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Fundamentals Final

Terms in this set (75)

Know ways to protect patient information- safeguards staff can take and who can receive patient information
Logging out of the computer after use, not leaving a computer unattended, only staff who are involved in the case can access the information
Know hand hygiene steps (water temp, amount of soap, which direction do you point fingers, how to dry)
o Turn on water to about 100F (or as hot as tolerated)
o Use 5mL of soap (1 teaspoon) and rub together vigorously
o Rinse hands (fingers down below elbows)
o Dry off hands with one time use paper towel
o Turn off water with one time use paper towel
Know actions to take when instilling nasal decongestant drops
o Tilt patients head back if sitting up, place over a pillow if lying down
o Have patient blow their nose
o DO NOT: stay in position for 2 mins (need to stay for 5), not lying down, put nozzle all the way into the nose
Review administering an enema and actions to help the patient manage discomfort
Cramping is normal, higher it goes in faster, so slow the rate by lowering the fluid slow infusion rate
Know precautions and restrictions about administering enteric coated medications
Do not crush or chew
48 hours post surgery- what would be concerning coming from a wound
Pus, foul-smelling drainage, redness- What should you report
Know what 13 year old concerns should be addressed at Well Child Visit (Ask about friends and if they do not have peer friendships, this is a concern over "normal" teenage physical findings like acne)
Friends, feelings
Know physical manifestations of hypocalcemia and what "sign" you need to assess particularly after thyroidectomy
o Muscle twitches
o Chvostek sign- cheek
Know what to do if you spot a fire on nursing unit (in order of priority)
o RACE
o Rescue, Alarm, Confine, Evacuate/Extinguish
Know Civil actions and examples of each (Invasion of Privacy, Assault, Battery, False imprisonment etc)
o Civil Action - noncriminal lawsuit
o Invasion of Privacy - breaching HIPPA (Ex. Talking loudly about a patient in the hallway)
o Assault - threatening to harm another person (Ex. Threatening to shove an NG tube down someone's throat if they don't want to eat)
o Battery - unlawful touching of another person without consent (ex. Physically shoving an NG tube down someone's throat)
o False Imprisonment - restraining an individual
Know what surgeries in the post op period may put you at risk for compromised airway (Think head and neck surgeries) and what might be priority intervention
Tracheostomy, Laryngectomy, Laryngeal Cancer Surgery
Know how to assess CN III
Snellen Chart
Know home safety for patient who has fallen before
Remove items that could cause the patient to trip, make sure sidewalks are in good shape, place grab bars in the bathroom
When a medication is given to the wrong client, what is the first thing to do?
Assess the client
Know what to do if a patient falls. Know what you can and cannot chart if a patient falls (do you complete incident report? Do you write a nurses note and do you mention incident report in your nurses note if you write one?)
Complete a safety event report. Describe the event using only facts, what you did, and who you contacted
Know safety precautions when transferring patient to or from bed or wheelchair and how to position patient in bed who may not be able to do so themselves
Evaluate the situation and determine If they need help moving. Lock wheelchair, place close to the bed where you help the pt up and all they have to do is pivot
Know precollege immunizations needed (Meningococcal)
Meningococcal, HPV, Flu
Know types of grief (Uncomplicated, complicated/prolonged, Anticipatory, disenfranchised) and examples of each
o Uncomplicated - normal, emotions can be negative but should be accepted within time
o Complicated/Prolonged - Difficult progression through the stages. Can result in suicidal ideation, feelings of guilt, changes in sleep patterns (ex. Grieving over a loved one for 10 years)
o Anticipatory - "letting go" before the loss, grieving process starts before the persons death (ex. A family member in hospice)
o Disenfranchised - loss that cannot be shared publicly or is not socially acceptable (ex. Grieving over a cat for a year)
Know how to apply ophthalmic ointment
Apply after pulling down sclera and go outside to inside corner
Know signs and symptoms of wound dehiscence and evisceration as well as interventions
o S/S: Redness, blood, pain, swelling, open wound, broken sutures
o Interventions: skin care, wound care, notify provider, pack and clean site
Know interventions for confused hospitalized patients
Communication with family members, place the pt close to the nurses station, reorient the client
Know how to teach SBE, when to perform around menstrual cycle and technique to perform
Go in an up and down motion covering every aspect of the breast, push hard - you have to get deep
Know nutrient needed to promote wound healing
More calories, protein, fluid, Vitamin A/C
Know nutrition breakdown of limiting saturated fat intake by limiting total fat intake to 30%
Individual should limit their intake to saturated and trans fat with less than 10% of calories per day
Know types of drainage and what each looks like and what it is composed of
o Serous - thin watery/clear serum, fluid in blisters
o Sanguineous - thick, red, blood
o Serosanguineous - Pinkish, mix of serum and blood
o Purulent - pus like, can smell bad, can be different colors (manifestation of infection)
o Pursanguineous - pus and blood mix
Key points about Incident report- Do not put "Incident report completed", what information should you include?
o Complete within 24 hours after incident, pt's ID,/time/place/date of incident, what happened (facts only), who you notified, what you did, your signature
Know pubertal sequence of events in boys ( when does voice change, when does growth spurt happen, when do scrotal changes happen)
o Scrotal Change 9-14
o Voice Change 11-14
o Growth Spurt 12-15
Know what are modifiable risk factors
Drinking, Smoking, Diet, Exercise
What nursing interventions do you implement in clients AT RISK for pressure ulcers
Assess patients risk, move patient every 1-2 hours, nutritional supplements, reposition
Know Trochanter roll, Sheepskin heel pad, Abductor pillow and footboard indications and use
o Trochanter Roll - used to prevent external rotation of the hip when the patient is laying on their side, usually a rolled towel placed under the patients hip
o Sheepskin Heel Pad - Used to relieve pressure points by re-distributing pressure, allowing for maximum circulation
o Abductor Pillow - used to prevent the hip from turning away from the body. Looks like a 3D triangle placed between the legs
o Footboard - If the patient has drop foot
Know when discharge planning begins
When the patient is admitted
Know ways to safeguard patient information
Log out of computers, be careful where you're speaking, don't discuss patient information
What are common lab findings with anorexia (low albumin)
Low albumin
Know what cannot be delegated to LPN or UAP
Anything involving clinical judgment/decision making or nursing decision making
Know Autonomy, Beneficence, Veracity and Confidentiality and examples of each
o Autonomy - respecting one's ability to make their own medical decisions
o Beneficence - benefiting the patient
o Veracity - truthfulness, honesty
o Confidentiality - respecting privacy
o Justice - ensuring everyone gets their due share
Know Erikson's stage for birth to adolescents (Be able to put in order and identify for certain ages) (Trust, Autonomy, Initiative, Industry, Identity)
o Infancy - Trust v. Mistrust
o Toddler - Autonomy vs. Shame and Doubt
o Preschool - Initiative vs. Guilt
o School Age - Industry vs. Inferiority
o Adolescence - Identity vs. Role Confusion
o Young Adulthood - Intimacy vs. Isolation
o Middle Adulthood - Generativity vs. Stagnation
o Late Adulthood - Ego Integrity vs. Despair
Know nursing roles and some examples of each (Advocate, caregiver, manager, educator)
o Advocate - advocating for a child who cannot speak up for themselves
o Caregiver - providing excellent care for a patient
o Manager - managing a patients care plan
o Educator - informing a patient about their disease/illness
Review steps of nursing process (ADPIE)
Assessment, Diagnosis, Planning, Implementation, Evaluation
Define what are direct nursing activities and what are indirect nursing activities
o Direct - something done in front of the patient for the patient (ex. Starting an IV)
o Indirect - something done not in view but for the patient (ex. Getting a bed pan)
· Know order of taking PPE off and on
o On: Gown, mask, goggles, gloves
o Off: Gloves, goggles, gown, mask
Know Airborne precautions, droplet precautions, contact precautions (what PPE for you and patient as well as any special room assignment considerations)
o Airborne - Private room, negative air exchange (mask and respirator
o Droplet - Private room with others who have the same infection (masks)
o Contact - Private room, dispose of infectious materials into a single use bag (gown and gloves)
Know MRSA, c. Diff and TB isolation (Contact, droplet, airborne etc) and (What PPE will you wear) any specific patient measures to reduce infections of these (Special baths or medications to use, how long do these live on surfaces or hands?)
o C.Diff - Private room, dispose of materials into single use bag (gown and gloves)
o MRSA - Good hand hygiene, disinfect/sterilize equipment (gown and gloves)
o TB - Private room, negative air pressure (gown, gloves, n95, goggles)
Know proper body mechanics to lift objects
Use major muscle groups to prevent back strain, active core, use legs, use assistive devices whenever possible or if lifting more than 35 lbs
Know Interventions to include on care plan for patients at risk for falls
Assistive devices, bed in lowest position/locked, night lights, keep bedside table within reach
Know interventions for end of life care for patient with dyspnea (opioid, fan, turn patient on side to promote comfort and decrease resp distress)
Fan, turn patient on side to promote comfort, decrease sleep distress, opioids
Know medication interactions for iron-
should be administered with orange juice
Know which route of administration has fastest absorption
IV
· Know action to take first when administering a powdered medication
o Iron should be administered with orange juice Check for allergies, then mix at bedside
· Know steps to administer a MDI
o Remove cap, insert MDI (Metered dose inhaler) , place mouthpiece between your teeth, breathe out, press the canister once, breathe in slowly
o First: shake the inhaler
· Know what hospice and palliative care are and the difference between the two
o Hospice - comprehensive care, without curative intent, implemented when a client is not expected to live more than 6 months. Focus on enhancing quality of life and peaceful, dignified death
o Palliative - Focuses on pain relief, spiritual/emotional/psychosocial aspects. Care provided by interprofessional team. Can still get curative treatment
o Main Difference - Palliative can still get curative treatment
Know what you should do in an unresponsive patient's room at the end of life
Continue as if they are awake
Know normal findings for someone at the end of life
o Decreased level of consciousness, loss of muscle tone, labored breathing "death rattle", touch diminished, mucus in large airways, incontinence, mottling, cyanosis, pupils no longer reactive, pulse slow and weak, BP drops, cool extremities, perspiration, decreased urine output, inability to swallow
Know signs and symptoms of hypokalemia and hyperkalemia
o Hypokalemia - blood potassium less than 3.5 mEq/L, increased loss of potassium from the body, decreased intake and absorption of potassium, movement of potassium into cells (Muscle Weakness!)
o Hyperkalemia - Blood potassium greater than 5.0 mEq/L, increased potassium intake, movement out of the cells, or inadequate renal secretion (Decreased Deep Tendon Reflexes)
Know signs and symptoms of Circulatory overload and dehydration
o Circulatory Overload - pulmonary edema, dyspnea, hypoxia, increased pulse
o Dehydration - poor skin turgor, dizziness, seizures, syncope (fainting), confusion, weakness, pee will be dark
Know age related risks for developing dehydration
Decreased total body mass, decreased realization of thirst, decreased kidney function
Know relationship of a negative body image and developing an eating disorder
Negative body image can instigate an eating disorder or weight fluctuation problems (even anxiety/depression)
Know the following components of self concept- self esteem, identity, body image, role performance
o Self-Concept -
o Self-Esteem - People with a positive self-esteem feel capable and competent, better equipped to cope with life's stressors
o Identity - Sense of individuality that implies the persons uniqueness compared with others, important for maintaining intimate relationships (ex. What words might others use to describe you?)
o Body Image - The way a person views their appearance, size, and body structure/function (ex. What aspects of your personal appearance do you wish you could change?)
o Role Performance - Ability to successfully live up to societal expectations as well as out own expectations regarding role specific behaviors
Be able to identify client at highest risk for skin breakdown (similar to the scenario we talked about in class- who was at highest risk for a stroke)
Immobile patients
Know Gait Belt, jacket harness, four wheel walker, standard walker and cane indications and use
o Gait Belt - used to transfer patients and assist with ambulation. When the patient has an unsteady gait
o Jacket Harness - Like a strait jacket. Wraps the patients arms close to their body and keeps them in place
o 4-Wheel Walker - used for patients who require a larger base of support and do not rely on the walker to bear weight. (best for patients who need minimal weight bearing)
o Standard Walker - Best for patients that have a gait that is too fast for a walker without wheels and have difficulty lifting a walker. Used for limited weight bearing patients
o Cane - widen a person's base for support. Hold 4 inches from the feet, use with lower extremity problems in one leg
Know what to do to keep patient safe if they start to fall
Call for help, grab them where you can, let them slide down your leg
Know positioning to help patient transfer from bed to chair and any assistive devices you might use (Gait belt etc) and safe use of the assistive device
o Assess how much the patient can move themselves
o Place the patient on the edge of the bed with feet touching the ground, place arms under their armpits, lift with the legs, and pivot patient to wheelchair
Know education points for someone on home oxygen therapy
o Clutter free environment, fire hazards that come with smoking, ensure electrical devices are working properly, do not use flammable materials nearby (alcohol, acetone), skin breakdown on top of ears/nose, no Vaseline, check cannula on a regular basis, no wool
Know least invasive to most invasive ways to increase a patients oxygen saturation
o Least: Reposition the patient
o Most: Intubate
Know how to suction patient
Adjust suction, don sterile gloves, check function of suction catheter, hyper-oxygenate, insert catheter without suction, apply suction while rotating catheter, assess for secretion clearance
Know sequence of events to suction a patient with a trach and how to determine effectiveness of suctioning
Don ppe, ask patient to cough up secretions, assess breath sounds, start suctioning mouth, limit suctioning to 10-15 seconds each
Know how to perform chest physiotherapy (CPT)
1 hr or 2 hours after meals, administer bronchodilatory or nebulizer treatment 30 mins-1 hr prior, offer emesis basin and facial tissues, apply manual percussion to chest wall, place hand on affected area and vibrate as client exhales
Know proper care of tracheostomy- interventions to implement
Suction trach, clean catheter, perform skin care around trach - clean with sterile water
Know what is conversion, projection, undoing, regression and identify each type defense mechanism example
o Conversion - changing/causing something to change
o Projection - estimate of a future situation based on a study of present ones
o Undoing - person's ruin or downfall
o Regression - return to a former or less developed state
·What are steps to remove PPE
Gloves, goggles, gown, mask
Know appropriate foods for toddler (remember they have small airway- stringy, thick, sticky foods or food shape and size of airway are not recommended but soft foods are appropriate- bananas are ok- peanut butter is not)
Bananas, yogurt, Milk, small fruits
Know subjective and objective data (what would fall into each category)
o Subjective - something the patient has said, symptoms
o Objective - something measurable or something observed through the senses
Know what is clear liquid diet and know what is full liquid diet
o Liquid - all foods that are liquid or will turn to liquid at room temperature (or melt at body temperature)
o Clear - water, tea, broth, jello, chicken broth, coke, sprite
Nursing Interventions for patients with decreased mobility to prevent skin related complications
Assistive devices, assess patients risk for skin complications, nutritional supplements, skin care/wound care
· Know what patient with tubes is most at risk to develop hypokalemia
Patients with a feeding tube NG tube suction
Stages of wounds?
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