NUR2115- Fundamentals of Professional Nursing Final Exam Concept Review All modules- Latest Updated 2022,100% CORRECT

All Modules NUR2115- Fundamentals of Professional Nursing Final Exam Concept Review- Latest Updated 2022 Review various nursing diagnoses related to specific patient problems discussed in Fundamentals Roughly 60% of the final exam will be cumulative over mod 1-7 Module 1-3 Concepts: Importance of documentation of assessments & interventions - Accurate documentation of the patient’s assessment is important to provide a baseline for later comparisons as the patient’s condition changes Types of nonverbal behavior which could promote improved communication - Body language - Gestures, movements, touch, appearance, adornments - Personal appearance - May express culture, religion, group associations, self-concept - Posture and gait - Erect vs. slouched posture - Facial expression) the most expressive part of the body) The importance of QSEN competencies in nursing education - To prepare nurses who combine the highest level of scientific knowledge and technologic skill with responsible, caring practice. - To challenge students to identify and master the cognitive and technical skills as well as the interpersonal and ethic/legal skills they will need to effectively nurse the patients in their care. - Patient-centered care - Teamwork and collaboration - Quality improvement - Safety - Evidence-based practice - Informatics What is a sentinel event? - An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. - Serious injury specifically includes loss of limb or function. - An error that causes serious harm to a client and singles out the need for investigation. What is the main purpose for incident reporting? - This helps document what happened to help the healthcare facility learn a way to prevent the incident from happening again. Examples of health promotion activities for primary, secondary and tertiary - Primary: Directed toward promoting health and preventing the development of disease processes or injury. - EX: Immunizations clinics, family planning services, providing poison control information, accident prevention education, teaching about a healthy diet, health-risk assessments. - Secondary: Focus on screening for early detection of disease with prompt diagnosis and treatment it identifies an illness, reverse or reduce its severity or provide a cure, and thereby return the person to maximum health as quickly as possible - EX: Assessing children for normal growth and development and encouraging regular medical, dental and vision examinations; screening for BP, cholesterol and skin cancer, routine GYN exams and mammograms, teaching testicular self-exams to men, administering medications, caring for wounds. - Tertiary: Begins after and illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning. Maintaining and preventing progression of severe diseases =, dying with dignity, assisting to cope with impending death. - EX: Teaching a diabetic patient how to recognize and prevent complications; using PT to prevent contractures in a patient who has had a stroke or spinal cord injury; referring a woman to a support group after removal of a breast because of cancer. ISBARR, DARE, SOAPIE notes for team communication - ISBARR allows for an easy focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety. - SOAPIE= used to organize entries in the progress notes of the POMR. The POMR includes the defined database, problem list, care plans, and progress notes. - ISBARR= Introduction, Situation, Background, Assessment, Recommendation/request & Read back of orders or response - DARE= Database of Abstracts of Reviews of Effectiveness - SOAPIE= Subjective data, Objective data, Assessment, Plan, Intervention & Evaluation Review teaching for a patient with modifiable health risk factors - T= Tune into the patient - E= Edit patient information - A= Act on every teaching moment - C= Clarify often - H= Honor the patient as partner in the education process Age related safety concerns across the lifespan - Infant: Falls, SIDS (must lay on back to sleep), Injury from toys, Burns, Suffocation and choking, Electrocution, Ingestion of foreign bodies, Child mistreatment (nurse obliged to report to DCF) **Need rear facing car seat - Toddlers: Falls, Cuts, Drowning, Concussions, Guns and weapons (locked and unloaded), Escape from home, Poison (Poison Control # on fridge), Suffocation and choking, Child mistreatment (nurse obliged to report to DCF) **Front facing car seat in the BACK seat - School age children: Sexual abuse, Burns, Broken bones, Concussions, Drowning, Guns and weapons, Use of Internet, Sports injuries (cognitive rest), Abduction, Bullying (cyberbullying), Child mistreatment (nurse obliged to report to DCF) **Back seat until age 13 - Teenager: Piercing & Tattoos, driving (distracted driving). texting especially, Firearms, Suicide, Drugs and Alcohol and Tobacco, Sexuality and STIs, Sexual abuse, Use of Internet, Risk taking (diving into unfamiliar water) **Seat belt and driving - Adults: Stress, Domestic Violence, MVA, Industrial accidents and exposure Drugs and alcohol abuse - Elderly: Falls #1, Elder abuse and neglect, MVA, Sensorimotor changes, Fires (candles, heaters) ...forgetfulness, Burns (electric blankets, hot water, heating pads), Accidental overdosing and polypharmacy 6 Dimensions of wellness definitions - Physical Wellness: Maintaining a healthy quality of life without excessive stress and fatigue and recognizing the importance of adopting healthful habits such as diet and exercise. - Emotional Wellness: Understanding yourself and being able to cope with life challenges. It also means that you can share your feelings (such as sadness, anger, fear, hope, and happiness) with others. - Sociocultural Wellness: Relating to and forming positive relationships with others such as family, friends, and co-workers and identifying and understanding the impact your cultural values and identity have on your decisions and action. - Intellectual Wellness: Being open to new ideas, experiences and learning opportunities. - Spiritual Wellness: Having peace and harmony in your life and being in congruence with your values and actions. - Environmental Wellness: Taking responsibility for making a positive impact on the world such as contributing to improving the quality of air, water, and land. Know the importance of basing our care plan on nursing theory HP 2020 Goals - Attain high-quality of life - Free of preventable disease, disability, injury and premature death - Achieve health quality - Eliminate disparities - Improve the health of individuals - Create social and physical environment that promote good health for all - Promote quality of life, healthy development, and healthy behaviors across all life stages Developmental theories: focus on Erickson’s - Stage 1: Trust vs. Mistrust (Birth to 18 months): Feeding and viewing the world as a safe place - Stage 2: Autonomy vs. Shame & doubt (18 months to 3): Walking, Becoming more mobile, asserting independence and potty training - Stage 3: Initiation vs. Guilt (3 to 5): Right & wrong and developing social skills - Stage 4: Industry vs. Inferiority (5 to 12): Competition, accomplishment, confidence, social and academic standards - Stage 5: Identity vs. Role confusion (12 to 18): Identity crisis, rebellion and learning adult roles - Stage 6: Intimacy vs. Isolation (18 to 40): Intercourse and developing friendships, relationships and goals - Stage 7: Generativity vs. Stagnation (40 to 65): Establishing career, raise kids, focused on work and close meaningful attachment - Stage 8: Ego Integrity vs. Despair (65 and up): Dealing with loss and adjusting to lifestyle changes EBP- what information to trust for best practices- ANA, CDC, US Dept of Health, National Institute of Health (NIH). No .com sites for professional nursing. No blogs should be used as a reference-. OK to use most .org .edu or .gov sites. P.I.C.O. statements - P= Patient, population, problem of interest - I= Intervention of interest - C= Comparison of interest - O= Outcome of interest ANA Scope of Practice - ANA Code of Ethics for Nurses clearly states that the primary commitment of the nurse is the patient, it also states that the nurse owes the same duties to self as to others—including the responsibility to preserve integrity, to maintain competence, and to continue personal and professional growth. ANA Standards of Professional Performance- definitions (mod 1) - The standards of professional performance describe how NPD practitioners comply with the standards of practice, apply the nursing process, and attend to other practice concerns and issues Musculoskeletal: Review education on crutch, cane, walker ambulation - Crutches: remind the patient that the support of body weight should come primarily on the hands and arms while using the crutches, not in the axillary areas, where pressure may damage nerves and cut off circulation, Also, the crutches should not be forced into the axillae each time the body moves forward. - Cane: Rounded grip – Needing slight assist with balance or minimal unweighting of the opposite leg. Straight grip – Needing a better grip and slightly more balance assistance. Quad - Helpful for patients needing a good deal of balance assistance. - Walker: Review safety precautions when repositioning patient in bed - If the patient is fully able to assist in moving up in the bed, allow the patient to complete the movement independently, with safe supervision - The patient assists movement either by pushing with the feet flat against the bed or by using an over bed trapeze. - If only partially able, encourage the patient to assist using a positioning aid or cues. - If the patient is less than 200 pounds, use a friction-reducing device and two to three caregivers. - If the patient is over 200 pounds, use a friction-reducing device and at least three caregivers. - If the patient is not able to assist, use a full-body sling lift and two or more caregivers. Friction- reducing sheets or other devices should be used to minimize shearing forces and work effort. Review nursing interventions which would be included in caring for a patient with contractures - Encourage continuation of daily routines and activities. - Maintain exercise program to tone and strengthen unaffected muscle groups without fatiguing affected muscles. - Range-of-Motion (ROM) exercises; first Active ROM, then passive. Ensure proper positioning, no pressure on bony prominsces. - Deep tissue massage to relax contractures. Review the difference between active and passive range of motion - Active: The patient independently moves joints through their full range of motion (isotonic exercise). In active ROM, the nurse may provide minimal support. - Passive: The patient is unable to move independently, and the nurse moves each joint through its range of motion. Vital Signs: Review the assessment of all vital signs including BP, HR, respirations, temperature and pulse ox. - BP: Selecting a cuff of the proper width is essential to obtain an accurate blood pressure reading. The correct cuff should have a bladder length that is 80% of the arm circumference and a width that is at least 40% of the arm circumference. If the cuff is too NARROW, the reading could be erroneously HIGH. If a cuff is too WIDE, the reading may be erroneously LOW. The series of sounds for which the nurse listens when assessing the blood pressure are called Korotkoff sounds. The first sound heard is the systolic pressure, and is recorded as the first number. The second number, the diastolic pressure, notes the level at which the sounds disappear completely. - HR: Apical pulse: If a peripheral pulse is difficult to assess accurately because it is irregular, weak, or very rapid, the apical rate should be assessed using a stethoscope. An apical pulse is also assessed when giving medications that alter heart rate and rhythm. Apical pulse measurement is also the preferred method of pulse assessment for infants and children less than 2 years of age. The contraction of the heart can be heard in the space between the fifth and the sixth ribs, about 8 cm (3 inches) to the left of the mid-clavicular line and slightly below the nipple. The apical rate of an infant can also be easily palpated with the fingertips as well as being auscultated. - HR: pulse by palpation: The radial pulse site is assessed most often in children and adults. Circulation to the legs and feet may be assessed at the femoral, popliteal, posterior tibial, or dorsalis pedis sites. The carotid pulse site is used during emergency assessments, such as for patients who are in shock or have had a cardiac arrest. When taking a carotid pulse, lightly palpate only one side at a time to prevent any decrease in cerebrovascular circulation. The brachial pulse site is used most often for infants. - Respiration: The nurse assesses respiratory rate (breaths per minute), depth (deep or shallow), and rhythm (regular or irregular) by inspection or by listening with the stethoscope. - Temperature: axillary: The axillary site may be used when both oral and rectal sites are contraindicated or when these sites are inaccessible. Place the probe in the center of the axilla.Hold the patient's arm by the patient's side until the measurement is complete. - Temperature: rectal: The rectal temperature, a core temperature, is considered to be one of the most accurate routes. The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal surgery or have a disease of the rectum. Because the insertion of the thermometer into the rectum can slow the heart rate by stimulating the vagus nerve, assessing a rectal temperature for patients with heart disease or after cardiac surgery may not be allowed in some institutions. Assessing a rectal temperature is contraindicated in patients who are neutropenic (have low white blood cell counts, such as in leukemia) and in patients who have certain neurologic disorders (e.g., spinal cord injuries). Do not insert a rectal thermometer into a patient who has a low platelet count. The rectum is very vascular, and a thermometer could cause rectal bleeding. - Temperature: oral: When selecting the oral site, the patient must be able to close his or her mouth around the probe. The probe must remain in the sublingual pocket for the full period of measurement. If a patient has had either hot or cold food or fluids or has been smoking or chewing gum, the general recommendation is to wait 15 to 30 minutes to allow the oral tissues to return to normal temperature. Don't take an oral temp on patients receiving oxygen by mask. - Temperature: tympanic: Pull pinna UP and back for adults, DOWN for children. The thermometer does not touch the tympanic membrane. This site allows easy and safe measurement of temperature and is readily accessible. Should not be used for patients who have drainage from the ear, ear pain, ear infection, or scars on the tympanic membrane. - Pulse ox: Measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. The reported result is a ratio, expressed as a percentage, between the actual oxygen content of the hemoglobin and the potential maximum oxygen-carrying capacity of the hemoglobin. A range of 95% to 100% is considered normal SpO2; values ≤90% are abnormal, indicate that oxygenation to the tissues is inadequate, and should be investigated for potential hypoxia or technical error. Think about how you would handle VS outside of range for each VS and Spo2 What trends in VS are worrisome and how should the RN respond? Review normal values for VS: BP, HR, respirations, temperature and pulse ox across the lifespan - BP: 120/80 (adults) - HR: 60-100 (adult/adolescents) - Respiration: 12-20 (adults), 20-25 (child), 20-40 (infant) - Temperature: 97.7 (axillary), 98.6 (oral, temporal), 99.5 (rectal, tympanic) - Pulse ox: 95%-100% (adults) When may it be inappropriate to delegate VS? Module 4-7: Review definitions of the nursing process including: Assessment - Subjective data: Information perceived only by the affected person - Objective data: observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them - Initial comprehensive assessment: performed shortly after admission, identify problems and care planning, performed to collect data on all aspects of patient’s health - Focused assessment: performed by the nurse to collect data about the specific problem - Emergency Assessment: Performed when a physiologic or psychological crisis present - Time-lapsed Assessment: performed to compare a patient’s current status to baseline data obtained earlier nursing diagnoses - Identify problems - What causes the problem - Solutions to prevent or resolve problems Planning - Specific - Measurable - Achievable - Realistic - Timely - Identify expected patient outcomes, establish priorities, select evidence-based nursing interventions, communicate the plan of care Outcomes - Implementation helps the patient achieve valued health outcomes. Promote health, prevent disease and illness, restore health, facilitate coping with altered functioning. - Cognitive: increase in patient knowledge; ask patient to repeat information or apply new knowledge - Psychomotor: patient’s achievement of new skill; ask patient to demonstrate new skill - Affective: changes in patient values, beliefs, and attitudes; observe patient behavior and conversation - Physiologic: physical changes in the patient; use physical assessment to collect and compare data interventions - Task healthcare providers do to help the patient get better. evaluation - Measure the patient’s outcome achievement When you obtain your assessment data, what is the next step in the process? Diagnosing the patient After establishing goals, what is the next step? You implement a care plan. After implementing a new teaching plan, what is the next step (using the nursing process?) You evaluate the patients progress. In order to create a nursing diagnosis, what details do you reference?: A. the medical diagnosis or B. the Nursing assessment? B the nursing assessment When prioritizing the nursing diagnoses, what goes first, your actual diagnoses or the “risk for” diagnoses. Actual diagnosis Respiratory/Cardiac: Review various lab data and normal values: BUN, electrolytes, CBC, blood glucose - BUN: 8-25mg/dl - Electrolytes: - CBC= RBC: 4-5.9; Hct: 40-54% (male), 37-46% (female); Hgb: 13.5-17 (male), 12-15 (female); WBC: 4-11; Platelets: 150,000 and 399,000 - Blood Glucose: 70-130 mg/dl Review the common adventitious lungs sounds (wheezes, pleural friction rub, rhonchi, crackles and stridor) and what specific conditions you would auscultate them (COPD, pneumonia, asthma, CHF) - Wheezes= narrowed airways; musical or squeaking sounds; heard on inspiration and expiration; classified as sibilant and sonorous (COPD, Emphysema, Sleep apnea, Pneumonia, Smoking, Respiratory tract infection, Asthma, Bronchitis, Lung cancer, or Foreign object). - Pleural friction rub= abnormal lung sound which is caused by inflammation of the pleural layer of the lungs rubbing together. Pleural friction rub is heard on inspiration and expiration and sounds like a low-pitch harsh/grating noise. (Viral infection such as flu, Lung cancer, sickle cell disease, fungal infection, bacterial infection like Pneumonia, Rib fracture, or Rheumatoid arthritis) - Rhonchi= air passing through or around secretions; sonorous or course sounding; heard on inspiration and expiration; coughing can clear secretions so sound will also go away (COPD, Bronchiectasis, Pneumonia, Chronic bronchitis, or Cystic fibrosis) - Crackles= occur when air moves through airways that contain fluid, bubbling, cracking, popping sound; heard on inspiration and expiration (Pneumonia, Heart failure, Bronchitis, Pulmonary edema, or Pulmonary fibrosis - Stridor= narrowing of upper airway, can be from prescience of foreign body; loud and high pitched; heard only on inspiration (Foreign body, Diphtheria, Anaphylaxis, Epiglottis, Lung cancer, Tonsillitis, Laryngitis or Croup) Review respiratory terminology: dyspnea, cyanosis, tachypnea, bradypnea, apnea in beginning of Chap 38 - Dyspnea- difficulty breathing - Cyanosis- blue skin color - Tachypnea- increased breathing over 20 - Bradypnea- decreased breathing under 12 - Apnea- absents of breathing Review the ACUTE and Chronic effects of hypoxia on the respiratory system and the rest of the body. - Acute hypoxia= Restlessness, Pallor, Tachypnea, Elevated BP, Use of accessory muscles, Nasal flaring, Tracheal tugging, Adventitious lung sounds - Chronic hypoxia= Confusion, Bradycardia, Bradypnea, Stupor, Cyanotic skin and mucus membranes, hypotension, cardiac dysrhythmia Review the anatomical locations for auscultation of cardiac and respiratory systems (aortic, pulmonic, tricuspid and mitral) Review how to determine types of pitting edema: 1+, 2+, 3+ and 4+ - 1+= Mild, Slight indentation (2 mm) disappears rapidly, Normal contours, Associated with interstitial fluid volume 30% above normal - 2+= Moderate, Deeper pit after pressing (4 mm), Disappears after 10-15 seconds, Fairly normal contour - 3+= Moderately severe, Deep pit (6 mm), Disappears after 1 minute, Skin swelling obvious by general inspection - 4+= Severe, Deep pit (8 mm), Remains up to 2 minutes, Frank swelling Review interventions to decrease risks for pulmonary embolism - Graduated compression stockings - Pneumatic compression devices Review grading of pulses: bounding, normal, diminished, absent - Strong= +4 - Bounding= +3 - Normal= +2 - Diminished= +1 - Absent= 0 Infection/ Inflammation/ Thermoregulation: Review the difference between inflammation and infection - Inflammation= a localized physical condition in which part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection. Symptoms include: Redness, Swollen joint that's sometimes warm to the touch, Joint pain, Joint stiffness, Loss of joint function - Infection= A person becomes sick after being contaminated by a virus, bacteria or fungi. Symptoms include: Fever and chills, very low body temperature, Peeing less than normal, Rapid pulse, Rapid breathing, Nausea and vomiting, Diarrhea Review the effects of excessive or ineffective inflammatory response which could occur in a patient - Local tissue damage from compression - Development of chronic inflammation - Systemic pathology - Atherosclerosis- build- up of fats, cholesterol, and other substances in and on the artery walls - Chronic renal disease - Neurologic disorders Review the purpose/benefits of the inflammatory process including fever benefits - A protective mechanism that eliminates the invading pathogen and allows for tissue repair to occur - Inflammation helps the body to neutralize, control, or eliminate the offending agent and to prepare the site for repair - In addition to infection, the inflammatory response also occurs in response to injury. It is either an acute or chronic process. Review infection terms: opportunistic, virulence, phagocytosis, hospital-acquired, nosocomial, immunocompromised - Opportunistic infection= also known as an immunocompromised infection; a patient who does not have the ability to respond normally to an infection due to an impaired or weakened immune system. This inability to fight infection can be caused by a number of conditions including illness and disease (eg, diabetes, HIV), malnutrition, and drugs. - Virulence= The ability of an agent of infection to produce disease. The virulence of a microorganism is a measure of the severity of the disease it causes. - Phagocytosis= the ingestion of bacteria or other material by phagocytes and amoeboid protozoans. - Hospital acquired infections= also known as a nosocomial infection; infection caused by an infection (bacteria) caught while in a hospital. Review the chain of infection: infectious agent, reservoir, portal of exit, portal of entry, susceptible host, mode of transmission - Infectious agent= Bacteria, viruses, fungi - Reservoir= natural habitat of the organism - Portal of exit= point of escape for the organism - Means of transmission= contact (direct/indirect), droplet, airborne - Portal of exit= point at which organisms enter a new host - Susceptible host= overcome resistance mounted by host’s defenses Review stages of infection: incubation period, prodromal stage, full stage of illness, convalescent period - Incubation period= organisms growing and multiplying - Prodromal stage= person is most infectious, vague and nonspecific signs of disease - Full stage of illness= presence of specific signs and symptoms of disease - Convalescent stage= recovery from the infection Review types of nosocomial and hospital acquired infections (HAI’s) - Urinary tract infections - Surgical site infections - Bloodstream infections - Pneumonia Review rationale of proper hand hygiene - Hand hygiene is the first step of infection control Review terminology: bacteremia - Bacteremia: the presence of bacteria in the blood Review signs and symptoms of infection - Redness - Heat - Swelling - Pain - Loss of Function Review the difference between endogenous nosocomial and exogenous nosocomial infection - Endogenous nosocomial infection= When the causative organism comes from microbial life harbored in the person. - exogenous nosocomial infection= when the causative organism is acquired from other people. (Mod 7) Integumentary and Tissue Integrity: Review the stages of pressure ulcers including I, II, II and VI ulcers as well as unstageable and suspected deep tissue injury - Stage I= non-blanchable erythema of intact skin - Stage II= partial- thickness skin loss - Stage III= full-thickness skin loss; subcutaneous fat may be exposed but does not involve underlying fascia - Stage IV= full-thickness skin loss with extensive destruction; exposed bone, tendon or muscle - Unstageable= base of ulcer covered by slough and/or eschar in wound bed Review integumentary changes in various developmental ages - Adult= maturation of epidermal cells is prolonged, leading to thin, easily damaged skin; circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damaged from pressure - Child= skin becomes increasingly resistant to injury and infection - Infant= those younger than 2 skins are thinner and weaker than it is in adults, skin and mucous membranes are injured easily and are subject to infection, careful handling of infants is required to prevent injury to and infection of the skin and mucous membranes - Elderly= skin is thin, easily injured, less capacity to insulate, wrinkles more easily, sensation of pressure and pain is reduced, dryer, pruritus (itching) may occur, healing time is delayed, hair becomes gray/white, skin may be unevenly pigmented, skin loses elasticity Review the importance of nutrition and wound healing - A patient who is malnourished is at a higher risk for alterations in fluid and electrolyte balance, delay in wound healing and wound infection Review the following precautions: protective, droplet, airborne, contact, standard, isolation, airborne - Contact precautions= - Airborne precautions= negative pressure/HEPA system, keep door closed, limit transport (if transported the patient must wear a mask), mask and respiratory protection device for caregivers and visitors, use a N95 on high-efficiency particulate air respirator; Tuberculosis, chicken pox, measles - Droplet precautions= a private room to ensure silent has their own equipment, mask for providers and visitors, disposal of infectious dressing material into a single, non-prow bag without touching the outside of the bag; Rubella, mumps, diphtheria, adenovirus, seasonal influenza, pertussis, certain bacterial meningitis - Standard precautions= used in the care of all patients regardless of their diagnosis/infection status, applies to blood, body fluid, secretion, non-intact skin, mucous membranes and excretions. Review the difference between a wound evisceration, dehiscence, fistula, hemorrhage. - Evisceration= separation of edges with spillage of viscera through incision - Dehiscence= separation of edges - Fistula= abnormal passage created - Hemorrhage= can lead to ischemia from increase pressure from blood Review the use and advantages of negative pressure wound therapy (wound vac) - Negative pressure in vacuum-assisted closure - Removes fluid from the wound through suction - Result: increase blood flow to the wound (by causing the blood vessels to dilate) and greater cell proliferation - Fluid removal also reduces bacteria colonization of the wound, and enhances the growth of granulation tissue Review process of healing: primary, secondary, tertiary - Primary healing= approximated edges; surgical incisions - Secondary healing= less approximated edges; large and open wounds such as burns and trauma - Tertiary healing= left open for several days to allow edema or infection to resolve and closed at a later date; wound vac Review the use and rationale of the Braden scale - Braden Scale= Helps assess a person’s risk for falls - Very high risk- 9 or less - High risk- 10 to 12 - Moderate risk- 13-14 - Mild risk- 15-18 - No risk- 19-23 Review the difference between acute and chronic wounds - Acute wounds= short duration, heal spontaneously without complications through the 3 phases of healing inflammation, proliferation, maturation; surgical wounds - Chronic wounds= exceed expected length of recovery, natural healing progression interrupted or stalled due to: infection, continued trauma, ischemia or edema, pressure, arterial, venous and diabetic ulcers, frequently colonized, last months or years Review the effect of shearing force and friction on skin integrity - Shearing= Combination of friction and pressure, epidermal layer slides over the dermis causing damage to vascular bed - Friction= force acting parallel to skin surface, damages the outer protective layer of epidermis 40% of exam will be on the following sections: Glucose Regulation: Review patient education a nurse would include in self administration of insulin - Teach clients to check blood sugars and to administer insulin - Inject insulin when levels are high (hyperglycemia) - DO it in s fatty area. - Inject medication by pinching area of injection and inject the medication - Hold for 3-5 seconds before removing syringe. - Hyperglycemia symptoms early signs; increased thirst, blurred vision, frequent urination, increased hunger, numbness or tingling in the feet, fatigue and headache - Hyperglycemia symptoms late signs: fruity smelling breath, nausea and vomiting, shortness of breath, dry mouth, weakness, confusion and coma Review the normal lab values for fasting blood glucose and A1C - A1C= 4-6% - Fasting blood glucose= 70-110mg/dL Review risk factors and complications of diabetes - Risk factors= Family history; Advanced age ≥45; Obesity; Physical inactivity; Member of high-risk population: African American, Hispanic/Latino, Asian American, American Indian, Alaska Native, Pacific Islander; History of gestational diabetes; Hypertension; High cholesterol; Cardiovascular disease - Complications= Skin infections; Gum disease; Retinopathy; Depression; Nerve damage (neuropathy); Foot amputation; Kidney disease; Heart failure; Diabetic ketoacidosis; Coma; Death Review treatment modalities for diabetes - Insulin= Rapid acting (Novolog, Humalog [lispro]); Short-acting (Humulin R, Novolin R); Intermediate acting (Humulin N, Humulin 70/30); Long-acting (Lantus) - Oral antidiabetics= Amaryl (glimepiride); Glucotrol (glipizide); Glucotrol XL (glyburide); Metformin; Avandia; Glucophage; Actos Review treatment for hypoglycemia - Some candy, Consuming high-sugar foods or drinks, such as orange juice or regular soda, glucose can treat this condition. Alternatively, medications can be used to raise blood sugar levels. It's also important that a doctor identify and treat the underlying cause. - Symptoms: confusion, weakness, fatigue, difficulty thinking, behavioral changes, seizures, loss of consciousness, brain damage, death, shakiness, heart pounding, nervous, diaphoresis, hunger, tingling Review education and teaching on foot care of a diabetic patient - Inspect your feet daily. Check for cuts, blisters, redness, swelling or nail problems. Use a magnifying hand mirror to look at the bottom of your feet. Call your doctor if you notice anything. - Bathe feet in lukewarm, never hot, water. Keep your feet clean by washing them daily. - Be gentle when bathing your feet. Wash them using a soft washcloth or sponge. Dry by blotting or patting and carefully dry between the toes. - Moisturize your feet but not between your toes. Use a moisturizer daily to keep dry skin from itching or cracking. - Cut nails carefully. Cut them straight across and file the edges. Don’t cut nails too short, as this could lead to ingrown toenails. - Never treat corns or calluses yourself. - Wear clean, dry socks. Change them daily. - Consider socks made specifically for patients living with diabetes. - Wear socks to bed. - Shake out your shoes and feel the inside before wearing. - Keep your feet warm and dry. - Consider using an antiperspirant on the soles of your feet. - Never walk barefoot even around the house. - Take care of your diabetes. - Do not smoke. - Get periodic foot exams. Gastrointestinal: Review the complete assessment of the GI system including inspection, auscultation, palpation and percussion - Inspection= first observe the contour of the abdomen, noting any masses, scars or areas of distention. Significant findings may include the presence of distention (inflation) or protrusion (projection). - Auscultation= use the diaphragm of a stethoscope listen to bowl sounds in all four quadrants. Note the frequency and character of bowel sound. They are usually high pitched, gurgling and soft, indicating bowel motility and peristalsis. Use the stethoscope to listen to the abdominal aorta, femoral arteries and iliac arteries for bruits. Bruit is a swooshing or blowing sounds. Describe sounds as hyperactive, hypoactive or inaudible. If there is a NG tube in place disconnect it from suction during this assessment to allow for accurate interpretation of sounds. - Palpation= Palpate each quadrant in a systematic manner, noting muscular resistance, tenderness, enlargement of the organs or masses. Be sure to watch the patients face for nonverbal signs of pain during palpation. If the patient complains of pain palpate the area of pain last. If the abdomen is distended note the presence of firmness or tautness. Abnormal findings include involuntary rigidity, spasm, and pain (which may indicate trauma, peritonitis, infection, tumors, or enlarged or diseased abdominal organs). - Percussion= Place your non-dominate hand firmly against the abdominal wall such that only your middle finger is resting on the skin. Tap on the middle finger using the middle finger of your dominant hand. Do it three times listening for the sound it makes. This is use for delineating the outlines of solid tissue (liver, spleen). Tones you are likely to here includes dullness, tympani and resonance. Dullness is heard over solid organs (liver, spleen). Tympani is commonly heard over areas that contain gas (stomach, intestines). Resonance is heard over healthy lung tissue. Review conditions of diarrhea and constipation and precipitating factors of each - Diarrhea= Disease process; Infections of intestines from contaminated food or water; (dysentery / cholera); Food poisoning – can result in severe GI symptoms, progressing to life threatening conditions; e coli, E coli 0157 H, salmonella; Parasites; Viruses; Travelers diarrhea-N/V/D, fever, abdominal cramping, pain, characterized by ≥3 loose stools in 24 hrs., (C difficile, norovirus) - Constipation= intestinal impaction, anal fissures, hemorrhoids, volvulus, intestinal obstruction, rectal ulcers, fecal seepage, bowel perforation. Review the components in a focused GI assessment - Change in Appetite - Weight gain or loss - Dysphagia - Intolerance to Certain Foods - Nausea and Vomiting - Change in Bowel Habits - Abdominal Pain Review risks and treatments for constipation & diarrhea - Risk for constipation= Female; Age 65 or older; Low-income; Of non-European ancestry - Treatment of constipation= Exercising regularly; Trying to have a bowel movement at the same time every day, such as 15 to 45 minutes after breakfast (eating stimulates colon activity); Reserving enough time to have a bowel movement; Not resisting the urge to have a bowel movement; Stool softeners; Saline laxatives; Bulk-forming laxative - Risk for diarrhea= People of all ages can get diarrhea. On average, adults In the United States have acute diarrhea once a year. Young children have it an average of twice a year. People who visit developing countries are at risk for traveler's diarrhea. It is caused by consuming contaminated food or water. - Treatment of diarrhea= Diarrhea is treated by replacing lost fluids and electrolytes to prevent dehydration. Depending on the cause of the problem, you may need medicines to stop the diarrhea or treat an infection. Adults with diarrhea should drink water, fruit juices, sports drinks, sodas without caffeine, and salty broths. As your symptoms improve, you can eat soft, bland food. Children with diarrhea should be given oral rehydration solutions to replace lost fluids and electrolytes. Review effects of immobility on the GI system - Immobility= Constipation Review the risk factors which increase irritable bowel syndrome (IBS) - Risk factors= The young; Females; Have a family history of IBS; Have a mental health problem Review diagnostic colon cancer screening - A diagnostic colonoscopy is just like a screening colonoscopy, but it's done because a person is having symptoms, or because something abnormal was found on another type of screening test. - For this test, the doctor looks at the entire length of the colon and rectum with a colonoscopy, a thin, flexible, lighted tube with a small video camera on the end. It is inserted through the anus and into the rectum and the colon. Special instruments can be passed through the colonoscopy to biopsy or remove any suspicious-looking areas such as polyps, if needed. - Colonoscopy may be done in a hospital outpatient department, in a clinic, or in a doctor’s office. Review teaching regarding a patient undergoing a colonoscopy - Do not eat anything for the next 24 hrs. - Take the laxatives given to help clear out the intestines for a clearer look Review education and teaching regarding ostomy care - Explain the reason for bowel diversion and the rationale for treatment - Demonstrate self-care behaviors that effectively manage the ostomy - Describe follow-up care and existing support resources - Report where supplies may be obtained in the community - Verbalize related fears and concerns - Demonstrate a positive body image. Review side effects of diarrhea & constipation - Diarrhea= Dehydration - Constipation= Abdominal pain Discuss the interrelationship between GI system disorders and antibiotics - Antibiotics are part of the treatment for GI system disorders. Genitourinary: Review the components of performing a GU assess - Kidneys: Palpation of the kidneys is usually performed by an advanced health care practitioner as part of a more detailed assessment. - Urinary bladder: Palpate and percuss the bladder or use a bedside scanner. - Urethral orifice: Inspect for signs of infection, discharge, or odor. - Skin: Assess for color, texture, turgor, and excretion of wastes. - Urine: Assess for color, odor, clarity, and sediment. Review s/s of UTI, risks for developing UTI and treatments - pelvic pain, increased urge to urinate, pain with urination, and blood in the urine Review the effects of immobility on the GU system - Immobility= Urinary stasis; Renal calculi; Urinary retention; Urinary infection Review causes of urinary incontinence - Transient: appears suddenly and lasts 6 months or less. Usually caused by treatable factors. - Mixed: urine loss with features of two or more types of incontinence - Overflow: over distention and overflow of bladder dribbling - Functional: inability to reach toilet due to environmental factors, physical limitations, loss of memory, or disorientation - Reflex: emptying of the bladder without sensation of need to void (spinal cord) - Total: continuous, unpredictable loss of urine (surgery, trauma, physical malformation) Review the GU terminology: micturition, oliguria, dysuria, retention, urgency - Micturition= The process of emptying the bladder - Oliguria= the production of abnormally small amounts of urine. - Dysuria= difficulty urinating - Retention= inability to completely or partially empty the bladder - Urgency= immediate need to urinate Review nursing care for urinary incontinence - Assessing data about voiding patterns, habits, past history of problems - Explore its duration, severity, and precipitating factors - Note the patient’s perception of the problem - Check the adequacy of the patient’s self-care behaviors. Review the process of obtaining a 24-hour urine collection - Discard first void and initiate 24-hour urine after this. - Collect all urine from each voiding - Usually refrigerated or iced - At end of 24 hours, have patient void and collect last specimen - Can be added together or separated depending on order Review the collection of a midstream urine specimen - First clean the area around the meatus. - Void a small amount of urine and discard (along with any organisms from the meatus). - Continue to void and collect using a sterile container. - Stop collecting before bladder completely emptied. - Finish voiding into toilet, bedpan, urinal. Pain/Stress & Adaptation: Review the effects that severe/uncontrolled pain has on VS - Increased heart rate, increase blood pressure, increased respiration Review the types of pain: chronic, acute, intractable, neuropathic, radiating, phantom, referred psychogenic - Chronic= May be limited, intermittent, or persistent; Lasts beyond the normal healing period; Periods of remission or exacerbation are common - Acute= Rapid in onset, varies in intensity and duration; Protective in nature - Intractable= hard to control or deal with - Neuropathic= Chronic pain condition; Result of nerve damage or a malfunctioning nervous system. - Radiating= Radiates into the lower extremity directly along the course of a spinal nerve root; caused by compression, inflammation and/or injury to a spinal nerve root arising from common conditions including herniated disc, foramina stenosis and peridural fibrosis. - Phantom= Feels like it's coming from a body part that's no longer there. - Referred= pain felt in a part of the body other than its actual source. Review which pain management tasks can be delegated to nursing assistant - Re-positing the patient every 2 hours Review alternative techniques of pain management: hypnosis, distraction, guided imagery, massage, reiki, music, aromatherapy - Hypnosis= Technique that produces a subconscious state accomplished by suggestions made by a hypnotist, has been used successfully in many instances to control pain - Distraction= talking to the patient or playing a game to help distract from the pain. - Guided imagery= Visualizing a particular out- come or scenario with the goal of mentally changing one’s physical reality - Massage= The manipulation of tissue to relax clumps of knotted muscle fiber, increase circulation, and release patterns of chronic tension - Reiki= Moving a practitioner’s hands over the energy fields of the client’s body to increase energy flow and restore balance - Music= helps relax and sooth the patient - Aromatherapy= The use of essential oils of plants to treat symptoms; reduce stress. Review risks of inadequate pain management - Increase the risk of chronic pain, abnormal VS, symptoms will get worse. Review care planning and prioritization of pain control - Establishing trusting nurse–patient relationship - Manipulating factors affecting pain experience - Initiating non-pharmacologic pain relief measures - Managing pharmacologic interventions - Reviewing additional pain control measures, including complementary and alternative relief measures - Considering ethical and legal responsibility to relieve pain - Teaching patient about pain Describe the body’s stress response - Alarm response= Person perceives stressor, defense mechanisms activated; Fight-or-flight response; Hormone levels rise, body prepares to react; Shock and counter-shock phases - Stage of resistance= Body attempts to adapt to stressor; Vital signs, hormone levels, and energy production return to normal; Body regains homeostasis or adaptive mechanisms fail - Stage of exhaustion= Results when adaptive mechanisms are exhausted; Body either rests and mobilizes its defenses to return to normal or dies What are the physiological effects of prolonged stress on the body? - Emotional response= Mind–body interaction; Coping mechanisms - Coping mechanisms= Crying, laughing, sleeping, cursing; Physical activity, exercise - Smoking, drinking; Lack of eye contact, withdrawal; Limiting relationships to those with similar values and interests - Anxiety (most common) = Mild, Moderate, Severe, Panic Describe sleep deprivation and establishing a care plan around sleep - Interventions: Prepare a restful environment, promote bedtime rituals, offer appropriate bedtime snacks and beverages, promote relaxation and comfort; Respect normal sleep–wake patterns; Schedule nursing care to avoid disturbances; Use medications to produce sleep; Teach about rest and sleep. - Sleep deprivations: the situation or condition of suffering from a lack of sleep.