needed.
Therapeutic Communication
- Avoid asking "why" questions.
- Utilize open-ended questions.
- Focus on assessments rather than assumptions. Avoid questions like "don't you do this?" or "don't you like this?"
Med Math
- Calculating mL/dose when given an order for a medication in mg/mL (e.g., order is for 1,000mcg, but the med comes in 2mg/mL; you will give 0.5 mL/dose).
- Converting mcg to mg (e.g., order is for 100mcg, but the med comes in 0.1mg/tablet; you will give 1 tablet).
- Calculating the number of capsules or tablets/ dose (e.g., order is for 7.5mg, but the med comes in 5mg scored tablets; you will give 1.5 tablets/dose).
- Calculating grams/day for a medication (e.g., order is for 250mg PO QID; you will give 0.25 grams/day).
Important Nursing Considerations
- Prioritize assessment before implementing any interventions.
- Aim to optimize hygiene and mobility while prioritizing the patient's safety and well-being.
- Start by assessing the patient's preferences, needs, and wants.
- Most of these tasks fall under nursing interventions; physician contact is usually not required.
- In NCLEX scenarios, consider the patient's self-reported pain as the gold standard. If the patient reports severe pain (7 or higher out of 10), they likely require more medication.
- Exceptions include signs of respiratory suppression (respiratory rate less than 12, lethargy).
Hygiene
- Promotes comfort, improves self-image, and decreases infection and diseases
- Work with patients to provide hygiene appropriate for their mobility, promoting independence with ADLs as much as possible
- For immobile patients, provide bed baths and wash hair with rinse-free shampoo caps
- 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 or packaged bath, and therapeutic bath
- When providing oral care for the unconscious patient, place the patient on their side with the head of the bed in a lowered position
- Cleanse dentures with warm water and toothpaste or denture cleaner and remove before bedtime
- Keep skin dry to prevent breakdown, as odor in folds may indicate moisture/fungus
- Obese patients are at higher risk for skin breakdown due to folds
- For shaving, use a warm, damp towel on skin first, pull skin back tightly and shave in the direction of hair growth, and avoid razors for patients with bleeding disorders
- Do not cut or shave hair without prior discussion with the patient/family
Mobility
- Goal is maintaining safety while encouraging and optimizing safe mobility
- Mobility limitations may preclude showering independently if unsafe
- To maintain proper posture, it is important to avoid arching shoulders forward when sitting
- Increased pressure, shearing, and friction can lead to breakdown
- Dehydration leads to poor turgor, and moisture leads to maceration (softening of skin)
- Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction or shear, with a score less than 18 indicating risk
- Norton Scale assesses patients' physical condition, mental state, activity, mobility, and incontinence
- The ONLY patients who should NOT be ambulating are those with a BEDREST order, usually only ordered immediately after an injury or awaiting surgery
- Active ROM: patient performs exercise without assistance
- Passive ROM: nurse performs ROM exercise
- Crutches use a three-point gait, with the uninjured leg bearing all weight along with hands on the crutches, and lead with the unaffected leg when going up stairs
- Walkers should be adjusted to a 30-degree bend in the elbows, and the patient should lift the walker forward about 6 inches before taking a step
- When ambulating a patient with a gait belt, walk slightly behind the patient
- Canes should have a rubber tip, be used on the strong side, and moved forward about 2 feet while taking a step with the weaker foot
- Do NOT pull the patient up in bed by grabbing under the armpits, use a draw sheet, and use a slide board for transferring from a stretcher to bed
- When transferring from bed to a bedside commode or chair, the bed should be down all the way, use a gait belt to stand and pivot the patient if weak, and place the chair/commode on the patient's strong side before pivoting
Pain
- Pain can be classified by location, duration, quality, periodicity, and intensity
- It is important to understand how pain is classified to develop an effective pain management plan
- Numeric (0-10) scale is not appropriate for dementia or delirium patients, instead, assess for nonverbal cues
- Make sure pain goals/outcomes are SMART goals
- Nonpharmacological 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/source
- Factors that influence pain include emotions, past experience, developmental stage, sociocultural factors, communication skills, and cognitive impairments
Sensory Perception
- Stimulus is a trigger that stimulates a receptor
- Reception is the process of receiving stimuli from nerve endings
- Perception is the ability to interpret sensory impulses and give meaning to impulses
- Sensory deprivation is a lack of response to stimuli, while sensory overload is an excess of stimulation
- Sensory deficits are a loss of one or more senses
- Nursing interventions for patients with sensory impairments include assessing how the patient prefers to communicate and making sure they have access to necessary aids like hearing aids and glasses
- Sensory overload can be caused by excessive stimuli, resulting in anxiety, increased heart rate, and high blood pressure
- Interventions for sensory overload include minimizing stimuli like turning off alarms, TV, and lights, and limiting visitors
- Sensory deprivation can occur due to reduced stimulation, affecting physical and cognitive function
- Nursing interventions for sensory deprivation include providing stimulation through sensory activities, socialization, and maintaining a comfortable environment
Delegation
- Do NOT delegate med pass, teaching, or assessment
- UAPs can collect vitals 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
Infection
- Chain of Infection: Infectious agent-Reservoir-Portal of exit-Mode of transmission-Portal on entry-Susceptible Host
- 5 stages of infection: Incubation, prodromal, illness, decline, convalescence
- Infectious agents include bacteria, fungi, parasites, and prions
- Reservoirs include people, water, and food
- Portals of exit include blood, secretions, excretions, and skin
- Modes of transmission include physical contact, droplets, and airborne
- Portals of entry include mucous membranes, respiratory system, digestive system, broken skin, vagina, mouth, and insect bites
- Susceptible hosts have traits that affect their susceptibility and severity of disease
- Monitor WBC count for leukocytosis, fever/chills, and positive blood cultures which indicate systemic infection
- Local infection occurs in a limited region of the body, while systemic infection spreads via blood or lymph
- Acute infections have rapid onset and short duration, while chronic infections develop slowly and have long durations
- Latent infections are present with no discernible symptoms
- Signs of infection may include white spots on the tongue, odor, redness, and itching/burning between toes
- Drainage can be serous, sanguineous, serosanguinous, or purulent
- Factors that increase risk for skin infections include diabetes, burns, and wounds
- Nursing considerations for infection control include hand washing, proper hygiene, and clean equipment
- Transmission precautions include contact, droplet, and airborne
- Contact precautions require gown and gloves, droplet precautions require a surgical mask, goggles, gown, and gloves, and airborne precautions require a positive airflow room, N-95 mask, gown, goggles, and gloves
- Healthcare-related infections can be exogenous or endogenous
- Exogenous infections are acquired from the healthcare environment, while endogenous infections arise when patients' normal flora multiply and cause infection as a result of treatment
- Suprainfection is a type of endogenous infection, such as a yeast infection after antibiotic use
- Implementing surgical asepsis requires a sterile environment, like an autoclave
Safety/Prevention
- For adolescents, focus teaching on driver's education
- When using restraints on a hospitalized client, ensure that the primary care provider renews the order for restraints once every 24 hours
Injury Assessment
- Assess for injuries if a patient is found on the floor, but do not move the patient.
Aspiration Precautions
- Always assess swallowing in patients with a history of stroke.
- Patients with decreased level of consciousness are at high risk for aspiration.
- Ensure suction equipment is readily available for patients at risk of aspiration.
- Use swabs connected to suction for oral care in unconscious patients.
- Do not perform oral care while the patient is supine.
- Avoid petroleum-based lip moisturizers and use water-based products instead.
DVT Prevention
- Encourage ambulation (if possible).
- Utilize compression stockings.
- Consider sequential compression devices.
- Administer prophylactic heparin injections.
Fall Prevention
- Assist patients safely to the ground if they begin to fall.
- Identify fall risk factors including:
- Older adults
- Sensory impairments
- Weakness or neurological problems (e.g., tremors)
- Dizziness, orthostatic hypotension, and/or history of falls
- Confusion (especially in patients experiencing urinary frequency or diarrhea)
- Implement fall prevention strategies, such as:
- Benches and rails in bathrooms.
- Use a gait belt for ambulating high-risk patients.
- Ensure the bed is low and locked.
- Avoid allowing patients with dizziness to be "up independently."
- Make sure high-risk patients can reach the call light.
- Keep a night light on in the room.
- Position items within reach of the patient (call light, bedside table).
- Conduct hourly rounding checks.
- Educate patients to avoid getting up too quickly (risk of orthostatic hypotension).
- Consider using siderails if a patient has multiple sensory deficits.
Patient Identification
- Ask the patient for two identifiers (name and date of birth) and compare to the wristband.
- If the patient is alert and oriented, only the patient should confirm their identity.
- Scanning the wristband without confirming identity is not sufficient.
Skin Breakdown and Pressure Injury Prevention
- Pressure injuries most often occur on bony prominences (e.g., heels, sacrum/coccyx).
- Avoid applying heat to bony prominences.
- Identify risk factors for skin breakdown:
- Diabetes
- Excess moisture (e.g., fever, diaphoresis)
- Malnutrition
- Immobility
- Impaired circulation
- Offload pressure to prevent skin breakdown:
- Assess the patient's ability to reposition themselves.
- Reposition the patient every two hours while in bed.
- If sitting in a chair, limit sitting time to one hour at a time, shift weight every 15 minutes, and provide a cushion.
- Additional prevention measures include:
- Adequate hydration and protein intake.
- Utilize the Braden Scale to assess risk for skin breakdown.
- A score of 23 represents the lowest risk for skin breakdown.
Body Mechanics for Patient Care
- Raise the bed to avoid bending forward while providing care.
- Limit bending and twisting of the neck and back.
- Maintain a wide base of support.
- Do not attempt to lift or turn a heavy or immobile patient without assistance.
- Utilize proper equipment (e.g., mechanical lift) when necessary.
Therapeutic Communication
- Avoid asking "why" questions.
- Utilize open-ended questions.
- Avoid questions like "don't you do this?" or "don't you like this?"
- Remember to assess the patient's needs and do not make assumptions.
Medication Math
-
Calculating mL/dose:
- Example: Order for 1,000 mcg, medication comes in 2 mg/mL, will administer 0.5 mL/dose.
-
Converting mcg to mg:
- Example: Order for 100 mcg, medication comes in 0.1 mg/tablet, will administer 1 tablet.
-
Calculating number of capsules or tablets/dose:
- Example: Order for 7.5 mg, medication comes in 5 mg scored tablets, will administer 1.5 tablets/dose.
-
Calculating grams/day:
- Example: Order for 250 mg PO QID, will administer 0.25 grams/day.
Nursing Process
- Utilize the nursing process by assessing before implementing interventions.
- Aim to optimize hygiene and mobility, while prioritizing safety and patient preferences.
- Seek patient input on their wants and needs.
- Most tasks are nursing interventions and usually do not require physician contact.
- In clinical settings, self-report is the gold standard for pain assessment. If the patient reports severe pain (7 or higher out of 10), they likely need more medication, unless signs of respiratory suppression are present.
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Description
This quiz focuses on essential nursing care practices related to infection control, oral hygiene for older adults, and the prevention of skin breakdown in patients. It covers appropriate actions for unconscious patients and the assessment of infection risks. Test your knowledge on these critical nursing concepts and improve your understanding of patient safety.
