Nursing Care Review

Patient Assessment and Care Fundamentals

Assessing Patient Conditions

• Patient Reports Constant Tiredness, Forgetfulness, Irritability (Despite $8$ Hours of Sleep):

  • First Factor to Assess: Quantity and quality of sleep.

  • Rationale: This assessment helps identify sleep deprivation or sleep disturbances, which can explain fatigue and cognitive changes.

• Pain Assessment Using PQRST Model:

  • The question "When did your pain start? Has it gotten worse or better over time?" addresses the Time component of the PQRST model.

  • Time refers to the onset, duration, and any changes in the pain over time.

• Assessing Postoperative Pain (PQRST Components):

  • When a patient rates pain as $8$ out of $10$ and describes it as "burning" at the surgical incision site, the nurse has assessed the Quality (burning) and Severity ($8$ out of $10$) components of the PQRST model.

• Type of Pain (Burning, Tingling, Numbness in Feet with Diabetes):

  • This indicates Neuropathic Pain.

  • Rationale: Diabetic neuropathy causes nerve damage, producing symptoms such as burning, tingling, or numbness in the extremities.

• Common Symptoms of Sleep Deprivation:

  • Mood changes

  • Increased irritability

  • Sleeping long hours when not intended

  • Excessive yawning

  • Feeling down/depressed

Workplace Conduct and Safety

• Workplace Mistreatment:

  • Scenario: A senior nurse loudly insults a junior nurse for being "too slow" in front of patients.

  • This demonstrates bullying.

  • Definition of Bullying: Repeated, hostile, and intimidating actions, especially in public.

• R.A.C.E. Acronym (Fire Safety):

  • R - Rescue: Assist clients, visitors, and employees.

  • A - Alarm: Activate the alarm per policy.

  • C - Contain: Close doors and windows.

  • E - Extinguish: Attempt to extinguish small fires if it is safe to do so.

• SBAR Acronym and Purpose (Communication):

  • S - Situation

  • B - Background

  • A - Assessment

  • R - Recommendation

  • Purpose: Promotes clear, concise, and effective information exchange to reduce errors and improve communication among healthcare workers.

• Read-Back Communication:

  • Definition: This communication technique requires the receiver to repeat the message exactly as they understood it to confirm accuracy.

  • Patient Safety Strategy: It ensures that verbal or telephone orders are accurately understood and carried out, reducing the risk of medication errors or miscommunication.

• Safe Practices with Electrical Devices and Equipment (Preventing Injury):

  • Avoid plugging or unplugging a device when hands are wet.

  • Avoid rolling over electrical cords with a client's bed or other equipment.

  • Unplug equipment by grasping the plug, not by pulling the cord.

  • Avoid using extension cords as a permanent solution.

  • If equipment is not safe, ensure it is tagged, removed from service, and notify clinical engineering.

• Vertical vs. Lateral Violence:

  • The statement "Vertical violence refers to bullying behaviors between colleagues at the same level of authority" is False.

  • Vertical violence occurs from a supervisor ("top-down").

  • Lateral violence occurs peer-to-peer (e.g., nurse-to-nurse).

Patient Positioning and Mobility

• Active vs. Passive Range of Motion (ROM):

  • Active ROM: Performed by the patient.

  • Passive ROM: Performed by the nurse/caregiver.

  • Mechanism: Active ROM uses the patient's muscles; passive ROM uses external force.

• Trendelenburg Position:

  • Description: The patient lies supine with the head lower than the feet.

  • Uses: Sometimes used to improve venous return and address hypotension.

• Orthopneic Position (Benefits):

  • Patients with COPD or chronic respiratory disease.

  • Patients experiencing dyspnea or difficulty breathing at rest.

  • Rationale: Forward leaning improves chest expansion and facilitates breathing.

• Sims Position:

  • Purpose: Required for rectal medication administration or an enema.

  • Description: The patient lies on the left side with the top leg flexed, facilitating rectal access and comfort.

• Safety Measures for Patient Transfer (Bed to Chair):

  • Use a gait belt.

  • Lock the wheelchair or bed brakes.

  • Ensure the patient's feet are flat on the floor.

  • Maintain proper body mechanics.

• Body Systems Affected by Decreased Mobility and Complications:

  • Musculoskeletal: Muscle atrophy, contractures.

  • Cardiovascular: Orthostatic hypotension, Deep Vein Thrombosis (DVT).

  • Respiratory: Pneumonia, atelectasis.

  • Skin: Pressure ulcers.

  • Gastrointestinal: Constipation.

  • Psychological: Depression, anxiety.

Discharge Planning and Fall Prevention

• Overall Goal of Discharge Planning:

  • To ensure the patient continues safe and effective care at home or in the next setting.

  • Focus: Continuity of care, patient safety, and preventing readmissions.

• Key Elements in a Patient's Discharge Plan:

  • Patient education on medications, procedures, or lifestyle modifications.

  • Coordination of follow-up appointments and community or home resources.

  • Safety considerations (e.g., fall prevention, mobility support).

  • Rationale: These elements help patients transition safely from hospital to home or another care setting.

• Fall Prevention Mechanisms (Hospitalized Clients - at least $3$):

  • Use of non-skid footwear (e.g., yellow socks).

  • Bed is maintained in a low position.

  • Wheels of the bed/recliner are locked.

  • Brakes are locked on a wheelchair.

  • Adequate lighting in the room.

  • Placing the call light within the client's reach.

  • Providing the client basic orientation to their room.

  • Maintaining a clutter-free environment.

• Macular Degeneration and Ambulation/Fall Prevention:

  • Patients with macular degeneration retain peripheral vision, allowing them to often safely ambulate if the environment is kept free of hazards.

  • Why Fall Prevention is a Major Nursing Priority: Central vision loss makes it difficult for patients to see hazards directly in front of them (e.g., curbs, rugs, steps), significantly increasing the risk of tripping and falls.

Communication and Sensory Perceptio

• Expressive Aphasia:

  • True. Expressive aphasia means a patient understands what is being said but has difficulty speaking or writing.

  • Explanation: In expressive (Broca's) aphasia, comprehension is relatively preserved, but verbal expression is impaired.

• Nursing Interventions to Support Communication with Aphasia Patients (at least $2$):

  • Use simple, short sentences, and speak slowly.

  • Provide communication boards or picture cards.

  • Allow adequate time for the patient to respond.

  • Maintain eye contact and use gestures.

  • Rationale: These techniques help to support patient expression and reduce frustration.

• PERRLA Acronym (Pupil Assessment):

  • P - Pupils

  • E - Equal

  • R - Round

  • R - Reactive to

  • L - Light

  • A - Accommodation

• Visual Change Caused by Cataracts:

  • Cloudy or blurred vision.

• Why Oral Care is Important for Patients with Sensory Perception Deficits:

  • Impaired taste can decrease appetite and nutrition.

  • Oral health strongly influences taste sensation; loss of taste reduces enjoyment of food and may consequently cause malnutrition.

• Sensory Overload:

  • Definition: Occurs when a patient experiences too much sensory input, such as constant alarms, bright lights, and frequent staff interruptions.

Delegation and Nursing Interventions

• The $5$ Rights of Delegation:

  • Right task

  • Right circumstance

  • Right person

  • Right direction/communication

  • Right supervision/evaluation

• Example of Right Direction/Communication in Delegation:

  • The statement: "Take the patient's vitals and report anything abnormal immediately." demonstrates Right Direction/Communication.

  • Rationale: Clear instructions with expected outcomes ensure safe delegation.

• Nursing Interventions to Promote Sleep in Hospitalized Patients (at least $2$):

  • Minimize noise and light during nighttime.

  • Encourage relaxation techniques (e.g., guided imagery, deep breathing).

  • Provide comfortable bedding and positioning.

  • Rationale: Environmental and comfort interventions support natural sleep cycles without relying solely on medications.

• Non-Pharmacological Nursing Interventions (at least $4$ examples):

  • Aromatherapy

  • Massage

  • Repositioning

  • Ice application

  • Heat application

  • Padding bony prominences

  • Healing touch

  • Music therapy

  • Guided imagery

• Objective Indicators of Pain (at least $3$ examples):

  • Vital signs changes (e.g., increased heart rate, blood pressure).

  • Grimacing or other facial expressions.

  • Guarding behavior (protecting a painful area).

  • Sweating.

  • Crying.

  • Moaning or groaning.

• Examples of Mechanical Restraints (at least $2$):

  • Hand mitten

  • Soft wrist restraint

  • Leather wrist restraint

  • Soft lap belt restraint that fastens around the waist

  • Vest restraint

Healthcare Ethics and Planning

• Importance of Inclusion in Healthcare:

  • Inclusion ensures that all patients feel respected, valued, and heard, which improves trust, patient satisfaction, and overall health outcomes.

• Language as a Barrier to Effective Pain Management and Solutions:

  • Why: A patient may have a different first language or might not speak English at all, potentially leading to underreporting pain due to the language barrier.

  • How to Combat: Utilize a MARTTI (Medical Assistance Resource & Telehealth Tool for Interpreting) or a qualified interpreter when needed.

• Health Equity vs. Health Equality:

  • Health Equity: Focuses on fairness and addressing disparities, which may require individualized care to meet each patient's specific needs.

  • Health Equality: Involves providing the same care to every patient regardless of individual circumstances.

• Vulnerable Populations (at least $4$ examples):

  • Clients with low-income or who are homeless.

  • Immigrants.

  • Children.

  • Elderly adults.

  • Clients with disabilities.

  • Veterans.

  • Racial/ethnic minorities.

  • Marginalized sexual groups.

• Why Vulnerable Populations are at Higher Risk for Poor Health Outcomes:

  • They often face multiple barriers such as poverty, limited access to healthcare, low health literacy, chronic illness, discrimination, or social instability.

  • These factors increase their risk of illness and prevent them from receiving timely and adequate care.

• SMART Goals in Nursing (Components and Purpose):

  • The five components of a SMART goal are:

    • S - Specific

    • M - Measurable

    • A - Achievable

    • R - Relevant

    • T - Timely

  • Reason for Use: To provide clear, measurable, and achievable targets for patient outcomes. SMART goals guide nursing interventions, allow for evaluation of progress, and improve patient-centered care.

• Explicit Bias in Clinical Practice (Example):

  • Refusing to take care of a client based on their race or religion.

  • Treating patients differently because of their gender identity.

  • Making derogatory comments about a client's weight.