nur-215-exam-2-sg-exam-2 .pdf

lOMoARcPSD|33372414 NUR 215 Exam #2 SG - exam 2 Fundmentals (Arizona College of Nursing) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Ryanna Mae Claveria (ryannamaeclaveria09@...

lOMoARcPSD|33372414 NUR 215 Exam #2 SG - exam 2 Fundmentals (Arizona College of Nursing) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 NUR 215 Exam 2 (Modules 3-5) – Outline for Success Module 3 – Infection 1. Infection Prevention – ATI p.55  Using frequent and effective hand hygiene before and after care  Educate patient on required and recommended immunizations and where to obtain them  Educate patient and ask for them to perform a teach back of good oral hygiene  Why? Good hygiene decreases the protein in oral cavity, causing decrease of the growth of micro-organisms  Encourage the patient to consume adequate amount of fluids to help preventing UTI’s and skin breakdown  Immobile patients: turn patient q2 hours (turning, coughing, deep breathing, & incentive spirometry  Use aseptic techniques and proper personal protective equipment (gloves, mask, gown, goggles)  Teach the use of respiratory hygiene & coughing etiquette (coving mouth and nose, using tissue, turning head patient coughing or at least 3ft distance 2. Risk factors for infection – ATI BOOK p.54  Nurses should assess patient for risk of infection specifically to patient, injury or disease or injury and the environment.  Risk factors:  Inadequate hand hygiene  Patients with compromised health or defenses against infection, such as; o Recent surgery o Indwelling devices o Breakdown on skin (wound, skin tear) o Poor oxygen o Impaired circulation Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 o Chronic or acute disease (diabetes, renal failure, chronic lung disease, adrenal insufficiency, hepatic failure)  Caregivers using medical/asepsis that does not follow the established standards  Clients w/ poor hygiene, nutrition, smoking, consuming excessive alcohol and those experiencing stress  Clients living in crowed environment 3. Transmission chain of infection – ATI BOOK p.53  Chain of infection  Causative agent o bacteria, virus, fungus, prion, parasite  Reservoir o human, animal, food, organic, matter on inanimate surfaces, water, soil, and insect  Portal of exit the host (leaving the host) o Respiratory tract (droplet, airborne): Mycobacterium tuberculosis and streptococcus pneumoniae o Gastrointestinal tract: shigella, salmonella enteritidis, salmonella typhi, hep A o Skin/mucous membranes: HSV and varicella o Blood/body fluids: HIV and Hep B & C o Transplacental  Mode of transmission o Contact  Direct physical contact: person to person  Indirect contact w/ an object  Fecal-oral transmission: touching food after using restroom w/o proper hand hygiene  Droplet: sneezing, coughing, & talking  Airborne: sneezing and coughing  Vector Borne: animals for insects as intermediaries (ticks transmit Lyme disease; mosquitoes transmit West Nile and malaria)  Portal of entry o entry to the host; might be the same as the portal of exit  Susceptible host: o comprised defense mechanism (skin breakdown) leaving the host more susceptible to infections. 4. Transmission precautions - 4 types of precautions  Airborne o Used to protect against droplet infections smaller than 5 mcg (measles, varicella, pulmonary, etc.)  Required supplies: private room, mask/respiratory protection devices for caregivers and visitors (N95 is pt is known or have TB) negative pressure room w/ at least 6-12 exchanges per hr, if splashing or spraying wear a full face (eyes, mouth, nose) Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 protection. If u have airborne infection, it advised to wear a mask outside the room/home  Droplet o Used to protect against droplets larger than 5 mcg and travel 3-6ft from client (flu B, mumps, rubella, pneumonia, sepsis, etc)  Required supplies: Private room or share room with someone who has same disease, mask for providers and visitors, if infected wear a mask out of room/house  Contact o 3 ft of client against direct client and environmental contact infections (respiratory virus, wound infections, herpes, scabies, impetigo)  Required supplies: private room or share room with someone who has same disease, gloves & gowns for caregivers and visitors, disposal of infectious items in proper nonporous bag  Protective o More of a prevention than “precaution”. Used to protect who are immunocompromised  Required supplies: private room, positive airflow 12 or more air exchange/hour, HEPA filtration for incoming air, mask for client when out of room 5. Personal Protective Equipment (PPE) DONNING (put on) DOFFING (Removal) 6. Therapeutic communication technique examples (From Therapeutic Communication pdf)  Active Listening: Being attentive to what the patient is saying (verbally and nonverbally)  Sit facing the patient, open posture, lean in, eye contact, relax  Sharing Observations: Commenting on how the patient looks, sounds, or acts  Sharing Empathy: The ability to understand and accept another person’s reality; To accurately perceive feelings and communicate understanding Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Sharing Hope: Communicating a “Sense of possibility” to others; Encouragement when appropriate and positive feedback  Sharing Humor: Contributes to feelings of togetherness, closeness, and friendliness; Promotes positive communication in prevention, perception, and perspective  Sharing Feelings: Help patient’s express emotions by making observations, acknowledging feelings, encouraging communication, and giving permission to express “negative” feelings and modeling healthy anger  Using Touch: **Most potent form of communication** Comforting touches are especially important for vulnerable patients who are experiencing severe illness/stress  Silence: Time for nurses and patients to observe one another, sort out feelings, think about how to say things, and reflect  Nurse should allow patient to break the silence  Providing Information: Relevant info is vital to decision making, reducing anxiety, and feeling safe/secure  Clarifying: To check whether understanding is accurate or to better understand  Focusing: Taking notice of a single idea/word expressed  Paraphrasing: Restating another’s own message, briefly, in one’s own words; conveys the essential idea  Asking Relevant Questions: To seek further information for decision making; Asking only one question at a time and fully exploring one topic before moving on to another  Open-ended questions allows for taking the conversational lead and introducing pertinent info about a topic  Summarizing: Pulls together information for documentation; A concise review of key aspects of an interaction; Brings a sense of closure and full understanding  Self-Disclosure: Subjectively true personal experiences about self are intentionally revealed to another for the purpose of emphasizing similarities/differences of experiences; Offered as an expression of genuineness and honesty  Confrontation: Helping the patient become more aware of inconsistencies in his/her/their feelings, attitudes, beliefs, and behaviors; Should be done with sensitivity and ONLY AFTER trust has been established 7. Delegation principles Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  What are the 5 rights of delegation? (Slide 13 on Module 1 PP AND Basic Nursing: Thinking, Doing, Caring pg 77)  Right Task: Can I delegate that?  Right Circumstance: Should I delegate that?  Right Direction and Communication: What does the UAP (Unlicensed Assistive Personnel) need to know?  Right Person: Who is best prepared to do that?  Right Supervision: How will I follow up? 8. What types of things can you delegate to assistive personnel? (Slide 12 on Module 1 PP)  Vital signs on a stable patient  Feeding/grooming/bathing/toileting a patient  Turning a patient  Ambulating a patient  Stocking supplies  Secretarial tasks  *Other types of tasks can be delegated depending on the UAP, facility, and facility policies Module 4 – Hygiene 9. Hygiene: Why it’s done for each body part (steps)  Bathing  bathe pts to cleanse the body, stimulate circulation, provide relaxation, and enhance healing.  Usually delegated to UAP but nurse is responsible for data collection and client care.  Bathe pts who health problems have limited their mobility o Give complete baths to pts who can tolerate it and whose hygiene needs warrant it o Allow rest periods for pts who can tolerate it and whose hygiene needs warrant o Partial baths are useful for clients that can’t tolerate a complete bath, need certain cleansing of odorous or uncomfortable areas, can perform part of the bath independently o Therapeutic baths are used to promote comfort and provide treatment (soothing itchy skin) *GIVING A BED BATH*  Collect supplies, provide privacy, and explain procedures  Apply gloves  Lock wheels  Adjust bed to working position  Place bath blanket across pt and remove pt gown  Obtain warm bath water Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Wash pt face 1st (let pt do it if able to)  Clean upper extremities first then lower, keeping cleansed area covered with a blanket or towel  Wash with long, firm strokes from distal to proximal (light strokes over lower extremities if pt has history of DVT)  Apply lotion/powder and gown  Replace water if cold and clean perineal area  Doc skin assessment, type of bath and client’s response  Oral  Helps decrease the risk of infection for clients living in long term care facilities, especially from the transmission of pathogens that can cause pneumonia. Meticulous oral hygiene include those who are seriously ill, injured, unconscious, dehydrated or AMS  Foot  Foot care prevents skin breakdown, pain, and infection  Very important for pts who have diabetes mellitus and qualified professional must perform it.  Hygiene: PATIENT CARE (steps)  Hand hygiene  Always hand wash if: pt has diarrhea, after bathroom use and ____  Wash hands for 30 sec.  Sanitize in/out of pt room  Oral care  Check for aspiration risk, impaired swallowing, and decreased gag reflex  Pts w/ oral mucosa require gentle brushing and flossing  Have suction equipment ready at bedside if pt is unconscious to prevent aspiration. Position pt on side or semi-fowlers  Denture care (Fragile)  Remove dentures with a gloved hand, pulling down and out the front of the upper denture and lifting up and out at the front of the lower denture.  Place dentures in denture cup, emesis basin, or in washcloth  Brush in HORIZONTAL back-and-forth motion with a soft brush and denture cleaner.  Rinse dentures in tepid (warm) water  Store dentures in denture cup, label w/ pt name  Place dentures in in the cup with water to keep them moist or reinsert dentures  Foot care  It is important to prevent any infection or pain that can interfere with gait. Professionals should perform foot care for clients who have diabetes, peripheral vascular disease, or immunosuppression to evaluate feet and prevent injury  Instruct pt at risk for injury to do the following:  Inspect feet daily, especially between toes Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414  Use lukewarm water and dry feet thoroughly  Apply moisturizer to the feet, but avoid between the toes  Avoid OFC products that contain alcohol or strong chemicals  Wear clean cotton socks daily  Check shoes for any objects, rough seams, or edges, that can cause injury  Cut the nails straight across and use an emery board to file nail edges  Avoid self-treating corns or calluses  Wear comfortable shoes  Do not apply heat unless prescribed  Contact provider if any indications of infection or inflammation appear  Nail care  Observe size, shape and condition of nails and nail beds  Check for cracking, clubbing and fungus  Before cutting nails, ensure pt has an order for it if needed or specialist (podiatrist)  Foot and nail care vary from the standard when caring for a pt who had diabetes mellites or PVD. Don’t soak feet due to the risk of infection and don’t cut nails, instead file them. Do not apply lotion between toes b/c the moisture can cause skin irritation and breakdown  Hair care  Caring for the hair and scalp helps with the patient appearance and sense of wellbeing.  Take in consideration of the pts cultural and beliefs  Brush/comb hair daily to remove tangles, massage scalp, stimulate circulation to the scalp. Use soft bristle to prevent injury or trauma to scalp and wide-toothed comb or hair pick to comb.  Start shampooing the hair at the hairline and work toward the neck. To wash the hair on the back of the head, gently lift head with one hand and shampoo with the other  Place a folded or rolled towel behind the neck to pad the edge of the sink. Then rinse, comb and dry the hair  PT ALTERNITIVES  Pts who can’t shower but can sit in a chair and lean back, shampoo their hair in the sink,  Pts on bedrest, use plastic shampoos trough. Dry/no-rinse shampoos and shampoo caps are optional 10. Seizure Precautions:  Make sure rescue equipment is available (padding, Oxygen, suction)  Ensure rapid intervention to maintain air patency  Inspect pt environment, is it safe?  Stay with the patient and call for help  Lower to the floor/bed and protect the head  Do NOT restraint  Do NOT place anything into the mouth o DURING SEIZURES Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 Stay with pt and call for help Maintain airway patency and suction PRN Administer medications Note duration of seizure, and type of movements o AFTER SEIZURES  determine mental status and measure oxygenation saturation and vital signs. Explain what happened and provide comfort, understanding and a quiet environment for recovery  Doc the seizure with any precipitating behavior and description of event (movements, injuries, duration of seizures, aura, postictal state) and report it to the provider 11. Types of Pain  Acute  Protective, temporary, self-limiting, resolves with tissue healing  Phycological responses (sympathetic nervous system) fight or flight responses (tachycardia, hypertension, anxiety, diaphoresis, muscle tension)  Grimacing, moaning, flinching, and guarding  Treatment of underlying problem  Can lead to chronic pain if not treated  Chronic  Not protective, ongoing, or reoccurring more than 6 months and persisting beyond tissue healing  Physiological responses do not usually alter vital signs but pts can be depressed, fatigue and a decrease level of functioning. It is not usually life threatening.  Psychosocial implications can lead to disability  Management aims at symptomatic relief  Categorized as either cancer pain or noncancer pain  Idiopathic pain = form of chronic pain w/o cause or pain that exceeds typical pain levels o Strategies to relieve chronic pain- administer long-acting or controlled release opioid analgesics (including transdermal route) also admin. Analgesics around the clock rather than PRN o Nociceptive o Pain arises from damage to or inflammation of tissue, which is a noxious stimulus that triggers pain receptors o Usually throbbing, aching and localized o Pain responds to opioids and non-opioid medications  Types:  Somatic – in bones, joints, muscles, skin or connective tissues  Visceral – internal organs (stomach/intestines) can cause referred pain in other body locations separate from stimulus  Cutaneous – in the skin or subcutaneous tissue  Neuropathic Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 o Arises from abnormal or damaged pain nerves o Includes phantom limb pain, pain below the level of a spinal cord injury and diabetic neuropathy o Pain is intense, shooting, burning or described as “pins and needles” o Responds to adjuvant medications (antidepressants, antispasmodic agents, skeletal muscles relaxants) Topical medications can provide relief for peripheral neuropathic pain 12. Pain Interventions  Nonpharmacological- used in place of pain measures, although the client has right to choose whether to use both types  Ensure bed linens are clean and smooth and that the client is not lying on tubing or other equipment that could cause discomfort  Position pt in anatomic position, using gentle positioning techniques and reposition frequently to minimize discomfort  Inform pt to use strategies to reduce pain o Cognitive-behavioral measures =changing the way a client perceives pain and physical approaches to improve comfort o Cutaneous (skin) = transcutaneous electrical nerve, heat, cold, therapeutic touch and massage. (Interruption of pain pathways, cold for inflammation, heat to increase blood flow and to reduce stiffness) o Distraction = includes ambulation, deep breathing, visitors, television, games, prayer and music. Decreased attention to the presence of pain can decrease perceive pain level o Relaxation = meditation, yoga, and progressive muscle relaxation o Imagery = focus on pleasant thought to divert focus, requires an ability to concentrate o Acupuncture and acupressure = stimulating subcutaneous tissues at specific points using needles (acupuncture) and or digits (acupressure) o Reduction of pain stimuli = in the environment o Elevation of edematous extremities = promote venous return and decrease swelling  Pharmacological- mainstay for relieving pain. 3 classes of analgesics are non-opioids, opioids, and adjuvants. Immediate, short-term relief of acute pain  Non-opioid = be aware of the hepatotoxic effects of acetaminophen. Client who has a healthy liver should o Monitor for salicylism (tinnitus, vertigo, decreased hearing activity) o Prevent gastric upset by administrating the medication with food or antacids o Monitor for bleeding with long term NSAID use  Opioid = appropriate for treating moderate to severe pain (cancer pain) o Sedation = monitor LOC and take safety precautions. Sedation usually precedes respiratory depressions o Respiratory depression = monitor respiratory rate prior to and following administration. (naloxone for reversed opioid) o Orthostatic hypotention = advise clients to sit or lie down if light headiness or dizzy. Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 oUrinary retention = monitor I&O, assess for distention and administer bethanechol and catharize o Nausea/vomiting = administer antiemetics, advise clients to lie and move slowly and eliminate odors o Constipation = monitor bowel sounds, fluids, fiber intake, exercise, enemas, stool softeners, etc).  Adjuvant= enhance effect of non-opioids, help alleviate other manifestations that aggravate pain (depression, seizures)  PCA pump = medication delivery that allows pt to administer safe dose to itself  Local and regional anesthesia and topical analgesic 13. Local vs Systemic infections Module 5 – Comfort 14. Sensory deficits = change in reception and/or perception. When sensory develops gradually. It is reduced sensory input from internal or external environment.  Contributing factors: o Vision loss- presbyopia, cataracts, glaucoma, diabetic retinopathy, macular degeneration, infection, inflammation, injury, brain tumor o Conductive hearing loss- obstruction. Wax accumulation, tympanic membrane, perforation, ear infections and otosclerosis o Sensorineural hearing loss- exposure to loud noises, ototoxic medications, aging, acoustic neuroma o Taste deficit- Xerostomia or reduced salivation; alters appetite o Neurologic deficits- peripheral neuropathy; peripheral numbness o Stroke- can result in loss of sensation, difficulty speaking and visual deficits  Caring/ communicating w/ people w/ sensory deficits  Basic info o Check for communication deficits and adjust care Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 o Collect equipment necessary to care for any assistive devices (eye lenses, hearing aids) o Make an effort to communicate with clients who have sensory perceptual losses because they tend to withdraw from interactions with others  Equipment – assistive devices, orientation tools (clocks, calendars), radio, television, CD/DVD player, digital audio player, large-print materials o *******Safety*******  Keep pts safe and free from injury  Make call light easily accessible  Orient clients to room  Keep furniture clear from path to the bathroom  Keep personal items in reach  Place bed in lowest position  Ensure iv poles, drainage tubes and bags are easy to maneuver  LEARN PTS PERFERED WAY OF COMMUNICATING  Hearing loss o Sit and face the pts o Avoid cover mouth when talking o Encourage using hearing aids o Speak slow and clear o Try lowering vocal pitch before increasing volume o Use brief sentences w/ simple words o Write down what the PTS DON’T UNDERSTAND o Minimize background noises o Ask for sign-language interpreter if needed o DO NOT SHOUT  Vision Loss o Call pt by their name when approaching to prevent scaring the pt o Identify yourself o Stay with pt visual field if they have a partial loss o Give specific info on the where items are o Explain interventions before toughing pt o Inform pt when you are leaving room o Assess pt clothing for tears or soiled o Make radio, television, cd player or digital audio o Describe the arrangement of the food on the try before leaving the room  Aphasia o Greet pts and call their name o One person speak at a time o Speak clear and slow using short sentences and simple words o DO NOT SHOUT o Pause between sentences so plt can understand info o Check for comprehension o Tell pt when you do not understand them o Ask questions that require simple answers o Allow plenty of time for pt to respond o Use methods speech therapist implement (picture chart) to improve communication o Acknowledge any frustration in communicating  Disoriented Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 o Call pt by name and identify yourself o Maintain eye contact at eye level o Use brief, simple sentences o As one question as a time o Allow pt time to respond o Provide adequate sleep and pain management o Orient pt to time, place, persong and situation o Keep clock in the room o Post calendar or write date visible o Provide and use assistive devices o Provide care pt cant do 15. Safety precautions with someone with peripheral neuropathy  Wear socks and well-fitting, protective shoes. Don't wear open-toed shoes or high heels. Never go barefoot. Before putting on your shoes, check inside for any loose objects such as pebbles. Avoid alcohol, inspecting feet often 16. Diagnostics for Vision Sensory complications 17. Conductive vs Sensorineural hearing loss  Assessment Findings/outcomes Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 18. Older pt skin s/s of infection Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 19. Type of pain assessment tools  Numerical Rating Scale (NRS)  Visual Analog Scale (VAS)  Defense and Veterans Pain Rating Scale (DVPRS)  Adult Non-Verbal Pain Scale (NVPS)  Pain Assessment in Advanced Dementia Scale (PAINAD)  Behavioral Pain Scale (BPS)  Critical-Care Observation Tool (CPOT) Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 Downloaded by Ryanna Mae Claveria ([email protected])