Crucial Content Fundamentals

a lotta stuff like restraints, fall risks, GI stuff, Pain, precautions blah blah blah

fall risk preventions

• fall risk wrist bands, room signs

• socks with traction beading

• bed lowest position + bed/chair alarms

• fall mats

• 1:1, close to nursing station

• Monitor O2 and BP

Restraints

always a last resort verbal orders arent allowed

types: chemical, vest, extremity, geriatric chair, 4 side rails, mitts

Physical care with restraints

• Q 2 rs: toilet, reposition, ROM exercises, food and fluids, Q 30 mins circulation

NG tubes care of client

• X-ray for visualization of tube tip

• measure exposed tube length

• aspirate gastric contents for pH testing

• pH 0-4 indicates gastric placement, > = to 6 indicates intestines or lungs

• color of aspirate should be cloudy + green

• flush tubes w NS before and after

• don’t reconnect to suction 30 mins after med admin, reg pressure is 80-120

enteral nutrition

• need functioning gi tract - bypasses mouth and esophagus - liquid food through stomach - duodenum, jejunum - confirm position by x-ray

enteral nutrition risks

• aspiration - tube clog/dislogdement - abnormal cramping or diarrhea - hyperglycemia

enteral safety

• HOB elevated - feedings at room temp - assess hang time - change feeding bag per policy - flush tubing before/after - use liquid meds - check glucose - residuals - skin around tube - G/J tube rotate 36 0 QD - check in and out play of ¼ in/ 6 cm

How to treat osteoporosis

• less dense quality of bone - seen with pathological fractures (fracture no trauma) - treat wth bisophosphonates

Dehydration s/s

• thirst - decreased urine - dark urine - dry skin - increased BUN

Urinary catheter considerations

• use aspectic technique - 14 cath size for adult - no tension tot catheter - empty when ½ full - minimal urine output is 30 mL/hr Good is 50 mL/hr

UTI types

Urethritis, Cystitis, Pyelonephritis

Urethritis

inflammation of urethra

cystitis

inflammation of the bladder

pyelonephritis

inflammation of the kidneys

UTI considerations

• fever in adults - confusion in older adults - midstream is best collection method - if with cath remove it and collect or if it can’t be removed use needless port

UTI treatment

• antibiotics - analgesics: phenazopyridine (urinary analgesic) - fluids

Pain on NCLEX

• expected pain - nagging pain - chronic

• think P” presents due to ischemia A: acute I: intense N: not relieved with treatment

• distractions are best used before pain starts

Standard precautions

• gloves used if body fluids > hands - gowns used if body fluids > body - mask/googles/face shield if body fluids > face

Contact precautions

• gloves + gown when entering room - mask + face follow standard precautions

droplet precautions

• mask required standing w/in 3 ft of client

• gloves, gown, face follow standard precautions

Airborne precautions

• mask fit tested N-95 when entering room

• gloves, gown, face follow standard precautions

Airborne transmitted diseases

• Measles, TB, Varicella (Chickenpox), disseminated herpes zoster (shingles)

Droplet transmitted diseases

• Meningococal meningitis, Rubella, Influenza, mumps, pertussis

Contact transmitted diseases

• rotavirus, Hep A for diapered/incontinent, chickenpox/shingles

RN always does in terms of delegation

• ADPIE - VS on admission + after procedures

Rights of delegation

• right task - righ person - right circumstance - right communication - right supervision

LPN/LVN delegation

• assigned stable clients + stable outcomes - knows abnormal vs normal

• knowledge of asepsis and dressing changes - can’t care for unstable or requiring assessment planning or initial teaching

• can do indwelling cath/aseptic dressing change - can admin routine meds no risk

UAP delegation

• can do enteral tube feedings following RN assessment - ADLS - VS weight height intake output glucose - simple specimens: stool, midstream urine, blood) - transport clients - restocking - can’t ADPIE

Prioritizing clients

stable vs unstable - expected vs unexpected - ABCs - potential vs actual - chronic vs acute