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NUR 215 Exam 2 Study guide **[Hygiene:]Promotes comfort, Improve self-image, and decrease infection and disease** - Work with patient to provide hygiene appropriate to the patient's mobility - Promote independence with ADLs as much as possible - If immobile, give bed bath and w...

NUR 215 Exam 2 Study guide **[Hygiene:]Promotes comfort, Improve self-image, and decrease infection and disease** - Work with patient to provide hygiene appropriate to the patient's mobility - Promote independence with ADLs as much as possible - If immobile, give bed bath and wash hair with rinse-free shampoo cap - Promote independence. - Skin tinting-Hydration - Nutritional status affects skin. At risk of skin breakdown. Rotate float heels off bed. - When providing oral care for the unconscious patient the nurse should place the patient on their side with the head of the bed in a lowered position - Plan hygiene care around patients needs **Factors that affect Hygiene** - Pain - Limited Mobility - Sensory deficits: Vision-Hearing - Cognitive impairment - Emotional or mental health disturbances: Schizophrenia **Common types of Bed baths** - Assist: Bathe areas hard to reach - Complete: Washing everything - Partial: Bathe only those area absolutely necessary including perineum (private area) - Towel bath. - Bag or packaged bath. - Therapeutic Bath: Oatmeal bath **Jeopardy** - When assessing the hygiene needs of an older pt that ambulates with a device, which question is most appropriate. Would you prefer a sponge bath or sit on a shower chair to take a shower. - What is the most appropriate question regarding care for a clients hair when assisting hygiene for an older client. How do you usually care for your hair at home? - When providing oral care on an unconscious pt, what action is most appropriate? Use a moistened mouth swab that is attached to suction for oral care. - When assessing the mouth of an unconscious pt, what should the nurse report to the provider. White spots on the tongue - What is the most appropriate was for a nurse to wash the hair of an unconscious pt that is on bedrest? Use rinse free shampoo or a basin and water in the bed - A pt reports burning and itching in the folds of the skin. The area is inflamed, excoriated, reddened, with a foul odor. This action is most appropriate by the nurse? Keep the area clean and dry and report the findings to the provider - The nurse is conducting a f/u home visit with a male client who lives with his daughter. The pt walks with a assistive device and is unsteady. Which statement by the daughter indicates a need for additional education regarding safety during hygiene care? He wont let me help him bathe, so I just let him do it by himself. - A pt with a cast on his LE has a foul odor and reddened skin between his toes, which assessment question should the nurse ask? Do you experience itching or burning between your toes - Give patient choices to promote dignity and consider patient's preferences - E.g., showering every other day or requesting same-sex UAP/nurse - Patient-centered care mandates that care be based on respect for individual patients' cultural background. - Develop culturally congruent care (Male-male) (Female-Female) plan for hygiene care. - Denture care: - Cleanse with warm water and toothpaste or denture cleaner - Remove before bedtime **Jeopardy** - Which statement by an older adult requires additional education r/t oral hygiene and denture care. I never take my dentures out even when I am asleep. - Keep skin dry to prevent breakdown - Odor in folds may indicate moisture/fungus - Obese patients are at higher risk for skin breakdown due to folds - Health promotion: dental visits should be twice per year - Shaving: - Use warm, damp towel on skin first - Pull skin back tightly and shave in direction of hair growth - Avoid razors if patient has bleeding disorder - Culture: Do not cut or shave hair without prior discussion with 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 important to avoid arching shoulders forward when sitting. - MOBILITY STATUS: Increased pressure, shearing, and friction can lead to breakdown. - Dehydration= poor tugor - Moisture leads to maceration(softening of skin) **Braden Scale:** Sensory perception, moisture, activity, mobility, nutrition, and friction or shear. Score less than 18=Risk **Norton Scale:** Patients physical condition, mental state, activity, mobility, and incontinence **Positions** - Fowler's 45-60 degrees. Head of Bed - Semi Fowlers: 30 degrees - High Fowler: 90 degrees - Lateral: Laying on side - Prone: On stomach - Sims: Sims position \| Nurse Plus - Supine: On back **Risk factors for Immobility** - Falling, Fractures, Pressure Ulcers, Pneumonia, constipation, decreased urination, blood clots, muscle contractors **Nursing Interventions for immobility** - Turning, repositioning, ambulate, float heels, elbows - Complications of immobility - Pressure injuries - Pneumonia - Weakness, muscle atrophy, and contractures - Urinary stasis (decreased urinary output) - Constipation (even if patient is not eating much! - 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, awaiting surgery - Look for active or passive ROM order - ROM is not just flexing muscles; it's the range/degree of joint movement. Maximum movement possible at joint - Active ROM: patient performs exercise without assistance (e.g., hand or foot circles) - Passive ROM: nurse performs ROM exercise (e.g., you pick up the patient's wrist and roll it in a circle while he/she relaxes the arm) - Crutches: three-point gait - ***Uninjured leg should bear all weight along with hands on the crutches*** - Do not bear weight on armpits. - Lead with the unaffected leg when going up the stairs - Keep elbows slightly flexed - Walkers - Elbows should be bent 30 degrees (adjust height of walker accordingly) - Patient should FIRST lift walker to move it forward \~6 inches - After moving walker, patient then takes a step forward - While ambulating patient with gait belt, walk slightly behind the patient - Walkers with seats can be used for those with fatigue/dyspnea (e.g., CHF) - Canes - Should have rubber tip for safety - Use cane on strong side - Move cane forward about 2 feet while taking a step with weaker foot - Then take a larger step with strong foot - Boosting and repositioning - Do NOT pull patient up in bed by grabbing under armpits (use draw sheet) - Transferring from stretcher to bed: use a slide board - Transferring from bed to bedside commode or chair and back - Bed should be down all the way so that patient does not fall when standing up - Use a gait belt to stand and pivot a patient if weak - Place chair/commode on the patient's strong side before pivoting - Do NOT let patient grab you near your neck [Pain ] **Classification of Pain** Cutaneous/Superficial Deep somatic: Cancer Visceral: Deep internal. Abdominal cramps Radiating/referred pain: Chest pain travels to jaw Phantom: Amputation. Still feel numb Psychogenic: In your mind. Anxiety Nociceptive: Skin/Inflammation Neuropathic: Nerves Acute: short term Chronic: Longer than 6 month Intractable: Nothing is helping. No relieve. Eg Compression fractures Quality: Dull, burning, achy Periodicity: Intermittent Intensity: Mild Moderate. Severe It is most important for the nurse to understand the various ways in which pain is classified so they can develop an effective pain management plan - Appropriate assessment & management of pain is crucial for healing - We can't expect patients to ambulate, bathe, etc. if they're in severe pain - Numeric (0-10) scale is not appropriate for dementia/delirium patients - Assess nonverbal cues (grimacing, restlessness, clenching, etc.) - Use Pain-AD scale or Wong-Baker FACES scale - The nurse is assessing the confused client. In trying to determine the client\'s level of pain, the nurse should: Observe the client carefully for changes in behavior or vital signs. Observe nonverbal cues - A post-op patient who cannot ambulate due to pain is NOT acceptable - If this is happening, the nurse must do more to manage pain better - Make sure pain goals/outcomes are SMART goals - Eliminating pain altogether is not a realistic goal - Work with patient to determine a tolerable pain goal (e.g., 3/10) - Nonpharmacological (non-medication) interventions - Distraction and relaxation techniques - Heat therapy (not appropriate for acute injuries if inflammation present - Cold therapy: remove after 15 minutes, do not apply directly to skin, assess for redness/blistering frequently (should NOT cause erythema!) - Acupuncture - Acupressure - Transcutaneous electrical nerve stimulation (TENS) - Percutaneous electrical nerve stimulation (PENS) - Referred pain: pain felt in an area far away from origin/source. - E.g., shoulder pain related to gallbladder **Factors that influence pain** Emotions Past experience Developmental stage Sociocultural factors Communication skills Cognitive impairments [Sensory perception] Stimulus: Trigger that stimulates receptor. E.g. (loud noise, bright light, sour fruit) Reception: Process of receiving stimuli from nerve endings. (Occurs through receptors eg. Thermoreceptors, proprioceptors, photoreceptors) The client who has had a stroke state to the nurse, "You know I cant even tell where my left leg Is. "This reflects lack of response to stimuli by the Proprioceptors. Perception: Ability to interpret sensory impulses/Ability to give meaning to impulses Sensory deprivation: Stepping on something not knowing. Sensory overload: ADHD Sensory deficits: Lose of taste smell. For a patient with an altered level of consciousness, the Glasgow coma scale score will help the nurse in planning care. True. The coma scale correlates to the client's ability to function. Score decrease requires more care. Arousal: Composed of consciousness and alertness. - Patients with diabetes often have peripheral neuropathy (numbness) - Risk of burns - use a thermometer to test bath water - Do NOT soak or bathe in hot water - Examine feet daily for skin breakdown - Wear gloves in cold weather to prevent frostbite - Avoid open-toed shoes - Nursing interventions for patients with sensory impairments - Always assess first how the patient prefers to communicate - Assess for hearing aids, glasses, etc. - Make sure they are easily accessible and ready to use - Sensory overload (overstimulation) - Risk factors - Elderly, mobility limitations, sensory impairments, isolation - Mr. Arbor complains to the nurse that he is feeling anxious. He states, "Im just so tired of all these test they are doing, and its so noisy here at night. "Mr. Arbor's pulse is 110beats/min and his BP is 140/70. Nursing actions should include Closing the blinds, dim the lights, and ask what other measures would help him rest. He is overstimulated. Sensory overload - Nursing interventions - Minimize stimuli (turn off alarms/TV/lights, limit visitors) - Sensory deprivation - Risk factors - Elderly, mobility limitations, sensory impairments, isolation [Delegation] - Do NOT delegate med pass, teaching, or assessment (e.g., pain assessment) - UAPs can collect vitals & assist with ADLs (repositioning, hygiene, toileting, ear cleaning, hearing aid careetc.) - UAPs can provide food/water, ice pack, back rub [Infection] **Chain of Infection** - **Infectious agent-Reservoir-Portal of exit-Mode of transmission-Portal on entry-Susceptible Host** Infectious agent(Bacteria, Fungi, Parasites, Prions): Micro-organisms capable of casing disease or illness. Allows bacteria to grow Reserviors(People, water, food): Place in which infectous agents live, grow, and reproduce. Esentially where pathogens live and mutiply. Standing water to reduce mosquitoes Portals of Exit(Blood, Secretions,Excertions,Skin coughing, sneezing, diarrhea,seeping wounds, tubes, IV lines, bandaging a MRSA wound ) Ways infectious agents leaves the reservior. TB Modes of Transmission(Physical contact, Droplets, Airborne). Ways in which infectious agent is spread from resevior to the susceptible host. How it gets there Portals of Entry(Mucous membrane, Respiratory system, Digestive system, Broken skin, Vagina, Mouth, Bite from bug) Ways in which infectious agent enters the suscepitble host. Susceptible Host (Immune deficiency, Diabetes, Burns, Surgery, Age) Individuals may have traits that affect their susceptibility and severity of disease. Affects Immune system. Chicken pox vaccine **5 stages of Infection** 1. Incubation: From time of infection until manifestation of symptoms. Can infect others 2. Prodromal: Appearance of vague symptoms. Not all diseases have this stage 3. Illness: Signs and symptoms present 4. Decline: Number of pathogens decline 5. Convalescene: Tissue repair. Return to health **Classification of Infections(Draw Blood Culture Before)** By location or how long they last Local: Occurs in a limited region in the body. In area of infection. Warm, swelling, pain Systemic: Spread via blood or lymph. Labs show elevated WBCs. Positive blood cultures. Affects may regions eg Septicemia. Fever, Chills present By Duration Acute: Rapid onset or short duration. E.g Common cold Chronic: Slow development, long duration e,g. Osteomyelitis Latent: Infection present with no discernible symptoms. E.g HIV/AIDS Syphilis - Monitor WBC count for leukocytosis (increased WBC count) - Leukocytosis, fever/chills, & (+) blood cultures indicate systemic infection - Possible signs of infection - White spots on the tongue may indicate thrush -- notify provider - Odor, redness, & itching/burning between toes may indicate tinea pedis - Monitor for these symptoms if concerned about poor hygiene - E.g., injured patients or those with limited mobility - Avoid lotion between the toes to prevent fungal infection - Drainage - Serous: clear or straw-colored fluid - Sanguineous: bloody - Serosanguinous: serous drainage mixed with blood - Purulent: pus-filled (yellow, green, etc.) - Factors that increase risk for skin infections: diabetes, burns, wounds, etc. - Nursing consideration for infection control: - Long fingernails harbor bacteria and increase spread of infection - Hand washing is the best way to prevent spread of infection - Inspect skin of your hands frequently for open sores or cuts - Keeping skin moisturized can help prevent cracking, but avoid applying lotion in between fingers because this can cause breakdown - Clean all equipment after each use in between patients - Avoid invasive lines and catheters if not necessary (e.g., foley or PICC line) - Medical asepsis: Clean environment techniques - Transmission factors: - Portal of exit: how pathogen leaves the body (e.g., sneezing or coughing) - We have some control over this factor educate on covering mouth - Vector: how pathogen is transported (e.g., mosquito, tic, etc.) - Pathogen: Worms, bacteria - Reservoir: environments where pathogen lives (e.g., food, water, humans) - Reservoir may be nonliving (food, floors, equipment, contaminated water) - Susceptible host: any person (multiple points of entry for pathogen) - Transmission precautions - Contact: gown and gloves - Used for MRSA & C-diff - Spead by direct contact - Sources of infection: Draining wounds, Secretions, supplies - Precautions Include: Possible private room, clean gown/glove use, Disposal of contaminated items in room, Double-bag linen and mark. - Droplet: surgical mask, goggles, gown, gloves - Used for respiratory viruses like influenza, chicken pox, covid - Coughing, sneezing, touching contaminated objects - Precaution: Same as contact - Addition mask/eye protection within 3 feet of client - Airborne: positive airflow, N-95 mask, gown, goggles, and gloves - Used for tuberculosis, varicella (chicken pox), etc. - Pathogen spread via air currents - Transmission via ventilation system, shaking sheets, sweeping - Precautions: Special room/mask. Protective isolation is used for immune compromised people. Precaution: Nurse is not assigned to other clients with active infection. Special ventilation. Screen visitors **Health-care Related Infections** Exogenous: Pathogen acquired from healthcare environment Endogenous: Arises when patients normal flora (Lives on skin) multiply and cause infection as a result of treatment. Suprainfection: ex: yeast infection after antibiotic use **Implemeting Surgical Asepsis: Sterile** Autoclave: (Etologic agent: infection link) Sterile environment [Safety/Prevention] In meeting the safety needs of the adolescent client, it would be most important for the nurse to focus their teaching on. Driver's education When implementing the use of restraints on a hospitalized client, the nurse should. Ensure that the primary care provider renews the order for restraints once every 24 hours. - Injuries - If patient found on floor, assess for injury (do NOT move patient!) - Aspiration - ALWAYS assess swallow in patients with history of stroke ([A]BCs) - Patients with decreased level of consciousness (LOC) are at high risk - Make sure suction is set up for these patients - Use swabs hooked up to suction for oral care if unconscious - Do not perform oral care while patient is supine - Avoid petroleum-based lip moisturizers (water-based is best) - DVT prevention - Ambulate (IF POSSIBLE) - Compression stockings - Sequential compression device - Prophylactic heparin injections (anticoagulant/"blood thinner") - Falls - If patient has begun to fall, the best action is to assist down to ground - Fall risk factors - Older adults - Sensory impairments - Weakness or neurological problems (e.g., tremors) - Dizziness, orthostatic hypotension, and/or history of falls - Confusion (especially if having urinary frequency or diarrhea) - Prevention - Benches and rails in the bath or shower - Use gait belt while ambulating high risk patients - Make sure bed is low and locked - Patients with dizziness should NOT be up independently ("ad lib") - Make sure high-risk patients can use the call light - Keep a night light on - Keep call light, items, and bedside table within reach - Hourly rounding - Educate not to get up too fast (risk for orthostatic hypotension) - If patient has multiple sensory deficits, leave siderails up - Identification: - Ask patient for 2 identifiers (name & date of birth); compare to wristband - If patient is alert & oriented, ONLY the patient should confirm identity (not a family member or other staff member) - Scanning wristband without confirming identity is NOT adequate/safe - Skin breakdown and/or pressure injuries: - Most often occur on bony prominences (heel, sacrum/coccyx, etc.) - AVOID heat on bony prominences - Risk Factors - Diabetes, excess moisture (e.g., fever/diaphoresis), malnutrition, immobility, impaired circulation, etc. (see Braden Scale) - Prevention: offload pressure - Assess patient's ability to reposition self - Reposition q2h while in bed - If sitting in chair: limit to 1 hour at a time, shift weight q15min, and provide cushion for patient to sit on - Other prevention measures: adequate hydration and protein intake - Braden Scale: used to assess risk for skin breakdown (be able to calculate) - 23 is the highest score (least risk for skin breakdown) - E.g., Skin rarely moist, slight mobility limitation but walks occasionally, slight sensory impairment, excellent food intake, no apparent friction/shear problem = 20 - Using proper body mechanics when providing care - Raise patient's bed (avoid bending forward) - Limit bending and twisting your neck and back - Keep a wide base of support - Do not try to lift or turn a heavy or immobile patient without assistance - Use proper equipment as necessary (e.g., mechanical lift) [Therapeutic communication] - Avoid asking "why" questions" - Ask open-ended questions - Avoid asking questions like "don't you do this?" or "don't you like this?" - Rule of thumb: assess; don't assume [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 [   .5  ]mL/dose) - Mcgmg (e.g., order is for 100mcg, but the med comes in 0.1mg/tablet; you will give [   1 ]tablets) - Calculating \# capsules or tablets/dose (e.g., order is for 7.5mg but med comes in 5mg scored tablets; you will give [  1.5   ]tablets/dose) - Calculating grams/day for a med (e.g., order is for 250mg PO QID; you will give [   .25 ] grams/day) [Tips] - Think about the nursing process...assess before determining an intervention - Our goal is to optimize hygiene and mobility, which often means determining the SAFEST or MOST APPROPRIATE way to accomplish this - We start by assessing the patient's preferences, wants, and needs - Most of these tasks are nursing interventions...it is usually not necessary to contact the physician - In "NCLEX world", the gold standard for pain is self-report. If the patient is reporting severe pain (7 or higher out of 10), the patient needs more medication - Unless there are signs of respiratory suppression (RR \< 12, lethargy, etc.)