Fundamentals Blueprint 2 PDF

California Baptist University NUR215/502, Fundamental Skills for Nursing Practice Test Blueprint 2 Mobility (29%) Discuss the musculoskeletal system. What does it provide the body? How might a nurse test a client's balance, coordination, and stability? **They musculoskeletal system provides:*...

California Baptist University NUR215/502, Fundamental Skills for Nursing Practice Test Blueprint 2 Mobility (29%) Discuss the musculoskeletal system. What does it provide the body? How might a nurse test a client's balance, coordination, and stability? **They musculoskeletal system provides:** - Balance - Coordination - Stability **Nurses test balance, coordination, and stability through 2 techniques:** - Wide the base of support (separate feet) - Increase balance by bringing the center of gravity closer to the base of support (squat) Know the functions of skeletal muscle/skeletal system. - **Skeletal muscle functions** - Movement: main skeletal function (stand, sit, run, jump, etc) - Posture and positioning: body alignment (stable) - Body alignment: the individual's center of gravity is stable - Without balance control, the center of gravity is displaced - Generate body heat: vital for homeostasis - **Skeletal system functions** - Support - Protection: protect internal organs - Produce: produces blood cells (RBCs, WBCs, platelets, macrophages) - Storage: free storage unit of minerals and nutrients - Movement: in conjunction with skeletal muscle How is the neurological system involved in movement? What does each part control? **Neurological system consists of two subsystems:** - Central Nervous System (CNS): coordinates all movements - Brain - Spinal Cord - Peripheral Nervous System (PNS): nerves that interact with the spinal cord Describe body alignment. What does normal alignment look like? - **Body alignment** - Position of body parts - Posture - **Normal alignment:** - Chin tucked, shoulder down and back with a neutral neck - Engaged core with no thoracic extension - Neutral hips and spine posture - Feet should have a strong stable arch. Weight distributed evenly. What are some examples of pathological influences on mobility (Kyphosis, scoliosis, trauma, etc.). - Postural abnormalities - Scoliosis - Lateral "S" shaped curve - Kyphosis - Hump on the top of the back - Lordosis - Lower part of back (sacral) curves inward causing a exaggerated arch - Muscle abnormalities - Damage to the CNS: can lead to weakness on one side or loss of complete functions - Strokes - Traumatic brain injuries - Paraplegia: paralysis of legs and lower body - Quadriplegia: paralysis of all four limbs - Direct trauma - Bruises - Contusions - Tears - Sprains - Fractures - Joint disease - Arthritis - Rheumatoid arthritis - Obesity How is each body system affected by immobility? Know what do assess and the interventions for each system. - Bones effects - Disuse osteoporosis - Assessment - Monitor for pain, specially in the vertebral areas - Interventions - Notify provider is a fragility is suspected - Ambulate client with assistance to protect from falls or injuries - Monitor for increased pain - Hourly rounding's to ensure client's needs are met and to decrease the risk of falls - Joint effects - Joint contractures: fixation of joint - Assessment - Muscle tone or rigidity of the extremities and joints - ROM - Stiffness and inability to move the joints - Interventions - Perform ADLs as able to promote flexion and extension - Move each joint at least q 8 hrs - Use splints (medical device that protects an injured or displaced body part) - Reposition every 2 hrs - Foot drop - Assessment - Observe position and ability of flexion - Monitor gait for the presence of toe dragging during ambulation - Interventions - Notify provider of foot drop if present - Apply splints as prescribed - Assist with ambulation to prevent falls - Muscle effects - Sarcopenia: decrease of lean muscle mass - Assessment - Observe for diminishing muscle mass, strength, coordination - monitor for weakness and unsteadiness - assess for manifestations of fatigue - interventions - encourage client to participate in self-care activities - increase activities to build strength - assist with ambulation to decrease risk of falls - Cardiovascular effects - Orthostatic hypotension - Assessment - Monitor vital signs while the client is lying, sitting, standing, and compare results - Monitor the client for reports of dizziness during position changes - Interventions - Elevate head of bed, to promote blood flow to the lower extremities - Assist patient - Apply antiembolism stockings to decrease venous pooling in lower extremities - Fall precautions - Deep vein thrombosis (DVT): blood clot - Factors that contribute to a thrombus formation - Damage to the vessel wall - Alterations of blood flow - Alterations in the constituents of the blood - Assessment - Assess pulse and capillary refill - Observe for presence of unilateral edema - Interventions - Exercises to promote contraction - Apply antiembolism stockings to promote venous return - Use SCD - Encourage fluid intake and decrease the risk of developing a clot - Administer anticoagulant - Embolus - Clot that has moved from its original location - Worse places are: lung, heart, (heart attack), Brain (stroke) - Respiratory complications - Atelectasis - Collapse of the alveoli (where oxygen exchange occurs - Assessment - Auscultate lungs to confirm air movement - Observe chest wall movement for symmetry and depth during respirations - Interventions - Encourage use of an incentive spirometer to promote lung expansion - Deep breathings and cough exercises - Monitor oxygen saturation levels - Provide supplemental oxygen as prescribed - Elevate HOB @ 30-45 degrees to encourage deep breathing - Reposition q 2 hrs - Pneumonia - Infection of the lung due to shallow breathing, thick mucous, or sputum build up - Assessment - Auscultate lungs for adventitious sounds - Observe rate of breathing (its normally faster for pneumonia) - Saturation levels - Swallowing - Interventions - Prone positioning to promote drainage of secretions - Elevate HOB @ 30-45 degrees - Fluids to thin secretions - Supplemental oxygen - Deep breathing and coughing - Reposition - Gastrointestinal effects - Constipation - Typically in large intestine - Assessment - Auscultate bowel sounds - Palpate abdomen for distention (sticking out) - Monitor bowel movement - Presence of nausea, vomiting, or pain - Interventions - Encourage fluid and high-fiber foods - Increase mobility to promote peristalsis (muscle contractions) - Gastroesophageal Reflux (GERD) - Assessment - Heartburn or regurgitation - Interventions - Elevate HOB after meals - Malnutrition - Assessment - Appetite and intake - Weight changes - Lab values (serum albumin, serum protein, glucose, electrolytes) - Interventions - Instruct client about high-protein, nutrient dense foods - Genitourinary effects - Urinary retention - Assessment - Presence of suprapubic pain or incontinence, which can retention - Monitor output - Interventions - Encourage fluid intake to increase bladder filling - Upright position as the urinate to use gravity - Assist to use the toilet - UTI - Assessment - Monitor urinary frequency, urgency and burning - Interventions - Encourage frequent voiding with decreases risk of renal calculi (kidney stones) - Encourage activity in bed - Maintain cleanliness to prevent bacteria - Integumentary effects - Pressure injury - Assessment - Asses skin daily - Identify areas of breakdown - Interventions - REPOSITION Q 2 HRS - Use pillows, assistive devices and proper technique - Use pressure redistribution devices on mattresses and chairs to crease pressure - Moisturize - Healthy diet: calories, protein, and MICRONUTRIENTS - Psychological effects - Depression - Social isolation How does a nurse do a mobility assessment? What are we looking for? - Assessment - Normal mobility status - Ability to sit, stand, walk - Need for assistance devices - Degree of mobility/immobility - Condition of skin - What are we looking for? - Activity tolerance: how much they can tolerate - ADLs - Balance - Posture Determine a client's level of assistance need (I will provide a scenario and the mobility assessment test from the module). You will need to determine their mobility level. How does aging affect mobility? What are some age-related changes nurses can expect in older clients? - Posture (kyphosis, increased flexion in knees and hips) - Reflexes (poor balance) - Joint mobility (slow movement, joint stiffness) - Muscle mass (less endurance, decreased strength) - Vision (lower vision acuity, reduced depth perception) What are the different positions nurses place client's in? Why? - Fowler's - HOB 45 degrees - High-fowler's - 60-90 degrees - Lateral - On the side - Prone - Stomach - Supine - On back - Trendelenburg - Head down and feet up - Lateral recumbent REFER TO ATI MODULE Review all checklists associated with this module (Potter et al., 2023, in NUR216 Blackboard). Hygiene (22%) Define hygiene and its purposes. - The action the client and us as nurses take and health practices that engage in that decease the spread of transmission of pathogens, decreasing risk of illnesses. Know the factors that influence clients' hygiene practices. - Social groups - Personal preferences: products, nature and frequency of personal care practices - Body images: emotional stresses - Socioeconomic resources - Religion/culture: language, rituals, different cultures - Developmental stage: children, adolescents, older adults - Cognitive functioning: strokes, dementia, injuries - Disease processes: multiple sclerosis, etc Which clients (and what disease processes and circumstances) put clients at risk for needing assistance during hygiene care? - Newborns and infants: bathe less, diaper dermatitis (diaper rash) - School-aged children/teenagers: hormonal changes, good hygiene habits - Older adults: dryer and less elastic skin, resist hygiene, oral hygiene changes - Clients at risk: immobility problems Know the nurse's role during hygiene. What can we accomplish? - Individualize: individualize care - Support: support client's health - Connect: connect with client - Perform: perform full assessment - Evaluate: evaluate client's abilities - Understand: understand client's needs - Educate: educate client on signs and symptoms of issues Differentiate between the different types of baths given. Why do we bathe clients? - Reason for bathing: remove dirt, swear, pathogens, dead skin, and promote circulation - Types of bathing - Complete bed bath: **nurse is doing everything** - Partial bed bath: cleaning of face, underarms, and perineal areas. **Client helps.** - Bag bath: pre moist and wipes - CHG: wipes/solution, do not use on face! (use water for face) What is important about hair and scalp care? How does it different between clients? - Ask about hair care preferences - Assess for dandruff, lice, and pressure injuries - Hair can be washed traditionally or in a no-rinse shampoo What order do we clean the body? What is special about the eyes? Ears? Feet (especially with our diabetic clients), and the nails?2 - **Order of cleaning: eyes, face, arms/chest, hands/nails, abdomen/legs, peri, back, buttocks** - Eyes a. No soap, from inner to outer canthus (for infection) - Ears b. Inspect for drainage c. Never insert cotton-tipped applicators - Feet d. Inspect well (especially for diabetes high risk for injury, wound healing is slow), wash with warm water, dry completely, apply lotion, trim toenails straight across - Nails e. Mode of pathogen transmission f. Short nails are best! Cut straight across Discuss perineal care. How does it differ for male and female clients? - Males: - between scrotum and anus - Foreskin must be retracted before cleaning uncircumcised clients and replace after cleaning - Females: - Between the valvula and anus - Anterior to posterior (front to back, or pubic area to anus) Review oral care. What is normal? Signs of issues? - Expected/normal - Lips and tongue are pink and moist - Clean teeth, not loose - Cheeks, upper palate, and tongue are clean - Saliva is visualized Review safety measures we take for clients with strokes, spinal cord injuries, visual impairments, our bariatric clients, those with dementia, and amputations. - Strokes - Assistance with hygiene due to motor/sensory loss - Hemiparesis: minor loss of strength on one side of body - Hemiplegia: paralysis on one side of body - Encourage client to do as much as possible, use adaptive equipment for safety - Spinal cord injuries - Paraplegia: inability to feel from the waist down - Quadriplegia: inability to feel from the neck down - Ensure safe water temperature - Caring for clients with assisted ventilation - Visual impairment - Educate on how they can adapt - Bariatric challenges - Clean and drying skin folds - Barrier creams in skin folds and perineal areas - Dementia - Gradual decline in ability to perform self care, adapt to client's needs or level of involvement - Amputations - Assess client's balance and strength, recommend assistive devices, bathe at the bedside (chair) Review all checklists associated with this module (Potter et al., 2023, in NUR216 Blackboard). Nutrition (20%) Review anatomy and physiology of digestion. What happens in each organ/part of the GI tract. - Salivary glands: saliva moistens and lubricates food. Amylase digest carbs. - Mouth: breaks up food particles. Assists in producing spoken language. - Esophagus: transports food - Pharynx: swallows - Gallbladder: stores and concentrates bile. - Liver: breaks down and builds up many biological molecules. Stores vitamins and iron. Destroys old blood cells. Destroys poisons. Produces bile to aid digestion. - Small intestine: completes digestion. Mucus protects, gut wall. Absorbs nutrients, most water. - Large intestine: reabsorbs some water, and vitamins. Forms and stores feces. - Stomach: stores and churns food HCI activates enzyme that breaks up food. Mucus protects stomach, limited absorption. - Pancreas: hormones regulate blood glucose levels, bicarbonates neutralized stomach acid. - Rectum: stores and expels feces. - Anus: opening for elimination of feces. What are the macronutrients? Micronutrients? What does each do? What are examples of foods in each category? - Macronutrients - Carbohydrates: 45-65%. MAIN SOURCE ENERGY - Proteins. 10-35%. Amino acids to BUILD AND REPAIR MUSCLE - Fats: 20-35%. ABSORB VITAMINS and provide energy - Monosaturated: good (nuts, olive oil, seeds, avocados) - Trans and saturated: bad, less than 10% - Micronutrients - Minerals - Support optimal functioning of the body - Vitamins - Promote health and ward off disease - Delivered by diet supplements What influences daily caloric needs? Who needs more? Less? - Age - Infants: high protein - Older people need less calories, more protein - Sex - Males: need more calories than females - Activity level - Active people: need more calories - Disease processes - Wounds, COPD: more calories - Diabetics: fewer sugars What is BMI used for? What are the ranges? - Body Mass Index: overall nutrition status, cholesterol levels - Underweight: less than 18.5 - Normal: 18.5-24.9 - Overweigh: 25-29.9 - Obese: 30-34.9 - Extremely obese: more than 35 Describe what a malnourished client looks like. What might you see on assessment? - Fluctuations in weight - Changes in: - Teeth (cavities, bleeding gums, loose teeth, falling), hair (falling, brittle, falling, loss of color), skin (older look), nails, digestion(constipation, diarrhea), immunity (infections) - Assessment: - 24-hr diet recall - Food frequency questionnaire - Weight an BMI - Lab tests - Head to toe (dysphagia, aspiration) - Aspiration: instead of going through esophagus, goes through trachea, and into lungs Define dysphagia. What are the signs? - Trouble swallowing - Coughing during eating, change in voice tone or quality after eating, abnormal movements of mouth, tongue or lips - Slow, weak, imprecise speech - Abnormal gag reflex - Delayed swallowing, pocketing of food, regurgitation (coming back up) Review the interventions to put in place for one at risk for aspiration. Who might we collaborate with? What might we teach clients at risk? - Assess - Make client NPO - Collab with provider or speech therapist - Positioning (HOB \@90 degrees) - Swallow techniques: - Chin tuck-position: chin pointed to chest while swallowing. Closes trachea. - Rotation of the head to the strong side - Glucose monitoring - For all clients - For diabetics (before meals, before bedtime, displaying signs and symptoms of high or low glucose) Why do providers order therapeutic diets? What are they? What do we recommend those on a cardiac, renal, or diabetic diet remove from their diet? - Providers order therapeutic diets based on client's disease process, ability to eat, chest, and swallow, and lab results - Diets include: - NPO - Regular - Soft/pureed (easy to digest, easy to swallow) - Liquid - Clear (broth, jello, juice, water) - Full - Disease processes - Cardiac (DASH) - Renal (electrolytes, low potassium, avoid phosphorus, avoid sodium) - Diabetic diet (away from simple sugars and carbs) Differentiate between hypoglycemia and hyperglycemia. - Hypoglycemia (under 70) - Diaphoresis: sweating - Shakiness - Confusion - Loss of consciousness - Hyperglycemia (give insulin with order) - Thirst - Headache - Lethargy - Increased urination What is enteral tube feeding? Why do nurses place NG-tubes? How do they insert/remove them? What are the complications? How do we prevent them? How do we verify the tube's placement? - Enteral nutrition: unable to swallow or taking meds orally, GI WORKING - Types - Nasogastric tube: nose-esophagus, stomach - Gastrostomy: directly to the stomach, stable, and long-term - Complications - Aspiration, diarrhea, constipation, tube occlusion, tube displacement, cramping, nausea, vomiting, serum electrolyte imbalance, fluid overload Insertion: - Measure from tip of the nose to earlobe and to xiphoid process - Once you feel the back of the throat, encourage client to tilt head forward and take sips of water - Order an x-ray for tube placement Removal - Ask client to hold their breath and remove it Define parenteral nutrition. Why do we use it? What are the risks? - Parenteral nutrition: GI NOT WORKING, can't absorb or digest nutrients - Through veins - Labs every day, change tubing or bag every 24 hours to prevent bacteria accumulation - Complications - Infections - Hyper and hypoglycemia Review all checklists associated with this module (Potter et al., 2023, in NUR216 Blackboard). **Tissue Integrity (29%)** Who is at risk for impaired skin integrity? Why? - Younger and older people - Age - The skin gets thinner and loses elasticity (risk for tearing) - Skin loses moisture, becoming dry - Alterations in mobility (multiple sclerosis, arthritis, spinal cord injuries) - Chronic conditions (diabetes, organ failure) - Obesity - Malnutrition What is the Braden Scale for? How do you use it? I will give a scenario along with the Braden Scale and you will have to determine the client's risk level. - It is a skin assessment tool - Measures: - Sensory perception - Risk for moisture - Activity level - Mobility level - Nutrition status - Risk for friction/shear - Low Braden score: prevent or care for risk of breakdown of skin - Hight Braden score: lower risk of developing breakdown Know how to do a wound assessment? What do we want to see for an acute (surgical) or chronic (pressure injury) assessment? What are signs the wound is worsening? - Assessment - Assess all wounds for signs of healing - granulation tissue - infection - drainage - odors - erythema - edema - Pain - Surgical wound assessment - Inspection (erythema, drainage, sutures/staples/glue intact, pain, approximated - Palpation (temperature, induration) - Chronic wound assessment - Inspection - Peri-wound - Wound bed - Size - Drainage - Tissue present - Types of wounds - Acute (surgical) - Traumatic - Surgical procedures - Moisture-associated skin damage (MASD), aka dermatitis - Chronic (pressure injury) - Wounds results from reduced blood flow - Stage III or IV pressure injuries - Signs of wound worsening? - Increased serosanguineous (pink) - Sanguineous drainage (red/blood) - Purulent drainage (yellow, sign of infection) Define pressure injury. What causes them? Who is at risk? What forces make clients more at risk (shear, friction, moisture, etc.). - What is a pressure injury? - Localized damage to the skin and/or the underlying tissue over a bony prominence or related to a medical device as a result of pressure. - Who is at risk? - Clients with - spinal cord injuries - Hip fractures - **Long-term clients in nursing facilities** - Acutely ill - Diabetes and chronic conditions - Sensory loss - Nutritional deficits (not enough calories, protein) - Risk factors - Immobility - Sensory loss - Malnutrition - Shear/friction - Shearing: - Internal movement of bone against muscle - Happens when HOB is elevated and the sliding of the skeletal starts but the skin is stationary or when transferring a patient from a bed to a stretcher - Friction - External - Force that opposes the movement of one surface across another - Moisture: tissue softening - Reduced skin perfusion Discuss pressure injury assessment. Where are they? What do we inspect/palpate for? What about darker skin? - Inspection - Bony prominences, erythema, edema, skin appearance - Palpation - Temperature, edema, induration (hardness), bogginess (squishiness), pain - For darker skin - Any changes - Temperature - Steps for cleaning - Clean the wound (per order) - Assess the peri-wound (circumference) - Assess the wound bed (inside the wound) - Measure the wound (length, width, depth) - Assess for tunneling and undermining (open area under the skin around the edge) - Document Know different types of tissue (slough, eschar, granulation). - Granulation (HEALTHY) - Beefy deep pink or red, irregular surface, living tissue, puffy or mounded bubbly - Necrotic tissue - Slough - Yellow, green, grey, non-viable, thin, no oxygen - Eschar - Black, brown, dry, thick, hard, leathery Discuss the stages of pressure injuries. Be able to stage based on a description or picture. - Stage I: non-blanchable erythema - Intact skin with non-blanchable redness - Painful area, firm, soft, warmer or cooler as compared to adjacent tissue - Stage II: Partial thickness skin loss - Skin is open - Through epidermis and dermis ONLY (partial thickness loss) - Wound bed is pink or red, no dead tissue - Stage III: Full thickness skin loss - Through epidermis, dermis, subcutaneous (full thickness loss) - Bone, tendon, or muscle are not exposed - Slough may be present, but does not obscure the depth - May include undermining and tunneling - Stage IV: Full thickness skin and tissue loss - Can extend into muscle, exposed bone/tendon is visible or directly palpable - Unstageable pressure injury: obscured - Full thickness tissue loss, base is covered by slough or eschar - The depth, and stage cannot be determined - Deep tissue pressure injury - Purple or maroon of discolored intact - Not open yet, but worse than a stage I - Device related pressure injury - From medical devices What is debridement? What are the different types?3 - Is the process of removing dead tissue - Types - Surgical: not under nurses scope - Irrigation - Removes surface tissue and decreases bacteria levels - Use pressure of the solution (saline or sterile water) to remove any tissue from the surface of the wound - Biological - Use of enzymatic agents like creams, ointments to clean a wound (with an order) Discuss different types of dressing changes and dressings. When would you use each one? - Clean-vs sterile - Clean: reducing organisms, on chronic wound - Sterile: performed on a wound after surgery, acute wound - Dry- vs wet - Dry: sterile injury - Wet: pressure injuries Review infection control practices in cleaning wounds. - Clean from least contaminated-most contaminated - Least contaminated: wound bed - Most contaminated: surrounding skin - Gentle friction - When irrigating, allow solution to flow from the least to the most contaminated area How do different wound drains work? What are the different types of drainage we may see? - Used to decreased accumulation of fluid and air, and collect drainage for testing - Types - Penrose - Portable wound bulb-suction (JP) - Circular portable suction Discus promoting wound healing for all clients and those at risk. What interventions will we put in place for both populations? All clients: - Hygiene: regular bathing, specialized cleansers, dry skin, apply lotion, barrier creams - Hydration: encourage to drink water or through IV - Nutrition: PROTEIN intake, high CALORIE with vitamins - Circulation: SCDs, IV medications to boost BP At risk clients: - Early identification of risk factors: skin assessments, Braden scale - Repositioning: every 2 hours - Correct positioning: HOB at 30 degrees or less - Support surfaces: different kinds of bed that release pressure (Extra foam, sand) - Protection of bony prominences What factors influence wound healing (delay or compromise it?) - Diabetes: delays - Infection: delays - Medications: delay - Malnourishment: delay - Necrosis: delay - Hypoxia: delay - Multiple wounds: compromise How do wound heal? - Primary intention: wound is closed with surgical intervention. Edges are brought together. Best choice for clean, fresh wounds. - Secondary intervention: wound is open and allowed to heal spontaneously. Increased scarring. Good for contaminates/infected wounds. - Tertiary intention: delayed primary closure. Closed eventually with a suture. Delayed primary closure. Good for wounds which are contaminated/infected initially. Know the complications of wound healing and the interventions used if/when they happen. - Infection - Dehiscence: separation of wound layers\| (pops) - Evisceration: the wound opens and visceral organs come out through the opening - Bleeding/hemorrhage Review all checklists associated with this module (Potter et al., 2023, in NUR216