NCLEX Fundamentals

Fall risk checklist

-Assign closest to nurse’s station

-Nonskid footwear

-Maintain clutter free environment

-Maintain low bed position

-Provide nightlight

Restraint teaching

-Restraints are used only if there is significant harm to pt, other pts, or staff

-Tie restraints to a non-moveable part of the bed.

-Notify provider when restraints are implemented

-Remove the restraints every 2 hrs

-Asses neuro and neurovascular every 2 hrs.

-Restraints are not PRN, providers have to renew prescription every 24 hrs.

Seizure Precautions by bedside

-Oxygen

-Suction

-Oral airway

-IV access

-Bed in low position and clutter free

Onset of seizure actions

1) Turn pt on the side with head slightly forward

2) If sitting or standing, ease pt to the floor

3) Do not put anything in their mouth

4) Loosen restrictive clothing

5) Administer Benzos

6) Document time

RACE

R → Rescue

A → Alarm

C → Contain

E → Extinguish

Who should you save first a pt who is bed bound or a pt who is mobile

Evacuate all the pts who can walk first, then go back to the other pts.

PASS for fire extinguisher

P → Pull

A → Aim

S → Squeeze

S → Sweep

Home health fire safety

-Post no smoking signs

-No petroleum jelly

-Keep oxygen source 10 ft away from electrical/heat sources

-Ensure fire alarms are working

-No extension cords and make sure they are not frayed.

Nursing Ergonomics

-Avoid twisting from the spine

-Avoid bending from the waist

-Use major muscle groups and strengthen abdomen muscles

Transferring client from bed to to chair

1) Lower the bed to the lowest setting

2) Position the bed or chair so that the client is moving toward the stronger side

3) Assist client to stand (monitor orthostatic hypotension)

4) Pivot patient and sit them in locked wheel chair

Trendelenburg vs Reverse Trendelenburg

Trendelenburg → Head down

Reverse Trendelenburg → Head up

Crutches positioning

-3 finger widths between the axilla and top of the crutch

-Position hand on hand grips with elbows flexed at 30 degrees

Weight baring crutches '“Two point gait”

1) Advance crutches

2) Advance bad leg

3) Advance good leg

4) Make sure steps are equal in length

Non-weight bearing crutches “Three point gait”

1) Advance crutches

2) Advance bad leg

3) Advanced good leg past crutches

“Four point gait”

Start with crutch, then foot and repeat

Walking up stairs

1) Up with good leg

2) Bring bad leg and crutches up at the same time

Walking down stairs

1) Down with bad leg and crutches at the same time

2) Good leg follows

Cane walking

-Can is used on good side

1) Move can forward

2) Move bad leg

3) Move good leg passed the cane

Walker fitting

-Make sure client wears shoes

-Clients wrists are even with the hand grips when arms are dangling

Walker walking

1) Advance the walker 12 inches

2) Advance bad leg

3) Advance good leg

Rolling walker

Parkinson’s disease pts should not have a rolling walker because of shuffling gait

Standard Precautions

Use alcohol based sanitizer and wash hands if it gets soiled.

Airborne Precautions “MTV on Air” (Measles, TB, Varicella)

-Private negative airflow

-N95 respirator

-Close door

-Pt leaves have them wear surgical mask

Droplet Precautions

Surgical mask required

Contact Precautions

-Gloves

-Gown

-Dedicated equipment wiped down with bleach

Protective Isolation

-Sterile gown and mask when in contact

-Positive pressure room

-No fresh flowers, or uncooked fruits and vegetables

Order of putting on PPE (Goes up the body, then to the hands)

1) Gown

2) Mask

3) Goggles

4) Gloves

Order of taking off PPE (Removal in alphabetical order)

1) GLoves

2) GOGgles

3) GOWn

4) Mask

Every disease is reportable to CDC except

-C-Diff

-Herpes

-Pneumonia

-Rotavirus

-Staph aureus

-MRSA

-RSV

Primary Prevention

-Immunizations

-Education

-Promoting fitness

Secondary Prevention

-Screening

-Early detection

Tertiary Prevention

-Promoting lifestyle with the condition/disease they have

When should men get a colorectal screening

Age 50

When should boys do testicular exams

Begin at age 15

When should women get Pap smears

-Ages 21 to 65

-Every 3 years

When should a women begin giving themselves a Mammogram

Begin at age 20 and every 3 years.

-Monks deliver last rites

-Believe in reincarnation

Buddhism

-Pt may lay on the floor when dying

-Believe in reincarnation

-Right hand is used for eating & left hand is used for toileting

Hinduism

-Hala food is good

-Pork & alcohol prohibited (haram)

-Die facing Mecca

Islam

Avoids blood products during care

Jehovah Witness

-Food is required to be kosher

-Milk and meat cannot be served at the same time

-Pork is bad

Jewish

Clear Liquid Diet “Liquid at room temperature”

-Water

-Tea

-Coffee

-Sodas & juices (all colors)

-Jello (gelatin)

Full liquid diet

Everything on clear liquid + all Milk products

Pureed Diet

-Scrambled Eggs

-Pureed meats

-Veggies

-Fruits

Soft diet (bland/low fiber)

-Processed wheat products

-Lightly seasoned

-Smooth and creamy

-Non gass forming so no beans, fruits, veggies

Mechanical Soft Diet

-Ground or diced meats

-Canned fruits

-Softly cooked veggies

-Rice

Foods to avoid of you have PKU

-Milk

-All dairy products

-Aspartame

Foods to eat on a low-cholesterol diet

-Sardines & Salmon

-Walnuts

-Lean meats

-Fruits and vegetables

Nutrition composition of protein, carbs, and fats

Protein → 20%

Fats → 20-35%

Carbs → 45 -65%

High K foods

-Bananas

-Apricot

-Prunes

-Beans

-Baked Potato

Low K foods

-Cereal

-Cabbage

-Cherries

-All the berries

High Iron foods

-Fish meats

-Leafy greens

-Dried fruits like raisins or apricots

-Bread

-Cereal

High Calcium foods

-Dairy

-Kale

-Brocoli

-Fish

Celiac Foods

-BROWS (bad) → Barley, Rye, Oats, Wheat, Spelt

-Rice, Corn, Millet is good