HESI Fundamentals Review

Taking a blood pressure and review implications on using wrong size cuffs.  Know your normal parameters for all your Vital Signs.  Abnormal Vital Signs- what are your implementations?  Know your techniques: o For a leg blood pressure o Orthostatic blood pressure monitoring o For the 2-step blood pressure technique o Repeat blood pressures  Nursing interventions for abnormal temperatures, respirations and pulses.  BP – orthostatic, lie, sit, stand – when can differences occur. HESI FUNDAMENTALS REVIEW : BASIC NURSING & VITAL SIGNS Vital Signs Continued….  Taking the temperature of your patient o Know the different ways to take temperature and which one would be more appropriate. o Circadian Rhythm o Hypothermia o Hyperthermia o Know how to take a tympanic temperature  Taking the pulse of your patient o Know your sites o Factors that influence pulse range o Pulse Deficit o Apical pulse o Pedal pulses  Taking the respiration of your patient o Factors influencing respirations and saturation levels o Review Clinical Text: skill 5-4 on page 86-87. Care of Wounds  Cleansing and irrigation of wound o Sterile Dressing Change o Different dressings changes- and solutions for granulating wounds  Wound drainage and signs of dehiscence and what to do with evisceration. o Remember clean to dirty o Use of Hemovac or other drainage devices and assessment of drainage amount  Braden Scale: Factors that influence the results (see handout) how to assess and reassess- pressure ulcer assessment. o Lab values o Diet  Patients on Oxygen and on Masks for Bipap or Cpap, need to be monitored for redness in pressure areas.  Nursing interventions for patients with impaired skin integrity or skin care for immobile client. o Skin rash assessment o Statis ulcer and inflammation Personal Care/ Hygiene/ Equipment  Oral care of an unconscious patient/ Denture care  Assessment of Stomatitis: foods to avoid, how to treat, how to prevent, etc.  Specialized Mattresses for use with patients that are bed ridden and are at risk for breakdown (or they already have a breakdown).  Care of patients on these specialized mattresses/ teach families.  To determine the level of assistance that a patient needs, you need to make sure to assess the patient Orientation Status.  Know hygiene self-care deficit – in patients that have issues in which they can not use their hands- neurological patient. (e.g. rheumatoid arthritis patients).  Patients with diarrhea- care of skin; see also older adult and skin care.  Soaking feet (when is it not appropriate); nail trimming (when is it not appropriate).  Safety on heat and cold therapies.  IV site care; pain, assessment, interventions. Infection Control  Know INFECTION CONTROL: Standard precautions, Airborne precautions and Contact Precautions.  When do you need to wear protective personal equipment (PPE) and how to apply and remove your PPE.  Proper technique on applying sterile gloves and removing gloves  Preparation of sterile field; surgical asepsis principles.  Collection of Specimen with patients on Isolation- specimens needs to be placed in a biohazard bag, regardless of type of isolation.  Remember treat every that is not on isolation as standard precaution.  HANDWASHING – Hand Hygiene – why important (infection control) and home teaching / discharge instructions and why- Droplet, Airborne and Contact!!!!  Respiratory – infection control and specimen see control of transmission on page 457-458. Bowel Elimination & Specimen Collection  Bowel training: how, when, and why is it needed  Stool Specimen for occult blood- how to obtain specimen.  Administration of Enema and fecal disimpactions.  Interventions for normal elimination and what to do for problems?  How to assess and care for patient with diarrhea– complications to watch for; see also signs of dehydration in box 47-2.  Bowel diversions- see also skill 47-3  Urinary diversions  Purpose and technique of colostomy irrigation.  Factors influencing bowel elimination.  Constipation interventions and causes. Urinary Elimination, Bladder Scans & Specimen Collection  How to insert a female and male catheter – know correct order of procedure – think infection control; skill 46-2  Preventing catheter-Associated Urinary Tract Infection (CAUTI); see also box 46-10.  Know the signs and symptoms of urinary retention and UTI.  Urine Specimen collection; Know the steps for collecting the specimens (Can patient void?). What to do if specimen contaminated?  Problems with urination- what interventions; see also table 46-2  Problems with catheter- what interventions  Residual urine  When to use a bladder scan? See procedural guideline box 46-11. Patient Safety  Know about RACE- Rescue, Activate the alarm, Confine, Extinguish. Know these steps. FIRE = RACE – KNOW – Rescue 1st, then activate alarm or call for help, 3rd – contain fire if possible and then extinguish the fire if possible  Review safety issues for patients with seizures.  Restraintso Check for circulation distal from restraint o Quick release o Procedure and delegation  Patient in bed – bed height and wheels locked – call bell in reach  Wheel chair safety.  Nursing action for confused patient: Sun-downing Basic nursing Skills / Mobility  Application of TED hose (anti-embolitic stockings)  Use of SCD’s (Sequential Compression devices).  Transferring patients safely and positioning patient in bed (log roll).  Know how to bathe patient, soak feet-when and why  Review the ROM Exercises- Know the terminologies.  Know gait- ambulation – patient tolerance – patient safety (return to bed or assist to chair/ wheelchair safety); visual impairment.  Know mobility-shoe safety and use when walking; how to ambulate an obese client; transferring post CVA stroke pt. from bed to w/c  Crutch walking 4 pt. gait- “up with good leg and down with the bad leg”  Immobility problems- interventions to provide to these types of patients (turning and ROM exercises). Know about shearing force. Medication Administration  ALWAYS CHECK PT. ID BEFORE ADMINISTERING MEDS o Using two identifiers. o Remember D/H x Q dosage ordered divided by dosage on hand/available, multiplied times quantity available.  Know your RIGHTS.  Automated Medication Dispensing System o Box 32-4 steps to take to prevent medication errors o Box 32-5 Informatics and medication safety  Prevention of Medication Error  Know how to administer eye drops (pull down lower lid and avoid inner canthus – review technique)  Know how to administer ear drops upward and outward for 4-older adult.  Know medication administration – basic math. o Dosage calculations  How do you assess for side effects? When? What are you looking for?  Priorities medication administration: acute vs. chronic; unstable vs. stable; sudden onset chest pain vs other pain, etc