Nursing Exam Notes

Sterile Loves and Exam Preparation

  • Sterile loves look easy when demonstrated, but require practice.

  • Exam questions will be med-surg focused, requiring detailed knowledge.

  • Review chapter content and tables talked about in lectures.

  • Rationales are available immediately after the test for review.

  • All lectures will be recorded

  • Test grades will be posted after statistical analysis.

  • Points may be added back based on analysis, with an announcement and explanation provided.

  • There is no cumulative final exam in this class.

  • Three tests cover content in sections: the first covers two chapters, the second covers the next two, and the third covers three (including an asynchronous lecture).

  • Questions should wait until after you get the exam.

  • Assessment

  • Clinical decision making/clinical judgment

  • Safety

  • Tissue integrity

Hygiene and Nursing Concepts

  • Hygiene is an important topic. Some students began hygiene ATI labs last week, so some concepts may be familiar.

  • The Nursing process is used for navigation in adult health lectures, including disease processes.

  • Nursing concepts related to hygiene include:

    • Assessment

      • Assess for:

        • Odors

        • Appearance

          • Cleanliness

          • Skin breakdown

    • Safety

      • Related to the skin.

      • Skin breakdown can lead to injury.

      • Prevent skin breakdown.

    • Tissue Integrity

      • Prevent skin breakdown.

    • Nursing assessment skills used to identify risks.

    • Clinical judgment/decision-making used to develop a plan of care.

    • Introduction to related concepts.

Factors Affecting Person Hygiene and PCC

  • Patient-centered care is important, as hygiene practices vary.

    1.Cultural:

  • It is important to identify cultural variations that could affect a patient’s personal hygiene preferences, such as typical bathing habits, and behaviors, such as:

    • Frequency of bathing varies across cultures.

    • Products used differ.

      • Washcloth vs. loofa.

      • Different soaps.

      • Bath vs. shower.

      • Deodorant vs. no deodorant.

  • Socioeconomic Status:

    1. A person’s socioeconomic status and financial resources often define the hygiene options available to that person. A lack of funds to obtain toiletries or clean clothing may contribute to an inability to maintain personal hygiene needs. Example:

    • Water access.

    • Affordability of hygiene products.

    • Education

  • Spiritual Practices

  • Spiritual practices, including religious beliefs, may dictate ceremonial washings and purifications, sometimes as a prelude to prayer or eating. For example:

  • In some religions, contact with a deceased person or a deceased animal may make a person “unclean.”

    • Bathing as a ritual in some religions (e.g., Judaism).

  • Access to modern utilities.

  • Developmental Level impacts hygiene.

  • Children learn hygiene practices while growing up. Family practices often dictate hygiene habits, such as morning or evening baths;

  • As adolescents become more concerned about their personal appearance, they may adopt new hygiene measures,

  • Older adults may experience an increase in skin conditions or problems, increasing the need for education related to hygiene and skin care

    • Children need assistance.

    • Education level

    • Cognitive Changes

      • Patients with Alzheimer's/dementia may not recognize the need for hygiene.

  • Health State

  • can affect self-care ability.

  • Disease, surgery, or injury may reduce a person’s ability to perform hygiene measures or motivation to follow usual hygiene habits.

  • Weakness, dizziness, and fear of falling may prevent a person from entering a tub or shower or from bending to wash the lower extremities.

  • Illness may also create a demand for new modified hygiene measures.

    • Mobility issues.

    • Disease processes.

      • Diabetes can cause neuropathy.

        • Decreased sensation in feet leads to unrecognized injuries.

        • Decreased circulation.

        • Infections can lead to amputation.

  • Personal Preferences impact hygiene.

    • Products.

    • Soaps.

    • Lotions.

    • Frequency of care.

    • Preference of showering everyday or not.

      • Skin needs time to regain oils.

      • Frequent showering can worsen dry skin issues.

      • Preference on pillow cleanliness.

Hygiene and the Nursing Process

  • Assessment is the first step of the nursing process.

  • The three parts of assessment:

  • history and physical assessment,

  • and diagnostic assessment.

  • History is what a patient's past apartment was, and is important.

  • Significant change can be noticed with dementia..

Assessment:

Nurse History and Physical

  • History involves gathering subjective data.

  • Physical assessment involves objective data collection.

  • Questions for history include:

    • Previous diseases (e.g., eczema, psoriasis).

    • Disorders of eyes, ears, or nose.

    • Musculoskeletal system involvement.

    • History of products used.

    • Frequency of preventative care (e.g., sunscreen, dentist).

    • Self-care procedures with normal routines.

      • Frequency of teeth brushing.

      • Showering.

      • Use of special soaps/lotions.

      • Hair washing frequency.

      • Ear cleaning practices (impacts ear wax impaction).

  • Physical assessment

  • requires looking at the entire body for:

    • Sores or breakdown.

    • Foul odors.

    • Teeth condition.

    • Hair patterns and loss.

    • Debris in hair (e.g., lice, dandruff).

Diagnosing

  • Nursing diagnoses differ from medical diagnoses.

  • Nursing diagnoses are conditions nurses can intervene upon.

  • Review the table on page 1096

  • With these different diagnoses, we could look at the patient's physical ability to care for themselves.

  • Consider cultural changes or practices.

  • Address self-esteem issues.

  • Assess social determinants of health for low-income patients.

Planning and Implementing

  • Planning and implementation involve:

    • Developing a schedule matching the patients normal life schedule.

    • Assisting the patient.

Assisting with Bathing and Skin Care

  • Bathing and skin care are important for:

    • Cleansing to prevent skin breakdown.

    • Relaxation.

    • Stimulating circulation through rubbing.

    • Exercise by moving limbs.

    • Improving self-image.

Bathing Options

  • Patients can shower independently if mobile.

  • Tub baths (whirlpool) are used in long-term care for circulation and debridement.

  • Bed baths are provided when patients can't get up, with the patient helping as able.

  • Bed baths are done with soap and water or disposable baths.

  • CHG wipes: Chlorhexidine gluconate wipes sterilize skin before procedures to prevent infection.

Promoting Healthy Skin

  • Teach patients self-assessment.

  • Perform frequent skin assessments in the hospital.

  • Use skin emollients (lotions) to keep skin moist.

  • Use barrier creams for incontinent patients.

Assisting with Perineal Care

  • Perineal care involves cleaning private parts.

  • Be respectful and explain the process.

  • Maintain a professional demeanor.

Perineal Care Considerations

  • Indwelling catheters require daily cleaning.

  • Incontinent patients are at higher risk for skin breakdown and infection due to moisture.

  • Frequent checks and changes are needed.

  • Use skin cleaners that are less harsh than soap.

  • Avoid douches or perineal deodorants in female patients.

Providing Perineal Care

  • Ensure proper steps are followed when providing perineal care for the female or male client.

  • Wipe from front to back in female patients to avoid infection.

  • Pull back foreskin and clean underneath in uncircumcised male patients, then replace the foreskin.

Body Piercing Care

  • Assess all piercings, especially in unconscious patients, before scans (MRI).

  • Monitor new piercings for infection.

  • Ensure patient safety while respecting piercings.

  • Genital piercings may need removal for catheter insertion.

  • Oral piercings may cause difficult, so can remove for intubation, using IV cath or plastic jewelry.

Assisting with Oral Care

  • Oral hygiene aids in pneumonia prevention in non-alert patients.

  • Mouth swabs or suction swabs used - avoid alcohol based.

  • Clean dentures and assess fit.

  • Clean oral cavity, tongue.

Eye Care

  • Moisturizing drops/lubricants are needed for unconscious patients.

  • Protective eye coverings can prevent injury if eyes are open.

  • Eyeglasses should be cleaned carefully.

  • Contact lenses need proper care.

Ear and Nose Care

  • Avoid swabs inside the ear.

  • Keep hearing aids accessible and replace batteries.

  • Encourage gentle blowing of the nose from both nostrils.

  • Use a warm washcloth to clean debris.

Hair Care

  • Hair care is important for self-esteem and cleanliness.

  • Shower caps are available.

  • Dry shampoo can be used.

Hair Care in Different Cultures

  • Hair care depends on cultural preferences.

  • Black patients may have specific practices that you want to educate yourself on.

Shaving and Nail Care

  • Use electric razors typically.

  • Male patients that have a beard, even our little old ladies that start getting their whiskers, they don't don't want that people to see that.

  • Clip nails straight across and push back cuticles.

  • Provide nail care for dependent patients, cleaning under nails with a blunt-tipped instrument, and follow with lotion.

Footcare

  • Assess for wounds (diabetic patients).

  • Cut toenails straight across, leaving them a bit longer.

  • Apply lotion.

  • Page 325 on 11:14 has information about foot care.

Hygienic Practices

  • Educate on benefits of clean skin.

  • Odor prevention through cleanliness.

  • Irritation reduction by using mild soaps, changing cosmetics frequently.

  • Sunscreen use is essential.

Environmental Care

  • Keep patient areas clean.

  • Proper placement of food and medical supplies.

  • Safety measures: bed alarms, call lights, low bed position.

  • Temperature and lighting control.

  • Minimize noise.

  • Change bedding when soiled.

Patient Education

  • Mild soaps/substitutes prevent drying of skin.

  • Soaps with pH closer to normal skin of pH of 4.54.5 to 5.755.75 pH is the best.

  • Educate on odor and perspiration.

Nursing Process: Evaluation

  • Evaluate goals established in the planning stage.

  • Assess:

    • Patient participation.

    • Improvement of skin lesions.

    • Improved mobility.

  • Revise plan if necessary.

Urinary Elimination: Anatomy and Physiology Review

  • Kidneys filter waste.

  • Nephrons remove waste and manage fluid/electrolytes.

  • Urine is waste, fluid, and byproducts.

  • Peristalsis moves urine from kidney to bladder.

  • Bladder prevents backflow into ureters.

  • The sympathetic nervous system relaxes the bladder and constricts the sphincter so your body can hold urine in the bladder.

  • The parasympathetic nervous system does the muscle to contract, and the sphincter to relax. The sphincter is at the base of the bladder.

  • Urethra transports urine out of the body.

    • Shorter in females, making them more prone to UTIs.

  • Bladder is traditionally sterile.

  • Urination is initially involuntary (reflex in infants), but can be controlled over time.

  • Injury can disrupt brain-bladder connection (autonomic bladder), leading to reflex voiding without control.

  • Urinary incontinence is leaking from the bladder with some control.

Frequency and Factors Affecting Urination

  • Frequency depends on fluid intake, kidney function, and time of day.

  • First void is most concentrated.

  • Inquire about any changes in frequency.

  • Urinary retention normal production, but not excretion.

  • Various factors affecting urination:

    • Developmental:

      • Initially, brain, infant cannot control

      • Brain has to be 18-24 months to learn to control

      • Child have ability to communicate, desire and motor to sit on toilet

    • Neurological function:

    • Food and Fluid Intake:

    • Psychological Variables:

    • Activity and Muscle Tone:

      • child bearing

      • Immobility:

    • Menopause:

    • Pathologic Conditions:

      • Birth defect

      • Diseases of the kidneys function

      • High blood pressure can cause kidney damage

      • Diabetes can cause kidney damage

      • Medications cause kidney damage. ex: Gentamycin, a anti biotic.

    • Medications, Drugs

Key Terms Table

  • Refer to page 1454, Box 38-1 for terms related to terms of urination like: old area in your. e.g., nocturia (increased voiding at night).

Factors Affecting Urination

  • Developmental Factors: Brain development needed for control (around 18-24 months).

  • Aging:

    • Decreased kidney function.

    • Neurological function. Can be hard for the elderly to make it to the bathroom leading to problems with urination or to recognize needing to void.

  • Food and Fluid:

    • Alcohol is a natural diuretic (Make you have to pee more)

    • Hight, sodium leads to retention of fluids

    • Foods affect odor and color. For example Asparagus for some can affect odor in some folks that don't have the gene

  • Psychological Variables: Stress can have difficulty urinating because the privacy is important

  • Activity and Muscle Tone: (Child bearing women can ruin muscle tone)

  • Pathologic conditions congenital abnormalities, disease of kidneys can affect the ability to produce urine, high blood pressure, diabetes.

  • Medications:

    • Nephrotoxic drugs can damage kidneys (e.g., gentamycin).

    • Diuretics impact reabsorption and excretion.

    • Cholinergic drugs stimulate destroy muscle contraction (the bladder).

    • Analgesics suppress the autonomic nervous system, affecting urination.

    • You might take a little while to void after surgery.

Urinary Elimination Factor to Assess

  • Assess usual urination patterns/habits

  • Assess for any changes.

  • Assess for any aids to elimination used.

  • Inquire about present and previous occurrence of voiding problems/UTIs.

  • Presence of urinary diversion(normal routine, history of problem)

  • Physical assessment includes:

Bladder Assessment

  • Bladder assessment to palpate for swelling, tenderness, use gentle palpation.

  • Use bedside bladder scanner if bladder isn't emptying correctly.

Urethral Meatus Assessment, color of urine, odor, clarity

  • A small lit above the clitoris is where assessment for drainage, and redness should occur as well as foul smell assessments.

  • Also assess skin for moisture and dryness. Pg1457

Urine Assessment & Diagnostic Tests

  • Assess color, smell, turbidity, and pH (normally 5-6) (Normal gravity is 1.015 to 1.025, abnormal to do is Glucose, Hubs, or blood

  • Specific gravity: Measure to gauge kidney function and hydration status. If outside the normal range, further evaluation may be needed.

  • Skin Integrity And Hydration

    • Because problem with urinary functioning may result in disturbances, hydration, and excretion of body wastes.

    • Assess Skin carefully for color, texture, and Turgor.

    • Assess the integrity of the skin in perineal area.

    • Problems with incontinence may result in severe excoriation (abrasion of the epidermis).

Urine Output Measurement and Urine Collection

*Measuring urine and diagnostic test.
Patient needs to state.
Urine collected in container in or out of bed then gloves, with is called a graduated calender measuring. Some the the beds are
Han, bed pen, urine containers that can collect.

Indwelling Catheters

*Drainage bag in calibration Device.
Calibrate measurement, urine. And record your measurement.
That used for sick patients, patients who have kidney trouble and need the amount.
Clean the tube to keep down on urine infections

Incontinent Patients

*Absorbance can't stop. and schedule two go every two hours.
External, urinary sheaths, that's great there's a for measuring.

Collecting Urine Specimens- sterile or clean catch. Aseptic, add name, is in bag, bring to lab. With paper.

Diagnostic Studies -Collecting Urine:

Use a sterile container and wipe with alcohol first and use that and straight in to it.. In a in and out catheter
Steril urine sample to check for white blood cells, bacteria cultures sent to the lab

Diagnostic Studies

  • Culture/Senditivity checks bacterial to see if bacteria is growing
    24 hour urine; to assess kidney function. Throw out the first void and then document what your output is for 24 hours
    pH, keytomes what you have in your urines dip stick that has multiple indicators in which it reads

Planing and intervention

The goals are going to show us that we need

  • Plan

  • Provide fluid

  • Provide for bladder, tell them the schedule for the bathroom.

  • They have the Urge.

  • Pelvic floor training.

  • You'll do it sitting on your back.

Continence Planning & Intervention

Treatments are short term antibiotics, take more liquid, void when have to, void before sex, cotton, and underwear

Interventions for Patients with Incontinence:

They have: transient(appears with sickness), stress(weak muscle), mixed(with sickness), Functional ( you not get to the rest room), total (surgery or trauma).
See masses, lumps for tenderness or distension on the Physical assessment with scanner for amount in the bladder with scanner for amount
And after that, what do we do. If a patient is needing a sterio sample, do what is called an in and out catheter, or a straight calf

Medical Equipment

The the different medial equip, that we have
Those three and out tubes and use that we can control. use that for patients.

Irrigation is fluid that goes in and flush the bag. Helps clotting.

Stint - you in our body until Surgery.

Dialasis is cleaning blood, what they have. Dialasis

Dialysis for those people that do have and are the patient at home on a dialysis treatment. So you put what do you put in her to. She had and the other. Do you put that stuff. Yeah. There's. That's the. that's the and that's how to it. That does. Okay. So this a 4 hour run it. Yep, do. What she did in her. Okay. So can. Okay. That stuff here. It's for for and.