NURS 3015 Foundations Kaplan Study Guide Assignments

NURS 3015 Foundations Kaplan Study Guide Assignments

NURS 3015 Foundations Kaplan Study Guide Assignments

1. Airborne Precautions: (page 45, Kaplan)
2. Used with pathogens smaller than 5 microns that are transmitted by airborne route; droplets or dust particles that remain suspended in the air
3. Private room with monitored negative air pressure with 6-12 air changes per hour (airborne infection isolation room)
4. Keep door closed and client in room; susceptible persons should NOT enter room or wear N-95 HEPA filter mask
5. Can cohort or place client with another client with the same organism, but no other organism
6. Place mask on client if being transported
7. Tuberculosis-wear fit-test respirator mask
8. Example of disease is category: Measles (rubeola), M. tuberculosis, varicella (chicken pox), disseminated zoster (shingles)
9. Ambulation: Crutches (page 28, Kaplan)

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Kaplan Study Guide Assignments

Gait	Description	Uses
Four-point	Slow, safe: right crutch, left foot, left crutch, right foot	Use when weight bearing is allowed for both legs
Two-point	Faster, safe: right crutch and left foot advance together; left crutch and right foot advance together	Use when weight-bearing is allowed for both legs; less support than four-point gait
Three-point	Faster gait, safe; advance weaker leg and both crutches simultaneously: then advance good leg	Use when weight-bearing is allowed on one leg
Swing-to-swing-through	Fast gait but requires more strength and balance; advance both crutches followed by both legs (or one leg is held up)	Use when partial weight-bearing is allowed on both legs; requires coordination

Note: To go upstairs-advance good leg first, followed by crutches and affected leg. To go downstairs-advance crutches with affected leg first, followed by good leg. “Up with the good, down with the bad.”

NURS 3015 Foundations Kaplan Study Guide Assignments – General guidelines

1. Client should support weight on hand piece, not axilla-brachial plexus may be damaged, producing crutch palsy.
2. Position crutches 8-10 inches to side
3. Crutches should have rubber tips

Canes: (page 806, Foundations book)

1. 2 types- single straight-legged and quad cane
2. A person’s cane length is equal to the distance between the greater trochanter and the floor.
3. The single straight-legged cane is more common and is used to support and balance a patient with decreased leg strength.
4. Keep cane on the stronger side of body
5. Patient should place the cane forward 15-25 cm (6-10 inches), keeping the weight on both legs
6. Move weaker leg forward to the cane so body weight is divided between the cane and weaker leg. The patient then advances the stronger leg past the cane so the weaker leg and the body weight are supported by the cane and weaker leg. The patient needs to learn that two points of support such as both feet or one foot and the cane are on the floor at all times.
7. Antiembolitic Stockings: (pages 424-426, Foundations, Procedural Guidelines 28-7)
8. DVT is a Never Event
9. Assess for risk factors in Virchow’s triad- hypercoagulability, venous wall abnormalities found in patient medical history (hx of orthopedic surgery, atherosclerosis), and blood stasis (immobility, obesity, pregnancy)
10. DO NOT massage patient’s legs/ Health care provider order is required
11. Assess condition of patient’s skin and circulation to the legs. Assess for contraindications for use of elastic stockings or SCD’s- dermatitis, recent skin graft, decreased arterial circulation in lower extremities as evidenced by cyanotic, cool extremities.

Applying TED hose:

1. Turn elastic stocking inside out by placing one hand into the sock, holding toe of the sock with hand. Using the other hand, pull sock over hand until reaching the heel.
2. Place patient’s toes into foot of elastic stocking, making sure that stocking is smooth.
3. Slide remaining portion of stocking over patient’s foot, being sure that toes are covered. Make sure that foot fits into toe and heel position of stocking
4. Slide stocking up over the patient’s calf until stocking is completely extended. Be sure that stocking is smooth and that no ridges or wrinkles are present, particularly behind the knee.
5. Instruct the patient not to roll stockings partially down because constricting ring around the leg can occlude circulation. NURS 3015 Foundations Kaplan Study Guide Assignments
6. Instruct patient not to massage legs
7. Reposition patient for comfort and perform hand hygiene
8. REMOVE STOCKINGS AT LEAST ONCE PER SHIFT
9. Inspect stockings for wrinkles, constriction, rolls, or binding
10. Apical pulse:

Neonate (page 465, Kaplan)	100 BPM (sleep), 120-140 (awake), 180(crying)
Adult (page 499, Foundations)	60-100
Infant	120-160

Fourth to fifth intercostal space at left midclavicular line

Normally you can feel the apical pulse as a light tap in an area 1-2 cm in diameter at the APEX. Another landmark is the epigastric area at the tip of the sternum, palpate there if you suspect aortic abnormalities.

When auscultating an apical pulse, assess the rate and rhythm ONLY

Assessing Apical Pulse: (pages 519-520, Foundations)

1. Supine or sitting position
2. Expose sternum and left side of chest
3. Locate anatomical landmarks-angle of Louis just below the suprasternal notch between sternal body and manubrium-slip fingers down each side of angle to find 2^nd intercostal space, carefully move fingers down left side of sternum to 5^th intercostal space and laterally to left midclavicular line.
4. Place DIAPHRAGM of stethoscope at 5^th intercostal space and auscultate for normal S1 and S2 heart sounds
5. When you hear S1 and S2, with regularity, use second hand of watch and begin to count rate
6. If apical pulse is regular, count for 30 seconds and multiply by 2. If irregular or patient takes cardiovascular meds, count for a minute.
7. Note if HR is irregular and describe pattern or irregularity

* if apical pulse is greater than expected normal value- identify related data, including fever, anxiety, pain, recent exercise, hypotension, decreased oxygenation, or dehydration. OBSERVE for signs & symptoms of inadequate CO, including fatigue, chest pain, orthopnea, cyanosis, and dizziness.

* if apical pulse is less than expected normal values- assess for factors that alter heart rate such as beta-blockers and antidysrhythmic medications. Observe for signs and symptoms of inadequate CO, including fatigue, chest pain, orthopnea, cyanosis, dizziness.

5. Aseptic Technique: (pages, 455,Foundations)

Aseptic technique refers to the practices/procedures that help reduce the risk for infection. There are 2 types- medical and surgical.

Basic medical aseptic techniques break the chain of infection- use these techniques for ALL patients, even when no infection is diagnosed. Examples- hand hygiene, barrier techniques, and routine environmental cleaning.

Surgical: (page, 467)

• A sterile object remains sterile only when touched by another sterile object.
• Only sterile objects may be placed on a sterile field
• A sterile object or field out of range of vision or an object held below a person’s waist is contaminated
• A sterile object or field becomes contaminated by prolonged exposure to air.
• When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action.
• Fluid flows in the direction of gravity
• The edges of a sterile field or container are considered to be contaminated.

Review Skills

1. 2 page 473 Preparation of sterile field
2. 5 page 481 Open Gloving
3. 2 page 11311140 Catheter
4. BP Cuff: (pages 506- 507, Foundations) * my notes said how to take a proper BP/ 5 sounds Normal adult BP 120/80.

KOROTKOFF Phases
Phase 1	A sharp thump (Systolic)
Phase 2	A blowing whooshing sounds
Phase 3	A crisp, intense tapping
Phase 4	A softer blowing sound that fades
Phase 5	Silence (diastolic)

Conditions NOT appropriate for electronic BP measurement: irregular HR, peripheral vascular obstruction, shivering, seizures, excessive tremors, inability to cooperate, BP less than 90 mm Hg systolic.

Kaplan, page 9 info

1. Check BOTH arms and compare results difference 5-10 mm Hg normal
2. Pulse pressure is difference between systolic and diastolic readings; normal 30-40 mm Hg
3. Cover 50% of limb from shoulder to olecranon with cuff; too narrow-abnormally high reading/ too wide-abnormally low reading
4. Body Mechanics: (page 804, Foundations)

NURS 3015 Foundations Kaplan Study Guide Assignments – Preventing Lift injuries in Healthcare Workers 39-1

Action	Rationale
When planning to move a patient, arrange for adequate help. If hospital has a lift team, use it as a resource	A lift team is properly educate in techniques to prevent musculoskeletal injuries
Use patient-handling equipment and devices such as height-adjustable beds, ceiling mounted lifts, friction-reducing slide sheets, and air assisted devices	These devices reduce the caregiver’s muscular strain during patient handling
Encourage patient to help as much as possible	This promotes patient’s independence and strength while minimizing workload
Take position close to patient ( or object being lifted)	Keep objects in same places as lifter and close to caregiver’s center of gravity. Reduces horizontal reach and stress on caregiver’s back.
Tighten abdominal muscles and keep back, neck, pelvis and feet aligned. Avoid twisting	Reduces risk of injury to lumbar vertebrae and muscle groups. Twisting increases risk of injury
Bend at knees; keep feet wide apart	A broad base of support increases stability. Maintains center of gravity
Use arms and legs (not back)	Leg muscles are stronger, larger muscles capable of greater work without injury
Slide patient toward your body using pull sheet or slide board. When transferring pt. onto a stretcher or bed, a slide board is more appropriate.	Sliding requires less effort than lifting. Pull sheet minimizes shearing forces, which can damage patient’s skin
Person with the heaviest load coordinates efforts of team involved by counting to three	Simultaneous lifting minimizes load for any one lifter
Perform manual lifting as last resort and only if it does NOT involve lifting most or all of patient’s weight	Lifting is a high-risk activity that causes significant biochemical and postural stressors

 

8. Bone marrow biopsy: Couldn’t find anything in Foundations book or Kaplan- Nursing 2016 article http://journals.lww.com/nursing/Citation/2006/03000/Assisting_with_bone_marrow_aspiration_and_biopsy.56.aspx

Nursing responsibilities include preparing and educating the patient assessing patient for complications, supporting patient during procedure, and assisting health care provider.

Reinforce the procedure’s purpose with the patient. Explain that they will feel some discomfort and pressure and may hear a crunching sound and feel a pop as the needle penetrates the bone. Make sure they have signed consent form.

Assess for bleeding risk: review history, coagulation studies, platelet count, anticoagulant therapy, and drugs or supplements that interfere with clotting. Assess for allergies to antiseptic or anesthetic solutions.

Determine the patient’s ability to stay still during the procedure and explain the importance of doing so. Take baseline vital signs and administer sedatives as ordered.

Help patient to the appropriate position: lateral decubitus or prone if the insertion site will be the posterior iliac crest, supine if the sternum or anterior crest will be used.

Help patient maintain position and encourage them to take deep breaths and use relaxation techniques during the procedure. Assess patient for pallor, diaphoresis, or other changes. Assist the practitioner as needed. NURS 3015 Foundations Kaplan Study Guide Assignments

After aspiration, apply direct pressure over the puncture site according to hospital policy for 5-10 minutes until bleeding stops. Cover site with a sterile dressing.

Help patient to a comfortable position. Monitor vital signs and assess the puncture site for bleeding.

Properly label and promptly transport all specimens to the lab.

Assess post procedural pain intensity and provide analgesics as ordered. Teach the patient to watch for signs of infection.

DO NOT: Leave the patient unattended during the procedure, don’t let them move during the procedure, and don’t administer analgesics containing aspirin-they may potentiate bleeding.

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9. Bronchoscopy: http://journals.lww.com/nursing/Citation/2000/30070/Preparing_for_bronchoscopy_.8.aspx

Bronchoscopy is performed with local anesthesia and conscious sedation. A clinician threads a flexible fiber-optic bronchoscope through the patient’s mouth to the bronchi.

• Prepare your patient: Obtain a medical history, especially any allergies to analgesics, anesthetics, or latex. Note bleeding disorders, respiratory conditions, and any problems with his cervical spine (because neck may be hyperextended during the procedure). Explain the procedure, including conscious sedation and how it will affect them. Also, tell your patient that:
• Cannot eat or drink for 6-8 hours before the test or 1-2 hours afterward to prevent choking
• If patient wears dentures, ask to remove them
• May be sitting or in the supine position during procedure
• An unpleasant tasting anesthetic sprayed in to his nose and throat will suppress gag and cough reflexes
• Patient will receive oxygen and should breathe through their nose
• BP, breathing, and heart rhythm will be monitored
• After procedure, patient will need someone to drive them home, and they shouldn’t drive for 24 hours
• May have hoarseness, be unable to speak, or have a sore throat or blood tinged sputum.
• Patient should seek medical treatment if coughing up frothy, bright red blood, has chest pain or trouble breathing
• Avoid airway irritation by not smoking or coughing for 24 hours

10. Changing Dressings: (pages 53-55, Kaplan)

Inspection- color, temperature, elasticity. Skin Lesions-describe size, shape, location, color, and distribution.

Measure	Rationale
Leave dry dressing intact	Prevention of contamination of area
Use sterile dressings and technique for open wounds	Prevention of infection
Observe for fever, elevated WBC count, swelling, redness of wound, wound culture of drainage	Signs of potential wound infection
Elevate extremities	Adequate circulation of WBC, nutrients promote healing
Debride or assist with debriding wound if necessary	Debris may also promote increased inflammation
Frequent dressing changes if drainage copious	Purulent drainage promotes skin breakdown; moisture promotes bacterial growth
Adequate nutrition including protein and vitamin C	Collagen formation requires protein and vitamin C

NURS 3015 Foundations Kaplan Study Guide Assignments

 (page 1226-1230, Foundations)

• Explain procedure and instruct patient to not touch wound area or sterile supplies
• Position patient comfortably and drape with blanket to expose only wound site
• Plan dressing change: 30-60 minutes following administration of analgesics
• Remove tape: gently push skin away from tape while pulling adhesive from site
• Remove gauze dressing one layer at a time, taking care not to dislodge drains or tubes.
• IF DRESSING STICKS ON DRY DRESSING, MOISTEN WITH SALINE AND THEN REMOVE.
• Observe wound for color, edema, drains, and exudates and amount of drainage on dressing
• Fold dressings with drainage contained inside and remove gloves inside out. With small dressings remove gloves inside out over dressing. Dispose of gloves and solid dressings in disposable bag. Perform hand hygiene.
• Open sterile dressing tray or individually wrapped sterile supplies. Place on bedside table and apply clean gloves.
• Clean wound with solution. Using gauze or antiseptic sab, clean from least contaminated area, which is the incision or the center of the wound, to most contaminated area, which is outside the incision and surrounding skin. Dry area. Remove and dispose of gloves and perform hand hygiene.
• If ordered irrigate wound- pour ordered solution into sterile irrigation container, apply clean gloves, protective eyewear, mask, and gown, if needed. Place waterproof pad under patient. Using a syringe, gently allow solution to flow over wound. Continue until irrigation creates a clear flow of solution. Dry surrounding skin with gauze pads. Measure wound. Remove gloves and perform hand hygiene.

*Never use a moist-to-dry dressing in a clean granulating wound. Use only for debridement. For highly colonized wounds, use sodium hypochlorite (Dakin’s solution) instead of water or normal saline.

*When a drain is present, use precut, split gauze. Never cut gauze to fit around a drain because the cut edges will fray and enter the wound or irritate the periwound tissue.

If you want to read the ways to apply dressings-Foundations book page 1228-1237.

11. Clear Liquid Diet (Judgement)

            Kaplan p 218 and Foundations Book 1074

• Fruit juices with pulp and milk are not allowed on a clear liquid diet
• The purpose is to maintain fluids
• Commonly used postoperatively, with acute vomiting, or diarrhea
• Sample meal items: gelatin dessert, Popsicle, tea with lemon, coffee, ginger ale, bouillon, or fruit juices without pulp.

12. Pt Outcomes ()

            Foundations book p. 244

• A nursing-sensitive patient outcome is measurable by the patient, family, or community.
• All goals and outcomes must be patient centered
• Nursing-sensitive outcomes are largely influenced by the nursing staff

 

13. Confidentially (Judgement)

            Foundations book p. 61, 293, 306, 359-361

• Guarantees that any information a patient provides will not be reported in any manner that identifies the patient and will not be accessible to people outside the research team
• HIPPA mandates confidentially and protection of patient’s personal rights
• HIPPA also defines fines for violations of HIPPA
• Patient confidentially is a sacred trust, and nurses are a big part in protecting this
• HIPPA does not require soundproof rooms, but hospital staff needs to avoid discussing info public settings.
• Only team members who need to know a patient’s information for treatment of the patient should access the record or discuss the patient
• HIPPA was the first federal legislation for patient records
• Even electronic documentation has risks. Charting needs to be done in a private setting where other family members or patients can easily see.
• Ensure all fax and telephone numbers are correct when sending information
• Use a coversheet to add privacy
• Use encryption feature on fax machines to make information impossible to read without the key.
• Log fax transmissions

14. Contact Lens (Judgement)

            Foundations book p. 844-845

• A thin, transparent, circular disk that fits over the cornea.
• Educate patients about the importance of removing the lenses periodically to prevent infections, corneal ulcers, and abrasions.
• Always thoroughly wash hands when applying or removing contacts
• If an unresponsive or confused patient comes to the hospital and it is determined the patient has contacts in, they must be removed to prevent these infections.
• Contact lens care
  • Instruct the patient on the following:
    • Do not use fingernails to remove dirt or debris
    • Do not use tap water to clean soft lenses
    • Follow recommendations of contact manufacture
    • Keep lenses moist when not being worn
    • Use fresh solution daily when storing lenses
    • Thoroughly rinse contact case daily, wash periodically with soap
    • If lens is dropped, moisten finger to pick it up and thoroughly disinfect
  • To avoid mix-up always start with the same lens when taking out and putting in contacts
  • Throw away disposable contacts as prescribed
  • Tech the patient RSVP, if any of these problems occur, remove lenses immediately and if problems persist contact your doctor
    • Redness
    • Sensitivity
    • Vision Problems
    • Pain

15. Documentation and Nursing Judgement (Concept) – NURS 3015 Foundations Kaplan Study Guide Assignments

            Foundations p. 356-358 and CH 26

• The definition of documentation is a nursing action that produces a written account of pertinent patient data, nursing and clinical decisions and interventions
• Truthful documentation is important because every member of the treatment team will look at a patient’s medical record for information
• Accurate documentation is one of the best defenses against legal action, this limits nursing liability by providing evidence of proper nursing standards during care
• Documentation needs to indicate the patient received individualized and goal-oriented treatment
• Always describe things exactly as they happened and follow agency standards
• Mistakes include; failing to record pertinent health or drug information, failing to record nursing actions, failing to record medication administration, failing to record drug reactions or patient’s conditions, incomplete or illegible records, and failing to document discontinued medications
• Many of the confidentially standards are also in this chapter

16. EKG (Concepts)

            Kaplan p 110-111

• Determine Rate
  • Count the number of 0.2-s intervals between two R waves, divide by 300
  • Count the number of R-R intervals in 6 seconds, multiply by 10 (only for regular rhythm)
• Determine Rhythm
  • Presence or absence of P wave- SA node originated impulse
  • Measure P-R interval- normal: 0.12-0.20 s
  • Measure QRS duration- normal: 0.04-0.12 s
  • Check P wave, QRS complex, ST segment, and T wave
• There is information in the foundations book about ECG on page 875 and 876, but I couldn’t find information on EKG. NURS 3015 Foundations Kaplan Study Guide Assignments

17. Elevated Body Temperature (Judgement)

            Foundations book p 488-

• Fever
  • Occurs because heat loss mechanisms can’t keep pace with heat production.
  • If a fever does not go above 102.2F in adults or 104F in children, it is not normally harmful.
  • One high reading does not mean a patient has a fever
• Hyperthermia
  • An elevated body temperature related to the inability of the body to promote heat loss or reduce heat production.
  • Fever occurs due to an upward shift in the set point, whereas hyperthermia occurs due to an overload of the thermoregulatory mechanisms of the body.
  • Malignant Hyperthermia: a hereditary condition of uncontrolled heat production.
• Heatstroke
  • Heat depresses hypothalamic function
  • Prolonged sun or high temperature exposure overwhelms the heat-loss mechanisms of the body.
  • Defined as a body temperature greater than 104F.
  • MEDICAL EMERGENCY
  • Highest risk patients: elderly, people with cardiovascular disease, hypothyroidism, diabetes, or alcoholism.
  • There are medications that decrease the body’s ability to lose heat, these patients need to be educated on these risks.
  • Signs and symptoms:
    • Giddiness
    • Confusion
    • Delirium
    • Excessive thirst
    • Nausea
    • Muscle cramps
    • Visual disturbances
    • Incontinence
    • MOST IMPORTANT: HOT, DRY SKIN
  • Vital signs: increase HR and decreased BP
  • Patients do not sweat
  • Heat Exhaustion
    • Occurs when profuse diaphoresis results in excessive water and electrolyte loss.
    • Signs and symptoms include deficient fluid volume.
    • Treatment includes transporting to a cooler environment and restoring fluids and electrolytes.

 

18. Enemas (Recall)

            Foundations book p. 1163-1166 and Skill 47-1 p. 1170-1173

• Position the patient on the bedpan, not the toilet, when inserting an enema. Placing them on the toilet places the enema tubing in dangerous positions that may cause harm.
• Different types of enemas:
  • Cleansing Enemas: promote complete evacuation of feces from the colon. This stimulates peristalsis through local irritation of the mucosa of the colon
  • Tap Water Enemas: A hypotonic solution that exerts an osmotic pressure lower than the interstitial spaces. After being infused tap water escapes the bowel into interstitial spaces. Be cautious when repeating this as circulatory overload may occur.
  • Normal Saline Enemas: This is the safest solution, because it exerts the same amount of pressure as fluids in the interstitial spaces surrounding the bowel. The saline stimulates peristalsis.
  • Hypertonic Solution Enemas: These pull fluid out of the interstitial spaces and promotes defecation. This is a low volume enema, and is contraindicated in patients who are dehydrated or young adults.
  • Soapsuds Enemas: This enema irritates the intestine to stimulate peristalsis. Only use the castile soap that comes in the kit. Use caution when using these in pregnant women and the elderly, this may cause electrolyte imbalance. These may be ordered as high or low cleansing enemas, high cleans more of the colon. After inserting the enema, have the patient lie on the opposite side of insertion to ensure the enema reaches all the large intestine. A low enema cleans only the sigmoid colon and the rectum.
  • Oil Retention Enemas: This enema lubricates the feces and softens the feces due to the feces absorbing the oil. To get the most benefit the patient must retain the enema for several hours if possible.
  • Kayexalate Enemas: A sodium polystyrene sulfonate used to treat patients with dangerously high levels of potassium in the body. This enema exchanges sodium ions for potassium ions in the large intestine.
  • Carminative Enemas: This type provides relief from gaseous distension. It is also called a MGW solution and it contains 30ml of magnesium, 60ml of glycerin, and 90ml of water.
  • Neomycin Solution Enemas: An antibiotic used to reduce bacteria in the colon before surgery.
• Skill 47-1 Administration of a clean enema
  • After preforming hand hygiene, identifying the patient, explaining the procedure, and gathering supplies assist the patient to a left sims lying position and flex the right knee.
  • Place a water proof pad and cover the patient as much as possible.
  • Examine the rectal area for abnormalities or lesions
  • Administering the enema:
    • Add warmed solution to the enema bag, check temperature on the inner wrist to ensure it is not hot as this may cause damage to the mucosal lining.
    • Prime the tubing, removing all air, and recap
    • Lubricate the tubing 6-8 cm of the tubing to ensure smooth insertion.
    • Separate the buttocks and instruct the patient to relax and slowly breathe out, promoting the relaxation of the sphincter.
    • Slowly insert the tip toward the patient’s umbilicus to prevent trauma. For an adult insert the catheter 7.5-10 cm and a child 5-7 cm.
    • Hold the tubing in place until all the solution has been administered.
    • Allow the solution to enter slowly holding the bag at the patient’s hip level.
    • Raise slowly until the proper height has been achieved. (30-45 cm for a high enema, 30 cm for regular enema, and 7.5 cm for a low enema)
    • If a patient is complaining of cramping or fluid is escaping from around the rectum, lower the enema.
    • Instruct the patient to hold the enema in for as long as possible

NURS 3015 Foundations Kaplan Study Guide Assignments

19. Eternal Tube Feedings (Judgement Call)

            Foundations book p. 1074-1077

• Eternal Nutrition is used for patients who have a functional GI tract but are unable to swallow or take nutrients orally
• Patients with a low risk of reflux receive GI feedings, if reflux is likely jejunal feeding is preferred
• After tube placement a X-Ray is required to verify placement of the tube.
• Tube feedings are started at low rates and slowly increased if no signs of intolerance occur
• A serious consequence of tube feeding is aspiration, due to the high glucose of the formula, if the patients aspirates the formula creates a bacterial medium and allows for rapid growth
• Always turn off feeding if the head of the bed must be lowered to prevent aspiration
• Always check the residual volume of the stomach to check for delayed gastric emptying
• Recommendations
  • Stop feeding immediately if aspiration occurs
  • Withhold feedings and reassess if GRV is over 500ml
  • Routinely evaluate the patient for aspiration
  • Use nursing measures to reduce the risk of aspiration if GRV is between 250 and 500ml
• Review inserting and removing NG tubes if necessary Skill 45-2 P 1085-1089
  • I chose not to include the steps because this is a judgement subject

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20. Epilepsy and Seizures (Priorities)

            Foundations book p 393-394

• Seizures can happen as a result of neurologic injury or metabolic disturbance
• A seizure is defined as hyperexcitation and disorderly discharge of neurons of the brain
• A general grand mal seizure lasts about 2-5 minutes
• During this many musculoskeletal injuries can occur, so it is extremely important to protect the patient
• Observe a patient during and after so accurate documentation can occur
• Seizure precautions
  • Protect a patient from traumatic injury
  • Position for adequate ventilation and drainage of secretions
  • Provide privacy and support
• Box 27-14 Tips for protecting patients during a seizure
  • When a seizure begins note the time, stay with the patient, and call for help. Track the duration of the seizure and notify the health care provider
  • Position the patient safely. Guide patient to the floor if standing or sitting and protect the head by placing on your lap
  • Do not lift patient while seizure is in progress. Clear surrounding area of any pillows or furniture and raise side rails is patient is on a bed
  • If possible turn patient on side slightly tilt head forward
  • Do not restrain patient, if limbs are flailing hold loosely. Loosen tight clothes
  • Do not place anything in the patient’s mouth. Insert a bite-block in advance if you recognize the possibility of a tonic-clonic seizure
  • Stay with the patient, observing the sequence and timing
  • Reorient and reassure the patient once they regain consciousness and place them in a comfortable position on the bed
  • Conduct a head-to-toe evaluation, including the oral cavity for damage due to bites and look for brusing

21. Ethics (Judgement)

Source:  KAPLAN Video à “Ethics”

Ethics—principles of right and wrong or good and bad

• These are used to identify solution from problems that arise from a conflict in values
• These are based off of personal beliefs and cultural values

NURS 3015 Foundations Kaplan Study Guide Assignments – ANA Code of Ethics

Ethical reasoning process

Behaviors for handling complaints

Ethical principles of Nursing

• Autonomy
• Beneficence
• Nonmalefiecence—do no harm
• Justice
• Veracity
• Confidentiality
• Fidelity

Sample Question:

Answer:  4

22. Fecal Impaction (Recall)

Source:  Foundations textbook (pg. 1152)

Fecal impaction—results when a patient has unrelieved constipation and is unable to expel the hardened feces retained in the rectum

• Patient’s at risk include:
  • Debilitated (weak)
  • Confused
  • Unconscious
• Signs of fecal impaction:
  • Inability to pass stool for several days, despite the urge to defecate
  • Continuous oozing of liquid stool
  • Loss of appetite, nausea or vomiting, abdominal distention, and possible rectal pain

Other notes about fecal impaction…

• A nursing “NO-NO”, NEVER DOCUMENT

23. Feeding A Client (Judgement)

Source: Foundations textbook

Assisting Patients with Oral Feeding (pg. 1074)

• Have HOB at 90 degrees
• Have patient flex the head slightly to a chin-down position to help prevent aspiration
• Sometimes patients with impaired vision or decreased motor skills can still be independent during meal times but they may need to use large-handled adaptive devices
• Determine which diet they should be on

Enteral nutrition (EN) = feeding tubes (NG tubes) (pg. 1074-1075)

• Preferred method of meeting nutritional needs if the patient is unable to swallow or take in nutrients orally, but they have a functioning GI tract
• Always verify placement via x-ray
• Start the rate off flow then gradually increase
• Aspirations are a large complication from this
  • Prevention: HOB at minimum of 30 degrees, preferably at 45 degrees, measure gastric residual volumes ever 4-6 hours

Parenteral nutrition = administer nutrition through an IV (pg. 1076-1078)

• Total parenteral nutrition (TPN) is administered through a central line
• Used for patients who are unable to digest or absorbed EN, or patients who are septic, head injury, or burns are candidates for PN therapy

24. Femoral Angiogram (Concepts)

(I think this might be one of the topics she said she would send us stuff about??? But this is my best interpretation as to what it is)

Femoral angiogram—an MRI that determines the blood flow to the femoral artery

(Angiogram = a type of MRI that uses contrast dye to take picture of the blood flow to an artery)

• Femoral artery is located in the inguinal region (groin)
• Sometimes deep palpation is necessary to find the pulse here

Signs of Arterial Insufficiency (Table 31-25, pg. 580)

• Color = pale; worsened by elevation of extremity, dusky red when extremity is lowered
• Temperature = cool (b/c blood flow is blocked to extremity)
• Pulse = decreased or absent
• Edema = absent or mild
• Skin changes = thin, shiny skin; decreased hair growth, thickened nails

^Since this question is an “understanding concepts” type questions, I have included these, because I can anticipate a question asking what would be a sign that you may need to obtain a femoral angiogram? Or something along those lines

25. Foot Care (Foot care)

Source:  Foundations textbook (pg. 838-839)

Foot care for patients includes:

• Soaking hands and feet to soften cuticles and layers of horny cells
• Thorough cleaning, drying
• Proper nail trimming

EXCEPTIONS:  patients with diabetes or peripheral vascular disease (because they are at risk for tissue ulceration or infection because soaking causes skin softening or maceration of tissue)

Diabetes:

• When you wash their feet, dry thoroughly, especially between the toes. Do not do long soaks
• Apply an emollient lotion over all surfaces of the feet, but not between toes
• Keep blood flow to feet by putting them up when sitting your toes and moving your ankles up and down for 5 minutes, 2-3 times a day
• Do not cross legs for an extended period of time
• Do not smoke
• Protect the feet from hot and cold. Do not use heating pads or electric blanket and always wear shoes when on hot pavement or at the beach

Other notes about diabetic patients and foot care….

• We never cut their nails; a podiatrist does this

NURS 3015 Foundations Kaplan Study Guide Assignments

26. Fowler’s Positions (Concept)

Source:  Foundations textbook (pg. 429, 848)

Fowlers—head of bed raised to angle of 45 degrees or more

• “semi-sitting” position
• Toot of bed may also be raised at knee

Uses:

• While patient is eating
• During NG tube insertion
• During nasotracheal suction
• Promotes lung expansion
• Eases difficult breathing
• Increases venous return

Semi-Fowlers—head of bed raised approximately 30 degrees

• Foot of bed may also be raised at knee

Uses:

• Promotes lung expansion (especially with ventilator-assisted patients)
• When patients receive oral care
• Gastric feeding to reduce regurgitation and risk of aspiration

Supported Fowler’s Position—head of bed is elevated 45 to 60 degrees, and patient’s knees are slightly elevated without pressure to restrict circulation in the lower legs

Uses:

• Supports need to permit flexion of the hips and knees
• Proper alignment of the normal curves in the cervical thoracic and lumbar vertebrae

 

27. Good Samaritan Law (Priorties)

Source: Foundations textbook (pg. 307)

Good Samaritan Law—encourage health care professionals to assist in emergencies

• Limit liability and offer legal immunity if a nurse helps at the scene of an accident

A nurse can be liable if…

• They act outside of their scope of practice (or one for which you have no training)

Other notes…

• Once you begin providing care you, nurse must stay with that patient until their care is safely transferred to someone who can provide the care needed (EMT)

NURS 3015 Foundations Kaplan Study Guide Assignments

28. Hair Care (Judgement)

Source:   Foundations textbook (pg. 828, 841-842)

Assessment

• Should be clean, shiny, and untangled, and free of lesions
• Observe patients ability to perform hair care

Common Hair and Scalp Problems & Interventions

• Dandruff
  • Shampoo w/ medicated shampoo
• Ticks
  • Using blunt tweezers, grasp tick as close to head as possible and pull upward
• Pediculosis capitits (head lice)
  • Wearing gloves, check entire scalp by using tongue depressor
  • Use special shampoo for eliminating lice
  • *Caution against use of products containing lindane because the ingredient is toxic and known to cause adverse reactions
• Pediculosis corporis (body lice)
  • Bathe or shower thoroughly
  • Apply recommended pidculicide lotion after they are dry from their bath
• Pediculosis pubis (crab lice)
  • Interventions: shave hair off of affected area
• Hair loss (alopecia)
  • Stop hair care practices that damage hair, do not use hair curlers, picks, or tight braiding b/c this contributes to hair loss

Hair and Scalp Care

• Brushing and combing
• Shampooing
• Shaving
  • Always ask first
  • For patients prone to bleeding, use personal electric razor (always check for frayed cords before using these
• Mustache and beard care

29. Hand Hygiene (Concepts)

Source:  Foundations textbook (pg. 458)

Hand hygiene—a general term that applies to four techniques:  handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis

Handwashing—the vigorous, brief rubbing together of all surfaces of lathered hands, followed by rinsing under a stream of warm water for 15 seconds

• Most effective way to prevent and control the transmission of infection
• Fundamental principle behind handwashing is to remove microorganisms mechanically from the hands and rinsing with water
  • Does not kill microorganisms
• Ethanol based hand antiseptics containing 60-90% alcohol seems to be the most effective against common pathogens found on the hands

When to wash hands…

• When hands are visibly dirty, soiled, before eating, after using the toilet
• After exposure to spore-forming organisms such as C. diff
• In clinical setting:
  • Before, after, and between direct patient contact
  • Before putting on sterile gloves and before inserting invasive devices such as catheters
  • After contact with body fluids or excretions, nonintact skins, and wound dressings (even if gloves are worn)
  • When moving from a contaminated to a clean body site during care
  • After contact with surfaces or objects in the patient’s room
  • After removing gloves

Source:  KAPLAN Video “Handwashing”

• Purpose: to decrease number of bacteria on hands and prevent spread of microorganisms
• Begin by standing in front of sink, keep enough distance between you and sink to prevent contamination
• Place hands under warm water
• Place small amount of soap on hands and rub (keep fingers pointed below wrist)
• Wash for at least 30 seconds
• Rinse hands under warm water, continuing to keep fingers pointed downward
• Dry hands thoroughly with paper towel, and turn off sink

NURS 3015 Foundations Kaplan Study Guide Assignments

30. Hazards of Immobility (Priorities)

Source:  KAPLAN Video “Immobility”, more specifically the “complications of immobility” section of this video

• Decubitus Ulcers
  • Interventions:
    • Nurse should use draw sheet when turning client to avoid any shearing force
    • Air mattress, flotation pads, elbow/heel pads, sheepskin = all help with preventing skin breakdown
    • Stryker frames and Circ-Olectric bed = help promote good skin integrity
  • Important for nurse to:
    • Turn client frequently
    • Ambulate client
    • Provide good skin care
    • Provide balanced diet with protein, vitamins, and minerals
  • Sensory input changes
    • Assess for: confusion and disorientation
    • Implementation:
      • Orient client frequently
      • Place a clock and calendar in line of vision
    • Osteoporosis
      • Assess for: pathological fractures and renal calculi
      • Interventions: weight bearing on long bones, a balanced diet, estrogen replacement therapy
    • Negative nitrogen balance
      • Assess for: anorexia, debilitation, and weight loss
      • Interventions: a high protein diet, small frequent feedings
    • Hypercalemia
      • Assess for: impaired bone growth
      • Reduce calcium in diet and encourage fluids
    • Increased cardiac workloads
      • Assess for tachycardia
      • Interventions: teach clients to use trapeze when moving in bed, teach clients to move without holding breath (AKA avoiding the Valsalva maneuver)
    • Contractures
      • Assess for any deformity
      • Prevention: pillow, trochanter rolls, footboard, frequent position change, exercise
    • Thrombosis formation
      • Assess for signs of pulmonary emboli
      • Interventions: TED hose, encourage leg exercise for 5 min every hour, change position, ambulate, do not use bed knee gatch, NO pillow behind the knees, check client for positive Homan sign
    • Orthostatic hypotension
      • Asses for weakness and dizziness
      • Implementations: change positions slowly, increase activity gradually
    • Stasis of respiratory secretions
      • Assess for signs of hypostatic pneumonia
      • Prevention: encourage client to cough, turn, and take deep breaths; and through performing postural drainage
    • Constipation
      • Assess for fecal impaction
      • Implementation:
        • Ambulate
        • Increase fluids and fiber in diet
        • Provide privacy
        • Administer stool softeners
      • Urinary stasis
        • Assess for urinary retention and renal calculi
        • Implementation:
          • Assuming normal position to void
          • Increasing fluid intake
          • Providing diet low in calcium
          • Acidifying urine
        • Boredom
          • Assess for boredom
          • Interventions: provide radio, TV, books, and phone
          • Encourage client to have visitors, occupational therapy may be beneficial
        • Depression
          • Assess for insomnia and restlessness
          • Interventions: encourage client to perform self-care care, start with simple gross activities, increase activities with client tolerance

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**KAPLAN Basics Book Pages 25-26 has other good info on immobility

31. Heat/Cold Therapy

Source:  Foundations textbook (pg. 1216-1218)

• Assess the area to be treated
  • Should be free of lesions, abrasions, open wounds, etc. anything that would increase a patient’s risk for injury
• Assess neurological function
  • To make sure that they can recognize when heat or cold becomes excessive
• Asses a patient’s mental status to be sure that he or she can correctly communication any issues with the hot or cold therapy
• Assess identification of conditions that contraindicate heat or cold therapy
  • Heat is contraindicated when patient has an acute, localized, inflammation (such as appendicitis because they heat could cause the appendix to rupture) or if the patient has cardiovascular problems (b/c the resulting massive vasodilation disrupts blood supply to vital organs
  • Cold is contraindicated if the site is already edematous, if patient has impaired circulation, neuropathy, or if patient is shivering

Other Notes…

• For patients with peripheral vascular disease à pay particular attention to colors of extremities
• When applying heat/cold therapy à allows check electrical equipment for cracked cords, frayed wires, etc. and make sure it does not have leaks, and check for evenness of temperature distribution
• Nurse is legally responsible for safe administration of heat and cold applications-

32. Hemoptysis: bloody sputum; If this is present you need to determine if it is from the upper respiratory tract, due to coughing and bleeding, sinus drainage or GI bleeding. Hemoptysis has an alkaline pH, which makes it different from hematemesis, which is acidic. Providers will do a chest x-ray or bronchoscopy if blood is present
33. Hypoxia: decreased O₂ in the tissues

• causes include: decreased hemoglobin level & lowered oxygen-carrying capacity of the blood, diminished concentration of inspired O₂, the inability of the tissues to extract oxygen from the blood, decreased diffusion of oxygen from the alveoli to the blood, and impaired ventilation;
• early symptoms: restlessness, nasal flaring, elevated BP, tachypnea, tachycardia, pale skin and mucous membranes, accessory muscle use;
• late symptoms: confusion and stupor, cyanosis, bradypnea, bradycardia, hypotension, cardiac dysrhythmias; This is LIFE-THREATENING!

34. Impaired Skin Integrity: It is the nurses’ job to assess the skin and try to prevent breakdown if possible; have pt lying supine when moving or transferring to reduce shearing and friction; Stages of pressure ulcers include:

• Stage I: intact, nonblanchable skin; redness at localized area; discoloration, edema, warmth, hardness, and pain may also be present
• Stage II: shallow, open ulcer w/ red-pink wound bed without slough; it can also be an intact, serum-filled blister
• Stage III: full-thickness tissue loss, sub Q fat may be visible; slough may be present
• Stage IV: full-thickness tissue loss with visible bone, tendon, or muscle; slough and eschar may be present
• Unstageable: full-thickness tissue loss in which slough and/or eschar obscures the actual depth of the ulcer
• Deep Tissue Injury: purple or maroon localized area of discolored intact skin or blood-filled blister

Patients should be repositioned every 2 hours; if they are in a chair, they should shift their weight every 15 minutes. With impaired skin integrity, there is increased risk for infection. Nutrients that are important in wound healing are calories, protein, vitamin C, vitamin A, Zinc, and fluid.  Complications include dehiscence (separation of wound) and evisceration (total separation of wound with protruding organs).

35. Spirometry: encourages and promotes deep breathing, prevents or treats atelectasis in the post-op patient; promotes lung expansion; pt should be in semi-fowler’s or high-fowler’s position; lips should completely cover the mouth piece; have pt inhale slowly and hold breath for 2-3 seconds; they should not exceed 10-12 breaths each minute; have them breath normally between each set of 10.
36. Indwelling Catheter: catheters should be cleaned 3x per day with soap and water, and clean away from the urethra; MAINTAIN STERILITY when inserting catheters; if a sample is needed, the first one may be taken from the bag, but after that you must aspirate from the catheter port.

• Indications for short term: obstructed urine outflow, surgical repair of bladder, prevention of urethral obstruction, measuring urine output for critically ill patients, and continuous or intermittent bladder irrigations
• Indications for long term: severe retention with recurrent UTI’s, skin rashes, ulcers, or wounds that would be irritated by urine, and terminal illness when bed changes would be painful for the patient

37. Informed Consent: the role of the nurse is to serve as a witness that the patient gives voluntary consent and to make sure the patient understands before they sign. The nurse also needs to notify the provider of any questions the patient may have and document.
38. Catheter: see above for indwelling catheters; straight catheters are used intermittently only; still a sterile procedure; no balloon; indications include: relieving discomfort, obtaining a sterile specimen, assessing residual urine, and management for patients with spinal cord injury or incompetent bladders on a long-term basis
39. Input & Output: when measuring input, all liquids must be documented. This includes but is not limited to: popsicles, any drinks the pt consumes, jello, broth, IV fluids, blood, ice chips, etc. When measuring output, discard the first urine and record all others after that. If you are doing a 24-hour output, you must document EVERY drop of urine, except for the first one of the morning. If any is poured out without being measured you must start over. I&O should always be about equal.  If it is not, there could be a problem with fluid retention or dehydration.  If I>O, could indicate retention. If O>I, the patient could be dehydrated or at risk for dehydration.

NURS 3015 Foundations Kaplan Study Guide Assignments – Exercise

40. Exercise

• Is a physical activity that conditions the body, improves health, and maintains fitness.
• A patient’s individual fitness depends on any health-related physical limitations, his or her, tolerance, and they type and amount of exercise or activity that he or she is able to tolerate.
• Isometric– involves tightening or tensing a muscle without moving a body part. ( tightening the quadriceps and gluteal muscles) these movements are ideal for patients who cannot tolerate activity. They prevent muscle wasting and promote toning.
• Isotonic – causes muscle contraction and changes in muscle length (walking, dancing, swimming, etc). Theses movements enhance circulation and respiration functioning, increases muscle mass and combat against osteoporosis.

41. Low Fat Diet

Kaplan book (pg 218) Simple meal items: fruit, vegetables, cereals, lean meats

Common medical problem: Atherosclerosis, Cystic fibrosis (CF)

Purpose: to reduce calories from fat and minimize cholesterol intake

Not allowed: Marble meats, avocado, milk, bacon, egg, yolks, and butter

42. Making an occupied bed

Steps

1. Check chart for orders or specific precautions concerning patient movement and positioning
2. Gather needed supplies, being sure not to let clan linen touch your uniform
3. Explain procedure to patent, including that he or she will be asked to tunr on side and roll over linen.
4. Perform hand hygiene and apply clean gloves( only wear gloves is old linen is soiled or risk for contact with body)
5. Assess potential for patient incontinence or excess drainage on bed linen
6. Arrange equipment on bedside chair or over bed table. Remove unnecessary equipment such as dietary tray or items used for hygiene. Pull curtain and close door
7. Adjust bed height. Lower side rails on side of bed. Remove call light
8. Loosen top linen at foot of bed
9. Remove bedspread and blanket separately. If spread and blanket are soiled place them in linen bag. Keep soiled bag away from uniform
10. If blanket and spread are to be reused, fold them. Then place them over back of chair
11. Cover patient with bath blanket in the following manner: unfold bath blanket over top sheet. Ask patient to hold top edge of bath blanket. If patient is unable to help, tuck top of bath blanket under shoulders. Grasp top sheet under bath blanket at patient shoulders and bring sheet down to foot of bed. Remove sheet and discard in linen bag.
12. Help patient turn toward far side of bed; turn onto side and facing away from you. Be sure that side rail in front of patient is up. Adjust pillow under patient’s head.
13. Loosen bottom linens, moving from head to foot. With seem side down, fan fold soiled draw sheet and bottom sheet toward patient. Tuck edges of linen just under buttocks, back, and shoulders. Do no fanfold mattress pad if it is to be reused.
14. Wipe off any moisture on exposed mattress with paper towel and appropriate disinfectant. Make sure that mattress surface is dry before applying linens.
15. Apply clean linen to exposed half of bed:
    1. Place clean mattress pad on bed(if used) by folding it lengthwise with center crease in middle of bed. Fanfold top layer over mattress( If pad is reused, simply smooth out any wrinkles.)
    2. If using flat sheet for bottom sheet, unfold sheet lengthwise so center crease is situated lengthwise along center of bed. Fanfold top layer of sheet toward center of bed alongside patient. Smooth bottom layer of sheet over mattress. If using fitted sheet, pull sheet smoothly over mattress ends.
    3. Allow edge of flat unfitted sheet to hang about 10 inches over mattress edge. Make sure lower hem of bottom flat sheet lies seam down and even with bottom edge of mattress
16. If flat she is used for bottom sheet make a triangular fold with sheet.
17. Place single waterproof pad over draw sheet with centerfold against patient’s side. Fanfold top layer toward patient.
18. Advise patient that rolling over thick layer of linens is necessary and that he or she will fell a lump. Have patient roll slowly toward you over the layers of linens. Have patient lie still and raise side rail on working side before going to other side of bed.
19. Lower side rail. Help patient to comfortable position on other side as needed. Loosen edges of soiled linen from under mattress
20. Remove all soiled linen by folding it into a bundle or square with soiled side turned in. discard in linen bag. If necessary wipe mattress with antiseptic solution and dry mattress surface before unfolding and applying clean linen.
21. Pull clean, fanfold linen smoothly over edge of mattress from head to foot of bed. Help patient roll back into supine position
22. If using a fitted sheet, pull it smoothly over mattress ends. If using a flat sheet, miter top corner of bottom sheet when tucking corner is sure that sheet is smooth and free of wrinkles.
23. Facing side of bed, grasp remaining edge of bottom flat sheet. Lean back, keep back straight, and tuck sheet under mattress. Tuck from middle to top and then to bottom.
24. Smooth fan folded draw sheet out over bottom sheet.
25. Place top sheet over patient
26. Place blanket on bed unfolding it so crease runs lengthwise along middle
27. Place spread over bed
28. Make cuff by turning edge of top sheet down over top edge of blanket and spread
29. Standing on one side at foot of bed. Lift mattress corner slightly with on hand and tuck sheet and blanket together under mattress. NURS 3015 Foundations Kaplan Study Guide Assignments
30. Raise side rail, make other side of bed.
31. Change pillowcase.
32. Place call light with patients reach and return bed to comfortable position and height. Open curtains.
33. Place dirty linen in hamper of chute. Remove gloves, dispose and preform hand hygiene
34. Ask patient if they feel comfortable.
35. Use this time to inspect skin for areas of irritation

 

43. Maslow

• Basic human needs are elements that are necessary for human survival and health.

·        Self -Actualization ·        Self-Esteem ·        Love & Belonging needs ·        Safety & Security ·        Physiological o   O2 o   Fluids o   Nutrition o   Body Temp o   Elimination o   Shelter o   Sex

44. NG Tube
45. Explain Procedure to patient
46. Perform hand hygiene & apply clean gloves
47. Prepare feeding container and formula
    1. Check expiration date. Integrity of container
    2. Have tube feeding at room temperature (cold formula causes cramping)
    3. Connect tubing to container as needed or prepare ready to hang container
    4. Shake formula well. Cleanse top of canned formula wit alcohol swab before opening it. Fill container with formula.
48. Place patient in High fowlers position or elevate HOB. (Prevents aspiration)
49. Verify tube placement
    1. Nasogastric tube- attach syringe and aspirate 5ml of gastric contents. Observe appearance and note pH.
    2. Gastrostomy tube- attach syringe and aspirate 5mL of gastric contents
50. Check for gastric residual volume before each feeding for bolus and intermittent feeding. (Q 4 hours for critically ill patients, Q4-6 hours non critical ill patients)
51. Flush tubing with 30mL of water.
52. Initiate feeding
53. Flush with 30mL of water
54. Rinse bag and tuning with warm water.
55. Change bag and new administration set every 24 hrs.
56. Evaluate patient.

45. Nursing Diagnosis – is a clinical judgment concerning a human response to health conditions/life process, or vulnerability for that response by an individual, family, or community that a nurse is licensed and competent to treat. Can be problem focused or state of health promotion or potential risks.

• Provides a precise definition of a patients response to health problems that gives nurses and other professionals a common language
• Allows nurses to communicate what they do among themselves with other health care professionals and the public
• Distinguishes the nurses role from that of other health care providers
• Helps nurses focus on the scope of nursing practices
• Foster the development of nursing knowledge
• Promotes creation of practice guidelines that reflect the essence and science of nursing.

Problem focused nursing diagnosis– describes a clinical judgment concerning an undesirable human response to health condition/life processes that exists in and individual, family, or community

• Defining characteristics
• Related to factors

Risk nursing diagnosis– clinical judgment concerning the vulnerability of an individual, family group, or community for developing undesirable human response to health conditions.

• Do not have Defining characteristics or related to factors. Instead they have risk factors

Health promotion nursing diagnosis– is a clinical judgment concerning a patient motivation and desire to increase well-being and actualized human health potential.

            Defining Characteristics.

46. Oral Care-

– Regular oral hygiene includes brushing losing and rinsing prevents and controls plaque associated oral diseases.

• Evidence relates poor oral health to risk of impaired nutrition, stroke, poor blood sugar control in diabetes, and nursing home acquired pneumonia. (pg 839)

47. Drainage

• Note color, amount, odor and consistency of wound drainage. The amount of drainage depends the type of wound.
• Serous (clear, watery plasma), purulent (thick, yellow, green, tan, or brown), serosanguineous ( pale, pink, water mixture of clear and red fluid), and sanguineous( Bright red, indicates active bleeding). If drainage has a pungent or strong odor you should suspect infection.
• Drains: Penrose drain lies under a dressing; at the time of placement a pin or clip is placed through the drain to prevent it from slipping farther into a wound. NURS 3015 Foundations Kaplan Study Guide Assignments

48. Pre OP

(1277)

-Explain the preoperative routines that a patient can expect. Knowing which tests and procedures are planned and why increase a patient’s sense of control. Explain that the anesthesiologist will visit. A patient usually takes nothing by mouth for several hours before surgery to reduce risks for vomiting and aspirating emesis during surgery. Instruct patient to eat adequate amounts of liquids and foods high in in protein weeks before the surgery. Also explain to patient and family the importance of following oral intake instructions for food and liquids before surgery.

– It’s also important to describe preoperative exercise and instructions.

49. Pressure Ulcers – pressure ulcers, pressure sores, decubitus ulcer and bedsores are to describe impaired skin integrity related to unrelieved, prolonged pressure.

*Prevention (in Kaplan book)

1. Frequent turning, skin care, keep skin dry
2. Ambulation as feasible
3. Use draw sheet when turning to avoid shearing force
4. Balance diet with adequate protein, vitamins, and mineral
5. Use air mattress, flotation pads, elbows and heel pads, sheepskin
6. Assist with use of styker frame or Circ-O-Letric bed
7. Gerontolgic considerations
   1. Increased risk- poor nutrition and weight loss, vitamin and protein deficiencies, decreased peripheral sensation, moisture
   2. Identify clients at Risk- Braden scale, weight loss, greater than total body weight, serum albumin less than 3.5 g/dL, pressure areas
   3. Avoid friction during position change, eliminate moisture, move weight bearing from pressure areas(heels protectors) include high protein, vitamins, and carbohydrates in diet.

Patients at risk-

1. older adults, those who experienced trauma
2. those with spinal cord injuries
3. fractured hip
4. those in long-term homes or community care
5. individuals with diabetes
6. patients in critical care settings.

3 Pressure-  related Factors

• Pressure Intensity
  • Blanching occurs when the normal red tones of the light skinned patient are absent.
• Pressure Duration
• Tissue Tolerance

Risk Factors for Pressure Ulcer Development – Impaired Sensory Perception, Impaired Mobility, Alteration in Level of Consciousness, Shear, Friction, and Moisture.

Classification

• Stage 1: Nonblanchable Redness
  • Intact skin, discoloration of skin(warmth, edema, hardness, or pain)
• Stage 2 : Partial- Thickness
  • Partial thickness loss of dermis. Presents as a shallow open ulcer with red-pink wound bed. Without slough. May also form a blister.
• Stage 3: Full Thickness
  • Fat may be visible, but bone, tendon, and muscle are not exposed. It may include undermining and tunneling
• Stage 4 : Full Thickness Skin Loss
  • tissue loss with exposed bone, tendon, or muscle subcutaneous fat may be visible.
• Unstageable/ Unclassified: Full Thickness or Tissue Loss- Depth Unknown
  • Full thickness tissue los in which actual depth of an ulcer is completely obscured by slough (stingy substance attached to wound bed) and eschar(necrotic tissue) in wound bed. True depth cannot be determined.
• Suspected Deep Tissue Injury- Depth Unknown
  • Suspected deep-tissue injury is a purple or maroon localized are of discolored intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure and or shear.

50. Pulse Ox (Foundations Book pgs. 522-525)

• Normal (acceptable) ranges: 95%-100%
• A value of less than 90% is considered hypoxemia
• However, values below 90% may be acceptable for certain chronic conditions
• Risk factors for decreased oxygen saturation: acute or chronic compromised respiratory function, recovery from general anesthesia or conscious sedation, traumatic injury to the chest wall, ventilator dependence, changes in supplemental oxygen therapy
• S/S of alterations in oxygen saturation: altered respiratory rate, depth, rhythm, adventitious breath sounds, cyanotic appearance (of nail beds, lips, mucous membranes, and skin), restlessness, irritability, confusion, reduced level of consciousness, and labored or difficult breathing
• Hemoglobin level, body temperature, and medications can influence SpO2 measurement
• Assess capillary refill of site before placing the probe on the site (if capillary refill is greater than 2 seconds, select a new site)
• Appropriate sites include: fingers, earlobe, forehead, etc.
• Site must be free of moisture, nail polish, or artificial nails
• If tremors are present, use the patient’s earlobe as the site
• If continuous pulse ox monitoring is necessary, assess skin integrity underneath the probe every 2 hours and change the site of the probe every 24 hours or more frequently if needed

51. Pulse Sites (Kaplan Basics Book pg. 13)

• Radial: passes medially across the wrist, felt on the radial (thumb) side of the forearm
• Ulnar: passes laterally across the wrist, felt on the ulnar (little finger) side of the wrist
• Femoral: passes beneath the inguinal ligament (groin area) into the thigh, felt in the groin area
• Carotid: pulsations can be felt over medial edge of sternocleidomastoid muscle in neck
• Pedal: passes laterally over the foot, felt along the top of the foot
• Posterior tibial: felt on inner side of ankle below medial malleolus
• Popliteal: felt in popliteal fossa, the region at the back of the knee
• Temporal: felt lateral to eyes
• Apical: left at fifth intercostal space at midclavicular line

52. Range of Motion (Foundations Book pgs. 595-597)

• Active ROM: the patient performs this by themselves
• Passive ROM: the patient relaxes as the nurse performs the ROM on the patient
• Compare the same body parts for equality in movement
• Never force a joint into a painful position
• Flexion: movement decreasing angle between two adjoining bones
• Extension: movement increasing the angle between two adjoining bones
• Hyperextension: movement of body part beyond its normal resting extended position
• Pronation: movement of body part so that the front or ventral surface faces downward
• Supination: movement of body part so that the front or ventral surface faces upward
• Abduction: movement of extremity away from midline of body
• Adduction: movement of extremity toward midline of body
• Internal rotation: rotation of joint inward
• External rotation: rotation of joint outward
• Eversion: turning the body part away from the midline
• Inversion: turning of the body part toward midline
• Dorsiflexion: flexion of toe and foot upward
• Plantar flexion: bending of toes and foot downward

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53. Stool Specimen (Kaplan Basics Book pg. 220)

• Fecal Occult Blood Test: tests for presence of blood; normally, blood absent
• Stool For Quantitative Analysis: reviewed for color, consistency, and amount
• Stool for presence of Clostridium difficile infection

54. Suctioning (Kaplan Basics Book pg. 167)

• Assess need for suctioning
• Wear protective eyewear
• Hyperoxygenate before and after suctioning- 100% oxygen for 3 minutes, at least 3 deep breaths
• Explain the procedure to the client because it could be a potentially frightening procedure
• Elevate the HOB to semi-Fowler’s position
• Lubricate catheter with sterile saline and insert WITHOUT applying suction
• Advance catheter about 16-20 cm; client will begin to cough; DO NOT apply suction
• Withdraw catheter 1-2 cm, apply suction and withdraw catheter with a rotating motion for no longer than 10-15 second; wall suction set between 80-120 mmHg
• Hyperoxygenate for 1-5 minutes or until client’s baseline heart rate and oxygen saturation are reached
• Repeat procedure after client has rested, up to 3 total suction passes
• Endotracheal tube or tracheostomy tube suctioned, then mouth is suctioned; provide mouth care
• Complications of suctioning

            -Hypoxia

            -Bronchospasm

            -Tissue Trauma

            -Vagal Stimulation

            -Cardiac Dysrhythmias

            -Infection

55. Presbycusis (Cleveland Clinic)

• Presbycusis is the loss of hearing that gradually occurs in most individuals as the grow older
• The loss associated with presbycusis is usually greater for high-pitched sounds
• Most commonly, it arises from changes in the inner ear of a person as he or she ages, it can also result from changes in the middle ear or from complex changes along the nerve pathways leading to the brain
• Tinnitus may occur

56. Setting Goals (Foundations Book Chapter 18)

• An important part of planning nursing care
• Criteria for Goal Setting; A goal must be….

1. Patient-centered (“The patient will….”)
2. Singular (one outcome)
3. Observable
4. Measurable
5. Time limited (set a time limit for the goal to be achieved, if the goal is not achieved in the specified time, maybe interventions are not appropriate and need to be changed)
6. Mutual factors (nurse and patient must agree)
7. Realistic (realistic for patient and staff)

NURS 3015 Foundations Kaplan Study Guide Assignments

57. Communication (Kaplan Basics Book pgs. 537-538)

• Therapeutic Communication is listening to and understanding client while promoting clarification and insight
• Nonverbal communication constitutes 2/3 of all communication and gives the most accurate reflection of attitude
• The person’s feelings and what is verbalized may be incongruent
• Implied messages are as important to understand as overt behavior
• Initiating phase- boundaries of relationship are determined
• Working phase- client develops insights and learns coping
• Terminating phase- work of relationship is summarized
• Therapeutic Responses are techniques which are the main tools to promote therapeutic exchange between the nurse and client

1. Using silence
2. Using general leads or broad openings
3. Clarification
4. Reflection

• Nontherapeutic responses are responses to avoid

1. Close-ended questions
2. Advice-giving
3. Responding to questions that are related to one’s qualifications or personal life in an embarrassed or concrete way
4. Arguing or hostile
5. Reassuring
6. “Why” questions
7. Judgmental responses

 

58. Transfer (Kaplan Basics Book pgs. 27-28)

• If a client has a stronger and a weaker side, move the client toward the stringer side (easier for the client to pull the weaker side)
• Use the larger muscles of the legs to accomplish a move rather than the smaller muscles of the back
• Move client with draw sheet; do not slide a client across a surface
• Always have an assistant standing by if there is any possibility of a problem in completing a transfer
• Sitting client at edge of bed

1. Place hand under knees and shoulders of client
2. Instruct client to push elbow into bed; at same time lift shoulders and bring legs over edge of bed, or use one leg to move other leg over edge of bed

• Assisting client to stand

1. Place client’s feet directly under body; client should wear nonskid slippers
2. Face client and firmly grasp each side of rib cage
3. Push one knee against one knee of the client
4. Rock client forward as client comes to a standing position
5. Ensure that the client’s knees are “locked” while standing
6. Give client enough time to balance while standing
7. Pivot with client to position and transfer client’s weight quickly to chair placed on client’s stronger side

• Use a transfer board when necessary
• Observe what the client can do and allow client to do it
• Encourage client to exercise muscles used for activity
• Start with gross functional movement before going to finer motions
• Extend period of activity as much and as fast as the client can tolerate
• There are alternate ways of doing one thing
• Give immediate positive feedback after every act of accomplishment

59. Urinalysis (Kaplan Basics Book pgs. 301-302)

• An elevated level of ketone bodies indicates altered fat metabolism
• Advise client to save first am culture
• For a urine culture, instruct the client to cleanse the external meatus with povidone-iodine or soap and water prior to the test
• The client should obtain a midstream specimen
• Normal culture- less than 100,000 colonies/ml
• Normal Urine Characteristics

            -Color: yellow

            -Consistency: clear, transparent

            -Specific gravity: 1.010-1.025

            -pH: 4.5-8

            -24-hour production: 1,000-2,000 ml

60. Wet-to-Dry Dressings (Foundations Book pg. 1209)

• The purpose of wet-to-dry dressings is to debride wounds
• Place the moist dressing over the wound bed, cover with a clean gauze and allow the contact layer to dry. In this case the contact dressing is allowed to dry so that it sticks to the underlying tissues and debrides the wound during removal
• This type of debridement can remove viable tissue, it is recommended for debridement in a necrotic wound

61: Wound Irrigation: debrides necrotic tissue with pressure that can remove debris from the wound bed w/out damaging healthy tissue; use a 19-gauge angiocatheter and a 35 mL syringe that delivers saline to a pressure ulcer at 8 psi. Look at the extent of impairment, size, length, width, and depth; look at the type of drainage, odor, and color of the wound; administer a prescribed analgesic 30-60 prior to irrigating; position the pt for easy access; insert your catheter and then pull out about 1 cm; use continuous pressure to flush; pinch catheter and refill the syringe; repeat until drainage is clear.

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