NUR 319 FINAL STUDY GUIDE.docx

Foundations Final Exam Study Guide 1. Documentation (If you didn't chart it, you didn't do it!) Guidelines / the DO'S of charting - must be complete, concise, current/factual - accurate - legal prudency - date and time, content - correct spelling and legibility, a signature, and re...

Foundations Final Exam Study Guide 1. Documentation (If you didn't chart it, you didn't do it!) Guidelines / the DO'S of charting - must be complete, concise, current/factual - accurate - legal prudency - date and time, content - correct spelling and legibility, a signature, and remain confidentiality Documentation Method - SOAP (Subjective info, Objective info, Assessment, Plan) DON'TS of charting - Don't chart symptoms without also charting what you did about the symptoms - Don't alter a patients record (criminal offense) - Don't abbreviate words that aren't widely accepted - Don't exaggerate descriptions - Don't include personal opinions - Don't contradict yourself - Don't generalize information - Don't accuse other staff members or say anything about staffing problems - Don't chart ahead of time - Don't say that you filled out an incident report - Don't say anything about what someone else said, saw, smelled, etc. Use quotations!! Incident Report - What is an incident report? - Document that records any unforeseen or adverse event while the patient is in the facility - What is documented in the incident report? - The date and time of the incident, facility location, where exactly the incident occurred, type of incident, and the people affected by the incident. - Why is it done? - To help identify patterns to prevent it from happening again, to protect nurses from liability, to improve safety in the workplace 2. Nursing Process - ADPIE - Assessment: subjective, objective date - Diagnosis: technically can't diagnose patient but can still do certain stuff, requires critical thinking - Planning: set goals for patient - Implementation: carry out the plan of care (the patient plays a part in the care) - Evaluation: did the plan work? Did the patient meet the goals? Were they not met? - POC (plan of care) - Includes specialized care, priorities that you want to set, coordinates care, evaluates patient response - Evaluation of POC: measures patient outcomes (were the goals met? They can be met, not met, or partially met) - Once a care plan is put in place, it will be followed by other nurses until goals are met - It's a legal documentation, used for insurance purposes - Subjective vs objective data - Subjective: information that comes from the patient directly - Objective: information collected from assessment (what the nurse sees themselves) - Critical thinking - The conclusion the nurse comes to after assessment and the decision to act - Problem solving Trial and error - involves testing any number of solutions until one is found that works. Example: pt is complaining about back pain, you have called doctor already, tried repositioning the patient, try giving them a back rub, etc. Scientific: systematic process (data collection, hypothesize, testing) Intuitive: expert decision making without solid evidence for the specific situation - Critical thinking (Priority) - AFTER assessing and analyzing, the Clinical judgement to act in providing care to the most urgent patient - Urgency can be based off the ABC's, safety and risk reduction, least restrictive and least invasive, acute vs. chronic, unstable vs. stable, and urgent vs. nonurgent - 1^st^ level priority: ABC's plus VS and lab value concerns - 2^nd^ level priority: mental status change, acute pain, acute elimination problems, untreated medical issues requiring immediate action, Imminent risks - 3^rd^ level priority: other health issues not in level 1 or 2 (rest, coping, etc.) 3. Hygiene - Nurses' role: we must interview the patient - Health History: allergies, diseases or conditions, sensitivities to smells - Culture - Personal preferences - Assessment: complete skin assessment, oral assessment, and vascular assessment - Oral Hygiene: encourage teeth brushing, flossing, mouthwash - Look for signs of gingivitis, periodontitis, oral infections, plaque, tartar 4. Safety/ Mobility - Patient support - Pain management (manage their pain) - Sensory aids/ prosthesis - Family involvement (how involved is the family for physical therapy) - Stimulation - Physical activity / therapy - Safety Considerations - Across the lifespan: where are they at in their life? - Abuse/ neglect: we are mandated reports for the children, elderly, mentally challenged - Restraints/ side rails/ bed alarm: last thing we want to do is retrain a patient, 4 rails up is considered a restraint (3 is the recommended). Bed alarm is used first before rails as well as a sitter can also be used - Poisoning - Fire -- R.A.C.E - Equipment - Immobility: the state of not moving - Factors affecting mobility: mental health, lifestyle, older adults, muscular and skeletal problems - Body Mechanics - Posture - Larger muscles: use them when lifting patients - Gravity: The base of gravity is stable, use gravity to help you! Feet spread apart - Close: stay close to patient when transferring, moving, lifting - Slide: also used when moving patient - Nursing Interventions - Educate patient on correct body alignment in/out of bed - Change position/ turn at least every 2 hours (bed s=must be at waist level) - Range of motion exercises - Antiembolitic compression stockings - Increase physical activity, ambulation, exercises - Safety equipment and devices - Gait belt: used on patient who can bear weight but not very stable on their feet - Sliding boards: hard boards that are used to move the patient (half and half is placed on stretcher and bed, patient slides) - Inflatable mattress: prevents pressure ulcers - Friction reducing sheets - Mechanical lift (Hoyler lift) - Foam wedge: used in patients who are in bed for a long time, also used to prevent pressure ulcers - Trapeze bar: triangle shaped bar on top of bed - Trochanter rolls: a big towel rolled up, used under a patient back so that they don't roll, also used under the feet 5. Asepsis and Infection control - Aseptic technique -- when do we use it? - Used in any sterile procedure, operating room, any medical procedure - HAI: Hospital Acquired Infection, who is most at risk? - The immunocompromised, the elderly, people on ventilators, and people with multiple diseases/conditions - Isolation precautions - Standard: wash your hands, wear clean nonsterile gloves, wear PPE - Airborne: patient in private room with negative air pressure, wear respiratory if pt has TB, transport patient only when necessary and put a mask on them - Droplet: use a private room, wear PPE, and keep visitors 3 ft away - Contact: private room, PPE, limit movement of patient in room, don't share medical equipment - PPE (in order of putting them on) - Hand hygiene - Gown - Mask or respirator - Goggles or face shield - Gloves Order of taking it off Gloves Googles or face shield Gown Mask or respirator Hand hygiene - Infection cycle - Infectious agent: bacteria, virus, fungus, parasite - Reservoir: Human, animal, surfaces, food, soil - Portal of exit: skin wound, mouth(vomiting), respiratory tract - Means of transmission: contact, droplet, airborne - Portals of entry: common ones include the nose, mouth, eyes, blood, bodily fluids, Gi system, urinary system, and the skin - Susceptible host - Infection stages - Incubation: starts to invade - Prodromal: patient is most contagious, more symptoms - Full stage: symptoms are more obvious and specific, different symptoms are felt throughout the body - Convalescent: recovery period 6. Vital signs - Pulse rates: 60-100bpm, 0= no pulse, +1= weak, +2= normal, +3= bounding - Tachycardia: greater than 100 - Bradycardia: under 60 - Dysrhythmia: not a normal beat - Peripheral pulse: used to assess blood flow adequacy, take apical pulse - Pulse deficit: difference between radial and apical pulse, difference should not be more than 4 - Apical pulse: between 5^th^ and 6^th^ intercoastal space, left midclavicular line, listen for lub-dub sounds, listen to for one FULL minute - Nursing actions for Blood Pressure: take BP in according to site, make sure pt is sitting and relaxed without their legs uncrossed, a lot of patient education - Hypertension: blood pressure over normal range that is sustained over time Primary: essential hypertension Secondary: due to a disease - Hypotension: systolic is 90 or less, pt presents with dehydration, loss of consciousness, tachycardia Educate patient on weight, diet, exercise, stress factors, lifestyle changes, no smoking Planning/intervention: diuretics, beta adrenergic blockers, ACE inhibitors Evaluation: make sure the pt understands the teaching 7. Medical Administration - Nursing action if incorrect dose is given - Assess patient immediately - Notify nurse manager and provider - Document med error and steps taken after error - Complete adverse or incident event report - Pharmacokinetics - Absorption: can be affected by blood flow, route given, and drug dosage - Distribution - Metabolism - Execration: through the kidneys (main one), skin and lungs (lesser amount excreted), exocrine glands, and intestines - Injection sites - Subcutaneous (SubQ): outer upper arm, lower abdomen, upper back, anterior thigh, and right on top of the butt - Intramuscular (IM): side of hip, thigh, upper arm - Intradermal (ID): forearm, upper back, scapula - Intravenous (IV) Others include intracardial, intraspinal, intra-arterial 8. Legal Ethical - Patient advocacy: working in the patient's best interest, based on their needs and wants - Fidelity: keep promises to the patient 9. FEAB - IV fluids - Isotonic (equal): 0.9% sodium and chloride - Hypotonic (lower): 0.33 NS, 0.45 NS. Cells swell, contains less sodium and chloride - Hypertonic (more): 3.0% NS, D5LR, D5NS. Cells shrink, A LOT more sodium and chloride. Give to patient with hyponatremia - Hypernatremia/ Hyponatremia (sodium imbalance), THINK NEURO - Hyponatremia: fluid volume overload, confusion, hypotension, muscle cramps, weakness, dry skin, cerebral edema, seizures - Hypernatremia: fluid volume deficit, neuro impairment, restlessness, weakness, hallucinations, disorientation, thirst, brain damage Stop the source (if it comes from patient vomiting, we must stop it, put them on a fluid restriction 10. Communication - Therapeutic communication: an ongoing communication between patient and nurse Phrases like ''Tell me more and tell me how'' 11. Nutrition - Diet for constipation: high fiber, avoid seeds, drink a lot of water. Foods with laxative effect include prunes, alcohol, chocolate, coffee, and certain veggies. - Diet types (clear, full. Soft, regular) - Clear: only liquid that we can see through - Full: orange juice, tomato juice, soup - Mechanical soft: eggs, mashed potatoes, oatmeal 12. GI/elimination - NG placement verification: pH test (paper down a tube to verify placement, gastric juices have a pH level of 2. Xray would give definitive answer of where the tube is at. - Stoma assessment: stomas must be pink and moist, should not be purple 13. GU/ elimination - Specimen collection (clean catch): pee a little, stop, continue peeing and catch the rest - Clinical findings of UTI: burning sensation while peeing, frequent peeing, frequent urge to pee but incomplete voiding, pain or pressure in the back or lower abdomen. Lab values would show elevated WBC, and a urine culture. 14. Perioperative - Post op nursing interventions: the PACU and Impatient hospital room - You monitor vital sings, their airway, and monitor surgical site - Monitor urine output and fluid intake during surgery - Clinical findings and nursing interventions for severe fluid loss -- bleeding - Sanguineous is bright red: active bleeding - Serosanguinous is pink, pale red, watery: healing - Serous is clear, watery plasma: healing - Purulent is thick and yellow. Green, tan, brown: infection 15. Wound - Pressure/ulcer injury there are - Stage 1: redness caused by pressure over a bony prominence - Stage 2: partial thickness skin loss with a visible injury or fluid filled blister - Stage 3: possibility of tunneling and eschar 9black slob) or slough (white dead tissue) - Stage 4: full thickness tissue loss without exposed muscle/bone - Factors aiding in wound healing: protein, good circulation, ambulation, vitamin K 16. O2 and perfusion - Purse lip breathing technique: used to promote proper breathing - Incentive spirometer: exhale fully away from tube, grab tube and inhale all the way, hold for 3 seconds, exhale away from tube fully. Used a lot with post op patients - Respiratory distress and nursing action - Take vital signs, auscultate the lungs, look at behaviors, and look at patient history - Interventions: place in high fowlers positions, administer supplemental oxygen (can administer up to 3L without doctor orders via nasal cannula, mask, etc.) Administer medications like bronchodilators or corticosteroids. - Nursing diagnosis problems - Impaired Gas Exchange, Ineffective Airway Clearance, Altered Tissue Perfusion, Ineffective Breathing Pattern, Anxiety, Fluid Overload, Dehydration 17. Pain - PCA pump: patient controlled; they can't overdose on it because there's a limit. Patients should press it as soon as they are feeling pain, not when it gets worse. Nurses should be on the lookout for family abuse of PCA pump. - Adjuvant Analgesic: you take Tylenol, still find bad, they give you another analgesic to help the main analgesic complete its therapeutic effects. - Components of pain: subjective information, can be rated on a scale from 1-10 or the faces scale, it's the 5^th^ vital sign, patient behavior can let you know if they are in pain, stereotypically men are more prone to handling pain 18. Sleep and rest - Insomnia: difficulty falling asleep or when they fall asleep, they don't stay asleep for long - Sleep deprivation: not getting any sleep AT ALL - Sleepwalking: patient is up and walking while sleeping and unaware of it (lasts 3-7 minutes). Consider safety!! They are at high risk of getting hurt, do not wake them up abruptly. You want to gently guide them back to bed. - Sleep apnea: you stop breathing while sleeping and wake up suddenly (elevate head when sleepingz) - Narcolepsy: patient falls asleep anywhere uncontrollably - Parasomnias: any activity that is normal when pt is awake but not normal when sleeping - Sleep related movement: jerking and muscles twitching, usually happens in people who are very active, restless leg syndrome - Hypersomnolence: excessive sleeping - Factors affecting sleep - Developmental considerations: infants and newborns sleep around 16 hours a day, half of that time is in REM. Toddlers hate to sleep, they need a new bedtime routine. Teenagers are sleepier during the day due to having so many activities. Adults decrease in the amount of sleep they get as they get older, sleep is not needed or required as much as a growing toddler would need. - Nutrition: patients should not eat certain foods before bedtime like sweets, coffee, high protein foods, etc. - Lifestyle changes - Environmental changes: nurses come in and out of patients' rooms, they are not in their usual sleeping environment. - Psychological stress - Illness: COPD patients and people with pneumonia can disrupt sleep - Drugs and other substances - Medications: melatonin, Ambien, - Sleep disorders: narcolepsy (causes excessive daytime sleepiness, muscle weakness, hallucinations & sleep paralysis) - REM/NREM - NREM: pt is first falling asleep, they are just starting to reach dozing off. - REM: deep sleep, body can have some paralysis. The body is in the repair and rebuilding stage. Sleepwalking and bed wetting can occur. Everything is decreased or irregular (heart rate, respirations, etc.) Rapid eye movement occurs, and REM sleep is about 20-25% of total sleep time. - Goals and interventions: prepare a restful environment, promote bedtime schedule, promote relaxation and comfort, respect normal sleep wake patterns, offer appropriate bedtime snacks and beverages, encourage activities during the day, encourage stress relieving techniques. 19. Older adult - Normal aging and cardiovascular health (BP) - Heart and blood vessels: stiffening of arteries and blood vessels, physical activity and walking may become more difficult. - Heart disease is a chronic illness in older adults - Be active daily to help decrease risk of falls and may improve core strength and focus - Avoid alcohol and smoking - Heart health screening tests: blood pressure, fasting lipoprotein profile, and body weight - Prevent heart disease by controlling blood pressure, keeping cholesterol and triglycerides levels under control, staying at a healthy weight, eating a healthy diet, get regular exercise, and limit alcohol. - Normal aging and dietary needs: encourage a diet low in fat and cholesterol - Diet should include all food groups (low in fat, saturated fat, and cholesterol). Recommended amounts of fruits, vegetables, and grains. Use salt and sugar in moderation. - Discuss with provider to include nutritional supplements as part of daily routine or not - Vaccine importance - Vaccines prevents tens of thousands of hospitalizations each year - 65+ and older are recommended to take flu shot - 50+ and older are recommended to take Zoster (shingles) vaccine - Children and adults 65+ are recommended for pneumonia vaccimobne - Effects of UTI on older adults: confusion, loss of appetite, agitation Loss, grief, and dying - Advance directive - The person who will make decisions for the patient in case the patient is unable to, will know the kind of medical treatment the patient wants or does not want. They will know how comfortable the patient wants to be, how the patient wants to be treated by others, and what the patient wants loved ones to know. - Hospice (death) less than 3 months to live - Prognosis is usually 6 months or less - Clients total care best managed by interdisciplinary team whose members communicate regularly - Pain and other symptoms must be managed - Client/family should be viewed as single unit of care: family can be super stressed and tend to fight over what is best for their loved one. Everyone is given the same communication. - Home care of dying necessary - Bereavement care must be provided to family members - Research and education should be ongoing - Palliative care= make patient as comfortable as possible - Goal is to prevent and relieve suffering and to support the best quality of life for clients and their families - Interdisciplinary collaboration - Settings: hospital, outpatient, skilled nursing facilities - All hospice care is palliative care BUT not all palliative care is hospice care - Assessment findings for impeding death - Difficulty talking or swallowing - Nausea, flatus, abdominal distention - Incontinence bowel and bladder or constipation - Decreasing blood pressure - Weak, irregular, slow pulse - Decreasing temp resulting in cold, clammy skin - Noisy, irregular, Cheyne-stokes respiration (the death rattle) - Restlessness and or agitation - Mottling and cyanosis of extremities (veiny looking legs and arms) - Loss of movement, sensation, and reflexes - Special order - DNR: do not resuscitate, allow a natural death, no CPR, no intubation, etc. - Terminal weaning: slowly weaning patient off ventilatory per doctors' orders - Voluntary cessation of eating and drinking: family is involved in this decision - Active and passive euthanasia: lethal dose of medication that is given to patient that will decrease respirations and blood pressure - Palliative sedation: patient is given a high sedative similar to morphine, that will further induce unconsciousness. The reason its given is to end patients suffering. Grieving Stages 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance Stages of Awaking from Anesthesia 1. Analgesia: decreased pain awareness, sometime w/amnesia, conscious may be impaired but not lost 2. Disinhibition: delirium, excitation, enhanced reflexes, irregular respiration & incontinence 3. Surgical Anesthesia: unconsciousness, no pain reflex, regular respiration, maintained BP 4. Medullary Depression: severe CVS & respiratory depression & patient require pharmacological & ventilatory support Narcan = reverse opioid overdose Pain Management Scales - \# Scale (most commonly used) - Wong-Baker FACES (for children) - FLACC Scale (for infants) Atropine Therapy (Antiarrhythmic, Anticholinergic) - Used to increase heart rate, decrease GI & respiratory secretions, reverse muscarinic effects Developmental Stages for Memory? Dementia (group of symptoms affecting memory, thinking & social abilities) Cause: damage/changes in brain S&S: change in mood & personality, confusion, difficulty solving problems, memory loss, problems w/language, misplacing thing, difficulty w/simple tasks, poor judgement, problems communicating Alzheimer\'s (gradual decline in memory, thinking & reasoning skills) S&S: vision problems, irritability, social withdrawal, wandering, trouble planning, difficulty completing familiar tasks, trouble in conversation, poor judgement, misplacing things, mood changes, memory loss Delirium (fast-developing confusion) Cause: low mobility, undergo surgery & treatments, conditions, medication, lack of pain management, social isolation, lack of stimulation Treatment: adjust medications, supportive care, avoid triggers Depression (persistent sadness & loss of interest) Confusion Sundowners (symptoms that occur in the late afternoon/early evening in people w/dementia & Alzheimer\'s) Risk of Aspiration - Health problems that affect swallowing (lung disease, seizure, impaired consciousness) - Poor oral health status - Impaired health status - Dysphagia - Intoxication (drug/alcohol) - Dementia - GERD 3 Checks for Medication Administration 1. When removing meds from med room 2. While preparing med 3. Before administering/\@bedside ! Take apical pulse for any cardiac medications (esp. Digoxin) ! Take BP before admin. BP meds ISBAR: communication tool Identify Situation Background Assessment Recommendation NG Tube \^ check placement before feeding (xray, pH test) \^ provide frequent oral care What can be delegated to an AP - Collecting vitals - Monitor I&O - Reinforce RN's patient teaching - Assist with ADLs Serum Levels Sodium 135 - 145 mmol/L Potassium 3.5 - 5.0 mEq/L Chloride = 95 -- 105 mmol/L Phosphorus = 3 - 4.5 mg/dL Bicarbonate = 23 -- 30 mEq/L Calcium = 8.5 - 10.5 mg/dL Magnesium = 1.3 - 2.1 mEq/L Albumin = 3.4 - 5.4 g/dL Respiratory Depression (hypoventilation) Leads to carbon dioxide buildup in blood Questions from Last Class Disengagement theory of adult = older adult may substitute activities but disengage from society Myths of older adults, delirium, stay in long-term facilities, cant learn new things Development task for middle adult = continuing established lifestyle Acute & chronic illnesses are likely to occur and recovery takes longer in middle adulthood (true) sundowning syndrome Dementia symptom = disorientation to familiar environment Insomnia nursing intervention = bedroom only for sleep, protein snack before bed Narcolepsy: uncontrollable desire to sleep Approaching death = difficulty swallowing Bargaining -- if you let me get through this, i will attend church Anticipatory loss = diagnosis of lung cancer