Midterm Exam- Nursing Skills 2350

What link of the chain of infections does hand washing break?

Mode of transportation

How can you break the chain of infection?

Washing your hands, tools, and surfaces

Whats the proper hand washing steps?

1. turn on water

2. wet hands

3. apply soap

4. rub soap in for 20 sec

5. rinse hands

6. Dry hand completely

7. turn water off with dry paper towel

When can you use sanitizer?

When your hands are not soiled

what are the 4 bed safety criteria?

1. Wheels Locks

2. Bed low

3. Safety rails up

4. Call light in reach

What are the 8 critical elements of principal-based procedures

1.Wash hands before and after

2.gather supplies

3. introduce self and others

4. identify patient x2

5. explain procedure

6. give privacy

7. use good body mechanics

8.provide patient safety

What is normal blood pressure?

120/80

What is a normal pulse?

60-100 bpm

What is a normal body temperature?

95.9-99.5

What is a normal respiration rate?

12-20 bpm

What is a normal O2 sat?

95-100

What is the purpose of assessing vital signs?

- to monitor body systems

- detect change in health

- evaluate effectiveness of treatment

- identify life-threatening warning signs

How often should you take vital signs on a stable patient?

4-8 hours

How often should you take vital signs on a post surgical patient?

15-60 min

How often should you take vital signs on a critical patient?

every 5 min

How regular should you check vital signs?

Doctor orders and nurses judgement

Where is the apical pulse?

Midclavicular line, 5th intercostal space

Where is the temporal pulse?

side of the head

Where is the carotid pulse?

side of neck, below chin

where is the Brachial pulse?

inner elbow

Where is the radial pulse?

Thumb side, inner wrist

Where is the femoral pulse?

bend of leg (groin)

Where is the popliteal pulse?

Behind the knee, inside

Where is the posterior tibial pulse?

inner ankle

Where is the dorsalis pedis pulse?

top of foot

What is the formula from F to C?

F- 32 x 5 / 9

What is the formula from C to F

C / 9 / 5 + 32

What is the physiology of blood pressure?

-Heart beat forces blood against arterial walls

- creates a pressure wave as left ventricle contracts and then releases

What is the peak phase of blood pressure?

Systolic pressure

What is the resting phase of blood pressure?

Diastolic pressure

When will hypotension be diagnosed?

systolic bp <100mmHg

What is orthostatic or postural hypotension?

sudden drop in BP

When will hypertension be diagnosed?

systolic > 140 mmHg or Diastolic > 90 mmHg

What makes up of 90% of hypertension cases?

Primary or essential hypertension

Why would a nurse use the nursing process?

to provide goal-directed care

What are the steps of the nursing process?

Assessment

Diagnosis

Planning

Implementation

Evaluation

What do you do in the assessment phase?

collect subjective and objective data

What do you do in the diagnosis phase?

actual and potential problems

What do you do in the planning phase?

Establish goals

What do you do in the evaluation phase?

evaluate effectiveness, patient response, goals, and plan

What is objective data?

What you observe and can measure

What is subjective data?

what the patient says

What is the percentage of verbal communication?

7%

What do you think when words are spoken?

Privacy

What do you think when words are writte?

Legal

What do you think when words are written electronically?

confidential

What is the percentage of nonverbal communication?

93%

What are some nonverbal communications?

body language

posture

stance

face

What are the 4 phases of nurse/patient therapeutic relationship?

Pre-interaction phase

Orientation phase

Working phase

Termination phase

What do you do in the pre-interaction phase?

gather information before meeting patient

What do you do in the orientation phase?

interview the patient

What do you do in the working phase?

use therapeutic communication

develop a plan

collaborate with your team

What do you do in the termination phase?

evaluate outcome

transition patient

What is the acronym for professional communication?

SBAR

What does SBAR stand for?

Situation

Background

Assessment

Recommendation

What is therapeutic communication?

Communication to help build a professional relationship with a patient

What is nontherapeutic communication?

communication that can be hurtful and damaging to others

Keeping a patient centered, empathetic, respectful relationship is a form of what communication?

Therapeutic

Only talking about yourself and having a social conversation is an example of what kind of communication?

Non Therapeutic

What is a legal issue in health care?

confidentiality and social media

What is a ethical issue in health care?

professional bounaries

Breaking a legal boundary can lead to what?

HIPPA violation- $ and jailtime

What is the importance of hygiene?

prevent infection

provides comfort

promotes health

improves self-image

What are the factors that influence hygiene?

Personal preference

Culture

Economic status

knowledge level

What are the activities of daily living?

bathing

eating

dressing

grooming

oral care

toileting

What direction do you clean the body?

Distal to Proximal

Why do you wash the body from distal to proximal?

to improve venous return

What areas do you clean first? clean or dirty?

Clean

How often should you perform oral care?

every 2 hours

What are the bathing steps?

Eyes, face, neck

hands, arms

chest

abdoment

feet, legs

perineal

back

rectum

How do you properly perform physical touch on a patient?

be professional

ensure privacy

ask if they can do it

be firm, not rough

What is a proper body mechanics?

Keep spine in natural alighment

Where should the bed be when working on a patient?

In the center of the body

What do you bend when lifting?

knees

What does supine mean?

laying down

What is high fowler's position?

90 degrees

What is low fowler's position?

45 degrees

What is Sam's position?

side laying w/ hip and knee flexion

What is prone position?

laying on abdomen

WBC for men

4.7-6.1

WBC for women

4.2-5.5

Hematocrit for men

42-52%

Hematocrit for women

37-47%

Hemoglobin for women

12-16

Hemaglobin for men

13-18

Platelete normal

150,000-400,000

Na+ level

135-145

K+ level

3.5-5.0

Ca+ levels

8.5-10.5

how many lbs in Kg

2.2 lbs

how many mL in 1 oz

30 mL

torts

unjust acts against a person

intentional torts

acts that knowingly cause harm

unintentional torts

acts that cause unintended harm

What law is practicing without a nursing license breaking?

state law

intentional torts examples

assault, battery, false imprisonment

unintentional torts example

malpractice, negligence

Whats the patient bill of rights?

right to know, understand, and agree to medical care

What does patient self-determination act say?

it requires health care facilities to provide information and ADVANCED DIRECTIVES to all patients