Foundations Exam 1 Study Guide PDF

Exam 1 Study Guide  Know information regarding restraints, how restraints are applied, restraint protocols, and what can be delegated to licensed and unlicensed individuals. When are restraints appropriate? o Physical: material or equipment that immobilizes  use as last resort – educate, communi...

Exam 1 Study Guide  Know information regarding restraints, how restraints are applied, restraint protocols, and what can be delegated to licensed and unlicensed individuals. When are restraints appropriate? o Physical: material or equipment that immobilizes  use as last resort – educate, communicate, reason with… *least invasive measures first*  if restraints needed, use least restrictive type o Provider orders required – must be ordered by provider, not via phone  Order must be current (within 24 hrs)  State type and location of restraint  Specify duration and cirumstances  Renewing order…  Must be done within specific time frame  In hospitals, each original restraint order and renewal limited to… o 4 hrs for adults (18 years +) o 2 hours for children (9-17 years) o 1 hr for children (under 9 years)  Orders may be renewed to time limits for max of 24 consecutive hrs  NOT ordered prn o If restraint d/t violence or self-destructive behavior, health care provider must assess pt within 60 mins o Goal: discontinue use of restraints as soon as possible o RN responsible – assess every 2 hours for nonviolent patient, every 15 mins for violent patient  Vitals, skin integrity, nutrition, hydration, hygiene, elimination needs, cognitive fxning, psych status, need for restraint  CMS – circulation, motor (ROM), and sensation  Skill of assessing patient’s behavior, orientation to environment, need for restraints, and appropriate use of restraints cannot be delegated  Nurse instructs AP about…  Appropriate restraint to use and correct placement of restraint  When and how to change patient’s position and provide ROM exercises, hydration, toileting, skin care, and time for socialization  When to report s/s of patient not tolerating restraint and what to do o Delegation…  RN must assess  LPN can take patient out of restraints  CNA cannot take patient out of restraints o Restraint use must meet one of the following…  Reduce risk of pt injury  Prevent interruption of therapy (i.e. IV infusions, NG tube feed, foley cath) This study source was downloaded by 100000831277951 from CourseHero.com on 10-13-2023 15:08:36 GMT -05:00 https://www.coursehero.com/file/201485485/NUR-320-Exam-1-Study-Guidedocx/  Prevent pt from removing life-support equipment  Reduce risk of injury to others by pt o Document!  Know isolation protocols for infection: What PPE is needed for each type of isolation, what isolation type is needed for specific diseases (Airborne, Droplet, Contact, standard). o Standard Precautions – use with all patients:  Apply to blood, blood products, all body fluids, secretions, excretions (except sweat), nonintact skin and mucous membranes  Perform hand hygiene before direct contact with patients; between patient contacts; after contact with blood, body fluids, secretions and excretions with equipment or articles contaminated by them; immediately after gloves removed  When hands visibly soiled or contaminated with blood or body fluids, wash with either nonantimicrobial soap or antimicrobial soap and water  Hands not visibly soiled or contaminated, use alcohol-based hand rub  Wash hands with nonantimicrobial or antimicrobial soap and water if contact with spores is likely to have occurred (i.e. C. diff)  No artificial fingernails or extenders if duties include direct contact with pts at high risk for infection and associated adverse outcomes  Wear gloves when touching blood, body fluids, secretions, excretions, nonintact skin, mucous membranes or contaminated items or surfaces; remove and dispose of gloves and perform hand hygiene between pt care encounters and when going from contaminated to clean body site  Wear PPE when anticipated pt interaction likely to involve contact with blood/body fluids  Discard sharps in puncture-resistance container  If needle recapping is necessary, use one-handed scoop method  Respiratory hygiene and cough etiquette – have pts cover nose and mouth when sneezing and coughing, use tissues to contain resp secretions and dispose, perform hand hygiene after contact with respiratory secretions and contaminated objects or materials; wear mask, sit at least 3 feet away from others if coughing o Airborne precautions (droplets <5 um)  Dz: measles, chicken pox (varicella), disseminated herpes zoster, Mycobacterium tuberculosis, rubeola  barrier protection  private room  neg-pressure airflow of at least 6-12 exchanges/hour via HEPA filtration  mask or respiratory protection device, N95 respirator o Droplet precautions (droplets >5 um; being within 3 feet of patient)  Influenza, adenovirus, group A strep, Neisseria meningitides, pertussis, rhinovirus, mycoplasma This study source was downloaded by 100000831277951 from CourseHero.com on 10-13-2023 15:08:36 GMT -05:00 https://www.coursehero.com/file/201485485/NUR-320-Exam-1-Study-Guidedocx/ pneumoniae, pertussis, diptheria, pneumonic plaque, rubella, mumps, respiratory syncytial virus o Contact precautions (direct patient or environmental contact)  Colonization of infectionwith multi-drug resistant orgs, such as VRE and MRSA, C. diff, shigella and other enteric pathogens, major wound infections, herpes simplex, scabies, varicella zoster (dissmenated), respiratory syncytial virus  barrier protection o private room or cohort patients (see agency policy), gloves, gowns o Protective environment: allogenic hematopoietic stem cell transplants  Private room  positive airflow with >12 air exchanges per hour  HEPA filtration coming in for air  Mask, gloves, gown o Protective environment  Allogenic hematopoietic stem cell transplants  Private room  Positive airflow with >12 air exhanges per hour  HEPA filtration for incoming air  Mask, gloves, gown  What are hospital acquired conditions "never events?" (Box 27-4). o Hospitals will not receive payment for cases in which one of the selected conditions was not present on admission…  Foreign object retained after surgery  Air embolism  Blood incompatibility  Pressure injury stages 3 or 4  Falls and trauma (fracture, dislocation, intracranial injury, crushing injury, burn, electric shock)  Catheter-associated UTI  Vascular catheter-associated infections  Manifestations of poor glycemic control (DKA, nonketotic hyperosmolar coma, hypoglycemic coma, secondary diabetes with ketoacidosis, secondary diabetes with hyperosmolarity)  Surgical site infections following:  Mediastinitis following coronary bypass graft  Certain orthopedic procedures (spine, neck, shoulder, elbow)  Bariatric surgery for obesity (laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery)  Cardiac implantable medical device  DVT/PE following certain orthopedic procedures (total knee replacement, hip replacement) This study source was downloaded by 100000831277951 from CourseHero.com on 10-13-2023 15:08:36 GMT -05:00 https://www.coursehero.com/file/201485485/NUR-320-Exam-1-Study-Guidedocx/  Latrogenic pneumothorax with venous catheterization  Procedures for Donning and Doffing PPE. o Donning: gown, mask, goggles, gloves o Doffing: gloves, goggles, gown, mask  Infection prevention techniques, when do we wash our hands? When do we use alcohol based rub? o Perform hand hygiene before direct contact with patients; between patient contacts; after contact with blood, body fluids, secretions and excretions with equipment or articles contaminated by them; immediately after gloves removed o When hands visibly soiled or contaminated with blood or body fluids, wash with either nonantimicrobial soap or antimicrobial soap and water o Hands not visibly soiled or contaminated, use alcohol-based hand rub o Wash hands with nonantimicrobial or antimicrobial soap and water if contact with spores is likely to have occurred (i.e. C. diff)  What are developmental related risk factors related to infection? What are some nursing considerations/prevention techniques? o Age – older adults  Age-related functional deterioration in immune system function  increased susceptibility  Older adults less capable of producing lymphocytes to combat challenges to immune system  less antibodies produced, shorter response and fewer cells  Poor nutrition, unintentional weight loss, lack of exercise, poor social support, low serum albumin levels  Intervention = vaccination! Proper hand hygiene o Multiple illnesses – dz process o Nutritional status o Immunocompromising treatments  Sources of infection: Endogenous/Exogenous o Exogenous: from microorganisms outside of individual – organisms do not exist as normal flora o Endogenous: part of patient’s flora becomes altered and an overgrowth occurs  i.e. after receiving broad spectrum antibiotics o iatrogenic: from a procedure or medication  Principles of sterility. How do we don sterile gloves? 1. 2. 3. 4. 5. Select correct size/type of gloves Examine package to ensure intact and dry Place package close to where you will be working Inspect hands and nails – look for cuts or lesions Wash hands This study source was downloaded by 100000831277951 from CourseHero.com on 10-13-2023 15:08:36 GMT -05:00 https://www.coursehero.com/file/201485485/NUR-320-Exam-1-Study-Guidedocx/ 6. 7. 8. 9. Open by carefully separating the packaging form two sides Open package, keep gloves on inside surface of wrapper Glove DOMINANT hand first! Use thumb and first two fingers of dominant hand to grasp glove for dominant hand – only touch inside surface 10. When finished putting on, interlock hands and hold above waist   Fall prevention and age related considerations and interventions (least invasive to most invasive). o Falls = leading cause of both fatal and nonfatal injuries  Past hx of fall is best predictor of risk for falls o Among adults 65 years +, falls are leading cause of both fatal and nonfatal injuries o developmental stage risk  infant, toddler, preschooler  school-age child  adolescent  adult  older adult – sensory deficit/decline, osteoporosis, decreased balance, decreased bone density, environment, meds (polypharmacy), poor mobility, fear of falling  highest risk of death or serious injury following a fall o interventions  least invasive: consistent rounding, call light, fall risk sign on door/chart (no PHYSICAL intervention)  moderately invasive: fall risk band, side rails, bed alarms  most invasive: restraints, mits, pharmaceutical sedation Understand each step (Assessment, Diagnosis, Planning, Implementation, Evaluation) of the nursing process, details for each step of the nursing process, nursing diagnosis (PES STATEMENT). Know the components of a (PES) statement. Identify proper nursing diagnosis. What are different types of nursing diagnosis? o Nursing Process  Assessment: Subjective and objective data  Review of systems, travel hx  Immunizations/vaccinations  Risk factors  Status of defense mechanisms  Pt susceptibility  Clinical appearance  S/S  labs  Diagnosis: data analysis, problem ID, label  Planning: priorities, goals, interventions  Implementation  Nurse-initiated treatments o independent This study source was downloaded by 100000831277951 from CourseHero.com on 10-13-2023 15:08:36 GMT -05:00 https://www.coursehero.com/file/201485485/NUR-320-Exam-1-Study-Guidedocx/ Doctor-initiated treatments o dependent  Evaluation: data, diagnosis, aetiologies, plans, interventions o PES statement =  Three-part statement:  Problem r/t etiology AEB symptoms  Two-part statement (risk)  Dx r/t etiology  One-part statement – problem/diagnostic label    Critically think through nursing diagnosis Assessment (subjective vs objective data) o Subjective = what patient says o Objective = what can be assessed using senses  What nurse sees/observes  Including chart, lab values, etc. This study source was downloaded by 100000831277951 from CourseHero.com on 10-13-2023 15:08:36 GMT -05:00 https://www.coursehero.com/file/201485485/NUR-320-Exam-1-Study-Guidedocx/ Powered by TCPDF (www.tcpdf.org)