NR224 Fundamentals Mastery Refresher Flashcards

NCLEX Client Needs: Management of Care

Prioritization Principles and Maslow’s Hierarchy of Needs

Prioritization involves arranging nursing actions according to Maslow’s hierarchy of needs to ensure the most critical requirements are met first. The hierarchy is organized as follows:

• Physiological Needs (First Level): This level includes the most basic requirements for human survival. If these are not met, the body cannot function correctly. Examples include:

  • Oxygen

  • Fluids

  • Nutrition

  • Temperature regulation

  • Elimination

  • Shelter

  • Sex

• Safety and Security: Once physiological needs are met, safety becomes the priority.

  • Physical Safety: Protection from physical harm or violence (e.g., protecting a client from an abuser).

  • Psychological Safety: Feeling secure in one's environment.

• Love and Belonging Needs: Focuses on social relationships and emotional connections, such as family support.

• Self-Esteem: Involves therapeutic communication to enhance a client's sense of self-worth and confidence.

• Self-Actualization: The highest level, representing the realization of personal potential or becoming the best one can be (e.g., a client stating, "I want to be a world-class athlete").

Application Examples

• Prioritizing Action: Administering medications to regulate body temperature (Physiological) takes precedence over collaborating with social services regarding physical safety (Safety), which takes precedence over contacting family members (Love/Belonging), which takes precedence over enhancing self-esteem (Self-esteem).

• Identifying Physiological Needs: A client who is homeless (Shelter), a client reporting dizziness for 2 days (Fluids/Oxygenation), and a client reporting an inability to eat due to throat pain (Nutrition) all fall under the first level of needs.

Ethics in Nursing

Ethical practice is guided by several foundational principles:

• Autonomy: A commitment to include patients in decisions about their care.

• Beneficence: The principle that the best interests of the patient remain more important than self-interest.

• Nonmaleficence: The avoidance of harm or hurt.

• Justice: Fairness in care delivery (e.g., providing the same level of care regardless of a client's financial status).

• Fidelity: The agreement to keep promises and the unwillingness to abandon patients (e.g., returning with medication when promised).

• Veracity: Truthfulness in communication.

Ethical Dilemma Resolution Process

When a nurse identifies an ethical dilemma, such as a lack of parity in care due to financial resources, the following steps are taken in order:

1. Information Collection: Gather relevant info from multiple sources.

2. Analysis: Determine if the situation is indeed an ethical dilemma.

3. Self-Examination: Examine one's own values regarding the issue based on the information obtained.

4. Verbalization: Agree on a clear statement of the problem.

5. Negotiation: Negotiate the outcome through proper group discussions.

Interprofessional Collaboration and Standards

Care coordination involves several professional roles and standards:

• Registered Dietitian: Manages nutritional plans and conditions like diabetes.

• Physical Therapist (PT): Manages physical condition and mobility.

• Occupational Therapist (OT): Assists with activities of daily living.

• Speech Therapist: Addresses communication and swallowing issues.

• Social Worker & Case Manager: Assist with resources and care transitions.

• Respiratory Therapist: Manages breathing treatments.

• Quality and Safety Education for Nurses (QSEN): Teamwork and collaboration include engaging PTs, consulting dietitians, and thorough handoffs between shifts.

• ANA Standards: Standard 5A (Coordination of Care) and Standard 11 (Collaboration) highlight the nurse's role in the interprofessional team.

Communication Strategies: ISBAR

Effective communication with healthcare providers utilizes the ISBAR format. An example regarding a medication route error:

• Identity: "Hello Dr. Smith, this is Shalonda Smith, RN calling from Chamberlain hospital’s med-surg unit 5 about your client Mr. Smith in room 511."

• Situation: "I was preparing to administer medications to Mr. Smith when I noticed the medication prescription route in the chart is listed as PO (by mouth) with an additional order that the client is NPO (nothing by mouth)."

• Background: "Mr. Smith is 1-day post operative for a bowel resection. Mr. Smith is NPO and has a nasogastric tube in place for medication administration."

• Assessment: "Nasogastric tube is intact and verified placement today. Client is not yet cleared to take medications PO."

• Recommendation: "Can you please update the medication prescription order to the nasogastric tube route instead of the PO route?"

Communication with Specific Populations

Hearing Impairment

To promote effective communication with clients who are hard of hearing:

• Equipment: Ensure hearing aids and glasses are used.

• Positioning: Face the client directly at eye level so the face and mouth are visible.

• Voice Quality: Speak in a normal, clear volume. Do not shout or use high-pitched tones. Speak a little more slowly but do not exaggerate lip movements.

• Environment: Use a quiet, well-lit environment with minimal distractions. Avoid chewing gum while speaking.

• Timing: Allow the client time to respond and ask questions. Keep communication short, concise, and ask one question at a time.

Vision Impairment

Professional communication for clients with severe visual impairment or legal blindness includes:

• Introduction: Knock and identify oneself by name and role immediately upon entering the room.

• Environment: Orient the client to the room layout. Keep the environment free of clutter and ensure bright, glare-free lighting.

• Description: Use the "clock method" to describe food placement (e.g., "The chicken is at 6 o'clock"). Verbally describe actions before performing them (e.g., "I am going to check your pulse").

• Technique: Speak directly to the client in a normal tone. Do not rely on family members to gather health history if the client can provide it.

Health Promotion and Prevention

Levels of Prevention

• Primordial Prevention: Focuses on establishing or maintaining conditions that minimize hazards to health (e.g., access to safe playgrounds).

• Primary Prevention: Activities performed before a disease or illness occurs to promote health (e.g., vaccines, immunizations, car seat safety, healthy living education).

• Secondary Prevention: Focuses on early detection, screening, and quick intervention to prevent complications (e.g., blood pressure screening, mammography, testicular self-exams, emergency surgery, drunk-driving checkpoints).

• Tertiary Prevention: Focuses on rehabilitation and maintenance of health after a diagnosis or stabilization (e.g., physical therapy after a stroke, occupational therapy, long-term treatment plans).

Health Belief and Motivation Models

• Health Belief Model: Relationship between a person's values, beliefs, and behaviors regarding the perceived threat of illness.

• Health Promotion Model: Defines health as a positive, dynamic state. It focuses on increasing well-being based on motivation and individual characteristics.

• Holistic Health Model: Considers the interactions of the body, mind, and spirit as emotional, spiritual, and physical aspects of wellness.

• Transtheoretical Model of Change:

  1. Precontemplation: Thinking there is no need for change.

  2. Contemplation: Thinking about change.

  3. Preparation: Planning for change.

  4. Action: Actively changing behavior.

  5. Maintenance: Changes are sustained over time and integrated into the lifestyle; this stage is reached 6 months after starting action and continues indefinitely. Old habits may still pose difficulties.

Psychosocial Integrity

Cultural Competence

Developing cultural competence requires five components:

• Cultural Awareness: Being aware of one's own biases and cultural background.

• Cultural Knowledge: Seeking out health-related beliefs and values of diverse groups.

• Cultural Skill: Learning to conduct culturally sensitive assessments.

• Cultural Encounter: Engaging in face-to-face interactions to modify existing biases.

• Cultural Desire: The motivation of the provider to become culturally aware and skillful.

Older adult Hispanic populations experience health disparities due to language barriers, inadequate health insurance, lack of healthcare facilities, and poor diet/nutrition.

Family and Grief

• Family Health System (FHS): Used to assess family dynamics. Assessing the "interactive process" involves asking how the family manages healthcare and interaction between members.

• Kübler-Ross Stages of Grief:

  1. Denial

  2. Anger

  3. Bargaining

  4. Depression

Domains of Learning

• Cognitive Learning: Gaining intellectual knowledge (e.g., gaining information).

• Affective Learning: Development of values, attitudes, and expression of feelings.

• Psychomotor Learning: Development of manual or physical skills (e.g., demonstrating body mechanics while transferring a patient).

Basic Care and Comfort

Complementary and Alternative Therapies

• Natural Products: Nutritional supplements, medicinal plants, probiotics, prebiotics, phytochemicals, and vitamins.

• Mind and Body Practices: Mindfulness, meditation, breathing techniques, and guided imagery. These can often be performed without specialized training.

• Specialized Training Needed: Acupuncture requires specialized training.

• Safety Warning: Not all herbal supplements are safe just because they are "organic." For example, garlic may interfere with anticoagulants.

Ambulation and Transfers

Safety is the priority during patient mobility. Tools include gait belts, non-skid socks, canes (straight or quad), crutches (2, 3, or 4-point gait), walkers, and Hoyer lifts.

Transferring from Bed to Wheelchair

1. Check weight-bearing status.

2. Position the wheelchair at a $45°$ angle on the patient’s strong side.

3. LOCK the brakes on both the bed and the wheelchair.

4. Apply non-skid footwear.

5. Assist the client to sit and dangle at the edge of the bed for a few minutes to check for dizziness.

6. Apply a gait belt.

7. Stand on a count, pivot on the foot farthest from the chair, and turn to a seated position.

8. Remove the gait belt after the transfer is complete.

9. Note: Do not lift using back muscles.

Pharmacological and Parenteral Therapies

Essential Conversions

• $1\,\text{L} = 1000\,\text{mL}$

• $1\,\text{tbsp} = 15\,\text{mL}$

• $1\,\text{g} = 1000\,\text{mg}$

• $1\,\text{tbsp} = 3\,\text{tsp}$

• $1\,\text{mg} = 1000\,\text{mcg}$

• $1\,\text{lb} = 16\,\text{oz}$

• $1\,\text{oz} = 30\,\text{mL}$

• $1\,\text{cup} = 8\,\text{oz}$

• $1\,\text{tsp} = 5\,\text{mL}$

• $1\,\text{kg} = 2.2\,\text{lb}$

Medication Calculations

• Oral Dosage: A client is prescribed $37.5\,\text{mg}$ of venlafaxine. The pharmacy provides $25\,\text{mg}$ tablets.

  • $\frac{37.5\,\text{mg}}{25\,\text{mg}} = 1.5\,\text{tablets}$

• IVPB Flow Rate: Administer $500\,\text{mg}$ cefazolin in $50\,\text{mL}$ of $5\%$ D5W over $20\,\text{minutes}$. Drop factor is $15\,\text{gtt/mL}$.

  • $\text{Rate} = \frac{50\,\text{mL} \times 15\,\text{gtt/mL}}{20\,\text{min}} = 37.5 \rightarrow 38\,\text{gtt/min}$

• IV Fluid Flow Rate: Administer $2\,\text{L}$ ($2000\,\text{mL}$) over $12\,\text{hours}$. Drop factor is $10\,\text{gtts/mL}$.

  • $\text{Rate} = \frac{2000\,\text{mL} \times 10\,\text{gtt/mL}}{12 \times 60\,\text{min}} = \frac{20000}{720} = 27.77 \rightarrow 28\,\text{gtt/min}$

Medication Administration Rights and Routes

Seven Rights of Medication Administration

1. Right medication

2. Right dose

3. Right patient

4. Right route

5. Right time

6. Right indication

7. Right documentation

Routes and Administration

• Oral (PO): Tablets, pills, capsules, elixirs. Do not crush enteric-coated or time-released medications. Assess swallowing ability.

• Parenteral (Injections):

  • Subcutaneous (SQ): $25\text{-}31\,\text{gauge}$ needle, $\frac{1}{4}\text{-to-}\frac{5}{8}\,\text{inch}$ length, $45\text{-}90\,\text{degree}$ angle. Max volume: $3\,\text{mL}$.

  • Intramuscular (IM): Sites include vastus lateralis, ventrogluteal, and deltoid. Use Z-track method at a $90\,\text{degree}$ angle. $21\text{-}23\,\text{gauge}$ needle, $\frac{1}{2}\text{-to-}1.5\,\text{inch}$ length. Max volume: $2\text{-}5\,\text{mL}$ for adults.

  • Intradermal (ID): $25\text{-}27\,\text{gauge}$ needle, $5\text{-to-}15\,\text{degree}$ angle. Used for forearm or upper back.

• Inhalation:

  • pMDI: Shake $2\text{-}5\,\text{seconds}$, tilt head back, inhale for $3\text{-}5\,\text{seconds}$. Prime if unused for 7 days.

  • DPI/BAI: Do not shake; hold breath for $10\,\text{seconds}$. Rinse mouth after use.

• Topical:

  • Eye: Administer in center of conjunctival sac; press on lacrimal duct.

  • Ear: Pull pinna down and back for age < 3; up and back for age $\ge 3$.

Reduction of Risk Potential

Specimen Collection

• Urine Dipstick: Quick bedside procedure using reagent strips.

• Clean Void/Culture: Detects bacteria/yeast. Sterile collection.

• 24-Hour Urine: Timed test to measure filtered substances. Instructions: Discard the first voiding, then start the clock. Keep urine stored in a refrigerator.

• Indwelling Catheter Urine Collection:

  1. Clamp the drainage tubing distal to the injection port.

  2. Clean the port with antiseptic.

  3. Attach a $5\,\text{mL}$ sterile syringe.

  4. Aspirate the urine.

  5. Inject into a sterile container.

  6. Remove the clamp.

Fecal Occult Blood Test (gFOBT/GUAIAC)

Screening for colon cancer (performed starting at age 50). Positive result is blue.

• Dietary Restrictions (3 days before): Avoid red/rare meat (beef, lamb, pork, liver), high-peroxidase fruits/vegetables (broccoli, turnips, radishes, horseradish, cauliflower, parsnips, cantaloupe), and high amounts of citrus fruits/juices.

• Medication Restrictions (3-7 days before): Avoid NSAIDs (aspirin, ibuprofen, naproxen) due to bleeding risk.

Enteric Feedings

Preferred for clients with a functioning GI tract who cannot swallow.

• Short-term Routes: Nasogastric (NG), nasoduodenal, nasojejunal.

• Long-term Routes: Gastrostomy (G-tube/PEG), Jejunostomy (J-Tube), Gastrojejunostomy (GJ tube).

• Aspiration Risk: Clients at high risk for aspiration should receive jejunal feedings.

• Feeding Cycle and Flushes:

  • Bolus/Intermittent: Flush with $15\text{-}30\,\text{mL}$ before and after feedings.

  • Continuous: Flush with $20\text{-}50\,\text{mL}$ every $4\,\text{hours}$.

• Nursing Care: Elevate the head of the bed at least $30\text{-}45\,\text{degrees}$ (though some guides specify at least $10$ for specific PEG procedures). Change the feeding bag and tubing every $24\,\text{hours}$. Use warm water for flushes.