Nursing Exam Notes

Musculoskeletal Assessment

• Percussion and auscultation are generally not required.
• Functional Activity Assessment (FAS) helps assess how well patients with musculoskeletal pain undertake daily activities.
  • A - unrestricted by pain
  • B - mildly to moderately restricted by pain
  • C - severely limited by pain
• Nurses must continually evaluate a patient's strength and endurance before and during ambulation.
• Falls Risk Assessment Tool (FRAT) should be completed on admission and after any change in circumstance.

Falls Prevention

• Australian National Standards are outlined in the Australian Commission on Safety and Quality Health Service (ACSQHC) Standard- the comprehensive care standard.
• Key elements:
  1. Screening and risk assessment using validated tools.
  2. Individualized falls prevention plans.
  3. Maintain a safe environment.
  4. Patient and carer education on falls risk and prevention.
  5. Multidisciplinary approach.
  6. Monitoring and incident reporting.
  7. Medication review.
  8. Post falls management e.g., injury assessment and review of care plan.

Safe Patient Handling

• Unsafe patient handling is a major cause of injuries to workers.
• The Occupational Health and Safety (OHS) Act 2004 and OHS regulations outline specific duties.
• Manual lifting of patients is to be eliminated except in exceptional or life-threatening situations.
• Safe patient handling involves specific training techniques, instruction, and appropriate equipment.
• Risk assessments and patient musculoskeletal and functional mobility assessments are required.
• Patients are categorized as able to assist or not able to assist to determine equipment needed.

Assisting with Elimination Needs

• Alterations in elimination patterns often occur during periods of stress and illness, changes to diet and environment.

Faecal Incontinence

• Leakage from the bowel due to poor bowel control.
• Provide non-judgemental care, hygiene assistance, continence aids, regular toileting, easily removable clothing, and easy access to the toilet.

Diarrhoea

• Frequent passing of loose, watery faeces.
• Acute diarrhoea is usually self-limiting.
• Chronic diarrhoea causes can include: coeliac disease, chronic constipation, hormone disorder, cancer, inflammatory bowel disease, irritable bowel syndrome, lactose intolerance and medications.

Constipation

• Infrequent bowel motions (less than three per week) that are painful and difficult.
• Recognized by hard stools, or Type 1 or 2 on the Bristol stool formed scale

Position to Promote Best Emptying

• Squatting is best position

Other Factors affecting toileting

• Access to toilet, confusing toilets, lighting, toileting in inappropriate places, privacy, cues, cultural awareness, stay positive

Stoma Care

• A stoma is a surgically created opening for faecal evacuation.
• Stomas can be short or long term.
• Patients may experience anxiety and depression.

Specimen Collection - Stool

• Explain procedure to patient.
• Use a clean bedpan or nappy.
• Use appropriate PPE.
• Use a sterile specimen spoon and container to collect stool from the bedpan or nappy
• Label the container with patient details, date, time, and test required.
• Place specimen in a biohazard bag for transport to pathology.

Urinary Incontinence

• Alterations in elimination patterns often occur during stress and illness, and changes to diet and environment.
• Acute urinary incontinence: transient and reversible.
• Chronic urinary incontinence: persistent condition.
  • Stress incontinence: uncontrolled loss of urine caused by physical exertion.
  • Urge incontinence: loss of urine caused by a premature contraction.
  • Functional incontinence: loss of urine caused by altered mobility or cognition.
  • Overflow incontinence: uncontrolled loss of urine due to bypassed sphincter mechanism.
• Risk Factors: pregnancy, menopause, obesity, urinary tract infections, constipation, specific surgeries, reduced mobility, neurological and musculoskeletal conditions, health conditions such as diabetes, stroke, heart conditions, respiratory conditions, prostate problems, and some medications.

Incontinence Aids

• Inserts and pads: waterproof backing.
• Adult continence aids and underwear: disposable or reusable, should fit snugly to avoid leakage.
• Documentation and care plans documenting bladder training techniques and skin integrity.

Indwelling Catheters

• Thin, hollow tube inserted to inject/remove fluid/urine.
  • indwelling catheter:
    • inserted through the urethra into the bladder and left in place for a period of time.
  • intermittent catheter:
    • inserted through the urethra into the bladder to empty it, then removed, several times a day.
  • suprapubic catheter:
    • inserted just above the symphysis pubis into the bladder and left in for a longer period of time.

Specimen Collection - Urine

• Urinalysis is part of routine assessment on admission.
• A fresh specimen of urine is used and tested.
• Full Ward Test (FWT) is a screening test for urinary protein, blood, nitrites, leukocyte esterase, specific gravity, pH level, glucose, ketones, bilirubin and urobilinogen
• If UTI is suspected, send specimen to laboratory for analysis.

Specimen Collection Techniques

• Clean-catch (midstream urine - MSU) method is used to prevent contamination.
• Explain procedure, gain consent, and ensure privacy.
• Advise patients not to touch inside of specimen cup or lid.
• Females: wash labia and urethra with water, wipe from front to back.
• Males: clean head of penis with sterile wipe, retract foreskin if uncircumcised.
• Infants use a special bag with a sticky strip.

Testing the Urine

• Full ward tests are usually performed in the pan room of a clinical setting.
• Note urine characteristics (colour, clarity, odour).
• Immerse dipstick completely in fresh urine, remove excess.
• Allow up to 2 minutes for results to be displayed.
• Document results on vital signs sheet.

Documentation and Charts

Bowel Chart

• Record frequency, colour, consistency, shape, amount, odour and appearance of stools.
• Maintain bowel charts in patients with abnormal bowel patterns.
• The Bristol stool chart allows for an accurate and descriptive recording of bowel movements

Fluid Balance Chart

• Balance of fluid intake (oral fluids/ intravenous fluids/ nasogastric feeds) and output (urine, vomitus, drain output).
• Commence chart for patients on intravenous therapy, indwelling catheter, dehydration, nasogastric feeds, postoperative, wound drains, fluid restriction and renal failure.
• Should be closely monitored and documented correctly.

Nutrition

• Nutrients are substances in food necessary for growth, health, and good condition.

Nutrient Classification

• Energy nutrients (carbohydrates, proteins and fats)
• Organic nutrients (carbohydrates, proteins, fats and vitamins)
• Inorganic nutrients (water and minerals)

Categories of Nutrients

• Carbohydrates e.g., 50%-60% of daily intake
  • main source of energy
• Proteins e.g., 10%-20% of daily intake
  • manufacture and repair of tissue, as a base for cell structure.
• Fats or lipids should be limited.
  • supply essential fatty acids used for cell structure.
• Vitamins maintain bodily function.
  • may be fat-soluble (vitamins A, D, E and K) or water-soluble (vitamin C and complex B vitamins).
• Minerals regulate bodily processes and build body tissue.
  • macrominerals or microminerals
• Water e.g., six to eight glasses of water are needed a day.

Physiology of Nutrition

• Digestion e.g., mechanical and chemical processes through mastication, deglutition and peristalsis
  • converts nutrients into a physically absorbable state
• Absorption nutrients pass through the lining of the small and large intestines.
• Metabolism chemical reactions and processes in the cells
  • includes glycolysis, aerobic metabolism (anabolism) and anaerobic metabolism (catabolism).
• Energy is often referred to as kilocalories.
  • The basal metabolic rate refers to the amount of energy needed to maintain essential physiological functions
• Excretion is the removal from the body of waste products.

Australian Dietary Guidelines

• To achieve and maintain a healthy weight, be physically active and choose amounts of nutritious food and drinks to meet your energy needs.
• Enjoy a wide variety of nutritious foods each day from the five (5) food groups
• Limit the intake of foods containing saturated fat, added sugar, added salt, and alcohol.
• Encourage, support and promote breastfeeding.
• If you choose to drink alcohol, limit your intake.

Factors influencing Nutrition

• Age
• Lifestyle, including Cultural or religious practices
• Socioeconomic status
• Lifestyle and preferences, including gender stereotypes and peer pressure
• Gastrointestinal disorders
• Medications

Nutritional Assessment

• goals are to collect subjective and objective data regarding a person's nutritional status and determine what types of nutritional support, if any, are needed.

Three Fundamental Components

• Nutritional history, social and family history, employment status, knowledge level and associated symptoms
• Physical assessment decision-making, problem-solving and organisation is guided by the clinical reasoning cycle
• Diagnostic and laboratory data provide objective biochemical data to detect alterations in nutrition and metabolism

Nursing Interventions to support nutrition

• Monitoring weight, intake and output
• Ensuring patients are able to manage their meals assisting with feeding as required

History should include

• General appearance
• Anthropometric measurements i.e measuring height, weight and waist circumference
• Change in apetite
• Nausea, vomiting or diarrhoea
• Complete a food diary

Inspection

• skin, hair, nails, and abdomen

Palpation

• skin

Body Mass Index

• BMI is calculated using an individual's weight and height $(weight [kg] divided by height [metres] squared)$
• BMI is flawed as it does not differentiate between muscle mass, bone density and fat distribution

Comprehensive Care Standard

• The ACSQHC Comprehensive Care Standard provides guidance for healthcare organisations on nutrition and hydration

Key elements of nutrition and hydration include:

1. Screening and assessment
   • Patients should be screened for nutritional risk assessment upon admission and weekly during an episode of care if care changes if the patient's condition changes or at routine reviewUse of validated tools e.g. Malnutrition Screening Tool- MST
2. Individualised care planning
   • The care plan should include nutritional needs, dietary restrictions and hydration requirementsInvolvement of dieticians, speech pathologists (for swallowing difficulties) and other healthcare professionals.
3. Monitoring and management
   • Regular monitoring of food and fluid intake, especially for high-risk patients (e.g. elderly, post-surgical, critically ill, dying patients)Consider the need for nutritional support such as oral nutrition supplements, enteral nutrition or parenteral nutrition when oral intake is inadequate or contraindicated
4. Safe and quality food service
   • Hospitals, day procedure services and aged care facilities must provide nutritionally adequate, culturally appropriate and safe mealsConsideration of texture-modified diets for dysphagia patients.
5. Patient and carer engagement
   • Educating patients and families about adequate nutrition and hydrationEncouraging shared decision-making regarding dietary preferences and needs.

Swallow Assessment

• The swallow assessment is performed by the Speech Therapist, as they are trained in undertaking this assessment.
• If you notice your patient is coughing, dribbling or drooling after drinking normal consistency fluids, please discontinue diet and fluids, and request a medical and speech therapist review.

Integumentary System,Wounds and Hygiene

Function of the skin

• Protects against environmental hazards and pathogens.
• Acts as a boundary to keeps fluids such as blood and mobile tissues within the body.
• Protects the organs and tissues of the body.
• Helps to regulate temperature.
• Contains pain, touch, pressure and temperature receptors.
• Excretes substances such as water, salts and nitrogenous wastes.
• Repairs wounds by producing cells for repair.
• Production of vitamin D.

Function of hair

• Provides warmth, protection and sensation to the underlying systems
• Shields against ultraviolet (UV) light.
• Filters dust and particulate matter.
• Symbol of beauty and wealth in some cultures

Function of nails

• Provide protection to the distal surface (end) of the fingers and toes (digits)
• Can be used for self-protection.
• In some cultures nail length equates to social and economic status

Assessment should include:

• Health history
• Physical examination - location, size, general appearance, drainage, odour, pain related to any wounds

Types of wounds

• Classified according to their aetiology, the status of skin integrity, the extent of tissue damage, cleanliness of the wound and descriptive qualities of the wound such as colour and odour.
• Classification system based on a three-colour tool to direct treatment known as the RYB wound classification system.
• Skin tears and pressure injuries have a specific classification system.

Pressure Injuries

• Pressure injuries are localised injuries to the skin that are a result of pressure, shear and/or friction or a combination.
• Pressure occurs when the patient's position is not changed frequently
• Shear force can occur due to incorrect patient transferring, or from patients sliding down the bed
• Friction is often caused by repetitive movements by the patient.
• Risk factors for pressure injury include:Immobility and inactivity, Increased intensity and duration of pressure, Reduced cognition or mental status, Diminished or altered sensory perception, Obesity, Medical devices including tubes and catheters, Circulation disorders, Lifestyle factors such as smoking or poor diet

Staging Pressure Injuries:

• Stage 1 - Intact skin with localised non-blanching erythema (redness)
• Stage 2 - Partial thickness skin loss involving epidermis, dermis or both
• Stage 3 - Full-thickness skin loss involving damage or necrosis to subcutaneous tissue that may extend to but not through underlying fascia
• Stage 4 - Full-thickness skin loss with extensive damage, exposed fascia, muscle, tendon, ligament, cartilage of bone
• Unstageable - full-thickness skin and tissue loss with the extent of damage unable to be confirmed due to being obscured by slough or eschar
• Deep tissue pressure injury - Intact of non-intact skin with localised area of persistent non-blanchable deep red, maroon, purple discolouration or epidermal separation. Dark wound bed or blood-filled blister.

Risk assessment

• Risk assessment tools including the Braden scale, Norton scale and Waterlow scale are commonly used

Prevention

• Regular position changes, Pressure relieving devices, Daily skin care and assessment of the patient's skin, Diet and lifestyle changes

Skin Tears

• Classification of skin tears is identified by STAR Skin Tear Classification
• Assessment & Management includes cleaning wound with saline or water, approximating the skin flap before dressing, Apply a skin barrier product
• Implement preventative skin care interventions to avoid further skin tears

Hygiene

• Dependent on the individual's ability, needs and practices.
• Factors influencing a person's hygiene practices include:Body image, Social and cultural practices, Personal preferences, Socioeconomic status, Knowledge

Factors to consider when assisting with hygiene includeinclude:

• Privacy, Comfort (warmth), Communication, Patient preferences, Cultural considerations, Confidentiality, Assessment & Bariatric considerations

Menstruation

• Essential aspect of personal care for girls and women between menarche and menopause
• Remain professional and make appropriate provisions for the dignified management of menstruation. Please keep in mind that it may not be only girls and women who menstruate, you may also have trans-men who continue to menstruate, or patients who do not present as female.
• Some common symptoms that occur with menstruation can include:lower abdominal, back or pelvic pain, bloating, headache & fatigue
  Implement access to sanitary products and a private area for washing and changing products

Admission Assessment

• The patient profile provides demographics including:full name, date of birth, address (mandatory information to be collected) age, gender, race, marital status, religion, country of birth, next of kin and any nominated medical decision makers
• Focus on patients immediate health concern for prioritization

Includes

• Present health and history, medications, alcohol and tobacco use, Exposure to diseases, any potential injuries in addition to blood transfusions,childhood illnesses, family history, any functional health issues (ADLS)
• Mental health,Sexual practices, Travel history, Work and home environment

PQRST Mnemonic

• Provoking factors - what caused or causes the health issue?
• Quality - how does it feel?
• Region - location or site and Radiation - does it stay in one place or move around?
• Severity - how bad is the health concern, what makes it worse or better, is there any associated pain or other signs and symptoms?
• Timing - when did it start (onset), how long does it last (duration) and how often is it present (frequency)?

Functional Health Assessment

• For older patients and or those with disability it is more important
• Nutrition including type of foods eaten and fluid, portion sizes and preference (likes and dislikes)
• Elmination patterns and consistency
• General activity including exercise patterns, sleep and rest
• Hygiene and ability to walk, cleanse body and dress self.

Mental health

• Mental health is a state of mental well-being
• Legal Frameworks governing are the Mental Health and Wellbeing Act 2022

Disorders (range from anxiety and mood)

• Hallucinations and delusions require acknowledge patient's reality without reinforcing the hallucinations.
• Requires that sensitive communication strategies are required when providing safety and support, and when perfoming a mental state assessment
• Evolution of mental health over time to include more community care rather than institutional settings.

Mental Health Self Care

• Cultivate resilience through activities that promote well-being (nutrition, exercise, hobbies)
• Balance of practical learning and study loads while maintaining personal life.
• Confidential short term counselling available to support wellbeing.

Neurodiversity and Neurodivergence

• Variations in the human brain regarding sociability, learning, attention, mood, and other mental functions including autism spectrum disorder ADHD dyslexia/ Dyspraxia, OCD and Tourette Syndrome
• Nurses are encouraged to familiarize themselves with the characteristics of various neurodivergent conditions to better support their patients' health and wellbeing
• Requires tailored care with compassion

Patient Deterioration and Escalation

Indicators:

• Changes in respiratory rate, agitiation, cognition with decreased cap refill and potential new pain.
• All potential indicators of patient deteriation that are escalated to the RN
• A respiratory arrest will progress to a cardiac arrest if the patient is not treated promptly
• The AED (automated external defibrillator) will identify shockable or unshockable
• When defibrillating (shocking patient) everyone needs to step away prior to the RN pressing the shock button from the AED.

Basic Life Support

• Must be performed to support through CPR
• CPR the technique of chest compressions combined with rescue breathing (ventilation) at a rate that supports brain function.
• Basic life support must be continued until the specialized team arrives.

Safety First

• Respond by using AVPU for pain and stimulus (if no response you must send for backup).
• CPR should include opening air way for unconsicious patients or when patients need rescue breathing.
• Check patent air way by checking that tongue is not blocking
• If patients are vomiting, the head should be tilted down and the mouth opened to have fluid drained.
• The recommended rate is 100 to 120 chest compressions per minute at a rate of 30:2
• CPR should NOT be interrupted to check for response, for breathing or to apply defibrillaiton pads
• The AED can assist to return the electrical current to normal rhythm following CPR.

Resuscitation Code

• Should only be continued until health professional stops it, when device advised, or physically exhausted.
  • Emergency codes are used to allow for quick response as needed based on medical need.

Life Stages

• All ages can be affected by factors like life experiences, health, and expectations including: Heredity & Health Status that influcence developmental progress or lack of progress; as well as: Physiological development, Psychosocial, Cognitive development, Moral and Spiritual life

Care of the elderly

• Some people consider someone as elderly as soon as they are 50 years old.
  • Negative aging can depict the old as senile or hard of hearing.
  • Stereotypes can further these wrong descriptions.
  • Most older people often have one of more health conditions or chronic illnesses
  • Negative stereotypes include thoughts that the elderly do not reside outside of nursing homes.
    Therefore, ongoing efforts need to be maintained to change such beliefs using: Multidisciplinary Teams

Use of Multidisciplinary Teams

• Requires that clinical disciplines work together with goals that will benefit the patient.
• Such people will generally work with health teams and care staff; patient and loved ones for continuous care
• Some teams or roles might include: Nurses from the ER, as well as: nursing staff; social workers; physiotherapists/OT support; pharmacogists and speech therapies; palliative support; and team members on home care situations
• All team members have to have good and open communication based on good and respectful relationships.
• The main idea is that well intergrated care is coordinated with the patient, resulting in less time in the hospital. The Nurse can maintain communication and a steady relationship in addition to being active in care.