Final For Nursing Practice

What are the steps of the nursing process

A= Assess

D= Diagnosis

P= Planning

I= Implementation

E= Evaluation

State some Interventions that should be used FIRST prior to using restraints

• Engage the client in social interactions.

• Offer client diversional activities.

• De-escalate the situation.

• Place the client in a room near the nurses’ station.

• Encourage family members’ presence at the bedside.

• Have a sitter at the client’s bedside.

• Use bed or chair alarms.

• Remind and reorient the client to not pull on the medical device or to get out of bed.

Use of a restraint should be a last resort to achieve client and staff safety

If restraints are warranted, you are the LEAST invasive restraint first - state the order you would go

• Physical – short term use only

• Mechanical – straps or mitt (this is least invasive mechanical restraint)

• Four-point extremity restraints are the most restrictive: aggressive and dangerous clients.

• Strap safety: quick release knot only, out of reach of the client, applied to the moveable bed frame, not the

side rails

• Chemical

• Barrier – having all four side rails up is a restraint

• Seclusion – inpatient psych settings typically

Nursing Considerations for Restraints

• Documentation

• MD Order

• Needs to be revised and reevaluated every 24 hours

• Pad bony prominences

• Two fingers should fit between restraint and client

Physical restraints can only be applied for either or both of two reasons:

Ø Medical necessity

Ø Behavioral or mental health issues

Assistance with applying and monitoring a physical restraint may be delegated to UAP

after the initial assessment of the patient.

Contact Precautions

gown and gloves at minimum

• Vancomycin- resistant Enterococcus (VRE),

• Clostridium difficile

• noroviruses

• other intestinal tract pathogens

• respiratory syncytial virus (RSV)

Droplet precautions

gown, gloves, surgical masks

• Influenza virus,

• adenovirus, \

• SARS-CoV1

• rhinovirus (common cold)

• Mycoplasma pneumoniae

Airborne Precautions

isolated private room, N95 or higher, gown, gloves

• TB or Covid 19

Donning PPE order

1.) Hand Hygiene

2.) Gown

3.) Mask

4.) Goggles

5.) Gloves

Doffing PPE order

1.) Gloves

2.) Goggles

3.) Gown

4.) Mask

5.) Hand Hygiene

State some Interventions to Maintain Skin Integrity and Avoid Pressure Ulcers + Treatment

• Q2 Turns

• Maintaining Dry Skin and checking patients with incontinence frequently

• ambulate patient

• frequently move devices resting on patient

• clean patient frequently

• maintain adequate fluid intake

• maintain adequate protein intake + vitamins A&C, omega fatty acids

• reposition patient frequently + properly

• avoid massaging bony prominences

• use positioning devices to prevent prolonged pressure on bony prominences

Clear Liquid Diet

Should be clear, liquid foods.

Examples Include: broths, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, popsicles

Full Liquid Diet

Consists of clear liquids with the addition of smooth-textured dairy products, custards, refined cooked cereals, vegetable juice, pureed vegetables, and all fruit juices

Pureed Food Diet

consists of foods that do not need to be chewed

full liquid diet with the addition of scrambled eggs, pureed meats, vegetables, fruits, mashed potatoes and gravy

Mechanical Soft Diet

pureed diet with the addition of ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, or peanut butter

Regular Diet

no restrictions

Soft/low residue diet

low-fiber, easily digested foods such as pastas, casseroles, moist tender meats, canned cooked fruits and vegetables, and deserts without nuts or coconut

Low Sodium Diet

specified as mild sodium restriction with no salt added to food (3-5 g sodium restriction), or moderate (1g) to severe (500 mg), requiring restricting or abstaining from high sodium foods.

Low Cholesterol Diet

Restricted to 300 mg/day of cholesterol

Florence Nightingale

pioneered what is recognized as the first correlation between infection and unclean conditions. Recognized the connection of calming fears and instilling hope and their positive impact upon healing.

clara barton

founded the Red Cross

Mary Eliza Mahoney

first African American licensed nurse

Lillian Wald

pioneer of public health nursing

Mary Breckinridge

founder of frontier nursing service, she pioneered midwifery in the US

Virginia Avenel Henderson

known as the “First Lady of Nursing” she created a nursing definition and framework focused on patient independence

Proper Procedure for Urinary Catheterization

1.) Ensure you have an order to place catheter

2.) Ensure there is no betadine/iodine allergy

3.) Perform hand hygiene

4.) Open the kit while maintaining sterility

5.) Place drape under buttocks

6.) Clean area with betadine

7.) Apply jelly to tip of catheter and insert into urethra

• Once urine is seen, advance

catheter 1-2 inches more

• Attach prefilled syringe to balloon

port and inflate

• Pull back on catheter to ensure it is

place

• Anchor catheter to leg

• Keep bag below bladder level

Ng Tube feedings and things to remember

• position patient at 30 degrees

• listen for audible bowel sounds

• check tube measurement marking

• make sure formula is warmed to room temperature

• test the pH if this is NOT the first feeding (if greater than 6, retake x-ray to confirm correct placement)

• instill 30 ml of air, then pull back in the syringe, pull back syringe, re-instill aspirated contents, then flush with 30 mL of sterile water

• connect to feeding

• flush w/ 30 mL of sterile water after feeding is complete

Checks to follow for enteral or tube feedings

• Aspiration can still be risk of tube feedings:

• Verify the initial tube placement with an x-ray before initial use.

• Check the tube placement every 4 hours by checking the pH of the gastric contents.

• Check the client’s tube feeding tolerance every 4 hours by measuring the residual.

• Follow the facility policy for residuals greater than 250 mL.

• Maintain the head of the bed at 30° to 45° during feeding.

• Maintain the head of the bed at 30° to 45° for at least 1 hour following bolus feeding

• S/S of aspiration: difficulty or painful breathing, wheezing, a productive cough, or a fever of 38°C (100.4°F)

Medications with enteral feedings

• Verify that the medication is compatible with EFT administration

• Elevate HOB to 30 degrees

• Pause tube feeding as policy states

• Confirm placement of the tube

• Aspirate gastric secretions

• Flush with 15-30ml sterile water

• Pour the medication into the syringe (you may need to mix medication with sterile water, can’t crush enteric coated or extended-release meds, sublingual medications)

• Flush with 15-30ml sterile water between medications

• Flush with 30-60ml sterile water after all medications

• Clamp the tube and reconnect to feeding if needed

Administering a Metered Dose Inhaler

shake MDI really well, apply spacer if needed, instruct pt to take a deep breath and exhale, insert mouthpiece and close lips tightly around it, tell patient to depress cannister and inhale slowly for 3-5 seconds, hold breath for 5-10 seconds and exhale. Repeat steps in 30 seconds if second puff is needed 

Proper Nail Care

use orange wood sticks to clean under the nails and soak hands in warm water for 10 mins if not bathing. patient diagnosed with diabetes is usually seen by a podiatrist or diabetic specialist for foot care. Orange sticks can be used for cleaning under nails and to push down cuticles. 

• (Cut nails straight across not rounded. Don’t trim edges.) Do not soak Diabetic and PVD feet, wash and make sure dry in between toes (lambs wool) 

• Pediculicidal shampoos-contraindicated for patients with a history of seizures, pregnant women, and young children 

Provision of Hygiene for pt who is immobile

• Perform hand hygiene before and after care 

• Explain procedures and maintain privacy 

• Encourage participation as able 

• Use warm water and mild soap 

• Clean from cleanest to dirtiest areas 

• Dry skin thoroughly to prevent breakdown 

• Observe skin for redness, breakdown, pressure injuries 

Oral Care for Immobile Patient

• For pt’s w/ special needs: toothette for oral care and place on side if unconscious 

• Moisturizer should be applied to the lips every 2 hours, and oral care performed more often in patents who are intubated or are using oxygen. 

• Chlorhexidine gluconate (0.12%) rinse should be used twice daily for patents who are intubated to prevent ventilator-associated pneumonia (VAP)  

Proper technique in providing perianal care

always performed when pt  is incontinent. For females wash front to back, for males – when uncircumcised – pull foreskin back and cleanse skin, then put back. For Foley Cath. the care is done every day and in these steps – labia, urethra, and then cath.

Prevention of constipation, causes, and interventions to promote bowel movements

Prevention: drink more water/fluids, eat more fiber, exercise more, and certain medications can help

Causes: diets with too little fiber, drinking too little water, medications, decreased activity

Assessment for urinary retention after the removal of a foley cath

• Can use bladder scanner to assess amount of retention

• If 300-500ml post void is seen, catheter may need to be reintroduced

UTI Symptoms and Signs

• dysuria

• frequent urination despite not having a lot of urine to pass

• confusion and change of mental status (in the elderly)

• lower back pain

• frothy urine, burning, or blood in urine

Daily Catheter Care

• wash area with soap and water

• check for kinks in tubing

• empty when 2/3 full

• change catheter if debris or encrustation of the catheter is noted

Foot care for patients

Clients who are at a higher risk for infection should have their feet more closely monitored as infections can cause serious foot problems.

•Wash daily with soap and water

•Dry completely especially between toes

•Apply lotion to heels but not between toes

•Diabetic patients:

•Warm water only, hot water could burn them

•No soaking the feet, as this can dry the skin

•Only trim toenails when acceptable

•Trim straight across

•File edges – DO NOT CUT

Infiltration vs. Phlebitis

Symptoms of infiltration may occur in the affected area and can include:

• pain

• swelling

• blistering

• blanching of the skin

• tingling, numbness, or “pins and needles” sensation

• reduction in temperature

• sensitivity at the IV insertion site

Symptoms of phlebitis may appear in the affected area, including:

• pain or tenderness

• swelling

• increased skin warmth

• itching

• skin discoloration

• changes to the texture of the surrounding skin, such as thickening or hardening

Hypervolemia Signs + Symptoms + What will lab lab values look like

• Hypertension

• Tachycardia

• Weight Gain

• Congestion

• Edema

• Nausea

• Dyspnea

• Bounding Pulse

• Lower, Diluted Labs —> hyponatremia, low hematocrit,

• JVD

• Adventitious Lung Sounds

Hypovolemia Signs and Symptoms + What will Lab Values Look Like

• First Stages: Dry Mucous Membranes, poor urinary output, poor skin turgor, tachycardia, blood vessels are constricted to reserve fluids in vital organs, flat neck veins, low BP

• If Untreated: cyanosis, change in alertness or consciousness, chest pain, palpitaion, no urine, tachypnea, weak pulse

• High and Dry Labs —> elevated BUN and Creatinine, decreased electrolytes, elevated lactate

Hyponatremia

Serum sodium level less than 135 mEq/L

Two types: hypovolemic and hypervolemic

S/S: Lethargy, confusion, seizures, muscle cramps

Tx: restrict water, encourage Na intake within MD order, Hypertonic saline

Hypernatremia

Serum sodium level greater than 145 mEq/L.

S/S: thirst, dry mouth confusion, irritability Decrease LOC

Tx: increase free water Na restriction, hypotonic solutions

BOTH REQUIRE MONITORING VITAL SIGNS, I&O, LOC, SERIAL LABS

Hypokalemia

Serum potassium level below 3.5 mEq/L

S/S: weak irregular pulse fatigue, lethargy muscle weakness, paresthesia, dysrhythmias,

Tx: K supplements

Hyperkalemia

Serum potassium level greater than 5.0 mEq/L

S/S: BradycArdia, Anxiety, twitching, abd cramps, cardiac dysrhythmias, irritability, confusion

Tx: Dextrose/Insulin, Calcium Gluconate, Kayexalate, Dialysis if chemical tx does not work

BOTH LEAD TOO LIFE THREATENING CARDIAC INSTABILITY. REQUIRE VITALS, CARDIAC MONITORING, SERIAL LABS

Hypocalcemia

Serum calcium level below 8.5 mg/dL

S/S: confusion anxiety, numbness/tingling extremities, MUSCLE CRAMPS, hyperactive reflexes, cardiac

dysrhythmias, positive Chvostek and Troussea

Tx: Ca supplements, dietary Ca,

SHOULD BE PLACED ON SEIZURE PRECAUTIONS

Hypercalcemia

Serum calcium level greater than 10.5 mg/dL

S/S: lethargy, stupor, decreased muscle tones, constipation, dysrhythmias, renal calcium

Tx: increase fluid intake, increase activity, utilizes Ca

BOTH REQUIRE CARDIAC MONITORING

what does ROME mean and break it down

ROME= Respiratory Opposite, Metabolic Equal :

Example: (Respiratory Alkalosis, PH high and C02 Low or Respiratory Acidosis PH low and Co2 High)

Metabolic Acidosis= PH Low and Bicarb low Metabolic Alkalosis PH High and Bicarb High.

Fluid Volume Deficit + Overload

Fluid volume deficit- dehydration- dry mucous membranes, flat neck veins, poor skin turgor, low BP

Fluid volume excess- overhydration. CHF

Metabolic Alkalosis s/s

Metabolic alkalosis occurs when there is an excess of bicarbonate or a loss of hydrogen ions, leading to a higher blood pH. Common symptoms include:

• Muscle Cramps and Twitches: Due to electrolyte imbalances, particularly low potassium levels.

• Confusion or Disorientation: Changes in mental status can occur as the body struggles to maintain balance.

• Irritability: Increased nervous system excitability can lead to feelings of anxiety or agitation.

Irregular Heartbeat: Electrolyte disturbances can affect heart rhythm, leading to arrhythmias.

Metabolic Acidosis S/s

Metabolic acidosis is characterized by an accumulation of acid or a loss of bicarbonate, resulting in a lower blood pH. Symptoms include:

• Fatigue and Weakness: General feelings of tiredness can occur as the body struggles to maintain homeostasis.

• Nausea and Vomiting: The body may react to the acid buildup by inducing nausea.

• Rapid Breathing (Kussmaul Breathing): The body attempts to expel carbon dioxide to raise pH levels, leading to deep, rapid breaths.

• Confusion or Lethargy: Severe acidosis can affect cognitive function, leading to confusion or decreased alertness

Respiratory Alkalosis

Respiratory alkalosis occurs when there is excessive elimination of carbon dioxide (CO2) from the body, often due to hyperventilation.

Signs and Symptoms:

• Lightheadedness: A common symptom due to reduced CO2 levels affecting brain function.

• Dizziness: Often accompanies lightheadedness and can lead to fainting in severe cases.

• Tingling in the fingers: Caused by changes in calcium ionization due to low CO2 levels.

• Muscle cramps or spasms: Resulting from altered calcium levels in the blood.

• Confusion or anxiety: Psychological symptoms may arise due to rapid breathing and decreased oxygen availability

Respiratory Acidosis

Respiratory acidosis occurs when the lungs cannot remove enough CO2, leading to increased acidity in the blood.

Signs and Symptoms:

• Headache: Often a result of increased CO2 levels and decreased pH in the blood.

• Confusion: Cognitive impairment can occur due to high CO2 levels affecting brain function.

• Drowsiness or lethargy: Patients may feel unusually tired or sleepy.

• Shortness of breath (dyspnea): Difficulty breathing is common as the body struggles to expel CO2.

• Cyanosis: A bluish discoloration of the skin, particularly around the lips and fingertips, indicating low oxygen levels.

Nasal Cannula

Delivers low concentration of O2 and is a preffered method. Settings vary from 1-6 L/min

• humidification is needed at 4 L

High Flow Nasal Cannula

forces the airway to remain open, needs humidification and a flowmeter

Simple Face Mask

deliver oxygen at a medium concentration, 5-10L/min, can retain CO2 so not recommended for COPD, risk of skin breakdown

Nonrebreather Mask

high flow oxygen, 10-15L/min, ensure the reservoir bag does not completely deflate, CO2 retention risk, snug fitting mask, only temporary

Bag Valve Mask

used for emergency situations where no respirations are occurring

Interventions for those with hearing loss

if hearing impaired patient provide written handouts for directions in addition to your teaching.

If hearing aides are worn, make sure family bring into patient and that they are able to put them on during hospital stay.

Interventions for those with vision loss

Make sure good lighting, patient has clean glasses on, no scatter rugs,

clutter/ cords should be at walls and behind furniture not across walkways.

What is GAS

• A three-stage response to stress that includes alarm, resistance, and

exhaustion.

• When activated, several body systems respond immediately to the stressor(s).

• These physiological changes occur whether the perceived stressor is considered positive (eustress) or negative (distress).

• The goal of GAS is for the body to return to a steady state of internal, physical, and chemical balance (homeostasis) to maintain optimal functioning.

KR stages of Grieving

Denial: Client refuses to believe the truth and this helps to lessen the pain

of the loss

• Anger: Client is trying to adjust to the loss and is feeling severe emotional

distress, often asking "why me?" and suggesting "it’s not fair”

• Bargaining: Usually involves bargaining with a higher power by making a

promise to do something in exchange for a different, better outcome

• Depression: Reality sets in, and the loss of the loved one or thing is deeply

felt

• Acceptance: Client still feels the pain of the loss but realizes they will be all

right

• Not sequential and may not experience all of these

Types of Grief

Normal: Also known as uncomplicated grief, is caused by the loss of someone very close, through death or the ending of a relationship

• Time varies

• Response varies from person to person

• Sadness, guilt, yearning, anger, and regret.

Anticipatory: Grief that is experienced before the expected loss of someone or something

Prolonged grief disorder (PGD): Previously known as complicated grief; lasts >6 months and can be so significant, it affects the client's ability to function

• self-blame, anger, and difficulty participating in new and different activities

Disenfranchised: Grief related to a relationship that does not coincide with what is considered by society to be a recognized or justified loss

• Left to grieve alone and often have feelings of isolation, depression, low self esteem

• Loss of a pet

Sources of Stress

Physiological (physical)

• Generally associated with injury or illness; the body’s reaction is immediate and necessary for survival.

Psychological (emotional)

• Associated with an event, situation, comment, condition, or interaction

that is interpreted as negative or threatening.

• S/S: poor eye contact, irritability,

agitation, poor sleep, lack of eating or

overeating, depression

Acute Stress

• The most common and frequent type of stress.

• Usually brief and can be positive or negative.

• Causes an immediate reaction and triggers the fight-or-flight response.

• EX: motor vehicle accident, experiencing the loss of a loved one

Episodic Acute Stress

• Episodic acute stress

• Occurs when someone experiences frequent bouts of acute stress.

• Over time, can negatively impact relationships, work, and overall health.

• EX: individuals taking on more responsibility than they can reasonably handle and frequently feeling disorganized and rushed

Chronic Stress

A disabling condition that occurs when stress levels are heightened, constant, and prolonged.

• EX: poverty, illness, disease, dysfunctional family system

Promoting Restful Sleep/Sleep Hygiene

• Avoid stimulants, such as caffeine, alcohol, and nicotine at least four to six

hours before bedtime.

• Remove unnecessary light and noise.

• Exercise during the day

• Establish a bedtime routine, such as taking a warm shower or bath.

• Keep room dark, quiet, and at a comfortable, cold temperature.

• Go to bed only when tired.

• Nap for less than 30 minutes

• Routine of same bedtime every night

• Avoid cell phones before bed

• If no sleep in 20 minutes, go to another room and read or listen to music.

• Turn the clock away from view.

Safe Sleep For Infants

• have baby sleep on their back

• Use a firm, flat, noninclined sleep surface to reduce the risk of suffocation or wedging/entrapment

• Breastfeeding is recommended.

• Roomshare without bedsharing.

• Offer a pacifier at nap time and bedtime.

• Avoid smoke and nicotine exposure, as well as alcohol, marijuana, opioids, and illicit drug use during pregnancy and after birth.

• Avoid overheating and head covering in infants.

• Swaddling should not be used as a strategy to reduce the risk of SIDS.

Active Exercises

In nursing, active exercises are movements performed by the patient themselves without assistance, using their own muscle strength to move a joint or limb through its range of motion

Passive Exercises

exercises wherein the nurse performs the movement of the exercise for the patient, manipulating the patients joint in the absence of voluntary muscle movement

Isometric Exercises

Isometric exercises are muscle contractions performed without any movement in the surrounding joints, often used in nursing to maintain muscle strength when a joint is immobilized.

• plank

• squat hold

• imaginary chair

• calf raise hold

• static lunge

Informed vs implied consent

Feature	Informed Consent	Implied Consent
Form	Explicit, verbal or written	Inferred from actions or context
Information	Detailed disclosure of risks, benefits, alternatives	Minimal or no formal disclosure
Documentation	Often formally recorded	Rarely documented
Legal requirement	Required for significant decisions, medical procedures, research	Applies in routine or low-risk situations
Decision-making	Requires understanding and voluntary agreement	Assumed from behavior or circumstances

HAIS

• Healthcare-associated infections (HAIs) are infections that patients get while or soon after receiving health care.

• HAIs can be caused by many different germs and include:

  • Central line-associated bloodstream infection (CLABSI)

  • Catheter-associated urinary tract infection (CAUTI)

  • Surgical site infections (SSI)

  • Ventilator-associated pneumonia

  • Patients and caregivers

    • Wash their hands often with soap and water or using alcohol-based hand sanitizer.

    • Remind people (including healthcare staff) to clean their hands before touching the patient or handling medical devices.

Some KEY things to recall for I&O and calcs

• 1 oz is 30 mL

• ice chips are HALF THE VOLUME WHEN CALC’d

Effective Patient Teaching

• Encourage questions and active listening.

• Use a personalized approach corresponding to patients’ learning needs, and combine different teaching methods if necessary.

• Use plain language and native language materials to overcome communication barriers.

• Involve Family Members

• Consider timing

• Consider providing written materials

DVT Assessment signs

• Swelling in one leg greater than the other

• Leg pain or tenderness 

• Warmth over the site

• Skin discoloration (A tender, subcutaneous venous segment that is indurated, palpable, and cord-like. Discoloration of the lower extremity (reddish-purple or cyanotic) Edema. Petechiae. Blanching on rare occasions)

• Test for Homans Sign (A widely recognized indicator of DVT is the classic finding of calf pain on dorsiflexion of the foot with the knee straight (Homan’s sign).)

DVT Complications —> Pulmonary Embolism

• Difficulty breathing

• Cough

• Chest pain

• Syncope (fainting)

• Palpitations

DVT Labs

• D-dimer levels are elevated with DVT due to the breakdown of fibrin from clots in the blood. A negative result can safely rule out DVT.

• A coagulation profile, including prothrombin time (PT) or activated partial thromboplastin (aPTT), evaluates hypercoagulability.