FON Final Study Guide PDF

FON FINAL STUDY GUIDE Types of Isolation: ☺ Airborne – Used for patient’s known or suspected to have serious illnesses transmitted by airborne droplet nuclei. o Examples of illnesses: ▪ Measles ▪ Varicella Zoster Virus ▪ TB...

FON FINAL STUDY GUIDE Types of Isolation: ☺ Airborne – Used for patient’s known or suspected to have serious illnesses transmitted by airborne droplet nuclei. o Examples of illnesses: ▪ Measles ▪ Varicella Zoster Virus ▪ TB ▪ Covid 19 ♦ How to isolate for airborne precautions patient: o Single patient room o Room with negative air pressure o Room vented to the outside o Door to patient room always closed o N-95 mask or better ☺ DROPLET – Used for patients known or suspected to have an illness caused by large particle droplets. o Examples of Illnesses ▪ Invasive Haemophiles Influenzae (meningitis, pneumonia, epiglottis, & sepsis) ▪ Invasive Neisseria Meningitidis Disease (meningitis, pneumonia, & sepsis o Serious respiratory illnesses caused by droplets: ▪ Diphtheria (Pharyngeal) ▪ Mycoplasma Pneumonia ▪ Pertussis ▪ Pneumonic Plague ▪ Streptococcal pharyngitis, pneumonia, & scarlet fever in infants and young children. o Serious viral illnesses caused by droplets: ▪ Adenovirus ▪ Influenza ▪ Mumps ▪ Parvovirus B19 ▪ Rubella o Isolation for droplet precaution: ▪ Standard PPE ▪ Private room or separated from roommate by minimum of 3 feet  ▪ Limited patient transportation – if transporting, must wear mask ☺ CONTACT – Serious illnesses easily transmitted by direct patient contact or by contact from items in the patient’s environment. o Examples of contact illnesses: ▪ GI ▪ Respiratory ▪ Skin ▪ Wound infections o Enteric Infections ▪ C-Diff ▪ Patients that are diapered or incontinent with E-coli, Shigella, Hep A, Rotavirus ▪ Respiratory syncytal virus, parainfluenza virus, & enteroviral infections in infants & young children ▪ Highly contagious skin infections: Diphtheria Herpes Simplex Virus (HSV)(neonatal or mucocutaneous) Impetigo Major (non-contaminated) abscesses, cellulitis, or decubitus ulcers Pediculosis Scabies Staphylococcal Furunculosis in infants & young children MRSA - (Methicillin Resistant Staphylococcus Aureus VRE - (Vancomycin resistant enterococci) Extended-Spectrum Beta Lactamase (ESBL) Varicella Zoster Virus Viral or hemorrhagic conjunctivitis Viral hemorrhagic infections (Ebola, Lassa, Marburg) o Isolation for Contact Precautions: ▪ Airborne infection isolation room (AIIR) ▪ Monitor air pressure daily ▪ Keep door closed unless entering or exiting ▪ Limit patient transportation to medically necessary only *pt must wear mask when being transmitted anywhere outside of the room ▪ N-95 Mask or higher ▪ Gloves ▪ Gown  ▪ Disposable equipment (ex: Stethoscope, disposable BP Cuff), or supplies and equipment designated ONLY for this patient. ☺ Wound Healing / Stages o Phase I: Hemostasis (termination of bleeding) begins as soon as the injury occurs. ▪ Blood platelets adhere to the walls of the injured vessel & a clot begins to form. Fibrin holds wound together & bleeding will subside. o Phase II: Inflammation phase: The flow of blood elements, (antibodies, electrolytes, plasma protein) cause engorgement (swelling), which allows repair cells to move toward the wound & causes the S/S of inflammation: erythema(redness), heat, edema(swelling), pain. Leukocytes (WBC) engulf phagocytize (engulf/eat like pacman) the bacteria, fungi, viruses and toxic proteins. Cells from the injured tissue migrate, divide, & form new cells in 24-48 hours. o Phase III: New cells & capillaries fill in the wound from the underlying tissue to skin surface – this process seals the wound & protects from contamination. Collagen formation occurs during reconstruction or proliferation phase. Would contracts as new tissue is reconstructed. Myofibroblasts produce collagen (glue like substance) & adds strength to the wound & tissue. Collagen formation increases rapidly between post op days 5-25. Wound dehiscence most frequently occurs during this phase. o Phase IV: Fibroblasts exit the wound, collagen forms & tissue and skin become stronger. Wound will continue to gain strength but healing can take up to 1 year. Internal wounds (Stomach/Colon) regain faster than skin wounds. **Occasionally, an overgrowth of collagen at the site of the wound forms – This is called a KELOID. African Americans, dark skinned people of all races, and young women are at the highest risk for developing keloids. PRIMARY INTENTION: Skin edges of wound are close together and little tissue is lost. Primary inention healing begins in the inflammatory phase. SECONDARY INTENTION: When a wound must granulate during healing, and edges are not approximate (come together), or when pus is visible. o Would Terminology: ▪ Purulent – Contains or producing pus ▪ Exudate – fluid cells or other substances that have slowly exuded or discharged from cells or blood through small pores or breaks in cell membranes. TERTIARY INTENTION: Delayed primary intention. The provider will leave a contaminated wound open and close later once the infection is controlled.  ☺ PPE: (Personal Protective Equipment) PPE Should be worn for any patient with any suspicion of or known infectious disease. Types of PPE: o Gown o Mask o Goggles (or other eye protection) o Gloves PPE removal order: o 1.Gloves o 2.Gown o 3.Goggles o 4.Mask DON – means to put on DOFF – means to take off ☺ RESTRAINTS: o Require a Drs Order o Try least restrictive options first o Must be the ONLY option left available o Check every 15-30 min; release to toilet and perform ROM exercises every 2 hours. o Check skin and circulation where distal restraints are placed often o Client can refuse, assess their mental function; notify doctor, responsible party, and document thoroughly. ☺ LIFTS: o Always lock before using o Make sure base of lift is spread out correctly o Place client in the center of the sling o Get training, if unsure, ask for help, DO NOT USE ALONE ☺ WHEELCHAIRS: o Lock wheels when stopped o Place closest to strong side of patient o Don’t secure any tubing or lines to moveable equipment ☺ O2 THERAPY: o KEY POINTS: ▪ O2 is an odorless, tasteless, colorless and non-flammable gas but does support combustion ▪ The FLOW METER regulates the rate of O2 flow ▪ Usually ordered in L/min  ▪ Chronic Respiratory Illnesses require lower O2 settings (No more than 1-2 L/min) ▪ Long term use of O2 requires humidification ▪ NO SMOKING SIGNS – AND ALWAYS ENFORCE THIS! ▪ Know location of all fire extinguishers ▪ Only use water soluble lubricant, any oil or pertroleum based lubricants can cause a combustion (ex: grease, oil, vaseline, alchohol, ether, or any ungrounded equipment around O2 o MEHODS OF O2 DELIVERY ▪ Nasal Canula (bi-prongs) Documented as BNP or BNC Fits into nares Concentration of 24-40 % 6 liters max Turn O2 on before putting on patient Tubing goes over ears and under chin Assess and document skin condition behind ears and in nares before applying and during treatment Use ONLY water soluble lubricants ▪ Face Mask Allows more control over O2 levels Concentration of 60-100 % (6-10 L depending on L/min Should see a fine mist with humidified O2 Adjust mask so it fits snugly over nose and chin Reservoir should never fully collapse (if it does, O2 needs to be turned up but only with permission from Dr.) Types of Face Masks:  Venturi – Delivers very precise amounts of O2  Non-rebreather – Can deliver up to 100% O2  Simple – 40-60% of O2 ▪ Oxygen Tent Fine mist, constant temperature, high concentration Canopy must at least cover patient’s torso Keep patient dry to prevent chilling and change linens frequently Temp inside should be at least 70 degrees Adjust O2 flow rate to 10-12 L/min Tuck sides of tent under mattress if needed Parent might have to get under tent with child  ▪ Hyperbaric Chamber Delivers 100% of O2 at 3 times the atmospheric pressure Helps regenerate new tissue at a faster rate (works good w/ wound healing) Ambu Bag Up to 100% concentration depending on presence of a reservoir Mask must firmly cover nose and mouth and make a seal Breaths should be delivered every 5 seconds May be attached to an endotracheal tube (ET) PATIENT TEACHING FOR 02 THERAPY: ▪ Application & safety ▪ S/S of O2 toxicity o Seen in concentrations over 50% for longer thatn 24-48 hours o Nonproductive cough o Substernal Chest pain o Nasal stuffiness/congestion o N/V o Fatigue o Headache o Sore throat o Hypoventilation ▪ Oral Hygiene ▪ Forcing Fluids ▪ T C D B - (Turn, Cough, Deep, Breath) ☺ FIRE SAFETY: RACE: R – RESCUE PATIENTS, A – PULL ALARM, C – CONFINE FIRE, E – EXTINGUISH PASS: P – PULL THE PIN, A – AIM LOW, S – SQUEEZE THE TRIGGER, S – SWEEP FROM SIDE TO SIDE. ☺ FALL PREVENTION: o Monitor those at risk more closely o Use call lights, brakes, and side rails appropriately o Teach Home safety ▪ Grab Bars ▪ Avoid use of rugs ▪ Keep floors clutter free ▪ Night lights ☺ INFECTION CONTROL: o THE SINGLE MOST EFFECTIVE WAY TO PREVENT SPREADING PATHOGENS IS HAND WASHING BEFORE AND AFTER PATIENT CARE OR CONTACT WITH PATHOGENS o Isolation will depend on how pathogen was spread or is spread: ▪ Contact – gloves, gown, goggles, mask ▪ Enteric – gloves, gown ▪ Respiratory Mask o CYCLE OF INFECTION: ▪ Pathogen, Reservoir, Exit, Transport, Entrance, Host ☺ SURGICAL: o Sterile to Sterile only o When in doubt, it’s contaminated o Review sterile techniques: All objects must be sterile If object is touched by a non-sterile object, it’s unsterile Keep sterile gloved hands between chest and waste at all time Never turn your back on sterile field Avoid contamination when opening supplies Sterile to Sterile only ☺ DOCUMENTATION: o Subjective: ▪ Known as “symptoms” ▪ Perceived only by the patient Pain Nausea Vertigo Anxiety ▪ Nurse is unaware of these symptoms unless told by the patient o Objective: ▪ Known as “Signs” ▪ Can be: Seen Heard Felt Measured Observed by others ☺ RULES OF CHARTING: o Ink Only (check facility policy for color of ink required) o No white out or correction fluid is to be used  o If a mistake is written, draw 1 line through and initial o Spelling and grammar need to be correct o Concise, accurate, and pertinent o Timely ☺ COMMUNICATION: o Verbal – includes spoken and written o Non-Verbal - (check for congruency – being suitable, agreeing and appropriate) o No giving false hope or using cliché's o Acknowledge client’s feelings/concerns o Special Situation: ▪ Confused/agitated - Remain calm and approach slowly ▪ Blind – Don't sneak up on them ▪ Hearing Impaired – Don't raise your voice at them, face them when speaking and speak clearly and distinctly ☺ DIAGNOSTIC TESTING o Plain X-Rays ▪ Non-Invasive ▪ Does not require a consent form ▪ Determine pregnancy status prior to x-ray ▪ Remove all metal object from area being x-rayed ▪ Have patient hold their breath while x-ray is being taken o Bone Marrow Biopsies ▪ Requires consent ▪ Local anesthetic used ▪ Pressure dressing – watch for bleeding ▪ Recent CBC must be obtained before test o IVP (Intravenous Pyelogram) ▪ Check for shellfish/iodine allergies ▪ Consent is usually obtained by radiology ▪ NPO if possible ▪ Force fluids post test ▪ Perform BEFORE any Barium studies ▪ Respiratory difficulties after injection of dye may indicate anaphylactic shock o ANGIOGRAMS ▪ Check allergies to shellfish or iodine ▪ Consent required ▪ Force fluids post test ▪ Monitor access site for bleeding – keep pressure dressing in place  ▪ Lay flat; keep affected extremity straight ▪ Check PUL? o VENIPUNCTURE ▪ Explain ▪ Protect self ▪ Get help as indicated ▪ Clean skin appropriately ▪ Have tubes ready and in correct order ▪ Release tourniquet before the last tube is completely full ▪ Apply pressure to site post procedure o SCOPIC EXAMS ▪ Require consent ▪ Bowel Prep required for colonoscopy ▪ NPO after MN ▪ NPO afterwards for Bronchoscopy & EGD until gag and swallow reflex have returned ▪ Vital signs every 30 min post procedure until stable ▪ Monitor for any respiratory distress/bronchoscopy ▪ Monitor for bleeding if polyps were removed during colonoscopy o URINE SPECIMENS ▪ Do Not touch the inside of the container for collection ▪ Label the container, not the lid ▪ Mid-Stream – Void a little, then collect urine ▪ Sterile – the only way to truly have sterile is an indwelling catheter o FLUID REMOVAL ▪ Sterile procedure performed by the provider ▪ Requires informed consent ▪ Position according to procedure ▪ Monitor access site post procedure for bleeding ▪ Monitor vital signs ▪ Monitor for respiratory distress/breath sounds w/ a thoracentesis/hemoptysis ▪ Empty bladder w/ a paracentesis & amniocentesis. o ULTRASOUND ▪ Most are NPO except for pelvic ▪ Non-Invasive ▪ Must be done before any BARIUM STUDY o CBC (Complete Blood Count) ▪ No Special Prep required  WBC – 5,000 – 10,000 Neutrophils Basophils Monocytes Eosinophils Lymphocytes ▪ RBC o 4.2-6.1 million – males o 4.2-5.4 million – females ▪ HCT o 42-52% - Male o 37-47% - Female ▪ HGB o 14-18 G/100ml o 12-16 G/100ml ▪ PLATELETS o 150,000-400,000 o COAGULATION TESTS ▪ APTT o Used to monitor Heparin therapy o Therapeutic range in Heparin therapy is 1.5 - 2.5 times the control or normal o Normal is 60-70 seconds ▪ PT o Used to monitor Coumadin therapy o Therapeutic range is 1.5 to 2.5 times the control o Normal – 11.5 - 12.5 seconds ▪ INR o Used in conjunction w/ PT for clients on Coumadin o Therapeutic ranges are 2.0 - 3.0 depending on the client’s problem. ▪ GLUCOSE o 60-110 mg/dl (normal fasting levels) o No special prep unless ordered as fasting then must be NPO overnight o Accu-Chek is a brand of Glucose check machines o Post Prandial check is an “after meal” check ▪ GLYCOSYLATED HEMOGLOBIN (AKA A1C) o Gives picture of accurate BS’s over the past 120 days  o Can be done any time – no special prep needed o Elevated w/ Diabetes Mellitus Values: Adult – 4-7 % Child –1.8 - 4% Poor diabetic control – 10-20% ▪ TERMINATING HYPOGLYCEMIA o Recheck of BS often to be sure that it’s remedied Can use OJ or other fruit juices Hard candy or honey Commercial Glucose Glucagon by SC, IM, or IV Glucose 10% or 50% IV URIC ACID o No special prep o Elevations seen in gout o Normal value range 3.0-7.0 mg/dl ▪ CREATININE o Looking at kidney function o Elevations seen in kidney failure o Normal level: 0.6-1.2 mg/dl ▪ BUN o Looking at kidney function o Elevations seen in dehydration & kidney impairment o Normal level: 10-20 mg/dl ▪ ELECTROLYTES o Potassium – 3.5 - 5.0 mEq/L o Sodium – 135 – 145 ▪ TRYGLYCERIDES o NPO 12-14 hours prior to test o No alcohol 24 hours prior to test o High fat ingestion up to two weeks prior to test may elevate findings o Normal Findings: 40-160 mg/dl - Male 35-135 mg/dl - Female Greater than 400 mg/dl is critical ▪ LIPOPROTEINS o HDL’S - High Density Lipoproteins (Good Cholesterol) 30-80 mg/dl  Lower Level – greater risk for heart disease NPO 12 – 14 hrs Smoking and alcohol may LOWER levels o LDL’s - Low Density Lipoproteins (Bad Cholesterol) 60-180mg/dl o VLDL’S - VERY Low-Density Lipoproteins (Very Bad Cholesterol) 25-50% NPO Smoking can elevate ▪ CHOLESTEROL o Fast 12-14 hours after eating a low-fat diet o No alcohol 24 hours prior to test o Normal Values: Adult / Elderly People – Less than 200 mg/dl ☺ WOUND CARE o W-D (Wet to Dry) Apply wet and allow to dry Used for wound debridement Sterile procedure Discard solution for the wetting after 24 hours Cleanse wound prior to putting on new dressing Document condition of wound and any drainage that is colorful or has an odor o Collect culture AFTER cleaning wound of any old drainage. o Use a sterile stick, swab or syringe ▪ WOUND IRRIGATION o Promotes wound healing and comfort o Method of cleansing wound o Gently done to prevent further tissue damage o Clean from least contaminated to most contaminated o Uses either a syringe alone or a syringe with an IV Catheter or needle o Wash hands before and after procedure o Use collection device to catch irrigation o Protect self with PPE ☺ TRACH CARE o Sames steps as we did with check-off o Suctioning: ▪ Nasopharyngeal / Tracheal-Sterile ▪ Oropharyngeal – Clean  ▪ Suction only when coming out ▪ Assess respiratory status before and after ☺ INDWELLING URINARY CATHETER o Sterile Procedure o Same steps as check off ☺ ENEMAS o Clean procedure o Types: ▪ Fleet ▪ Oil retention ▪ SSE (Soap/Suds enema) ▪ TWE (Tap water enema) o STEPS TO PERFORM ENEMA o Patient in L Sims position o Temp is no higher than 105 degrees o Do not add soap until water is in o Hold no higher than 18 inches from patient’s body o Typically, no more than 3 buckets w/o physicians' permission o Review procedure ☺ TUBE FEEDING o Exactly like we checked off – be sure to remember to check placement every time the patient is fed if on intermittent, and every shift if constant ☺ HYGEINE o No soap on face unless requested by patient o Rinse all soap from body – can cause skin irritations if not o Use long strokes when washing that go TOWARD the heart. ☺ BATHS o TEPID – Used to reduce fever o SITZ – Used for comfort after childbirth or rectal surgery or even for hemorrhoids o MEDICATED – To moisturize & treat dry skin – ALWAYS MONITOR FOR SKIN BREAKDOWN ☺ VITAL SIGNS o Pain is now known as 5 th vital sign o Know patient’s baseline o Weights – use same scale, same amount of clothes, and at the same time every day. ☺ PAIN o Assess before and after giving for therapeutic effectiveness  o Vital Signs (except temp) may be elevated with pain o Believe patient, NO MATTER WHAT!! ☺ MEDICATION ADMINISTRATION o 6 Rights of Med Admin: ▪ Patient, drug, dose, route, time, documentation ▪ Verify orders ▪ Routes of meds will affect absorption (ex: PO, SL, SQ, IM, IV) ▪ Monitor for therapeutic and non-therapeutic effects ▪ Asses for Allergies FIRST ▪ Know how to avoid medication errors and always double check ▪ Some medications can cause life-threatening allergic reactions. ☺ LEGAL/ETHICAL ISSUES o Informed Consent ▪ Physician discusses the risks, benefits, etc ▪ Nurse is responsible for witnessing the signature only ▪ If patient has questions, be sure they are answered prior to procedure ▪ Usually done only with invasive procedures o Incident Reports ▪ DO NOT chart in nursing notes that a report was filed ▪ Document unusual events ▪ Use factual info o DEFINITIONS: o Assault – Intentional threat to cause bodily harm; does not have to include any bodily contact. “An act that creates apprehension in another of an imminent, harmful, or offensive contact.” The act consists of a threat of harm accompanied by an apparent ability to carry out the threat. o Battery – Unlawful touching of another person without informed consent o Defamation: ▪ Slander – Malicious or untrue spoken words about another person that are brought to the attention of others. ▪ Libel – Same as slander except instead of spoken words it’s Written words. ▪ Tort – A type of civil law that involves wrongs against a person or property. Torts include negligence assault, battery, defamation, fraud, false imprisonment, and invasion of privacy. ☺ INVASION OF PRIVACY o Privacy is a client’s right o Keep door closed, no photographs o Keep client info confidential o DO NOT try to access records of a client that is not your client or part of your responsibility ☺ NEGLIGENCE o Four things must be proved: 1. Duty, 2. Duty was breached, 3. Injury occurred, 4. Proximate cause - the breach of duty was the cause of the negligence ☺ CLIENT/ PATIENT BILL OR RIGHTS o Written by the AHA (American Hospital Association) o List of client rights: Right to information Right to refuse Right to adequate, competent care Right to have their bill explained Right to confidentiality Etc. ▪ DEFINITIONS o Delegation: transferring to a competent individual the authority to perform selected nursing tasks in a selected situation o Accountability: being responsible and answerable for actions or inactions of self or others in the context of the delegation process o Unlicensed Assistive Personal (UAP) Any unlicensed personnel, regardless of title, to whom nursing tasks are delegated o Supervision: Provision or guidance or direction, evaluation, and follow up by a licensed nurse for the completion of assigned tasks delegated to UAP ☺ GUIDELINES FOR DELEGATION o Must be a delegable task o Patient’s needs must be a priority o Competency of UAP o Communication with the UAP o Evaluation ▪ 5 RIGHTS OF DELEGATION o Tasks to delegate are the “right tasks” o Is it under the “right circumstances”? o Is it the “right person”?  o Is it the “right directions/communication”? o Is it the right “supervision/evaluation”? ▪ DELEGATION & SUPERVISION o Must provide clear instructions and evaluate outcome. o RN’s delegate to other RN’s, LPN’s & AP o LPN’s delegate to other LPN’s & AP o Only delegate tasks for appropriate skill level/education level of the person receiving the assignment o RNs cannot delegate the nursing process, client education or tasks that require nursing judgement to LPN’s or AP’s ▪ TASK FACTORS o Predictability of outcome o Potential for harm o Complexity of care o Need for problem solving & innovation. o Level of interaction with the client ▪ DELAGATEE FUNCTION (Person ordered to perform task) o Education, training, experience o Knowledge & Skill to perform task o Level of critical thinking required o Ability to communicate with others (pertaining to task) o Demonstrated competence o Facility policy & procedures o Licensing legislation (Nurse practice acts) o Examples in ATI Book (Pg 44)