NR226 Fundamentals CJE

The plan of care goals S.M.A.R.T. stands for?

S: Smart

M: Measurable

A: Attainable

R: Realistic

T: Timed

(Interventions & Evaluation)

Non-maleficence

The duty to cause no harm, both individually and for all

Autonomy

Freedom of choice

Beneficence

Taking positive action to help others

Justice

Fair distribution of resources (Access to healthcare)

Fidelity

Agreement to keep promises

Accountability

Responsible legally and professionally for decisions

Advocacy

Protecting patients' human and legal rights

Veracity

Being honest and telling the truth (Honest about risks for a procedure)

Maslow's Hierarchy of needs:

§ Basic Needs- food, warmth, water, rest

§ Safety Needs- Security and safety

§ Belongingness and Love Needs- Intimate relationships and friendships

§ Esteem Needs- Prestige and feeling of accomplishment

§ Self-Actualization- Achieving one's full potential, including creative activities

Priority Nursing Interventions

o Providing physical treatments, emotional support, and patient education are all examples of nursing interventions; nursing care plan to monitor and improve their patient's comfort and health

o Survival needs or imminent life-threatening problems take the highest priority

o What is the nurse's priority? Which client should the nurse see first? If you can only choose one option...? What should the nurse do next?

Prioritizing Patients

o Consider age of patient, vital signs that are out of range, ABCs, pain and safety

Priority 1: Treatable life-threatening illness or injury

Priority 2: Serious but not life-threatening illness or injury

Priority 3: Walking wounded

Priority 4 (sometimes called Priority 0): Dead or fatally injured

Delegations: UAP/CNA

o NEVER delegate clinical reasoning, judgment, education, and critical decision-making to UAP

o Right task, right circumstance, right person, right directions or communication, and right supervision or evaluation

Hospice

o Focuses on care of terminally ill patients, usually those who have less than 6 months to live

o Non-curable

o No identifiable cause

o More suffering with pain

§ Goal is to manage pain, provide comfort, and ensure the quality of life

Palliative Care

o Care designed not to treat an illness but to provide physical and emotional comfort to the patient, and support and guidance to his or her family

o Curable

o Available for anyone, no age limitations

o Focuses on prevention, relief, and reduction of symptoms

§ Goal is to help achieve the best possible quality of life

Sleep Disorders

o Bed wetting, sleep-onset anxiety, sleep apnea, delayed sleep phase disorder, sleepwalking/talking, night terrors

The RN is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?

A. A client with diabetes is being discharged today.

B. A 35-year-old male with tracheostomy and copious secretions.

C. A teenager is scheduled for physical therapy this morning.

D. A 78-year-old female client with a pressure ulcer needs a dressing change.

Correct Answer: B. A 35-year-old male with tracheostomy and copious secretions.

The patient with an airway problem should be given the highest priority. The ABCs identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities in that sequential order.

The nurse is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

A. A client is scheduled for a cardiac ultrasound this morning.

B. A client with syncope is being discharged today.

C. A client with chronic bronchitis is on nasal oxygen.

D. A client with a diabetic foot ulcer needs a dressing change.

C. A client with chronic bronchitis on nasal oxygen.

A client with airway problems should be attended first.

You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given a nursing diagnosis of Activity Intolerance. Which action should you delegate to the nursing assistant?

A. Instructing the patient to alternate rest and activity periods

B. Encouraging, monitoring, and recording nutritional intake

C. Monitoring cardiorespiratory response to activity

D. Planning activities for periods when the patient has the most energy

B. Encouraging, monitoring, and recording nutritional intake

The nursing assistant's training includes how to monitor and record intake and output.

Confidentiality

o Guarantees that any information a subject provides will not be reported in any manner that identifies the subject and will not be accessible to people outside the research team

Therapeutic Communication

o Active listening, sharing empathy, humor, feelings and observations, and using touch or silence

Grief & Coping

o Cannot be defined, different for everyone

§ Affected by age, personal relationships, nature of loss, coping, socioeconomic status, cultural and religious belief

Wound Care

Wound assessment, wound cleansing, timely dressing change, selection of appropriate dressings, and antibiotic use

o Primary Intention – Surgical incision

**Approximated – Healing occurs quickly, the risk for infection is low

o Secondary Intention – Wound where tissue is lost such as pressure injury, the burn of severe laceration

o Tertiary Intention – Delayed primary wound healing after 4–6 days. This occurs when the process of secondary intention is intentionally interrupted and the wound is mechanically closed. This usually occurs after granulation tissue has formed

Metabolic Alkalosis

o pH > 7.45, PaCO2 normal, HCO3 > 26mEq/L

o Symptoms - Lightheadedness, muscle cramps, confusion, circumoral paresthesia, dysrhythmias

o Causes - Hypokalemia, excess sodium bicarbonate, massive blood transfusion, excess vomiting or gastric suctioning

Metabolic Acidosis

o pH < 7.35, PaCO2 normal, HCO3 < 22mEq/L

o Symptoms - Decreased LOC, increased rate and depth of respirations, dysrhythmias

o Causes - Ketoacidosis, burns, renal disease, lactic acidosis, diarrhea pH < 7.35, PaCO2 normal, HCO3 < 22mEq/L

o Symptoms - Decreased LOC, increased rate and depth of respirations, dysrhythmias

o Causes - Ketoacidosis, burns, renal disease, lactic acidosis, diarrhea

Respiratory Alkalosis

o pH > 7.45, PaCO2 < 35mmHg, HCO2 normal

o Symptoms - Lightheadedness, numbness, tingling, increased rate and depth of respirations, excitement then decreased LOC, dysrhythmias

o Causes - Hypoxemia, anxiety, inappropriate ventilator settings, head injury, aspirin overdose

Respiratory Acidosis

o pH < 7.35, PaCO2 > 45mmHG, HCO2 normal

o Symptoms - Headache, lethargy, confusion, dysrhythmias

o Causes - Airway obstruction, respiratory muscle weakness, drug overdose, head injury

Tracheostomy Suctioning/Risk Factors

o Any modifications of the skill such as the need for supplemental oxygen

o Appropriate suction limits for suctioning nasotracheally and for suctioning ETTs and TTs and risks of applying excessive or inadequate suction pressure

o Reporting any changes in patient's respiratory status, level of consciousness, restlessness, secretion color and amount, and unresolved coughing or gagging

o Reporting any changes in patient's color, vital signs, or complaints of pain

Fall Risk Factors

o Older adults have the highest risk of death or serious injury following a fall

o Occupations at elevated heights or other hazardous working conditions.

o Alcohol or substance use.

o Socioeconomic factors, including poverty, overcrowded housing, sole parenthood, or young maternal age.

o Underlying medical conditions, such as neurological, cardiac (orthostatic hypotension), or other disabling conditions.

o Polypharmacy and side effects of medications.

o Physical inactivity and loss of balance, particularly among older adults.

o Poor mobility (impaired balance, gait, coordination), cognition, and vision, particularly among those living in an institution, such as a nursing home or chronic care facility.

o Unsafe environments (e.g., broken stairs, icy sidewalks, inadequate lighting, throw rugs, exposed electrical cords, barriers along walking paths, and improper equipment for ambulation).

o Foot problems that cause pain and unsafe footwear, such as backless shoes or high heels.

Culturally Sensitive Care

o Show your patient respect and understand their individual needs and differences

o Put your biases aside before providing care

SBAR stands for

o Situation - Introduce with position, title, role and relationship to patient, always include the reason why you are calling

o Background - Date and time of admission, symptoms, diagnosis, vitals and labs, allergies and medications

o Assessment: State your professional conclusion, based on the situation and background

o Recommendation - What treatment you believe the patient should get (surgery, blood work, physical therapy, blood work)

Hypomagnesemia

(< 1.5 mEq/L)

§ Causes - Malnutrition, chronic alcoholism, chronic diarrhea

§ Symptoms - Positive Chvostek sign, hyperactive deep tendon reflexes, muscle cramps, twitching, grimacing, dysphagia, tetany, seizures, tachycardia, hypertension, dysrhythmias

Hypermagnesemia

(>2.5 mEq/L)

§ Causes - Excessive use of magnesium laxatives and antacids, parenteral magnesium overload

§ Symptoms - Lethargy, bradycardia, hypotension, flushing, decreased rate and depth of respirations, dysrhythmias, cardiac arrest

Hypocalcemia

(<8.4 mg/dL)

§ Causes - Conditions that cause calcium ions to be bound and passed out of the body (pancreatitis)

§ Symptoms - Neuromuscular excitability, such as facial or eye twitching

Hypercalcemia

(>10.5 mg/dL)

§ Causes - Some cancers, parathyroid disease

§ Symptoms - Decreased neuromuscular excitability, lethargy, pathological fractures

Hypokalemia

(<3.5 mEq/L)

§ Causes - Diarrhea, vomiting, potassium-wasting diuretics

§ Symptoms - Muscle weakness, cardiac dysrhythmias, abdominal distention

Hyperkalemia

(>5 mEq/L)

§ Causes - Increased potassium intake, shift of potassium from cells into extracellular fluid, decreased potassium output

§ Symptoms - Abdominal distention, muscle weakness, cardiac dysrhythmias and cardiac arrest

Hypernatremia

(>145 mEq/L)

§ Causes - Diuretics, diarrhea, heart failure

§ Symptoms - Confusion, lethargy, thirst, seizures

Hyponatremia

(<135mEq/L)

§ Causes - SIADH, heart, liver and kidney problems, hypothyroidism

§ Symptoms - Confusion, lethargy, seizures

Nursing Process (ADPIE)

o A- An assessment of something new: When the nurse assesses lung sounds, checking lab values, health history, neuro assessment, etc.

o D- Deciding on a nursing diagnosis: Creating a nursing diagnosis based on a priority need

o P- Thinking or planning ahead: Creating goals and outcomes for a client, making a game plan, and panning for client needs, etc.

o I- Implementing the plans into action: Turning the client, educating the client, performing wound care, etc.

o E- Evaluating how it worked? This is AFTER a tx is finished: Reassessing pain scale AFTER giving meds, checking how client tolerated a procedure AFTER the procedure is completed

IV Insertion

o Consider client's condition, what type of fluid will be infused, how long the therapy will last

o DO use - Veins of forearm, antecubital space, AVOID - Lower extremities and small diameter veins

Cephalic and Basilic are most commonly

Extravasation

Leakage of fluid in the tissues around the IV site

What signs or symptoms will there be with an extravasation of an IV site?

-Redness around the site.

-Swelling, puffy or hard skin around the site

-Blanching (lighter skin around the IV site)

-Pain or tenderness around the site

-IV not working

-Cool skin temperature around the IV site or on the scalp, hand, arm, leg, or foot near the site

-A vesicant medication leaked and causes tissue damage

Anticipatory Grieving

o Grief response in which the person begins the grieving process before an actual loss

o This grief implies the "letting go" of an object or person before the loss, as in a terminal illness.

o Individuals have the opportunity to start the grieving process before the actual loss.

For example, if a loved one has a life-threatening illness such as cancer, a family member or close relative may experience anticipatory grief at any point from the initial onset of symptoms to the time of the diagnosis to when they enter hospice care

Perioperative Care Environments

o Hospitals, surgical centers, and/or health care providers' offices

o Nursing goals in the preoperative area are based on the following:

§ Quality improvement and evidence-based practices through the application of current research and the generation of ideas for new research knowledge

§ Patient safety through high-quality care

§ Teamwork and collaboration

§ Effective communication and interactions with a patient, the patient's family members, and the surgical team, fostering shared decision making

§ The nursing process to deliver timely assessment and interventions in all phases of surgery

§ Advocacy for a patient and the patient's family

§ Cost containment

· End of Life Care

o Care needs - Nausea, incontinence, dehydration, ineffective breathing, fatigue, anxiety, care of eyes and mouth

Constipation

o Too much water is absorbed from the colon causing hard, dry stool; impairments of GI functioning; accumulation of hardened feces

Bowel Training

o Setting up daily routine for bowel movements, includes hot beverages, prune juice

o Patient leans forward on the commode typically 1 hour after eating

· Incident Reports

o Confidential documentation that describes any patient accident while the person is on the premises of a health care agency

Post-Op Pain Management

o Minimization of patient discomfort, facilitate early mobilization and functional recovery, and prevention acute pain developing into chronic pain

o There are three phases of anesthesia recovery

§ During phase I close monitoring is required; for the first 1 to 2 hours the focus is on assessing for the after effects of anesthesia, including airway clearance, cardiovascular complications, fluid management, temperature control, and neurological function

§ Plans and care are provided to progress the patient home (such as ambulatory surgery, where the patient

§ Phase III recovery (convalescence) focuses on providing ongoing care for patients who are hospitalized and require extended observation or intervention after transfer from phase I or phase II; preparing for self-care

Anesthesia Care

o A blueprint and an excellent tool to help the anesthetists improve the quality of care they provided

o The Anesthesia Team develops a pain management plan to help the client feel comfortable as they recover in the hospital and after returning home

Colostomy Care

o Colostomy - artificial opening from the colon to the outside of the body

o Change all of the supplies weekly including the wafer

o Use the right size pouch and skin barrier opening

o Change the pouching system regularly to avoid leaks and skin irritation

o Be careful when pulling the pouching system away from the skin and don't remove it more than once a day unless there is an issue

o Clean the skin around the stoma with water

o Watch for sensitivities and allergies surrounding the stoma

Paralytic Ileus

o Loss of function in the intestine which causes abdominal distention

§ Ask patient if they are passing gas

Informed Consent

o Explanation of the procedure or treatment including death or serious harm

o Patient has the right to refuse procedure or treatment

o MUST be signed by the individual providing the care

Non-Pharmacological Comfort Measures

Distraction

Biofeedback

Self hypnosis

Guided Imagery

Heat & Cold applications

Relaxation techniques

Transcutaneous Electrical Nerve Stimulation (TENS)

Music therapy

Massage

How to promote healthier sleep & rest habits?

-Follow normal routine

-Position

-Decrease noise/distraction

-Decrease lighting

-Decrease anxiety

-Do not wake client up for prn sleep medications

-PRN sleep meds should not be administered routinely--give when other measures fail

-White noise

-No caffeine, alcohol, or tobacco

Hypnotic

-A drug that induces sleep. Given at night (HS)

-Lose effect after 1-2 weeks

A nurse is caring for a client who is sitting in a chairand asks to return to bed. Which of the followingactions is the nurse's priority at this time?

A. Obtain a walker for the client to use to transfer back to bed.

B. Call for additional staff to assist with the transfer.

C. Use a transfer belt and assist the client back into bed.

D. Determine the client's ability to help with the transfer.

D. Determine the client's ability to help with the transfer.

Rationale: The first action that should be taken using the nursing process is to assess or collect data from the client. Determine the client's ability to help with transfers and then proceed with a safe transfer.

A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure?

A. Check how long the feeding container has been open.

B. Verify the placement of the NG tube.

C. Confirm that the client does not have diarrhea.

D. Make sure the client is alert and oriented.

B. Verify the placement of the NG tube.

Rationale: The greatest risk to the client receiving enteral feedings is injury from aspiration. The priority nursing assessment before initiating an enteral feeding is to verify the proper placement of the NG tube by checking gastric pH through aspirating for residual volume.

NPO (Nothing Per Oral)

no food or fluid at all by mouth, not even ice chips; requiring a provider's prescription before resuming oral intake

Clear liquid diet

liquids that leave little residue (clear fruit juices, gelatin, broth)

Full liquid diet

Clear liquids plus liquid dairy products, all juices. Some facilities include pureed vegetables in a full liquid diet.

Pureed diet

Clear and full liquids plus pureed meats, fruits, and scrambled eggs

Mechanical soft diet

Clear and full liquids plus diced or ground foods

Soft/low-residue diet

Foods that are low in fiber and easy to digest (dairy products, eggs, ripe bananas)

High-fiber diet

Whole grains, raw and dried fruits

Low sodium diet

No added salt or 1 to 2 g sodium

Aggrastat at 17.2 mg in 450 mL is to be infused at 8 mcg/kg/hr in a patient who weighs 64 kg. At what flow rate in mL/hr will you set the pump? (Round to the nearest tenth, if applicable).

13.4 mL/hr

Solumedrol 2.5 mg/kg is ordered for a child weighing 14 kg. Solumedrol is available at 125 mg / 1 mL is available. How many mL must the nurse administer? (Round to the nearest hundredth, if applicable).

0.28 mL

Low cholesterol diet

No more than 300 mg/day of dietary cholesterol

Diabetic diet

Balanced intake of protein, fats, and carbohydrates of about 1,800 calories

Dysphagia diet

Pureed food and thickened liquids

Regular diet

No restrictions (unless specified)

Intentional Torts

Harm caused by a deliberate action (assault, battery, false imprisonment)

Unintentional Torts

Accidents or mistakes that are not planned or intended that result in harm to another (Negligence, malpractice)

Quasi-intentional Torts

A voluntary act that causes injury or distress without intent to injure or cause distress (invasion of privacy, defamation of character, libel, and slander)

Hyperglycemia

-High blood sugar

-Hot & dry

Hypoglycemia

-Need some candy

-Cold & clammy

-Severely low blood sugar

Sterile technique/surgical asepsis

"sterile" (surgical asepsis)

Used to prevent contamination with microorganisms

You MUST use sterile gloves, instruments, devices, and a mask

Antiseptic skin preparation

Keeping doors closed, no fans, no extra personnel

Ex: insert indwelling catheter

Nurse's role when a restraint order is needed for a patient?

Obtain physician order in writing after the patient has been seen face-to-face by the provider (usually within 1 hour)

Renew restraint orders every 24 hours

Release every 2 hours for assessment of skin, ROM activities, and for hygiene and elimination

Secure restraints to an immovable part of the bed frame. If restraints with a buckle strap are not available, use a quick-release knot to tie the strap.

Clean technique/medical asepsis

"clean" (medical asepsis)

Reducing the numbers of microorganisms

Use NON-Sterile gloves and hand hygiene

Environment undergoes routine cleaning

Prevent contamination of supplies and materials

Ex: removal of an indwelling catheter

Patient's medical need for restraints

For client's pulling out lines/tubes or getting out of bed

Patient's behavorial need for restraints

For client's in imminent risk to themselves or others

Isotonic IV solution

(252 mOsm/L)

D5W solution

*Treats hypernatremia

*Free water

-Used with administering some medications

Hypertonic IV Solution

(505 mOsm/L)

*Irritating to the vein; can cause increased risk of heart failure and pulmonary edema

*Free water only

1/2 NS IV Solution

*0.45% NaCl

Hypotonic

-Maintenance solution

(154 mOsm/L)

-Maintenance solution to replace other daily electrolytes

-Free water & NaCl

-Can cause IVF overload if administered too rapidly

NS IV Solution

*0.9% NaCl

Isotonic

-Used for postoperative fluid intake

(308 mOsm/L)

-Increases IVF and replaces fluid loss

-No free water

-Can cause fluid overload

-Only solution that can be administered with blood products

-NaCl in higher concentration than blood levels

Signs that a teen is not getting enough sleep?

Daytime sleepiness

Feeling tired during the day

Accident prone

Poor school performance

Ages 10-12 require how many hours of sleep a night?

10 hours

Signs a child is getting enough sleep:

Fall asleep within 30 minutes of going to bed

Wakes up easily

Child is mentally alert and does not need to nap

Preschool and elementary school kids sleep how many hours a night?

7-9 hours a night

Sleep-onset anxiety

Occurs in young children

Bedwetting (nocturnal enuresis)

Usually stops after 5 years old

Delayed Sleep Phase Disorder

Occurs in teens and other children

REM Behavior Disorder

A rare disorder in which the mechanism that blocks the movement of the voluntary muscles fails, allowing the person to thrash around and even get up and act out nightmares

Sleep-walking/talking

Children

Night terrors

a sleep disorder characterized by high arousal and an appearance of being terrified; unlike nightmares, night terrors occur during Stage 4 sleep, within two or three hours of falling asleep, and are seldom remembered

Older adults >64 years require how much sleep a night?

7-8 hours a night

Sleeping requirements for adults

High levels of stress can interrupt sleep

Exposure to blue light before bedtime can disturb sleep

Avoid caffeine products and other stimulants before bed

Shift work can disturb circadian rhythms

Caring for infants and sick family members can cause sleep deprivation