Fundamentals of nursing exam 1

personal hygiene

promotes physical and psychological well being; must be carried out frequently

for personal hygiene, nurses should always…

respect individual patient preferences!!

give care the patient cannot, or should not, provide for themselves

when bathing a patient…

use a no-rinse, pH-balanced cleanser!

avoid soap and hot water, and MINIMIZE skin exposure to moisture

when should the nurse assess pt’s skin?

daily, and after every episode of incontinence

considerations when bathing bariatric patients

they have an increased risk of skin integrity issues

assess twice daily, lifting and separating skin folds

use NONSOAP cleansers, make sure skin is dry

considerations when bathing incontinent patients

special attention to perineal area

clean skin exposed to irritants well, but without soap or excessive force

considerations when bathing infants/young children

have supplies within reach

hold/support child securely at all times

NEVER leave child alone

considerations when bathing older/dementia patients

check temp of water

focus on comfort, needs, abilities, autonomy, self esteem of pt

individualize patient care

assess behavior (is it a good day or not?)

ensure privacy and warmth

sooth anxiety, remain relaxed, encourage independence

assessments to be made when giving a bath

pt’s knowledge of hygiene/preferences

frequency, time of day, type of products used

any physical limitations

pt’s ability to bathe independently

pt’s skin (dryness, redness, breakdown?)

perineal care for a female pt

spread labia and move washcloth from pubic to anal

proceed from LEAST contaminated to MOST contaminated

use clean portion of washcloth for EACH stroke

rinse washed areas w/ plain water

perineal care for male pt

clean TIP first in circular motion

clean shaft using downward strokes

when uncircumcised, retract foreskin while washing, then pull back into place

home care considerations for bathing

overall safety

protect mattress

using standard precautions w/ body fluids

teaching family to perform comfort care/cath care if needed

assessments made when providing oral care

pt’s preferences

limitations

oral cavity and dentition (ulcers, lesions, decay, patches, dehydration)

lips for dryness, cracking, pain

outcomes when providing oral care

clean mouth and teeth

positive body image

verbalized understanding of oral care importance

demonstrated appropriate oral skills

oral hygiene needs for cognitive impairments

break into small steps w/ help of family; provide distraction and allow pt to participate

nursing diagnoses for pts with dentures

ADL deficit

impaired oral mucous membranes

disturbed body image

considerations for pts with dentures

encourage to wear dentures if not contraindicated

refrain from wrapping dentures in napkins or bedding

place in cool/cold water when not in use

assessments for eye care

check for contact lenses (one or both eyes?)

if eye injury present, DO NOT remove contact lens; notify physician only

assessments when shampooing pt’s hair

note preferences, limitations, activity

inspect scalp for cuts, lesions, bumps, flaking, drying, excessive oiliness, or lice

if a patient is accidentally cut while shaving…

apply pressure w/ gauze or towel for 2-3 minutes

resume after bleeding stops

assessments when providing nail care

pt preferences, limitations

conditions that put pt at risk for nail problems (diabetes and peripheral vascular disease)

color and temp

pulses and capillary refill

skin around

changes in color, shape, thickness, separation, pain, bleeding

assessments when making occupied bed

pt’s preferences and limitations

check bed for pt belongings

presence and position of tubes or drains

lifting or repositioning of draw sheet

what is the first step when helping any patient?

assess the patient!!!!!!!

infection control measures

identify

prevent

control (minimize complications and reduce adverse outcomes)

teach patient about infection (super important!)

medical asepsis

“clean technique”

involves procedures and practices that reduce the number and transfer of pathogens

ex: hand hygiene and wearing gloves

surgical asepsis

“sterile technique”

includes practices used to render and keep objects and area free from microorganisms

ex: when inserting foley catheter, picc line

skills for preventing the spread of infection

hand hygiene

using PPE

preparing a sterile field

adding sterile items to a sterile field

donning and doffing sterile gloves correctly

5 Moments for Hand Hygiene (WHO, 2009)

before touching a patient

before a clean/aseptic procedure

after body fluid exposure risk

after touching a patient

after touching patient surroundings

conditions requiring hand hygiene

hands are visibly dirty

in contact with blood/body fluids

before eating and after using restroom

exposure to anthrax or c diff know or suspected

advantages of alcohol based hand rubs

saves time

more accessible

easy to use

reduce bacterial count on hands

less irritation and dryness than soap and water

basic principles of medical asepsis

carry soiled items away from body, kept off the floor

clean from least to most soiled

avoid splashing body fluids

clean/sterilize soiled items

avoid having pts cough, sneeze, breathe on others

basic principles of surgical asepsis

only sterile and touch sterile

open sterile packages with wrapper away from worker

avoid spills on sterile set up

hold sterile objects ABOVE waist level

avoid reaching/talking/breathing over a sterile field

never turn your back on/walk away from a sterile field

sterilize all items in contact w/ broken skin or cavities

outer 1 inch and all suspect items are always contaminated

when to use surgical asepsis

surgery

labor and delivery

diagnostic or special procedures (central, picc lines)

procedures requiring intentional perforation of skin/devices inserted in body cavity

when skin integrity is broken

infection

entry and multiplication of agent into the host

colonization

pathogen enters host but does not cause harm to cells or tissues

symptomatic

pathogen enters host and causes clinical signs and symptoms

communicable (contagious)

pathogen can be transmitted directly from one person to another

order of the chain of infection

infectious agent

reservoir

portal of exit

means of transmission

portal of entry

host

3 reservoirs for infectious agents

humans

animals

environmental (water, soil, plants)

portal of exit

route by which the disease agent may escape from the human or animal reservoir; may be one or more, depending on organism

examples of portals of exit

bodily fluids

skin/mucous membranes

respiratory tract

GU/GI tracts

transplacental

means of transmission

direct- immediate, direct contact w/ reservoir through contact or droplet

indirect- animate (vectors, such as flies, ticks, etc) or inanimate (environmental, such as food, water), or airborne (tiny particles that are inhaled)

portal of entry

usually same route as exit; through a break in defenses

hosts are susceptible through what factors?

genetic factors- specific to disease, not well understood

general resistance factors- intact skin/mucous membranes, gastric acid in stomach, cilia in resp. tracts, cough reflexes

active natural immunity

acquired by experiencing an infection

passive natural immunity

transfer of antibodies for a temporary time

active artificial immunity

vaccination; longer lasting

passive artificial immunity

short term antibodies from antitoxins/immune globulins

nosocomial infections

hospital acquired infections

cauti, clabsi, vap

how to break the chain of infection

use the aseptic techniques! (medical, protective, surgical)

breaking the chain via infectious agent

control/eliminate pathogens

clean hands and other objects, with sterilization prn

breaking the chain at the reservoir

control or eliminate sources that harbor pathogens

ex: hand hygiene, dressing changes, dry environment, proper handling and disposal of contaminated articles

breaking the chain at the portal of exit

avoid contaminated sterile areas

cover open draining wounds

careful handling of body discharge, drainage, and secretions

treat ALL lab specimens as infectious

breaking the chain- transmission

hand hygiene

standard transmission based precautions (PPE)

minimize use of shared equipment

be smart with dirty linens

discard anything that touches the floor

breaking the chain at the portal of entry

protect skin integrity (turns, hygiene)

protect wounds (cover and clean them)

keep all drainage systems closed and intact, draining downwards

breaking the chain at the susceptible host

reduce susceptibility!- adequate nutrition and rest, promote body defenses, give immunizations, isolate overly susceptible

latex allergies

up to 8.2% of the generation, positive skin test is approx 1%

risk factors for latex allergies

spina bifida

congenital/urogenital defects

history of long term or repeated catheterization

use of condoms/condom catheters

those with high latex exposures (healthcare, housekeepers, food handlers)

multiple childhood surgeries

food allergies- banana, kiwi, raw potato, peach, tomato, chestnut, papaya)

levels of latex reactions

irritant dermatitis- redness and itching

type 4 hypersensitivity- redness, itching, hives, local swelling, red/itchy/runny eyes and nose, coughing

type 1- life threatening, hives, difficulty breathing, hypotension, tachycardia, respiratory or cardiac arrest

important principles of sterile gloving

proper fit

correct material

sterile field

area free from microorganisms

kit or tray, draped with sterile towel or wrapper; whole table covered with large sterile drape

sterile drape

creates a sterile field around a treatment site; fenestrated drape have opening to expose only so much

steps to preparing a sterile field

prepare supplies and area

hand hygiene

prepare sterile surface- kit in center of area, above waist level; open and remove outer cover

open outermost AWAY flap first

open side flaps

open last

grasp ONLY the outer border

when placing sterile items on the field…

do not allow outer wrapper to touch sterile field

place item down at an angle, do not hold arm over field

pouring sterile solutions

verify contents and due date

get receptacle near work space

pour about 2 inches above receptacle

order of PPE donning

gown

mask

goggles/face shield (if needed)

gloves

indicators of the heart’s effectiveness

pulse (rate, strength, rhythm)

blood pressure

skin color and temp

level of consciousness (LOC)

electrical therapy devices

implantable cardioverter-defibrillator (ICD)

synchronized cardioversion

pacemakers

biventricular pacemakers

elements of CPR

30:2 if no pulse and no breathing

used defibrillator as soon as possible

if pulse but no breathing, begin rescue breathes (1 breath/6 seconds ~ 10 breaths/min)

hands-only CPR

can double or triple a person’s chance of survival if started as soon as possible

when performing chest compressions and you hear a crack…

this is normal. recheck hand position, and then continue

when should defibrillation be used?

as early as possible! this is critical for patient survival

assessments made prior to defibrillation

responsiveness

any vitals

partial or complete airway obstructions

any respirations

for what heart rhythms should defibrillation be used?

ventricular fibrillation and pulseless ventricular tachycardia

how does defibrillation work?

the electrical shocks depolarize the heart temporarily and allow coordinated contractions to continue; provides momentary asystole, providing an opportunity for the natural pacemakers to resume normal activity

two types of cardiac monitoring

hardwire- connected to bedside monitor; may also be transmitted to a console at a separate location

telemetry- uses a small transmitter connected to an ambulatory pt

functions of cardiac monitors

display heart rate and rhythm

produces printed record of rhythm

sounds an alarm if hr exceeds or falls below limits

recognizes abnormal heartbeats and rhythms

stores and analyzes trend data

outcomes to expect when using a transcutaneous (external) pacemaker

no adverse effects from application

the regain/maintenance of adequate circulation and minimal set heart rate

pt should not experience injury- may feel burning sensation and involuntary muscle contractions

effects of immobility on the body

muscle and bone weakness

limited endurance

decreased coordination

decreased ventilatory effort and increased risk for lung collapse

increased cardiac workload, orthostatic hypotension, blood clots

altered circulation and skin integrity

increased risk for urinary stasis and constipation

altered sleep patterns

active ROM

patient able to perform exercises independently

passive ROM

pt unable to perform exercise alone; needs assistance of caregiver

ROM exercises

ankle pumps, foot circles, and knee flexion

assessments made prior to moving a patient

check mobility orders and weight bearing status (non, partial, as tolerated, full)

activity level- up x1, x2, bedrest, up ad lib

if pt reports pain, administer medication- premedicate prior to PT if possible!!

assess LOC and ability to follow commands

assess assistant needs and equipment that may be in the way

assess skin

socks are on, path is clear, chair is locked, and all equipment is in reach

equipment for moving patients

gait belts

stand assist

repositioning aids (TAP)

lateral-assist devices

friction reducing sheets

transfer chairs

transfer boards

lifts- sit2stand, hoyer

assessments before moving patient from bed to stretcher

review chart for contraindications to moving pt

perform pain assessment, and administer medication prn

look for tubes, drains, iv’s, or equipment that might be in the way

assess LOC, ability to follow commands, and ability to assist with moving

determine if bariatric equipment needed

documentation of pt from bed to chair

amount of time pt sat in chair

pt’s tolerance and reaction to the activity

use of transfer aids

number of staff needed

any pertinent observations

staff needed for log roll - spinal precautions

team lead, to support spine/neck

person 2&3- support hip and shoulder alignment

person 4- on opposite side, slides spinal board under pt

when are spinal precautions needed?

when pt cannot or is too unsafe to move- must maintain spinal alignment and prevent further injury

usually in trauma settings, with a suspected spinal injury and an unconscious pt

outcomes when performing ROM exercises

pt completes exercises

pt maintains or improves joint mobility

muscle strength is improves or maintained

atrophy and contractures are prevented

how to perform an assisted fall when ambulating

feet wide apart, with one foot in front

rock pelvis to side nearest the pt

grasp gait belt and guide patient slowly to the floor, supporting them on your thigh and down

slide down gently while protecting their head

stay with pt and call for help

outcomes for a patient using a walker

pt is safe, free from falls or injury

proper use

pt has increased muscle strength, joint mobility, and independence

when patient uses walker, elbows should be?

slightly bent, about 15 degrees

how crutches should be fitted per person

crutches should be 1-2 inches below the armpit

elbows should be bent about 30 degrees, and kept close to sides

4 point crutch gait

moves one crutch at a time, with opposite foot following

right crutch, left foot, left crutch, right foot, repeat

three point crutch gait

pt bears weight on stronger leg; move affected leg and both crutches at the same time

two point crutch gait

partial weight on both feet; move left crutch and right foot, then right crutch and left foot

how should canes be used?

hold cane on STRONG side, moves forward w/ bad leg

ex: affected left leg, cane is held on right side

TED hose

thromboembolism deterrent compression stockings

physician ordered for use in patients at risk for venous stasis, DVT, and thrombophlebitis

when should TED hose be applied?

in the morning while pt is still in bed, and supine

legs elevated at least 15 minutes before applying stockings

wash with soap and water, dry overnight

CPM device outsomes

pt experiences increased joint mobility

atrophy and contractures are prevented

alterations in skin integrity and peripheral neurovascular function are prevented