nurs 12- skills quiz 1

Why do we do hand hygiene?

prevents infections and illness

When do we preform hand hygiene?

1. before touching a patient
2. before a clean or aseptic procedure
3. after a body fluid exposure risk
4. After touching a patient
5. after touching patient surroundings

Insurance policies no longer cover

costs of Hospital Required Infections

Communication process Source

Patient, doctor, nurse, family, manager doctors

Communication process message

verbal, nonverbal, nursing notes, doctor consults

communication process channel

auditory, visual, touch

communication process receiver

interprets message

feedback

confirmation they recieved the message

noise

distractors in the process

verbal communication consideration

intellectual development, primary language, culture

non verbal examples of communication

touch, eyes, facial expression, posture, gait, gestures, physical appearance, sounds, silence

effective communication

sit eye level, use interpreter, give them space, eye contact, recognize cultural differences, soft spoken

SBAR

Situation \n Background \n Assessment \n Recommendation

Situation (SBAR)

What is happening at THIS time \n \n vital signs,

Background (SBAR)

What are the circumstances leading to this situation \n \n mental status, skin, patient is on

Assessment (SBAR)

What do I think the problem is?

Recommendation (SBAR)

\-What do you want the patient/prescriber to do? \n -What action do you propose? \n -What do you need?

QSEN

\n Patient-Centered Care \n Teamwork and Collaboration \n Evidence-Based Practice \n Quality Improvement \n Safety \n Informatics

Why is mobility important?

Prevent DVTs and increase perfusion

* helps open our lungs and prevents atelectasis/closed alveoli which can case pneumonia
* increases strength, joint mobility, and coordination
* increases gastric motility

preventing DVTs

SCDS, heparin IV drip

fowlers position

Protective supine position

protective side lying or lateral position

protective sims positions

Protective Prone Position

If patient falls

gently guide them to the floor

Gait belt

hold gait belt and stand on weaker side

walker and cane

15 degrees at elbow

walking w walker

\-step into walker with weeks side first \n \n - don't use on stairs

walking with cane

* cane is on strong side
* weak leg and cane move at same time

transferring patient from bed to chair

* use gait belt
* encourage to stand uprigh t
* get wide apart
* life with legs not back
* 2 person assign if applicable
* make sure wearing non slip socks

asepsis and infection control

immunization, hand hygiene, sterilization dry dressing, gloves, cover mouth and nose, masks, disposable needles

Hospital inquired infections

* catheter-associated UTI
* Surgical site infection
* Central line- associated bloodstream infection
* ventilator associated pneumonia

airborn diseases

measles, chicken pox, TB, herpes zoster, smallpox

airborne precautions

private room w negative pressure, N95 mask, gown, gloves

droplet diseases

Rubella \n Pertussis \n Mumps \n Pneumonia \n Influenza \n Meningitis \n Edenovirus

droplet disease precaution

private room, mask , gown, gloves

contact disease

MRSA

contact disease precaution

private room, gown and gloves

CDIFF precautions

hand washing with soap and water, alc does not kill cdiff

when do you wear gloves

* at risk of exposure of bodily fluids
* take off when done and wash hands

needle stick injury

* follow hospital policy


* wash hands
* notify charge nurse
* got to ER for lands drawn
* F/U w employee health

applying PPE

* wash hands


* put on gown
* put on mask
* goggle if required
* gloves

removing PPE

* untie front of gown
* remove gloves
* remove eyewear
* remove gown
* remove mask
* wash hands

Transfer from gurney to bed

transfer sheet or plastic to prevent friction

Repositioning

every 2 hours

when do we take vital signs

* admission


* change in pt condition
* facility policies (every 4 hours and ICU and ER every 2 hours)
* loss of consiousness
* b4 and after surgery
* admin meds for cardio or rest system (BP MEDICINE)
* anytime you suspect something wrong

normal temp

96\.7-100.4

temp over 100.4

risk of seizures \n pyrexia \n sign of infection

temperature important

to assess baseline for b4 and after surgery

treating temp

treat the underlying cause

first time fevers

ask for specimen cultures to rule out infection

hypothermia

less than 96.7 \n warm up using BAREHUGGER

Temperature sites

Oral, rectal, axillary, temporal, tympanic

oral temp

close mouth around probe, not suitable for kids. \n \n MOST COMMON

oral temp precautions

if eating hot or cold, smoking, chewing gum - wait 15-30 minutes

tympanic temp

ear

temporal temp

forehead

axillary temp

armpit, most commonly used in pediatrics

rectal

most accurate, put lubricant

normal pulse

60-100

tachycardia

HR above 100

decrease in BP

heart rate yes higher to compensate

elevated temp

usually causes 7-10 beats/min for each 1 degree above

less oxygen

higher heart rate to get more oxygen

strong emotions

higher heart rate

some medications epinephrine

higher heart rate

bradycardia

HR less than 90

factors relating to low heart rate

* sleep
* medication
* heart blocks
* hypothermia
* vagal stimulation
* hypothermia

apical pulse

listen to apex of heart , hold for HR less than 60

required prior to giving Digoxin

apical pulse

pulse deficit

difference between apical and radial pulse

why do we check radio land doralis pedis pulses

MOST DISTAL FROM HEART

Pulse amplitude 0(dead)

absent, unable to palpate

pulse amplitude +1

diminished, weaker than expected

pulse amplitude +2

Brisk, expected (normal)

pulse amplitude +3

bounding

pulse rhythm

regular or irregular

normal respirations

12-20 breaths per minute

respiratory arrest

no breathing

respiratory distress

breathing too fast, above normal rate \n \n MEANS YOU NEED MORE O2

respiratory depression

breathing too slow; below the normal rate

normal blood pressure

120/80 \n \n within 10 differences is normal \n (110/70 or 130/90)

concerning BP

systolic over 160 and diastolic under 90

BP should not be taken on

arms with IV infusions in place, side of mastectomy, or side of Dialysis AV fistula. \n \n \n Ask pt if it is ok to use the chosen arm before taking BP

Elevated bp

120-129/

Hypertension stage 1

130-139 /80-89

Hypertension Stage 2

140 or higher/90 or higher

hypertensive crisis

>180 and/or >120

Normal O2 saturation

greater than 94%

Pain PQRST

P - Provoking Factors \n Q - Quality \n R - Region / Radiation \n S - Severity \n T - Time \n If nonverbal → use Wong Baker Faces

Doppler ultrasound

ultrasound machines used to find pulses that are not palpable

tools by nurses - flashlight

Viewing inside the mouth and nose; reaction of the pupils of the eyes

tools by nurses - stethoscope

Measure blood pressure, listen to heart, lung, abdomen, cardiovascular sounds

tools by nurses- Measuring tape

Measure waist, measure head - chest - circumference, measure sizes of wounds

tools by nurses - BP cuff

measure blood pressure

tools by nurses - thermometer

measures body temp

tools by nurses- O2 sat probe

measure oxygen levels in blood

inspection

look

palpation

to examine by touch \n \n skin temp, texture, moisture