Nursing Foundations Key Points PDF

**Critical Thinking Components** **Implementation:** - - - - **Patient safety and quality** Common environmental hazards - Factors influencing patient safety - - - - - - - - - **Behavioral/violent restraints: 4 hours** **Pulling out IV: 24 hours** **\*\*A...

**Critical Thinking Components** **Implementation:** - - - - **Patient safety and quality** Common environmental hazards - Factors influencing patient safety - - - - - - - - - **Behavioral/violent restraints: 4 hours** **Pulling out IV: 24 hours** **\*\*Always try restraint alternative before using a restraint\*\*** **Infection Prevention and Control** Infectious agent → reservoir → portal of exit → mode of transmission → portal of entry → susceptible host **Handwashing is \#1 in preventing spread of infections** C. diff- wash hands with soap and water Serosanguinous: pink Serous: clear Sanguineous: blood Purulent: white, thick **Health care associated infection** - - - - **Foley:** bag below bladder, not touching ground, straight tubing, labeling canister (switching it out every 24hrs) **Isolation precautions** - - - **Donning PPE** - - - - **Doffing PPE** - - - - **Delegation (good reference)**  **Values** Sodium : 136-145 meq/L Potassium: 3.5-5 meq/L Calcium: 9-10.5 mg/dL Ionized Ca: 4.5-5.3 mg/dL Chloride: 98-106 meq/L Magnesium: 1.3-2.1 mg/dL Phosphorus: 3-4.5 mg/dL **Activity and Exercise** Acute rehab: 4 hrs/day Subacute: 2hrs/day **Assess** - - - - - **Planning** - - - **Implementation** - - - - **Supporting a falling pt** - - - **Assistive Devices For Walking** - - - - - - - - - - - - - - - First: four point gait Second: three point gait Third: 2 point gait   - **Walker:** - - **Hoyer lift:** dependent patients can't get out of bed **Sara Steady:** moving patients from bed → chair → bathroom **On admission, 2 RNs have to look & document skin** **Range of Motion:** - - - - - - - - - - **Immobility** **Effects of Immobility** - - - - - - - - - **Respiratory** - **Cardiovascular** - **Musculoskeletal:** - **Urinary:** - **Integumentary** - **Psychosocial** - **Best way to avoid osteopenia and osteoporosis is to move** **Health Promotion** - - - - - **Risk factors for DVT:** - **Positioning Techniques:** - - **Chapter 48: Skin Integrity and Wound Care** **Pressure Injuries** - - - **Risk factors:** - - - - **Classification** - - - - - - Medical device related injuries Medical adhesive related - **Healing Process** - - - - **Complications of Wound Healing** - - - - - **Wound Assessment** - - **Factors influencing pressure injury formation and wound healing** - Abrasion: scrape Laceration: cut Wound vac: suck out excess drainage, heal from the inside out **Prevention of Pressure Injuries** - - - - **Wound Management** - - - - - - - - **Oxygenation** - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - **Lab** **Droplet Precautions** - - - **Airborne Precautions** - - - **Contact Precautions** - - **Bath Stuff** - - - - **Restraints** - - - - - - **Intake and Output** - - - - - **Measurement Stuff** 5mL = 1 tsp 3Tsp = 1 tbsp 15mL = 1 tbsp **30mL = 1 oz** **8 oz = 1 cup** **1 kg = 2.2 lbs** **Routes for Meds** - - - - - **Ways to give Meds** Sublingual - - - - Buccal - - - - - DO NOT CRUSH ENTERIC-COATED PILLS PCA - - - - - - **Orders** - - **6 medication rights** 1. 2. 3. 4. 5. 6. Enteric coated, controlled release, extended release, double strength, sustained release Black box warning: serious adverse side effects **Subcutaneous Meds** - - - - - Tuberculin syringe: to the tenth **Intradermal** (not sure if anyone remembers when they asked this question lol) - - - If order says ac + hs - - - - - **Insulin** - - - **Insulin Pen** (not sure we need this but had this in my lab book from sarah) - - - **Vials** - - **Ampules** - - - **Other Medication Routes** - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - **Intramuscular** - - - - - - - - - **IV stuff** Risks - **Types of IV** - - - - - - - **Need to assess IVs every hr, especially if running** **IV Care:** - - - - - - - - **Saline Lock** - - - - SASH- Central Line (heprin at end) 10 mL SAS- Periperal Line 3 mL **Death and Greif** - Mangerational loss: Not planned or wanted Sudden: Situational loss (self-esteem or ileostomy) Actual: Lose body part, death of family, or loss of job (can see) Percieved: What we feel and can't see (rejection of a friend) - - - - - - - - - - - - - - - **IV Complications**   - - - - **Wound Characteristics that need to be documented** - - - - - - **Drains** - - - **Oxygen** - - - **Nasal Cannula** - - - **High Flow** - **Non-Rebreather** - - - - - **Venturi Mask** - - - **CPAP** - - **BiPAP** - - **Ventilator** **Trach collar** - **Seizures:** - - - - **Reconstitution** - - -