344 FUNDAMENTALS REVIEW (part 1)

Explain to the patient/CNS how to use a CANE.

o Cane should be __**level with the hip joint**__ with patient’s __**arm comfortably bent**__ when patient is walking

o Patient should __**hold cane on their stronger side**__ and move cane forward first, followed by the weaker leg then the stronger __***(3-point gait)***__

o Patient should be encouraged to __**stand up straight**__ and __**looking forward**__, so safety and posture isn’t jeopardized

What does a score of 19-23 mean on a BRADEN scale?

* no risk
* continue to assess per agency timeline

What does a score of 15-18 mean on a BRADEN scale?

* at risk
* identify areas of risk
* select at least one intervention __**WITHIN**__ risk category & implement

What does a score of 13-14 mean on a BRADEN scale?

* moderate risk
* identify areas of risk
* select at __**least one**__ intervention from each risk category & implement
* refer WOCN

What does a score of 10-12 mean on a BRADEN scale?

* high risk
* select ALL APPROPRIATE INTERVENTIONS including at least ONE UNDERLINED intervention
* refer to WOCN

What does a score of

* all of the above
* pressure reduction support is required
* refer to WOCN

What does WOCN stand for?

Wound, Ostomy, and Continence Nurse

How can a nurse improve a pt’s __**SENSORY PERCEPTION SCORE**__ on the braden scale? (HINT:4)

* Reduce pressure on ankles and feet
* Inspect feet and ankles daily
* Instruct to avoid hot water and heating
* Educate patients and caregivers about causes and risk factors for

pressure ulcer development

How can a nurse improve a pt’s __**MOISTURE SCORE**__ on the braden scale? (HINT: 8)

* Establish a __**bowel and bladder program**__ for incontinent patients
* Cleanse ***gently*** after each incontinent episode
* Encourage appropriate __**hydration**__
* Instruct to apply __**skin barrier ointments**__ to protect skin
* Instruct to __**avoid diapers**__ to contain effluent (waste) except when patient is out of bed to __**walk or in a chair**__
* Consult with __**WOCN**__
* Identify __**fungal infections,**__ notify MD, and treat quickly
* Order __**low air loss bed**__ to dry constantly moist skin

How can a nurse improve a pt’s __**ACTIVITY SCORE**__ on the braden scale? (HINT: 4)

* Position chair-bound patients when seated with attention to anatomy, postural alignment, distribution of weight and support of feet
* Instruct to reposition chair-bound individuals __**every hour**__ if they cannot perform pressure relief exercises __**every 15 mins**__
* Encourage increased activity
* Order specialty bed or overlay to reduce pressure. Continue turning but increase frequency

How can a nurse improve a pt’s __**MOBILITY SCORE**__ on the braden scale? (HINT: 4)

* Instruct to turn and reposition at least __**2-4 hours**__ on a pressure reducing mattress or __**2 hours**__ while in bed or chair
* Inspect bony prominences every day/visit
* Place “at risk” individuals on __**pressure reduction surface**__
* Refer to physical and/or occupational therapist

How can a nurse improve a pt’s __**NUTRITION SCORE**__ on the braden scale? (HINT: 7)

* Evaluate __**nutritional status**__ of patients at risk by __**obtaining recent diet**__
* Encourage __**liquid nutritional supplements**__ as ordered
* Instruct to __**increase protein intake**__
* Instruct to __**supplement diet with multivitamin**__
* Consult with nutritionist
* Monitor weights, intake/output, count calories if indicated
* Assess lab parameters to determine nutritional status (__**low albumin, pre-albumin, transferrin, total lymphocyte count blood levels**__ correlate to decreased wound healing and increased pressure ulcers)

How can a nurse improve a pt’s __**FRICTION & SHEAR SCORE**__ on the braden scale? (HINT: 8)

* Use __**turning sheets or pads**__ to reposition. Trapeze bar to encourage patient to assist
* Elevate head of bed __**no more than 30 degrees**__
* Protect vulnerable areas from friction by applying t__**ransparent film, socks, or elbow protectors**__
* Instruct to avoid excessive rubbing when cleansing and drying skin
* Instruct to avoid soap. Use moisturizer on dry skin and bony prominences daily
* Instruct not to massage reddened bony prominences
* Avoid foam rings, donuts, and sheepskin
* Lower head of bed 1 hour after meals or tube feeding. If not possible, assess sacral region more frequently

What is a LIFT?

* Preferred methods to decrease incidence of patient and staff injuries
* Patient is placed in harness and lifted to a point where feet are just

touching the ground
* Patient walks holding onto lift device
* Weight is fully supported by lift device and prevents falls and injuries

What is a GAIT BELT?

* should be used for patients with an __**unsteady gait or generalized weakness**__
* applied snugly patient’s waist, leaving only enough room for the nurse to grasp the belt firmly during ambulation
* if the patient has a __**weaker side**__, the __**nurse should stand**__ on that side and __**hold the gait belt firmly at the back**__ of the patient’s waist while ambulating

What is a SLIDEBOARD?

* Made of plastic-like material to reduce friction
* Linens easily slide over the board, facilitating bed linen changes
* Patients can be repositioned or transferred with minimum force

__**TRUE OR FALSE:**__ Chronic use of nasal decongestants may lead to rebound effect

true

How do you administer a NASAL DECONGESTANT?

* Have patient blow their nose first
* Tilt patient’s head slightly back or have patient lie in supine position

with head tilted back
* Have patient breathe out through mouth
* Insert the deliver service 1/3 inch into one nostril, have patient plug

opposite nostril, and __**do not touch inside the nares with device**__ because

it may cause sneezing and contamination
* Administer drops or spray as patient inhales through nose
* Have patient exhale through mouth
* Keep patient’s head tilted back for several mins while patient continues to breathe through mouth

What should the nurse be consider when administering SUBLINGUAL MEDICATION CONSIDERATION?

* The patient should not eat or drink anything until medication is completely dissolved
* Medications should not be chewed, swallowed, or taken with liquids
* Nurse should use standard precautions because the nurse’s hand may come in contact with oral secretions
* Buccal med is placed in the side of the mouth against the inner cheek
* Alternate cheeks to avoid mucosal irritation o Sublingual med is placed under the tongue

What should a nurse consider during flushing and nursing care of management of a NASOGASTRIC TUBE

* Check pH levels just before intermittent feedings if placement of tube is questioned
* Assess exit of location marking to ensure NGT hasn’t moved
* Flush before and after med admin

What should a nurse consider during flushing and nursing care of management of a NASOGASTRIC TUBE

* Check residual volume if patient is already on feed
* If residual amount is less than 250 mL or half the amount of last feed, proceed with new feeding; do not proceed if gastric residual volume exceeds 500 mL
* Ensure nutritional feeding solution is as order and check expiration date o Ensure feeding is at room temp; shake container thoroughly and clean top with alcohol swab before opening
* Measure feeding amount (for continuous feeding, use not more than the amount require for 4 hours plus the amount needed for priming and tubing)
* Fill pump tubing with irritation solution to prime tubing (if not automatic)
* Flush NGT with irritation solution before initiating feeding
* Label feed bag with type, strength, amount, date and time – a new set should be used every 24 hours

Why should a nurse be aware of a patient’s pH level?

* Should be < 5 if placed correct
* 6 or > indicate tube has been inadvertently placed in a lung or intestines
* If NGT placed correctly, pH of 4.5-6 may be due to medications or feedings

How do you assess the C in COLDSPA?

* characteristics
* What is the quality of the pain? Stabbing, burning, etc?

How do you assess the O in COLDSPA?

* onset
* when did the pain start? was it gradual or sudden?

How do you assess the L in COLDSPA?

* location
* where is the pain located? does it radiate?

How do you assess the D in COLDSPA?

* duration
* how long does the pain last? is it intermittent?

How do you assess the S in COLDSPA?

* severity
* on a scale of 1-10, how bad is it with 10 being the worst?

How do you assess the P in COLDSPA?

* pattern
* what makes it better or worse

How do you assess the A in COLDSPA?

* associated factors
* what other symptoms occurs with the pain?

How do you assess FACIAL EXPRESSIONS on the neonatal infant pain scale (NIPS)?

1. 0 (relaxed muscles) → neutral expression
2. 1 (grimace) → tight facial muscles

How do you assess CRYING on the neonatal infant pain scale (NIPS)?

1. 0 (no cry) → quiet, no crying
2. 1 (whiper) → mild moaning, intermittent
3. 2 (vigorous cry) → loud scream, shrill, continuous

How do you assess BREATHING PATTERNS on the neonatal infant pain scale (NIPS)?

1. 0 (relaxed) - usual pattern for this infant
2. 1 (change in breathing) - irregular, faster than usual, gagging

How do you assess the ARMS on the neonatal infant pain scale (NIPS)?

1. 0 (relaxed/restrained) → no rigidity occasional random movement
2. 1 (flexed/extended) → tense, rigid, rapid extension/flexion

How do you assess LEGS on the neonatal infant pain scale (NIPS)?

1. 0 (relaxed/restrained) → no rigidity, occassional random movement
2. 1 (flexed/extended) → tense, straight legs, rapid extension/flexion

How do you assess STATE OF AROUSAL on the neonatal infant pain scale (NIPS)?

1. 0 (sleeping/awake) → quiet, peaceful sleeping, random movement
2. 1 (fussy) → alert, restless, thrashing

What are the ADVANTAGES of __**oral**__ medication?

* Convenient, cost-effective, comfortable with low stress for patient
* Certain oral tablets formulated to dissolve on contact with tongue

What are the DISADVANTAGES of __**oral medication**__ care?

* Inappropriate for patients with nausea/vomiting; contraindicated for patients with swallowing difficulty
* Can irritate GI lining, have unpleasant taste, or discolor teeth
* Patient must be A&Ox4 to safely administer
* Cannot be used with simultaneous gastric suctioning or before various diagnostic or surgical procedures
* Possible irregular or slow absorption

What are the ADVANTAGES of __**intravenous**__ care?

* Can be used if oral route is contraindicated


* More rapid response than oral or topical
* Can be used for critically ill patients for long-term therapy
* IV route can decrease discomfort and can better control absorption if peripheral infusion is compromised

What are the DISADVANTAGES of __**intravenous**__ care?

* Sterile technique must be used as the skin barrier is compromised


* More costly to formulate and administer
* Affected by circulatory status
* Can produce anxiety

What does __**PICC**__ stand for? What is this used for?

* peripheral inserted central catheter
* used in patients that need long- term IV therapy because it can be inserted in a vein in the arm that has lower rates of complications compared to other types of CVCs
* Also used in patients with failed IV access with short peripheral catheters

T/F: __**PICC**__ can be left indefinitely as long as there are no complications

true

Where could a PICC be inserted? List the veins & the correct location of a PICC.

Inserted in the __**cephalic**__ or __**basilic vein**__ or __**antecubital space**__ and threaded up until it rests in the superior vena cava outside the right atrium

Nurses need to maintain PICC lines to prevent what type of infection?

central-line associated bloodstream infection (CLABSI)

t/f a PICC line often has multiple lumens and can simultaneously infuse incompatible meds, fluid, blood, or TPN

true

What is a CVC/CCVAD? What is this used for?

* central venous catheter/central venous access device
* inserted into a major vein in the arm or chest and the tip lies in the superior vena cava, outside the right atrium
* allows rapid infusion of large amounts of fluid
* irritating meds & hypertonic solutions are rapidly diluted → reducing phlebitis
* can be used for blood draws for patients needing frequent lab monitoring
* allows monitoring of central venous pressure

When would a nurse use a 16 needle gauge?

trauma & massive fluid/blood administration

When would a nurse use a 18-20 gauge needle?

large volume, viscous solutions

When would a nurse use a 22-24 gauge needle?

children & geriatric

\*\*What is PHLEBITIS ?

Phlebitis is when a vein (a blood vessel that carries blood back to the heart) gets swollen and painful. This can happen when a blood clot forms in the vein or when the vein is irritated. It usually happens in the legs. The symptoms include redness, warmth, and swelling in the affected area. Treatment may include medicine or wearing special stockings.

Why are __**Hypertonic IV solution**__ designed to meet patient’s total nutritional needs ?

* Contains amino acids, glucose, lipids, vitamins, minerals, electrolytes, and trace elements
* Provides calories, protein building blocks, and fluid needed to promote wound healing and meet metabolic requirements
* Used when patient is unable to meet nutritional and metabolic demands through oral intake or surgery requires bowel rest

What should a nurse consider regarding TPN monitoring/care? \*is this for tpn in general or for hypertonic iv solutions specifically?

* Central line must be used to administer
* Designate separate lumen and label; do not infuse other substances into

this line
* Ensure vitamin K has been ordered (vitamin K is produced largely by

intestinal bacteria that currently may be absent, but is needed to

produce clotting factors in the gut)
* Do not use TPN after 24 hours; discard any unused solution
* Assess vitals q4h, daily weight, and I&O
* Administer slowly in beginning, increase slowly, and wean off gradually; do not suddenly stop, hang D10 if line runs dry (prevents hypovolemic shock)

What are some __**complications**__ that could occur during TPN monitoring/care? \*is this for tpn in general or for hypertonic iv solutions specifically?

* Higher risk for infection; use strict sterile technique during IV care
* Patient can develop hyperglycemia due to high levels of dextrose
* Insulin often ordered and BG checked routinely

What is the partial or complete obstruction of a vascular access device, caused by clot formation in catheter or obstruction ?

*Catheter occlusion*

What are the symptoms of a __***Catheter occlusion***__*?*

* IV flow is sluggish or stopped


* Attempts to flush catheter are met with resistance

What should a nurse consider regarding a __**catheter occlusion**__?

* Assess tubing site for obstructions


* Attempt to flush catheter with normal saline; do not force (can cause embolism)
* If peripheral IV, discontinue site and start a new one
* If CVC, notify PCP or IV team

What is a local infection that occurs at insertion site (can become systemic and life-threatening), caused by poor aseptic technique during insertion or dressing/tubing changes or if site is used >4 days

*Catheter-related infection*

What are the symptoms of a *Catheter-related infection?*

* Pain at site, tenderness, erythema, swelling, increased emp, purulent drainage


* Fever, chills, tachycardia, hypotension, complaints of headache, backache

What are some considerations of a __**catheter-related infection**__? (HINT:7)

* Prevention is key – use aseptic technique during site care and insertion
* Rotate sites per agency protocol
* Assess site frequently
* If symptoms evident,

discontinue IV and start

in a new location
* Place used catheter in sterile container and send to lab for culture

sensitivity testing
* Notify PCP of findings
* Do not discontinue CVC

without physician’s order

What is an inflammation of the vein caused by poor insertion and care technique, frequent manipulation of catheter, size and length of catheter, use of irritation meds or fluids, or infection?

phlebitis

What are the symptoms of __**phlebitis**__? (HINT:3)

* Tenderness, redness, swelling at site
* Pain, burning, heat along vein (especially during infusion)
* Palpable venous cord

What should a nurse consider regarding **phlebitis**? (HINT:5)

* Discontinue catheter immediately if infection suspected; send catheter tip for culture


* Clean insertion site with disinfectant
* Apply warm moist compress for 20 min 3- 4x/day
* Use opposite extremity when inserting new IV
* Use small gauge, stabilize catheter securely to minimize movement or rotate sites to avoid phlebitis

What kind of complication involves the infusion of IV solutions and/or meds going into surrounding tissues & is caused by puncturing blood vessels through improver insertion/frequent manipulation?

infiltration

What are the symptoms of **infiltration**?

swelling, tenderness, coolness, firmness of extremities, & blanching of the skin

What are some nursing considerations for __**infiltration**__? (HINT:8)

* assess q2h
* Discontinue infusion, remove catheter


* Apply pressure at site to stop bleeding
* Apply warm compress to increase circulation for isotonic/hypotonic solutions
* Apply cold compress for hyperosmolar
* Use skin marker to outline area of visible damage to assess change
* If leaking, cover area with sterile dressing
* Use opposite extremity for new IV insertion

Which complication involves the inadvertent infusion of vesicant (causing blisters, ulceration, sloughing) or irritating solution/med into surrounding tissues; can lead to permanent tissue/nerve damage ?

Extravasation

* Similar to infiltration


* Burning and discomfort
* Blistering is a late sign

\

What are some nursing considerations for __**extravasation**__? (HINT: 7)

* Know which meds are considered vesicants (dopamine, norepinephrine, high concentrations of electrolytes, certain antibiotics)


* Vesicant solutions/meds should be infused slowly and through a CVC
* Discontinue site, start new IV on opposite extremity
* Notify PCP and obtain orders for treatment or antidote
* Use skin marker to outline area of visible damage to assess change
* Cautious use of cold or warm compress
* Never apply pressure

What is absolutely necessary to maintain during blood administration?

Necessary to maintain the __**patient’s oxygen and carbon dioxide transport capacity**__, for clotting, to maintain oncotic pressure, and to protect from infection

What are the 5 complications that could occur during blood administration? Describe each.

1. __**allergic response**__ → common; based on hypersensitivity response to foreign plasma proteins


1. __**acute hemolytic reactions**__ → occurs when antigen-antibody

reaction due to ABO or Rh incompatibilities; can result from errors in mislabeling, improper crossmatching, or errors in patient/blood verification at bedside
2. __**febrile nonhemolytic reactions**__ → occurs when patient reacts

to the white blood cells in doner blood; occurs in 6% in all transfusions
3. __**bacterial contamination**__ → occurs during the donation or

preparation of blood, usually by organisms capable of surviving cold temp
4. __**circulatory overload**__ → occurs when whole blood is transfused to quickly or packed red blood cells lead to a fluid shift from the interstitial to vascular space s

What occurs when antigen-antibody reaction due to ABO or Rh incompatibilities; can result from errors in mislabeling, improper crossmatching, or errors in patient/blood verification at bedside?

*Acute hemolytic reaction*

What kind of blood administration complication occurs when a patient reacts to the white blood cells in doner blood; occurs in 6% in all transfusions?

*Febrile nonhemolytic reaction*

What kind of blood administration complication occurs during the donation or preparation of blood, usually by organisms capable of surviving cold temps

*Bacterial contamination*

What kind of blood administration complication occurs when whole blood is transfused to quickly or packed red blood cells lead to a fluid shift from the interstitial to vascular space

circulatory overload

What kind of symptoms would a patient display if they were experiencing a MILD allergic response?

local erythema, hives, itching, asthmatic wheezing

What kind of symptoms would a patient display if they were experiencing a SEVERE allergic response?

laryngeal swelling, dyspnea, tachypnea, chest pain, cardiac arrest

What are some nursing considerations for a patient experiencing an allergic response during a blood administration?

* Stop transfusion
* Notify ordering physician
* Administer antihistamines
* Continue to assess patient, monitor vitals
* Document reaction, treatment, and response

What are the symptoms of an __**acute hemolytic reaction**__?

Chills, fever, facial flushing, burning along vein, lumbar or flank pain, chest pain, shock

What are some nursing considerations for an acute hemolytic reaction?

* Stop transfusion
* Remove tubing and replace with new IV tubing and normal saline at keep-vein-open rate


* Notify ordering physician
* Notify blood bank
* Monitor vitals
* Have emergency equipment availabl


* Send remaining blood, blood tubing and filter, and a sample of patient blood and urine to lab e
* Document reaction, treatment, and response

What are some symptoms of a __**febrile non hemolytic**__ reaction?

* Defined as 2° F rise in body temp


* Chills and malaise

What should a nurse consider for a pt experiencing a __**febrile non hemolytic**__ reaction?

* Stop transfusion
* Notify ordering physician
* Notify blood bank
* Administer antipyretics

and/or antihistamines
* Document reaction,

treatment, and response
* Can be avoided by using

leukocyte-reduced components or washed red blood cell s

What are some symptoms of a __**bacterial contamination complication**__?

Abdominal cramping, chills, diarrhea, fever, shock, onset of renal failure, vomiting

What should a nurse CONSIDER while taking care of a pt with a __**bacterial contamination complication**__?

* Infuse blood in less than 4h; stop after 4h
* Change administration sets q4h
* Stop transfusion if symptoms occur
* Notify ordering physician
* Administer antibiotics, corticosteroids, and epinephrine
* Have emergency equipment available


* Instruct patient to contact PCP if symptoms occur

What are some symptoms of a __**circulatory overload complication**__?

Signs of fluid volume excess – dyspnea, headache, tachycardia, hypertension, distended jugular veins

What should a nurse CONSIDER while taking care of a pt with a __**circulatory overload complication**__?

* Stop infusion
* Use PRBCs instead of

whole blood
* Notify ordering physician
* Administer oxygen PRN
* Administer diuretics PRN
* Instruct patient to contact PCP if symptoms occur

How do you perform oral care on a __capable patient__?

Encourage to perform oral hygiene independently

How do you perform oral care on a __patient with dentures__?

* Oral care should be performed at least every morning and evening


* The nurse or UAP performs this procedure for patients who cannot

clean their own dentures
* Gloves should be worn

How do you perform oral care on a __patient with special needs__?

* Unconscious or intubated patients may not be able to swallow own saliva; oral care should be provided q2h by using a toothbrush and a small amount of water or a moistened toothette


* Unconscious patients are at risk for aspiration; place patient on their side to avoid aspiration

What is the intimate zone?

* (client’s personal space) – 8 inches to 4 feet from patient
* Reserved for affectively close people that have permission to approach; most procedures and interventions are performed at this distance
* Always ask permission and inform patient of what you’re doing

T/F: when it comes to trach care & suctioning, the nurse can only delegated this task to a UAP.

false, Cannot be delegated to UAP; respiratory therapist may wish to care for or assist with care

Why are velcro tracheostomy tubes more preferred over tracheostomy ties?

Tracheostomy ties will cut into the patient’s skin, causing trauma and providing site for infection… therefore Velcro tracheostomy tube holder is recommended

T/F trach care and suctioning is a clean procedure.

false! Nurses need to maintain a __**sterile procedure**__ for trach care and suctioning to prevent microorganisms from entering the respiratory system and causing infection

Which PPE is required for suctioning?

face mask, shield, clean gloves

how should you position your patient before suctioning? (trach care)

Patient should be in fowler or semi-fowler position

What should you ALWAYS assess before and after suctioning?

respiratory status

What are some __**nursing considerations**__ for suctioning? (HINT: 8)

* PPE: face mask, shield, clean gloves
* Patient should be in fowler or semi-fowler position
* Assess respiratory status before and after procedure


* Place bag-valve-mask at head of bed and ensure it has 100% oxygen airflow


* Set pressure of suction device to 80-100 mmHg continuous
* Insert catheter __**12-13 cm**__ into trach and withdraw catheter slowly while rotating and moving thumb on and off suction control; suction on the way out, not going in


* Maximum time for each suction should be 10-15 seconds
* Place trach oxygen mask and let patient catch their breath before proceeding to suction again

What results from blockage or collapse of air passages in at least one lobe of the lungs ?

Atelectasis

What are some risk factors of __**atelectasis**__?

* __**Anesthesia, prolonged bed rest, shallow breathing**__ can decrease movement of the *diaphragm and chest wall,* which results in **hypoventilation**, leading to small airway obstructions from retained secretions → a.k.a atelectasis
* Patients who have __**abdominal**__ or __**chest surgery**__ are at risk for *hypoventilation* and atelectasis because incisional pain may result in shallow breathing

What aids in lung expansion and decreases the likelihood of pulmonary secretions pooling in dependent areas of the lungs ?

incentive spirometer

What are some nursing consideration for __**incentive spirometer**__?

* Patient should be in __**semi-fowler**__ or __**fowler**__ if possible
* Instruct patient to __**inhale slowly**__ with the mouth on the mouthpiece
* Inhale as much as possible and hold that breath for __**3-5 seconds**__
* Remove mouthpiece and exhale slowly
* Repeat each in halation and exhalation __**5-12 times**__
* End with __**two controlled coughs**__
* Perform this exercise every __**1-2 hrs**__