Exam 1 Review - Foundations of Nursing Practice PDF

Exam 1 Review Foundations of Nursing Practice  Logistics Exam one is a 50 question exam which you will have 60 minutes to complete. Certain questions are SATA. These questions have up to 6 response choices. Regarding these questions, the rule is: one an...

Exam 1 Review Foundations of Nursing Practice  Logistics Exam one is a 50 question exam which you will have 60 minutes to complete. Certain questions are SATA. These questions have up to 6 response choices. Regarding these questions, the rule is: one answer could be correct or more than one or all answers could be correct. Questions may come from lecture notes, textbook, and/or lab/lab manual principles.  NORMAL VITAL SIGNS TEMPERATURE PULSE RESPIRATIONS 36.5°-37.5°C or 97.6° Adult: 60-100 beats/min (bpm) Adult: 12-20 breaths/min -99.6°F = Afebrile (NO Newborn: 130-160 bpm Newborn: 40-60 breaths/min fever) *Strong, regular, palpable BLOOD PRESSURE O2 Saturation PAIN Adult: SBP 10 mmHg when getting up from lying down. - Dehydration, blood loss, anemia, and patient on BR  Practice Question Your patient had surgery 1 week ago and has been on bedrest. They decide that they want to get up and walk around the unit today, but when they do, they get dizzy and stumble. What are your priorities as their nurse in this scenario? (SATA) a) Take their blood pressure b) Help them continue to walk around the unit c) Take their temperature d) Help the patient return to bed  Practice Question Your patient had surgery 1 week ago and has been on bedrest. They decide that they want to get up an walk around the unit today, but when they do, they get dizzy and stumble. What are your priorities as their nurse in this scenario? SATA a) Take their blood pressure b) Help them continue to walk around the unit – you can consult PE at a later time to work with the patient on ambulation, but this is not a priority in this scenario c) Take their temperature d) Help the patient return to bed  PAIN Pain can lead to changes in vital signs (objective data) - Elevated BP - Increased HR - Increased RR - Stress response Subjective data: whatever the patient says their pain is Pain assessment scales: numerical vs CRIES vs faces *NON- pharmacological things nurses can do to treat pain: - Heat/cold - Massage - Positioning - Hygiene: wash their face/hair - Ensure comfortable environment: lighting, music, cleanliness of room - Distraction, guided imagery, meditation etc. - PROPER BODY MECHANICS - Assess – position/weight of patient - Legs – not your back! Height - raise the bed Device- use sliding boards, lift - REVIEW MOVEMENT VOCABULARY - - BR, BRP OOB- ad lib - to chair, NWB Friction – two surfaces rub together MOBILITY - Shearing – tissue layers rub against each other - Review Transfers: - Bed to Chair - *Bed to Stretcher → use slide assistive device - Up in Bed - Hoyer Lift  *Ways to decrease shearing/friction? - Use Hoyer lift - Use draw sheet to transfer patient - Instruct patient to put chin to chest / cross arms over chest - Keep skin dry - Regularly rotate positions  Why do we do it? Promote healing and tissue repair Relieve swelling Purposeful Decrease pain immobility Alignment *RN Role: Support a weakened area Avoid dislodging a DVT - keep leg immobile/elevated Assessing Fall Risk Ambulation Devices -Canes = positioned elbows at 160 degrees - Crutches - Walkers - Wheelchairs -*Footboard splints to prevent foot drop -Abduction pillows -Trapeze  Fall Risks - Poor balance - History of fall - Pain medications (i.e. narcotic) - Patients with urgency to go to the bathroom - Tethered patients Benefits of Ambulation Strengthens lower extremity muscles Decreases calcium loss leading to osteoporosis Maintains normal breathing function Increases joint flexibility Stimulates circulation Stimulates appetite Relieves pressure on skin/tissues Prevents constipation *RN ROLE: Move to strong side to support Effects of Immobility on the Respiratory System : Decreased activity ↓ Decreased BMR Decreased CO2 production → decreased stimulation to breathe Slower, more shallow respirations Respiratory Changes due to immobility Lack of exercise & movement put patient at risk for: ○ *Atelectasis - Collapse of alveoli leading to partial collapse of lung ○ *Hypostatic Pneumonia - Inflammation of lung tissue from stasis or pooling of secretions ○ Both decreased oxygenation, prolong recovery, & add to discomfort Effects of Immobility on the Cardiovascular System : Orthostatic hypotension (check BP when mobilizing) Increased workload of heart due to decrease in venous return to the heart Risk for thrombus Prevent Thrombus Formation: Anticoagulants (Heparin, Lovenox) TED Stockings Calf pumping exercises Sequential Compression Device (SCD) Effects of Immobility on the Musculoskeletal System Osteoporosis Atrophy Contractures/spasticity Decubitus ulcers Effects of Immobility on Nutrition and Metabolism Decreased BMR Negative nitrogen balance- protein breakdown Calcium loss from bone  Practice Question Which patients are at an increased risk of falls? SATA a) 55 year who has heart failure and is taking diuretics. b) 45 year old healthy individual c) 10 year with a temperature of 99.5F d) 40 year old who had leg surgery and is taking narcotics for his pain  Practice Question Which patients are at an increased risk of falls? SATA a) 55 year who has heart failure and is taking diuretics. b) 45 year old healthy individual c) 10 year with a temperature of 99.5F d) 40 year old who had leg surgery and is taking narcotics for his pain  Practice Question Your patient just got out of surgery and will be on bedrest for 2 weeks. To decrease the negative effects that immobility might have on your patient, you should: (SATA) a) Round less on the patient so you avoid disturbing them b) Encourage them to use their incentive spirometer every 1-2 hours c) Request an order for SCDs or TEDs to place on the patient d) Give them sugary foods to make them happy and less sad after their surgery  Practice Question Your patient just got out of surgery and will be on bedrest for 2 weeks. To decrease the negative effects that immobility might have on your patient, you should: (SATA) a) Round less on the patient so you avoid disturbing them b) Encourage them to use their incentive spirometer every 1-2 hours c) Request an order for SCDs or TEDs to place on the patient d) Give them sugary foods to make them happy and less sad after their surgery  HYGIENE AND COMFORT  Basic Care of the Patient Feet & Nails: don’t trim - can create wound that isn’t worth it, clean under nails instead Hair: wash to remove dried blood, oils, dirt, get knots out Oral Care: decrease bacteria/promote healthy gums, brush teeth, clean dentures, use toothette to swab mouth Toileting: offer urinal, help on/off bedpan, assist to bathroom Dressing & Grooming: new gown Beds/Bed Making Active Listening: show interest instead of just doing your tasks, ask about day & pain Rapport: pt needs to trust you, eye contact, touching  Bathing Benefits Remove transient microorganisms, body secretions/excretions, dead skin cells Stimulate circulation Produce a sense of well being Promote relaxation & comfort Prevent/eliminate unpleasant body odor Create a positive rapport Assessment: look at skin integrity, cognition, pain, mobility (can they assist you?)  *Levels of Bathing Self: independent Partial: with assist from nurse Complete: pt doesn’t assist at all, done by nursing care  Practice Question # You get report from the day shift nurse that one of your patients needs full P.M. care. This patient is a complete care patient, you recognize that this means you will have to: a) Leave towels in their room for them to wash themselves when they are ready b) Provide the bathing supplies and wait for them to call you into the room when they need help getting the hard-to-reach areas c) Provide all of the ADLs for this patient d) Give them a bed bath, but they should be able to brush their hair and teeth themselves  Practice Question # You get report from the day shift nurse that one of your patients needs full P.M. care. This patient is a complete care patient, you recognize that this means you will have to: a) Leave towels in their room for them to wash themselves when they are ready b) Provide the bathing supplies and wait for them to call you into the room when they need help getting the hard-to-reach areas c) Provide all of the ADLs for this patient d) Give them a bed bath, but they should be able to brush their hair and teeth themselves  Bath Basics Identify pt Supplies at bedside Proper bed height, don clean gloves Basin vs. wipes: CHG wipes - prevents HAI especially in critical care setting No soap on face Eyes (inside to out) Respect, room temperature, safety, assessment Documentation  Bathing the Infant/Child Safety first Supervision *Temperature control: check water temperature Teaching Clean to dirty Limbs first  Bathing the Obese Patient Safety - in and out of shower Assistance *Pannus: large abdominal skin folds, lots of crevices and skin on skin ○ Greater chance of skin breakdown because moisture gets trapped ○ Yeast infection can occur → dark/moist area ○ Clean well/keep dry ○ If sweating: don’t use powder. Instead put towels or gauzes in skin fold to absorb moisture and change often Breast and thighs Gowns Foot Care: they may not be able to see/reach feet  Bathing the Elderly Patient Dry/fragile skin: careful when rubbing skin because it can tear easily ○ If wounds - pat instead of rubbing Lotion: while skin is damp Water temperature Sensitivity to heat Safety  Bathing the Unconscious Patient Biting reflex: may bite your finger it it’s in their mouth ○ Put mouthwash on toothette ○ Make sure there isn’t extra liquid going down throat that makes them aspirate *Side lying and/or suctioning: ○ Put emesis basin next to mouth so water can drain out Aspiration: don’t want to breathe water in Unable to express pain ○ Be conscious of positioning, look at pressure on limbs Communication ○ Still talk to them because they may be able to hear Assistance  Bed Positions Flat Low Fowler’s: 15-30 degrees ○ Comfort, breathe better when head is up Semi Fowlers: >30-45 degrees ○ Assist with breathing, watch TV, easier to eat High Fowler’s: 80-90 degrees ○ Sitting all the way up, eating/swallowing, TV, conversations Trendelenburg: head down, feet up ○ Bed flat, gravity helps to move patient up in bed Reverse Trendelenburg: feet down, head up ○ Bed flat, for gastric reflux to prevent aspiration if patient can’t sit up  Basics of Changing an Occupied Bed ID patient Linens – fitted sheet, draw sheet, flat sheet, pillow case, comforter Bed position: raised so comfortable for you Don clean gloves *Safety – proper use of bed rail and bed height ○ Rail near you down, opposite rail is up, call bell in reach Basic steps – see lab manual  Comfort May decrease pain, reduce fear and anxiety ○ Distraction: TV, book, magazine, music ○ Guided Imagery ○ Reiki ○ Clean Linens, Bed Bath ○ Listening: let them vent, interact, hold hand ○ Restful environment ○ Massage: hands, feet, back, scalp ○ Touch ○ Heat: promote circulation, pain relief ○ Cold: decrease swelling, pain relief 20 min on/ 20 min off Towel/cloth/chux between source of hot/cold and skin Special considerations with patients who have diabetes, paresthesia, paralysis, or are unconscious May not feel that it’s too hot/cold so inspect to ensure no skin damage  Special Considerations: Diabetic Patient Discharge education Inspect feet daily Clean with mild soap Do not soak feet Dry feet carefully especially between toes, do not scrub skin ○ Blot instead of rubbing ○ Don’t want skin to be more susceptible to breakdown Wear sturdy, well fitting shoe & check often for blisters/wounds Diabetic & peripheral neuropathy patients both don’t have feeling that they stepped on something or that blister formed  Delegation Five Rights ○ Right task: does person know policies/procedures to do task correctly? ○ Right circumstance: is pt too critical to delegate too UAP ○ Right person: do they have the right skills/knowledge? ○ Right direction/communication: is person aware of importance of communication and what to do if there is a sudden change? ○ Right supervision/evaluation: make sure it was done correctly Do NOT delegate ○ Evaluation ○ *Assessment: only nurse can do ○ Teaching ○ Medication ○ Unstable patients  Practice Question You are very busy during your shift and your nursing assistant asks if he can help you with anything. Which patient(s) should you select to delegate? SATA a) The patient who recently became disoriented and needs a neuro assessment b) The patient who is fairly self-sufficient, but needs help washing his back c) The patient who has new-onset low blood pressure and is due for a blood pressure recheck d) The patient who needs a bed bath and is due for pressure ulcer wound care & assessment  Practice Question You are very busy during your shift and your nursing assistant asks if he can help you with anything. Which patient(s) should you select to delegate? SATA a) The patient who recently became disoriented and needs a neuro assessment b) The patient who is fairly self-sufficient, but needs help washing his back c) The patient who has new-onset low blood pressure and is due for a blood pressure recheck d) The patient who needs a bed bath and is due for pressure ulcer wound care & assessment Medical Asepsis Differentiate the difference between medical asepsis and surgical asepsis Medical: Clean Reduce number or spread of microorganisms Helps leave microorganisms you have been in contact within room and not spreading to others Surgical: Sterile Prevent introduction of microorganisms where they aren’t present and could cause damage Ex: use with dressing change on wound to help it heal, not infected and you want to prevent that *If you drop something out of the sterile field, get new item! Nosocomial Infection HAI: Healthcare Associated Infections Infection was not present nor incubating at the time of admission. Infection develops during patient’s hospital stay. CLABSI: Central Line Associated Bloodstream Infections Central line access device issue, most likely sterile technique was broken CAUTI: Catheter Associated Urinary Tract Infection SSI: Surgical Site Infection VAP: Ventilator Associated Pneumonia Superbugs: Bacteria or fungi that have developed the ability to withstand commonly prescribed drugs VRE: Vancomycin-resistant enterococci- Purell MRSA: Methicillin-resistant staph aureus- Purell C-Diff: Clostridium difficile- Soap and water Norovirus- Soap and water Prevent spread by: Washing hands, gloves, medical/surgical asepsis, avoid cross contamination, holistic care of the patient, ask questions, talk to them  Handwashing Proper Disposal *Before/after entering patient’s room/donning and Red bags: more expensive to dispose (avoid placing other removing gloves trash) Soiled dressings: saturated with blood/drainage Clean dressing: disposed in normal trash (spots of Agents: alcohol (hand sanitizer) and soap & water blood/minimal drainage) How long: alcohol until dry, water (15 sec at least) Sharps: needles, broken glass, ampules Nails: scrub under, palms, back of hands; bacteria NEVER RECAP A USED NEEDLE – except a needle in med room grows under acrylic nails after drawing up meds Contact Precautions (ex: c. diff, MRSA) Wash hands before entering or donning gown and gloves Infection transmitted through touch and not air Remove gown and gloves and then step outside of room, make sure trash can is just inside room Droplet Precautions (ex. influenza, rubella, HIV) Large droplets in air Hand hygiene, gown, gloves, eye protection, mask Isolation cart outside of room Take off supplies just in room (cannot exit room in dirty PPE) Try to cluster everything in room (think ahead of what you need!) Airborne Precautions (ex: TB, measles, SARS, COVID) Hand hygiene, gown, N-95 (fit test for size)/PAPR Patient in negative pressure room ANTI room: step in, put on PPE, enter patient room, take off all PPE in anti-room before exiting into hallway *Ex. if computer in room not working, write vitals on piece of paper IN ROOM and tape on wall to be visible outside of the room  Practice Question You are about to enter a patient’s room that has c. diff in their stool. What would you put on before entering their room? SATA a) Gloves b) Gown c) Surgical Mask d) Respirator  Practice Question You are about to enter a patient’s room that has c. diff in their stool. What would you put on before entering their room? SATA a) Gloves b) Gown c) Surgical Mask d) Respirator Basic Principles of Asepsis/Sterility = sterile equipment & supplies for procedures or dressing changes Sterile touching nonsterile: if anything non sterile touches sterile field you must start over because you don’t want to introduce microorganisms Sterile field on non sterile field: set up on bedside table and clean table first ○ One-inch border: not sterile ○ Arms above waist once sterile gloves are on (watch reach!) -> sterile field extends above *** ○ *Reach AROUND sterile field NOT through ○ Flowing fluid: off elbows Factors Affecting Wound Healing = have strong understanding of all of these aspects Nutrition: need protein to go to wound to heal Circulation/Oxygenation: bleeding could be good because that means the wound is healing Immune status Age: Slower healing *Obesity: adipose tissue decreases ability for blood to get to wound to heal, may put pressure on suture line and increase risk of dehiscence, could lead to evisceration (medical emergency) Smoking: decreases circulation Medication: steroids decrease wound healing Stress: decreases circulation Wound Assessment Types of Wound Healing Primary Intention Size: width, length, depth (measured with Edges approximated q tip, break it off at surface and then Minimal scarring measure with a ruler later) Lower risk of infection ○ Ex: surgical wound Drainage: Secondary Intention Serous: clear/depth/cloudy/ blister Gradually fills in with granulation tissue popping Slower healing, wound stays open longer Sanguineous: bloody (sangria = red), Greater chance of scarring/infection new wounds Tissue missing so must heal from bottom up Serosanguinous: clear/pink drainage Wound packed (wound healing) Purulent: milky/pus Odor: infection? 1. Area of redness, may be painful to touch, unblanchable 2. Partial thickness loss of dermis, red/pink wound bed, Broken skin, popped blister 3. Full thickness tissue loss, may see subcutaneous fat but no bone, tendon or muscle, possible tunneling 4. Full thickness loss with exposed bone, tendon/muscle, possible slough/eschar (dead tissue that needs to be removed), tunneling, and risk of osteomyelitis (bone infection) Last is unstageable: Full thickness tissue loss, significant amounts of slough/eschar present *Eschar = black, needs to be removed because can’t see under it - debridement cream Suspected Deep Tissue Injury (DTI) Purple/dark red colored area of intact tissue or blood filled blister, may be painful, firm, boggy Skin will still be intact but can see injury underneath Mucosal Membrane Wound Not stageable, just say its present Ex: person bit gum/wound and little ulcer in mouth Medical Device Wound Wound caused by medical device (ex. nasal cannula causing sores on ears)  Practice Question This wound should be documented as: a) Stage 1 pressure ulcer b) Stage 2 pressure ulcer c) Stage 3 pressure ulcer d) Stage 4 pressure ulcer e) Unstageable  Practice Question This wound should be documented as: a) Stage 1 pressure ulcer b) Stage 2 pressure ulcer c) Stage 3 pressure ulcer d) Stage 4 pressure ulcer e) Unstageable  Practice Question How would you document this wound? a) Unblanchable, area of redness b) Partial thickness loss of dermis, red/pink wound bed c) Full thickness tissue loss with SQ fat showing, but no bone, tendon, or muscle showing d) Full thickness loss with exposed bone, tendon/muscle, with possible eschar e) Unstageable wound  Practice Question How would you document this wound? a) Unblanchable, area of redness b) Partial thickness loss of dermis, red/pink wound bed c) Full thickness tissue loss with SQ fat showing, but no bone, tendon, or muscle showing d) Full thickness loss with exposed bone, tendon/muscle, with possible eschar e) Unstageable wound Pin Care External fixator keeps affected limbs immobile as bone heals Pins are placed in the skin and drilled into the bone, we want to avoid this becoming an infection site Assess for signs of infection: redness, discharge, pus Clean all areas where pin goes into bone. Keep area clean and remove dried blood Use pressure when cleaning so skin doesn’t grow to pins What we need: Chlorhexidine or normal saline (sodium chloride) Long Q-tips Chucks pad Gloves sterile/clean depending on policy Wound VAC (vacuum assisted closure) *For irregularly shaped wounds/extensive draining Document extensive drainage (quality and quantity) Benefits Decrease edema, increase capillary growth and blood flow, promotes granulation tissue growth, proliferation of cells, decreases healing time and hospital stay, can go home with them *Contraindications Eschar/slough, untreated osteomyelitis at wound, cancer in wound/tumor, fistula to organ or body cavity in vicinity of wound (unnatural opening of wound into abdominal cavity), active bleeding, anticoagulation therapy/low platelet counts, necrotic tissue or visible bone SURGICAL NURSING  Types of Surgery Inpatient: pt may admitted to hospital unit before surgery, transferred to OR from unit, then to PACU and back to original unit Outpatient: Patient arrives for surgery, is prepped in pre-op area, goes to OR then to PACU/recovery area, return home in same day  Pre-operative Nursing Most involved Time from decision to have surgery until patient transferred to OR Patient consent needed ○ Adequate disclosure ○ Patient not under influence ○ Medical emergency: if pt comes in as trauma, 2 Drs sign off on consent Patient ○ NPO: midnight the night before no food or H2O ○ Allergies: ask multiple times - food, latex, meds ○ Medications and other prep ○ Knowledge, Advance directives, education ○ Active listening, correct surgical site, OR checklist  Intra-Operative Nursing Time from when patient enters OR until pt transferred to PACU OR Team ○ Anesthesiologist/CRNA: in charge until pt is unconscious ○ Surgeon: in charge once pt is unconscious ○ Scrub nurse: assists surgeon (holds retractors, touch pt) ○ Circulating nurse: brings supplies, not sterile ○ Both nurses count all supplies before and after surgery Surgical gowning/gloving ○ Hands above waist once sterile - clasp hands and don’t touch anything If they go below waist you are no longer sterile ○ Do not touch mask/cap ○ Don’t touch any areas that aren’t sterile  Post-OP Nursing Patients admission to PACU through follow up after discharge PACU (Post Anesthesia Care Unit) Restore to the maximum level of functioning → way they came in Prevent complications and intervene as needed *Maintain airway – O2 given if needed Monitor VS and orientation (monitor for CV complications include hypotension, shock, hemorrhage, hypertension, dysrhythmias, DVT, PE) Discharge instructions  Effects of Surgery on GU System Pt may experience decreased urine output secondary to stress from surgery Intake may be greater than output in the first 24-48 hours Possible urinary retention secondary to opioids/anesthesia INTERVENTIONS: ○ Monitor I’s and O’s – need for a urinary catheter if not voiding (sometimes just need 1x catheterization) ○ Hydrate as ordered: run fluids ○ Urinary retention – catheterize, bladder scan ○ Pain management – may not want to move to use bedpan or ambulate to BR  Effects of Surgery on GI System Ileus: delay in GI motility after surgery, no peristalsis, bowel is asleep Peritonitis/bowel perforation/obstruction N/V – secondary to anesthesia → put basin in bed just in case Thirst Constipation d/t meds INTERVENTIONS ○ GI assessment to monitor peristalsis (bowel sounds) ○ Fluids ○ Stool softeners, laxatives, enema  Effects of Surgery on Respiratory System PE – thrombus from another site in the venous system or in heart, obstructs one or more pulmonary arteries Atelectasis: lung collapse, chest tube may be needed, can be done at bedside INTERVENTIONS: ○ Encourage coughing and deep breathing ○ Be sure their pain is under control so they feel comfortable to do deep breathing exercises ○ Respiratory assessment  Effects of Surgery on Neurological System Level of consciousness (LOC): varies because of anesthesia but should get back to baseline Sensation Over sedation INTERVENTIONS: ○ Neuro checks as ordered: Q2 or Q4 to check for A&O ○ Re-orient as often as needed  Effects of Surgery on Cardiovascular System Shock – body’s response to decrease in circulating volume, impaired tissue perfusion, hypoxia, death Hemorrhage: not enough volume in system so tissue perfusion impaired DVT – in pelvic vein or lower extremities ○ Occurs from circulatory system slowing INTERVENTIONS: ○ Fluids, blood transfusion, anticoagulants (decreases blood clot chances) ○ CPR and code blue if necessary  Pain Major stressor: fearful of pain after surgery, always address it May interfere with healing: pt hurts so much they don’t want to eat/move INTERVENTIONS: ○ Pain medication ○ Comfort measures (reposition, elevate, splint incision (abdominal surgery - hold pillow against incision when cough/sneeze), ice/heat, massage) ○ Antiemetics ○ Ambulate: helps body function return to normal  Possible Complications Infection – culture and treat with antibiotics as ordered ○ May see fever, drainage, pus Hemorrhage – excessive bleeding, alert Dr. and monitor pt Compartment syndrome ○ Pain: so severe that pain meds don’t work ○ Redness ○ Swelling: feels tight/warm when touching area ○ Pressure: relieved by secondary/tertiary intention or will go back to OR ○ Decreased Circulation: toes turn blue, can cause tissue death  Possible Complications - Dehiscence & Evisceration Dehiscence ○ Rupture of surgical wound ○ Edges are no longer approximated ○ Risk factors: age, obesity, malnutrition ○ Sudden increase in abdominal pressure Evisceration - happens after dehiscence ○ Internal organs protrude through abdomen ○ Medical emergency ○ Possible impending shock ○ Cover with sterile towel/gauze moistened with sterile saline  Discharge Care of Patient Sign and symptoms of infection Activity level: what are the orders? Weight bearing? Diet Pain medication Use of braces Lifting limitations over a certain weight - common in abdominal surgery Driving restrictions Care of drains Follow up physician appointments  Safety Keep at least two side rails up (top 2) Bed alarm if disoriented Assess often for over sedation Positioning *Patients in wrist restraints = check circulation/distal pulse q 2 h GOOD LUCK!! You got this!