Safety and Infection PDF

Safety and Infection Pressure Ulcers (Decubitus) Stage I Non-blanchable redness (erythema) Superficial (intact skin) Epidermis tissue showing Stage II Red or pink (erythema) ulcer Dermis tissue showing Partial thickness (damage of epidermis and dermis) Risk for infection...

Safety and Infection Pressure Ulcers (Decubitus) Stage I Non-blanchable redness (erythema) Superficial (intact skin) Epidermis tissue showing Stage II Red or pink (erythema) ulcer Dermis tissue showing Partial thickness (damage of epidermis and dermis) Risk for infection Hydrocolloid dressing needed for autolytic debridement; should be left on for several days at a time to be effective Stage III Yellowish ulcer Adipose tissue showing Full thickness (damage of epidermis, dermis, and deeper tissues) Wet-to-dry dressing until debrided to establish granular tissue Consult wound care; debridement needed Stage IV Bone or muscle showing Wet-to-dry dressing until debrided to establish granular tissue Consult wound care; debridement needed Unstageable Black Unable to assess underlying tissues; wound base is obscured by slough or eschar Nx Tip: A wet-to-dry dressing consists of gauze moistened with normal saline and placed in the wound bed, then covered with dry gauze. When the dressing is removed, a mechanical debridement occurs. This is a very basic method of wound care, and can cause discomfort when the dressing is removed. It can be used initially for open wounds until an appropriate dressing or wound vac can be applied. Wound-care teams will be consulted on wound management and will generally assume the care/treatment of acute and chronic wounds until healed inpatient and outpatient follow-up. Prophylaxis for Pressure Ulcers Basic Care and Comfort Turn patient every 2 hours (minimum) to off-load any pressure areas. Never massage bony prominences, as it can cause more tissue damage. Use specialty rotation beds for Stage III and Stage IV pressure ulcers. Do range-of-motion (ROM) exercises. Use heel cushions designed to off-load pressure from heels to protect from injury. Braden Scale Risk Assessment The six variables evaluated on this scale are listed below and are scored on a scale of 1 to 4. The resultant risk levels are as follows: Severe Risk: High Risk: Moderate Risk: Mild Risk: Total Score ≤ 9 Total Score 10–12 Total Score 13–14 Total Score 15–18 Sensory perception Moisture Activity  Mobility Nutrition Friction and shear Nx Tip: Do not worry about memorizing every component of the Braden Scale. Understand the six variables and how they are ranked. If the NCLEX would want a Braden calculated, it would provide the scale in the question. For other questions, however, it is important to simply know what is included versus what is not. Important: Total Score of 12 or less represents a high risk. Taking Care of Skin Intact Skin For intact skin: Soap and water Broken/Infected Skin For skin that is broken and at risk for infection or already has an infection: Alcohol, diluted hydrogen peroxide, chlorhexidine, neomycin Betadine, povidone (surgical use) decreases superficial bioburden Use normal saline (NS) for flushing wounds; avoid cytotoxic agents. Falls Prophylaxis for Falls Frequent rounding Room close to nurses’ station Bed/chair alarms Morse Fall Risk Assessment The six variables evaluated on this scale are as follows: History of falls Secondary diagnosis  Ambulatory aid IV therapy/heparin lock Gait Mental status Infections Horizontal transmission: Person to person Vertical transmission: Mother to child PRIORITY: Wash hands! Always! Handwashing is the best way to prevent the spread of infection. Wash when entering the room and again when leaving the room. Standard/Universal Precautions Wear gloves to reduce risk of bodily fluid exposure. Blood-borne infectious diseases: Ebola, Hep B, Hep C, HIV Anthrax Inhaled as a white powder Not communicable Contact Precautions Wear gloves and gown as a precaution for the following: C. Diff Handwashing with soap and water Often caused by overuse of antibiotics Severe and foul-smelling diarrhea VRE/MRSA (including infected open wounds) Gastroenteritis (viral) Often called the stomach flu May be caused by rotavirus May be caused by norovirus (also called Norwalk virus) Vomiting and diarrhea Croup (also called laryngotracheal bronchitis) Caused by diphtheria virus Barking cough and stridor Minor: Treat with anti-inflammatories.  Major: Treat with epinephrine. Rabies Leads to meningitis Hepatitis A Enteric precautions (similar to contact) Impetigo Common in pediatric population Honey-crusted lesions on mucous membranes (sometimes on back) Lice/scabies Respiratory syncytial virus (RSV) Contact precautions unless productive cough exists, then droplet precautions Conjunctivitis (pink eye) Droplet Precautions Wear gloves, gown, mask, and goggles as a precaution for the following: Epiglottitis Often caused by H. influenzae (Hib vaccine to prevent) Also caused by bacterium Influenza type b (Hib) Vaccinate to prevent. Meningococcal meningitis Mumps Vaccinate to prevent (MMR). Swollen salivary glands Fever and headache Rubella (German measles) Vaccinate to prevent (MMR). Streptococcus Most commonly respiratory Pharyngitis Pneumonia  Pertussis Parvovirus Causes fifth disease (common in children) Appears as rash on face (looks like redness from a slap to the face) Sepsis Pertussis (whooping cough) Common in children Airborne Precautions Wear an N95 mask or a surgical mask and use a negative airflow room as a precaution for the following: Herpes zoster (shingles) Only possible if chickenpox infection occurred in past Begins with pain; rash forms after Measles (rubeola) Vaccinate to prevent (MMR). Fever, irritability Varicella zoster (chickenpox) 7-day incubation period Oatmeal baths Tzanck test Pain when chewing Sudden acute respiratory syndrome (SARS) Tuberculosis Other Infection Routes Yersinia pestis Transmitted by rats and fleas Cause of bubonic plague Shigella Similar to salmonella Contracted by consuming undercooked food Causes diarrhea  Yellow fever Transmitted by mosquitoes Causes headache and vomiting West Nile virus Transmitted by mosquitoes May lead to meningitis Lyme disease Transmitted by ticks Bullseye rash Causes flu-like symptoms Brucellosis Contracted by consuming uncooked meat or unpasteurized milk Typhoid fever Contracted by consuming contaminated food or water Causes diarrhea Pinworm Transmitted via ingestion Fecal-oral route More common in children Place tape on anus during sleep to diagnose. Legionnaires’ disease Contracted by inhaling droplets of contaminated water Found in fountains and ponds with stagnant water Cohorting of Patients Post-operative patients No cohorting with risk for infection (immunosuppressed, chronic kidney disease, HIV) No cohorting with actual infections (anything that ends in “itis”) Do not cohort airborne-infection patients. Contact and droplet infections Cohort same infection, such as VRE with VRE or flu with flu. 4-foot rule  Distance to the infected Patients apart from each other Visitor may sit by the door without a mask. Transporting of Patients Contact infection: Patient wears gown. Droplet or airborne infection: Patient wears mask. Neutropenic Precautions Suppressed immune system AIDS, major burns, lupus Cryptosporidium (common in AIDS patients; causes diarrhea) Do not cohort. Similar to contact precautions No fresh fruit, no fresh veggies, no fresh flowers, no pets, no kids Open Wounds Cover the wound (in room or in transport). Follow contact precautions. Removing Personal Protective Equipment (PPE) Hands are most contaminated body part; remove gloves first. Gloves → Goggles → Gown → Mask → Wash hands Preventions Primary Prevention Prevent problem from ever existing (Examples: vaccinations, condoms, exercise, diet). Secondary Prevention Screenings (Examples: mammogram, colonoscopy, PSA blood levels, pap smear) Tertiary Prevention Prevent the progression of disease/illness (Example: post–heart attack aspirin regimen). The 5 W’s of Post-Op Fever The 5 W’s is a mnemonic that is often utilized in medicine; however, it also has its uses for nursing—we simply do not have to take it to as high of a degree. Use the 5 W’s not so much as a tool, like doctors do, but as a guideline for distinguishing general post-operative complications that nurses have to look out for. The information below presents those risks and how, as nurses, we prevent them. Wind Atelectasis/pneumonia Post-op days (POD): 1–2 Normal prevention Deep breathing Incentive spirometry (10 times an hour) Splint chest with pillow and manage pain (post–open-heart surgery) Ventilator-associated pneumonia Elevate head of bed. Frequent oral care (every 4 hours) Administer PPI (pantoprazole). Water UTI/CAUTI Post-op days (POD): 3–5 Prevention Switch catheter out every 72 hours. Perineal care Push fluids. Wound  Surgical site infection Post-op days (POD): 4 and greater Prevention Surgical staff performs the first dressing change. After 24 hours, nursing staff changes dressing. Sterile technique when needed Use cleaning agents (alcohol, chlorhexidine, etc.). Walking DVT/PE Prevention Early ambulation Sequential compression devices (SCDs) TED stockings SubQ heparin/enoxaparin Wonder Drugs Not on NCLEX  Scope of Practice – RN It is incredibly important to understand the nursing scope of practice. It is also important to understand the scope of practice of other positions, including those holding higher licenses. It would be hard to delegate or refer to other positions without the knowledge of what can legally be done by that position. This is scope of practice. “Delegation” is another chapter in this book. In this chapter, you will learn exactly how to follow the nursing scope of practice, in addition to some information about other jobs in a hospital. It is important to reach out for help when a problem arises. The trickier question is then to assess whether a problem is within a nursing scope of practice or if other help is needed. Throughout this book, there is information about independent diseases and problems. Within that information, you’ll find key points on interventions the healthcare team may execute. Utilize the information that follows to study all of the different types of people in a hospital and how they may help the interdisciplinary team in the care of a patient. When taking the NCLEX, be very careful when clicking on answer choices that are interventions. Make sure interventions are within your scope of practice and follow nursing process (ADPIE). How to Follow Orders Nurses may be completely aware of how to treat a problem they encounter; however, many issues require a higher license to prescribe orders to proceed. It is generally accepted that you should not click on answer choices on the NCLEX that are outside of the nursing scope of practice UNLESS one of the following three circumstances occurs: 1. “As ordered,” “anticipate giving,” “recommend giving”  Do not click on interventions unless the answer choice says “as ordered,” “anticipate giving,” or “recommend giving.” Example: Administer vasopressin as ordered (CORRECT) Administer vasopressin (INCORRECT) 2. Medical emergencies For medical emergencies, interventions may be performed without rule #1 above. When practicing for NCLEX questions, it is easier to assume a physician is next to the RN providing verbal orders. 3. Nurse-managed orders For nurse-managed orders, interventions may be performed without rule #1 above. A nurse-managed order is one that already exists in the chart, so the nurse can proceed with following the order. Example: Sliding scale (insulin, heparin, warfarin) PRN anything (oxycodone, etc.) How to Utilize Scope of Practice Ask yourself: 1. Is this within my scope of practice, and can I do this legally? If yes, follow ADPIE. If no, refer to other practices. 2. Do I have time to do this? There are other patients on the floor, and time management is an important consideration to achieve care goals for your shift. It is unrealistic to think an RN can be on the phone for 30 minutes with an insurance company trying to work out a problem. The same rule applies to many situations and questions posed by a patient or by a patient’s family. Refer questions and concerns to specialty and support services within your organization: Spiritual Care, PT, OT, Patient Services, Continuity of Care before discharge for insurance concerns, support services at home, long-term care placement, Respiratory Care, Wound Care, Nutrition, or Speech Therapy, to name a few. Remember, the job of an RN is to act as the hub of care for all other  services to filter through during the 8 or 12 hours you are working with your patients. The RN is NOT a bouncer; get security if patient or patient family behavioral issues occur. The RN is NOT Dr. Phil; refer big problems to specialty and patient care services for support. Hospital Personnel Below are other positions that work together within the hospital to achieve patient care goals. They are important to understand for the NCLEX. Nurses may “refer” to other practices in the hospital, but nurses do not “consult.” Physicians in the various med-surg specialties are requested to provide consults. HCP/MD/NP/PA Prescribes orders and medications Refer to for change in orders Refer to for change in medication dose or change in route of administration Performs larger procedures (surgeries, scopes, etc.) Multiple specialties Follow SBAR when communicating with these providers: Situation Background Assessment Recommendation Nurse Hierarchy Charge nurse/nurse manager Follow RN hierarchy, even regarding a problem with another department. Do not go to that department head. Go to your nurse manager. LPN/UAP Licensed practical nurses and unlicensed assistive personnel assist RNs in daily care. Covered in more detail in the “Delegation” chapter Respiratory Therapist Administers postural drainage (chest physiotherapy) Oversees function of mechanical ventilator Administers nebulizer treatments Social Worker Assists in social issues (financial concerns, housing, food, transportation, etc.) Assists in money-related problems (medications, wound-care supplies, etc.) Case Manager Coordinates outpatient medical care (assistive devices, home health care, etc.) Note: The RN manages inpatient care. Pharmacist Call for information regarding liquid versus tablet formats. Call with questions about administration (onset and duration of action, side effects, etc.). Physical Therapist/Occupational Therapist Examines patients and develops plan of care to promote movement, reduce pain, restore function, and prevent disability; restores passive and active range of motion IT Provides computer charting access Maintains a 24-hour service line for password issues or computer access problems Provides training during orientation Chaplain Provides religious and spiritual services Acts as sounding board for patients and stressed family members who need someone to talk to Housekeeping Cleans rooms between patients, cleans spills, cleans and maintains public areas Security Provides safe environment Holds patients’ valuables Assigns access to staff in the organization Facilities/Maintenance Utilizes a work order system for repair requests Maintains grounds and all hospital buildings Radiology Administers all imaging: x-ray, MRI, CT, nuclear medicine, interventional radiology, etc. Labs Includes chemistry, microbiology, serology, hematology, etc.  Scope of Practice – PN The similarities between the NCLEX-PN and the NCLEX-RN are numerous. The style of questioning is similar, as is the content. This chapter is for those who are planning on testing for the NCLEX-PN. If you are testing for the NCLEX-RN, ignore this chapter. The PN scope of practice has limitations. For example, an LPN is allowed to perform focused assessments, such as listening to lung sounds or bowel sounds. The LPN would do this when the patient may be experiencing a problem, but should be very careful. Few assessments are allowed to be performed by an LPN. When in doubt, refer to the RN. A good rule of thumb is that if you find yourself not knowing what the underlying cause of the patient problem may be, ask the RN. Any acute change or emergency requires a higher license, such as an RN. Another thing to keep in mind is that an LPN cannot do anything invasive. The only exception to this rule is if an LPN has special certification to perform an NG tube or IV placement. LPNs can perform sterile procedures such as an indwelling catheter placement or changing a sterile dressing, but only when it is uncomplicated. It can be tricky to be able to tell if such a procedure will be uncomplicated, so it is recommended that you study your specific scope of practice so nothing is missed. As you read this book chapter by chapter, you’ll find information regarding diseases and the important assessments and interventions revolving around those diseases. As someone testing for the LPN, understand that not all of the assessments and interventions fall under the purview of an LPN. While the LPN may not be the one performing that action, the NCLEX can still ask about what is likely or what may be performed in general by the interdisciplinary team. Being a well-rounded LPN in a hospital and on the NCLEX revolves around the general understanding of roles and responsibilities of all those on the patient care team. Moving forward, be very careful when clicking on answer choices that are interventions. They should be within your scope of practice and follow nursing process (ADPIE) to be correct. The “Delegation” chapter will provide an overview of these things and aid in the ability to tell the difference between what you can legally do and not do.  Basic Care and Comfort Nursing Ethics There are six key ethical principles of nursing that should be followed in all nursing situations. On the NCLEX, you may be presented with a scenario and be required to distinguish which answer choice applies to which ethical principle. For example, if the nurse does not relay patient desires to the appropriate people, you are effectively burying patient autonomy and their right to self- determination of care. Autonomy Justice Fidelity Beneficence Nonmaleficence Veracity Freedom of Fairness, Faithfulness to Doing good Doing no harm Truthfulness choice, self- equal commitments, determination treatment following through IVs and Central Lines IV Gauge/Length 0.5 inch needle subcutaneous for child or adult 0.5 inch needle intramuscular (IM) for young child 1–2 inch needle intramuscular for older child/adult 1 mL maximum administration per IM shot If order says 2 mL, two shots must be given. The higher the gauge, the smaller the needle: 28 gauge: subQ 24 gauge: IM 20 gauge (or larger): blood administration The Three IV Problems  Infiltration Catheter falls out of the vein (third spacing of fluid) Coolness, redness, swelling, discomfort Stop the IV infusion, discontinue the IV, apply a warm compress, elevate extremity. Thrombophlebitis Formation of a clot/inflammation at the catheter site Warmth, redness, swelling, pain, discoloration of vein Stop the IV infusion, discontinue the IV, apply a warm compress, elevate extremity. Extravasation Infiltration of third space with a vesicant medication (chemotherapy, dopamine) Destruction of cells and pain at the site Stop the IV infusion, aspirate out as much fluid as possible, call the HCP. A medication may be ordered to soak up vesicant. Central Line Types PICC/Midline Placed by specialist RN Long-term antibiotics Broviac/Hickman/Groshong Commonly used for therapy for leukemia and bone marrow or stem cell transplant Some types are used for apheresis or dialysis. Vas Cath/Port-a-cath/Perm-a-cath Commonly used for chemotherapy Troubleshooting Central Lines Small clot on the end of line: Do not force flush. Kink: Change patient position. Sitting on side of vessel: Attempt to flush. Infiltrates: more common in peripheral Disaster Scenarios Code Red (Fire) RACE mnemonic: Rescue Alarm Contain Extinguish PASS mnemonic: Pull Aim Squeeze Sweep Code Black/Pink/White Bomb threat, infant abduction, aggression— every hospital has these as overhead pages to alert staff. Focus on the role of the RN in that moment. Do not respond as a manager unless the question specifically says “nurse manager.” Stay in current location and assess area needs. Culture and Religion In nursing, you’ll interact with patients (and families) with various religious, spiritual, and cultural backgrounds. If a question specifically identifies a culture, it is a safe bet that the question writer included the culture information for a reason. Frame your mind in a culturally sensitive manner. Many NCLEX test- takers may be Anglo-Saxon in background, but an easier way to think about it is simply “American.” For example, most Americans would be comfortable with physical touch. This is NOT the case with many other cultures. Be familiar with the following common practices regarding culture and religion. Religious Beliefs Christianity  Anointing of the oil upon death Judaism 2–3 hour gap between eating dairy and meat Islam Face east toward Mecca to pray Genuflect (kneel) upon praying; assist a patient to the floor if able. Do not touch deceased Muslim if not Muslim yourself. Direct eye contact considered sexually advancing Buddhism Commonly practiced in China Karma (consequences come from actions) Hinduism Reincarnation Jehovah’s Witness No blood products Nx Tip: Religion does not allow parents to refuse lifesaving medical treatment for a child. It is considered illegal. They do not have the right to leave without care. Example: meningitis in child. Spirituality Not necessarily needing of religion to follow. Religion is a collection of beliefs that people follow together, often in a congregation format. Many spiritual people do so on their own. All religion is spiritual, but not the other way around. Think more Golden Rule. Culture Anglo Saxon Caucasian Eye contact considered respectful May sit closer Mexican  Hot milk concept Asian Stoic in relation to pain Hot-cold concept (cold food given for a sickness of heat, and vice versa) Native American Higher prevalence of diabetes mellitus Muslim Do not sit too close; considered rude No caring for patient of opposite sex Men often are the decision makers. Nx Tip: If a client turns away with no eye contact during teaching, continue the teaching and assess for understanding afterward. At times, avoiding eye contact is cultural and not to be taken as a lack of attention. Do not immediately assume the patient needs a different form of teaching. Nx Tip: The same thought above needs to be taken into account if a patient of a different culture simply smiles and nods when asked questions. It’s possible that smiling and nodding is a cultural sign of respect rather than an actual sign of understanding. Continue the teaching and assess for understanding afterward. Legal Issues Assault Verbal Telling a patient if he or she does not do something, a bad consequence will occur Battery Physical Injecting a medication when a patient refuses  Unlawful restraint of a patient Good Samaritan Law Cannot be sued for trying to help someone within your scope of practice False Imprisonment Hospital, nursing home, etc. Holding someone against their will Exceptions: Patient at risk to self or others, patient under influence of a substance People have the right to refuse. Informed Consent Must be obtained by physicians Nurse may witness. Advance Directive/Living Will May include a do not resuscitate (DNR) order Specifies healthcare decision making (healthcare power of attorney) Specifies healthcare decisions No tube feedings No intubation past 20 days DNR No extraordinary measures, such as CPR, intubation, vasopressors, defibrillation Post-Mortem Care Allow the family to help if they desire. Leave dentures in. Keep head of bed elevated (semi-Fowler’s). Non-Muslim cannot touch deceased Muslim. Gerontological Considerations Normal Changes in Aging Skin loses collagen and elasticity. Decreased kidney/liver function Decreased thirst mechanism Decreased peripheral sensation Decreased hair on scalp Solar lentigo (sun spots) Xerostomia (dry mouth) Elder Abuse RN mandatory reporting (call authorities) Physical, psychological, sexual Untreated bedsores, withdrawing from activities Financial abuse Stolen checks, money Neglect Soiled sheets, build-up of trash Poor grooming Nurse-Client Relationship 1st: Address client anxiety. 2nd: Assess learning needs. 3rd: Assess knowledge level. 4th: Acknowledge specifics. NPO Rules for Medical Procedures The rule of thumb here is that if the procedure does not qualify as one of the three things listed below, do not place the patient on NPO (nothing by mouth) status unless there is a good reason. There are many medical reasons why a patient may be NPO; the following list is a very specific showcase of why this order would be given for a procedure. It is not as vast as many people believe. General Anesthesia Upper/Lower GI Series Upper/Lower GI Scopes NPO to prevent aspiration X-ray/fluoroscopy Esophagogastroduodenoscopy (EGD)  Typically 8–12 hours before Barium swallow/barium Colonoscopy (includes bowel enema prep) Typically 8 hours before Typically 8 hours before Routes of Administration This list of routes is presented in order of the fastest route of administration to the slowest as well as a most invasive to least invasive mentality. It is important to pay attention to route on the NCLEX. If a patient is having an emergency, it is the goal of healthcare workers to fix the problem as soon as humanly possible; that often removes oral medications since they take time to digest and work. Think about how to fix the emergency right now. Intrathecal Administration into central nervous system (CNS) Performed by certified registered nurse anesthetist (CRNA) or anesthesiologist Types: subdural catheter, epidural catheter Risks Meningitis Shift of cerebrospinal fluid (CSF) Inhaled Administration via lungs Performed by respiratory therapist or RN Types: nebulizers, inhalers Intraosseous Administration via bones Performed by RN (with training) Used when veins are not good to use Used mostly in trauma scenarios Intravenous Administration via veins IV cannulation (starts) performed by RN  Administration may be done by RN or LPN with specialized certification. (An NCLEX question must specifically state that the LPN has certification; otherwise, assume the LPN does not.) IV line may be discontinued by unlicensed assistant personnel (apply pressure for 5 minutes; no peeking). Intramuscular Administration via muscles Performed by RN or certified LPN Subcutaneous Administration via adipose (fat) tissue Insulin, heparin Performed by RN or certified LPN Oral/Sublingual Administration via mouth and under tongue Performed by RN or certified LPN Transdermal Administration via skin (patch or topical) Performed by RN or certified LPN Remove old patch before new applied. Rotate patch sites. Always wear gloves. Intradermal Administration via dermis Performed by RN or certified LPN Allergy testing Mantoux TB skin test/PPD Patients Unable to Leave: Against Medical Advice (AMA) Under influence of substances (alcohol, drugs) Parents with minor (child) requiring life-saving treatment (meningitis) Homicidal or suicidal Psychotic, delusional, or demented  ADPIE (Nursing Process) When reading and analyzing a question, it is of utmost importance to follow nursing process. The healthcare team, including the RN, do not perform actions without having a specific reason for doing so. Ask yourself, “Do I have the assessment that warrants this intervention?” Correct answers will not be interventions that do not have clear reasoning in the question itself. Do not click on answer choices just because they sound good; there must be a reason. ADPIE (Assess, Diagnose, Plan, Implement/Intervene, and Evaluate) can be applied to numerous questions found on the NCLEX. ADPIE can be used to answer questions that ask what the nurse should do first. Such questions are testing if the nurse understands how to apply the scope of practice to a patient situation. It is important to use ADPIE while also applying scope of practice and prioritization. Reading questions and answer choices very carefully, thinking critically, and applying these thought processes will aid you in eliminating incorrect answer choices. Process of elimination is incredibly helpful on the NCLEX. Assess Process is chronological: inspection, palpation, percussion, auscultation. Do not go backward. Repetition or redundancies are not correct on the NCLEX. Example: While assessing a patient post cardiac catheterization, the nurse is unable to palpate the dorsalis pedis pulse. What action should the nurse do first? Doppler the extremity (CORRECT) Inspect the leg (INCORRECT) If the nurse is palpating for a pulse, it is implied that an inspection has already been performed. Do not go back and redo work that is done. For abdominal/renal assessment, follow this order: inspection, auscultation, percussion, palpation. Diagnose The nursing diagnosis provides the basis for selecting nursing interventions to achieve optimal patient outcomes. Plan Develop a plan and establish SMART goals (specific, measurable, attainable, realistic/relevant, and time restricted). Implement/Intervene Follow less invasive measures first. Non-pharmacological over pharmacological Elevating the head of bed over oxygen Follow scope of practice. Evaluate Focus on good and positive answers. Do not “expect” bad outcomes; healthcare providers who perform actions without any clear goal to achieve are committing malpractice. Look for factual, specific answers. Weight gain for anorexics Weight loss for fluid overload Objective over subjective Weight gain or loss over “feelings”  Leadership and Management What to Do When People Are Doing Something Wrong! Questions may come up on the NCLEX that ask how a nurse should respond in a given situation. Many times they are worded “most appropriate” or “best response.” There are many ways such questions could be phrased, but the key point of the question and what should be felt upon reading it is “this does not sound good!” Someone may be doing something improper or, as the nurse, something may be worrisome to you about the safety of the patient. Working in a hospital requires a high level of professionalism that we are all expected to follow. People are responsible for doing their jobs. There are a series of questions that fall back on this key point. Safety of the patient, basic respect, and safety of the patient again, because it bears repeating. The vast majority of the time, the best answer is to simply go directly to the source of the problem and address it. I like to call this “acting like an adult.” It really is the best way to go in a variety of situations. Case Study A nurse is working on a unit when a fellow employee says something sexually inappropriate. What is the most appropriate action by that nurse? A. Contact human resources. B. Speak with the nurse manager about the unwanted advances. C. Take the fellow employee to a private area and tell him or her it is inappropriate. D. Ignore the advances, as it is part of the job. Answer: C In this situation, what the person is doing is absolutely inappropriate for a hospital setting. What he or she is doing is not going to cause harm to a patient, nor is it worthy of taking it to someone higher as if it were illegal (at least not yet). If a problem happened repeatedly, then it would be more appropriate to reach out to a superior. Harassment is still a problem in many careers and is no different for nurses. Oftentimes it may be a patient who is being sexually inappropriate with a nurse. The same intervention would apply. If a patient is acting inappropriately and is cognitively aware of what he or she is doing, then the patient needs to be told the behavior is not appropriate. It is completely legal for the nurse to do this. See the directions below for how to apply this strategy in other situations. Minor Problem Go directly to the person and solve. Examples: Witnessing an RN do a procedure incorrectly (never interrupt; inform after) Witnessing an MD not wash his or her hands before entering a room Interacting with a UAP (unlicensed assistive personnel) who does not do a finger-stick check Witnessing an RN giving incorrect discharge instructions Legal Problem Go directly to a superior (charge nurse, nurse manager). Examples: Witnessing an RN pocket narcotics Witnessing an intoxicated RN Witnessing an RN verbally threaten or abuse a patient Patient Harm Problem 1. Fix the problem. 2. Assess the problem (the patient). 3. Call the HCP. 4. Fill out an incident report (does not go in chart). Examples: Walking into a room and noticing an infusion running faster than ordered Witnessing a patient fall or other sentinel event Cardiovascular Myocardial Infarction (Heart Attack) Pathophysiology Ischemia of heart muscle Causes Clotting (embolism) Atherosclerotic (narrowed coronary) Vasospastic (Prinzmetal’s angina) Caused by stimulants (cocaine) Signs and Symptoms Common in men Chest pain radiating down the left arm Shortness of breath Chest pressure Tachycardia Jaw pain Common in women Nausea/vomiting Malaise Cold sweats Jaw pain Nx Tip: The elderly’s signs and symptoms are similar to those in women. Interventions MONA Protocol (1st treatment): Morphine: treats pain; also aids in vasodilation Oxygen: delivery to the point of infarct Nitroglycerin: vasodilator Aspirin/clopidogrel: prevents growth or further exacerbation Nx Tip: Oxygen and nitroglycerin can be given by paramedics and RNs without an order. Morphine, oxygen, nitrates, and aspirin, known as MONA, are no longer collectively considered the preferred interventions for chest pain. Oxygen can actually cause harm if used inappropriately, so remember, only provide oxygen if the patient truly needs it. A dyspneic patient does not necessarily need oxygen; assess the pulse ox. Case Study For questions on “what action does the nurse perform first,” follow the sequence given below. A 43-year-old male comes in with chest pain, dizziness, and shortness of breath. 1. Assess vitals/ask patient to describe pain. 2. Do EKG/ECG. Check ST elevation. Note STEMI versus NSTEMI. 3. Check troponin and creatine kinase levels. 4. Take chest x-ray. Rule out other causes (GERD, PE, pneumothorax). Cardiac Catheterization/Percutaneous Coronary Intervention (PCI) Remember: Time is muscle. Types:  Angiogram (x-ray and/or visualization) Angioplasty (surgical, stent, etc.) Alteplase (clot buster, thrombolytic) Procedure: Arterial sheath in radial or femoral artery Risk for bleeding (PRIORITY) Risk for infection Post-cath: Neurovascular exams Capillary refill Pulses (dorsalis pedis, posterior tibialis) Doppler if cannot be palpated Sensation/strength (bilateral) Hourly (q1) assessments of the sheath site (always RN) Compression devices/dressings used to prevent bleeding Is the patient complaining of feeling wet or damp? (not good... it might be blood) Patient positioning Femoral entry sheath: Patient must lie supine for 4 hours. Radial entry sheath: Patient may be semi-Fowler’s (affected extremity must remain immobilized for 4 hours). Coronary artery bypass graft (CABG) Graft harvested from the greater saphenous vein (thigh) Swelling (edema) and bruising expected on the thigh after surgery 100 mL/hr or more of drainage into the chest tube is considered hemorrhage (PRIORITY). Heart Failure/Cardiomyopathy Pathophysiology Preload: pressure of blood filling into relaxed ventricles Afterload: pressure ventricles overcome to push blood out of the heart Nx Tip: Both preload and afterload may increase in heart failure (right- or left-sided). Cardiac output (HR × SV): decreases in heart failure Diagnosed via echocardiogram External Transesophageal echocardiogram (TEE): sedation and oxygen required Men and pregnant women have higher cardiac outputs. Ejection fraction (percentage showing function of heart) Causes R-sided Pulmonary hypertension (pulmonary vasculature) Myocardial infarction L-sided Systemic hypertension Myocardial infarction Signs and Symptoms R-sided Edema: peripheral, dependent (gravity), generalized, legs, ankles, abdominal ascites Jugular venous distention (JVD) Assess at 30–45 degrees Hypertrophy L-sided Fatigue and shortness of breath Decreased cardiac output and ejection fraction leading to hypotension Pulmonary edema Fine crackles (auscultate) May increase a pulmonary pressure Hypertrophy Interventions Low-salt diet (less than 2,000 mg per day) No canned foods, no Chinese food, no processed foods Fluid restriction Pharmacology Diuretics, ACE inhibitors, digoxin Intra-aortic balloon pump (IABP) AICD Defibrillator placement Surgery/transplant Nx Tip: Remember, interventions are LEAST invasive to MOST. Endocarditis/Pericarditis/Valvulitis Pathophysiology Inflammation of the layers of the heart Common in those with a history of grafts, IV drug users, and previous heart surgery patients Nx Tip: Any abnormalities in heart structure (anatomy) increase the risk of these infections. Signs and Symptoms Elevated WBC, fever, pain May decrease cardiac output, causing hypotension Pericardial friction rub Interventions IV antibiotics Cardiac Tamponade Pathophysiology Medical emergency Pericardial effusion (fluid build-up) May be blood (trauma) Signs and Symptoms Shortness of breath Tachycardia Narrowing pulse pressure Systolic minus diastolic 120/80: Pulse pressure equals 40. 110/90: Pulse pressure equals 20 (narrowed). Muffled heart sounds Pulsus paradoxus BP drops more than 10 mmHg during inhalation. Interventions Pericardiocentesis Patient supine May cause a pneumothorax (RN to assess) Aortic Aneurysm/Aortic Dissection Pathophysiology Bulging of the aorta (aneurysm) Tearing away of the aortic lining (dissection) Signs and Symptoms Thoracic Back pain indicates emergent rupture (PRIORITY). Abdominal (AAA) Palpable pulsating mass Never palpate it again. Interventions BP management (beta blockers) Interventional radiology Surgical graft repair Assess for post-op pre-renal acute kidney injury (oliguria). Marfan Syndrome Pathophysiology Genetic Abnormal weakening of the vessel lining (affects the connective tissue) Signs and Symptoms Frequent aneurysms Tall body with thin and long fingers Interventions Screening and preventions to treat the various complications Heart Sounds S1/S2: normal “lub dub” S3: extra heart sound after S2 S4: fluid overload (normal in pregnant women) Murmurs Expected when blood moves in an abnormal direction Grades 1–6 Grade 1 (softer than heart sounds) Grade 6 (very loud) APE 2 MAN Strategy This strategy and the figure that accompanies it work as a pictorial mnemonic. Beginning with the “a” for the aortic valve, you begin by assessing on the right- hand side of the body at the 2nd intercostal space. From there, the “p” for pulmonic, “e” for Erb’s Point, “2” as a stand-in for the letter “t” for “tricuspid,” and “m” for “mitral.” When auscultated, you create a wave. Try practicing on your own body with your stethoscope. Nx Tip: On NCLEX assessment questions, it may help to close your eyes and imagine the movement. Arterial Versus Venous Arterial Has a blood pressure/pulse Dangle the arteries. Intermittent claudication Pain in the calves  Light ambulation helps with increased blood flow. Pentoxifylline may help. Peripheral arterial disease (PAD)/arterial insufficiency Diabetes mellitus Decreased peripheral sensation Inspect the feet daily Wear cotton socks Snug-fitting shoes (not loose) Lotion prevents cracking Cotton between toes prevents Take care cutting toenails friction Venous Elevate the veins. Ambulate (venous valves prevent blood from pooling). Varicose veins if valves fail DVT prophylaxis Anti-embolism stockings (delegate to UAP) Sequential compression devices (delegate to UAP) SubQ heparin Venous stasis ulcer/stasis dermatitis Painful ulcer on lower extremities Shock Pathophysiology Decreased perfusion to vital organs and tissues Signs and Symptoms Acute kidney injury (first organ to fail) Decreased urine output Elevated lactate Interventions Fluids Vasopressors Treat the underlying condition. Types of Shock Anaphylactic Cardiogenic Hemorrhagic/Hypovolemic Allergic response Decreased cardiac Loss of blood volume output Vasodilation MI, HF, Hypovolemia cardiomyopathy EpiPen, antihistamines, Dobutamine, dopamine, Stop the bleeding or loss diphenhydramine epinephrine of fluids (burns). Neurogenic Septic CNS damage Caused by sepsis Loss of vessel tone Vasodilation (smooth muscle) Vasodilation May lead to acute respiratory distress syndrome (ARDS) Antibiotics Critical Care Hemodynamic Monitoring Arterial Line (Red) Catheter typically radial or femoral artery Continuous blood pressure ABG blood draws (must be an RN) Central Venous Pressure (Blue—Not Seen on Image) Sensor via central line catheter Sits in a venae cavae Good indicator of preload and pressure from the right side of the heart Often used in heart failure Normal CVP is 2 to 6. Elevated (worsening heart failure) Decreased (hypovolemia) Pulmonary Pressure/Pulmonary Wedge Pressure (Yellow) Sensor via Swan-Ganz catheter Sits in the pulmonary artery Good indicator of pulmonary hypertension Can inflate balloon for pulmonary wedge pressure Never inflate for prolonged periods of time. Never remove specialized syringe to inflate. Vital Signs Use the below numbers as benchmarks for NCLEX vitals of concern. Individual patients may vary, but these numbers are general benchmarks for the board exam. Pediatric vital signs can be found in the “Pediatrics” chapter; this section does not apply to peds. Blood Pressure (BP) 89 mmHg or lower: shock 180 mmHg or higher: hypertensive crisis Anything in between is not a priority unless the patient exhibits signs and symptoms of compromise. Mean Arterial Pressure (MAP) 60 mmHg or higher: indicates adequate perfusion to organs NCLEX does not require knowledge on how to calculate MAP. Temperature