skills final

Hand Hygiene

-wash hands 20 sec
-gel in and out

SBAR

Situation
Background
Assessment
Recommendation

Situation

I am calling about.....
Code status is.....
Vital signs are.....
Concerned about.....

Background

Mental status is......
Came in for......
Current condition is......
History is.....

Assessment

This is what I think the problem is
These are the issues going on

Recommendation

I think we should do......
Test we should order
From physician

HIPPA

Cannot share information, even to family members

Critical Thinking

thought that is disciplined, comprehensive, based on intellectual standards, and as a result, a systematic way to form and shape one's thinking that functions purposefully and exactingly
-applying knowledge
-put puzzle pieces together
-what's most priority

Clinical Reasoning

"critical thinking in a clinical setting"
-a specific term usually referring to ways of thinking about patient care issues (determining, managing, preventing problems) for reasoning about other clinical issues (teamwork, collaboration)
-nurses usually use this

Critical Judgement

thinking: the process
judgement: the result, decision made
-use critical thinking skills in the clinical setting to make judgement calls

Hygiene and activity

front to back for females

High Fowler's position

Semi High Fowler's Position

30 degrees

Protective Supine Position

Protective Side-Lying or Lateral Position

Protective Sims' Position

Protective Prone Position

If someone is falling

let them fall gently to floor

If walking someone

use a gait belt

How to measure a cane

15 degrees at elbow, should be hip level

How to measure a walker

15 degrees at elbow

Which leg goes first into walker

Step into with weak side first

Which side does the cane go on

goes on strong side

Why do we use a board when transferring bed to bed?

to prevent friction

Airborne Infectious Organisms

TB, Measles, Chickenpox, Shingles

Airborne Isolation Precautions

faceshield, mask, gown, gloves
private room with negative pressure

Droplet Infectious Organisms

Entero/rhino
Influenza

Droplet Isolation Precautions

Mask, gown and gloves
private room

Contact Infectious Organisms

MRSA
C.diff
VRE
ESBL
Acinetobacter

Contact and Droplet Infectious Organisms

Metapneumovirus and RSV

Contact Isolation Precautions

Gown and gloves
private room

C. Diff Isolation Precautions

Gown and gloves
Wash hands with soap and water

How to break the chain of infection

hand hygiene, sterilization, dry intact dressing, wear gloves if body fluids, cover nose & mouth when sneezing, immunizations, screen health care staff, wear masks, proper disposal of needles/sharps, adequate refrigeration, use pesticides

Hospital Acquired Infections

Catheter-associated urinary tract infection (CAUTI)
Surgical site infection (SSI)
Central line-associated bloodstream infection (CLABSI)
Ventilator-associated pneumonia (VAP)

When do I wear gloves?

-when at risk for exposure to bodily fluids (poop, pee, sputum, blood, breast milk, wound drainage)

Applying PPE

wash hands
put on gown
put on mask
googles/faceshield
gloves

Removing PPE

untie front of gown if tied on front
remove gloves
remove eyewear/faceshield
remove gown (let fall away from body)
remove mask
wash hands

Normal Temperature

96.7-100.4

Normal Pulse

60 to 100 bpm

Normal Blood Pressure

120/80
Anything above 130 is elevated, anything below 90 concerning

Normal O2 Sats

Above 94%

Most Accurate Temperature

rectal

Factors Contributing to Tachycardia

-anything that lowers the fluid volume in blood (dehydration, hemorrhaging)
-respiratory distress (low oxygen)
-decreased blood pressure w/blood loss
-elevated temperature
-exercise
-prolonged application of heat
-pain
-strong emotions
-some medications

Factors Contributing to Bradycardia

-heart block (delay in system)
-hypothermia
-vagel stimulation
-sleep
-medications

Vagel Stimulation

baroreceptors sense when BP is high so it tells heart to slow down
-can be accidentally stimulated or induced

Pulse Amplitude

0 is dead
+2 is normal
+3 is bounding

Posterior Tibial Pulse

Dorsalis Pedis Pulse

Pulse Deficit

difference between apical and radial pusle

When to treat blood pressure

over 160 and less than 90

less than 90 bp

shock
elevate legs to shunt blood to vital organs

PQRST

Provoking factors
Quality
Region/Radiation
Severity
Time

Wong-Bakers Faces

for pediatrics or nonverbal patients

Doppler Ultrasound

when you don't feel a pulse

Measuring tape

used to measure head, legs, hips, etc to check for edema

Health History

has questions about problems, what medications, allergies

Head to Toe/Physical Assessment

vital signs, assessments for all systems

Head to Toe Entry

wash hands
identify patient
scan room and patient
ask about allergies

Head to Toe Vitals

temperature
pulse
respiratory
blood pressure
O2
PAIN

Head to Toe Neuromuscular

LOC
Orientation x4 (Person, Place, Time, Situation)
PERL
strength x4

Head to Toe Cardiac

skin color/warm
pulse strength and regularity x4
cap refill x4
edema x4
heart sounds

Head to Toe Respiratory

lung sounds
cough/sputum
SOB

Head to Toe GI

inspect
ascultate
palpate
last bowel movement
nausea

Head to Toe GU

describe urine
discomfort
incontinence

Head to Toe Skin

wounds
abnormalities
incision
skin risk assessment (flip over and check)

Head to Toe IV

check site
trace the line
tubing dates

Head to Toe Activity

activity level assessment
assistive devices (cane, walker)

Head to Toe Fall Risk

IV pole
confused
medication/narcotics
need assistance

Head to Toe Psychosocial

anyone visit today
support
mental health (depressed)

Head to Toe Exit

reposition
offer assistance
answer questions
discuss plan/goals/teach
scan patient and room
safety (bed lowest, call bell, side rails up, bed alarm on, tell them if fall risk)

Fall Risk Assessment Categories

age
fall history
elimination
medications
equipment
mobility
cognition

Fall Risk Preventions

Call bell in reach, bed in lowest position, side rails up, provide nonskid socks, instruct pt how to use call bell, leave night light on, indicate risk on pts door, keep bed wheels locked, eliminate physical hazards, move bedside commode out of sight, leave water tissues bedpan within reach

Sepsis

body's overreaction to an infection that causes vasodilation
-causes body to go into shock which deprives organs of oxygen

What kind of shock is sepsis?

distributive shock

Sepsis Screening

HR\>90
Temp\>100.4 or Temp

Lactate Acid

because of shock the body switches from aerobic to anaerobic metabolism which produces....

Restraints Alternatives

-assess underlying cause
-bed alarms
-sitter/family at bedside
-deescalate using good communication skills

Charting Tips

-document in military time
-document objectively
-document interventions followed by response to interventions
-document time recorded and time occurred
-document incidences & assessments as soon as possible
-never document interventions before carrying them out
-any change in pts status
-always write a nursing note for: admissions, transfers, discharges, when procedure is performed, receiving a post op pt, & communication w/health care provider

Fixing Documentation Error

draw straight line through error and write "error", initial & then add proper documentation

DAR Format

Data: your assessments
Action: what did you do about it
Response: what happened after & what is the plan moving forward

olfactory nerve (1)

sense of smell

optic nerve (2)

ability to see

oculomotor (3)

ability to move and blink your eyes

trochlear nerve (4)

ability to move your eyes up and down or back and forth

trigeminal nerve (5)

Sensations in your face and cheeks, taste and jaw movements.

abducens nerve (6)

ability to move your eyes

facial nerve (7)

facial expressions and sense of taste

auditory/vestibular (8)

sense of hearing and balance

Glossopharyngeal (9)

ability to taste and swallow

vagus nerve (10)

digestion and heart rate

accessory nerve (11)

shoulder and neck muscle movement

hypoglossal (12)

ability to move your tongue

Ischemic Stroke

blood clots stop the flow of blood to an area of the brain

Hemorrhagic Stroke

occurs when a blood vessel in the brain leaks or ruptures; also known as a bleed

Monroe Kellie Doctrine

when one content in the skull increases, another must decrease to compensate and maintain normal ICP
-subdermal, subarachnoid or intracerebral

Accommodation

the process by which the eye's lens changes shape to focus near or far objects on the retina

Convergence

movement in which both eyes rotate inward so that the lines of sight intersect in front of the eyes

Glascow Coma Scale (GCS)

neurologic assessment of a patient's best verbal response, eye opening, and motor function
-includes eye opening, verbal response and motor response

Decorticate Posturing

arms flexed inward and bent in toward the body and the legs are extended

Decerebrate Posturing

posturing in which the neck is extended with jaw clenched; arms are pronated, extended, and close to the sides; legs are extended straight out; more ominous sign of brain stem damage. Most Severe.