NURS 342Fundamentals Study Guide LATEST UPDATED 2022., Exams of Nursing

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ATI Fundamentals Proctored Exam Review ❖ Nursing Process- ATI Fundamentals Ch. 7 ➢ Assessment/ Data Collection ▪ Pt. interview ▪ Medical history ▪ Physical assessment ▪ Lab reports ▪ S/S, feelings ▪ Objective data  VS ➢ Analysis ▪ ID pt. health status ▪ Recognize trends and patterns ➢ Planning ▪ Nurse initiated/Independent Interventions ▪ Provider-Initiated/Dependent interventions ▪ Collaborative interventions ▪ Establish priorities ➢ Implementation ▪ Base care according to data and plan of care ▪ Use problem-solving and critical thinking ▪ Minimize risks ▪ Implement nursing action based on delegation ➢ Evaluation ▪ Evaluate client responses to interventions for form clinical judgement ▪ See if goals are met ▪ Determine effectiveness of nursing care plan Practice Question: A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? ➢ A. “I will determine the most important client problems that we should address.” ➢ B. “I will review the past medical history on the client’s record to get more information.” ➢ C. “I will go carry out the new prescriptions from the provider.” ➢ D. “I will ask the client if his nausea has resolved.” Practice Question: By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? ➢ A. Reassess the client to determine the reasons for inadequate pain relief. ➢ B. Wait to see whether the pain lessens during the next 24 hr. ➢ C. Change the plan of care to provide different pain relief interventions. ➢ D. Teach the client about the plan of care for managing his pain ➢ NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ❖ Medical and Surgical Sepsis- ATI Fundamentals Ch. 10 ➢ Hand Hygiene  PRIMARY BEHAVIOR!!!!!! ➢ 3 essential components (at least 15 seconds and up to 2 minutes if more soiled) ▪ Soap ▪ Water ▪ Friction ➢ Must perform hand hygiene with either soap and water or alcohol-based product ➢ Alcohol based amount- usually 3-5mLs (rub until completely dry) ➢ If visible soiled= soap and water (2 min) ➢ Perform hand hygiene using recommended antiseptic solutions for immunocompromised or multi-drug resistant micro-organisms ➢ Personal Protective Equipment (PPE): ▪ Put on (or Don): Gown  Mask  Googles  Gloves ▪ Take off (or Doff): Gloves  Googles  Gown  Mask ➢ Physical Environment: ▪ Do not place items on the floor (even soiled laundry) ▪ Do not shake linens  can spread microorganisms in the air • Keep from touch clothing  keep away from you ▪ Clean LEAST soiled areas FIRST ▪ Use plastic bags for moist, soiled items ▪ Place specimens in biohazard containers ➢ Maintaining a Sterile Field: ▪ Prolonged exposure to airborne micro-organisms can make sterile items nonsterile. • Avoid coughing, sneezing, and talking directly over a sterile field. • Ask patients to refrain from touching supplies ▪ Only sterile items may be in a sterile field. • The outer wrappings and 1-inch edges of packaging that contains sterile items are not sterile. • Touch sterile materials only with sterile gloves ▪ Microbes can move by gravity from nonsterile item to a sterile item. • Do not reach across or above a sterile field. • Do not turn your back on a sterile field. • Hold items to add to a sterile field at a minimum of 6 inches above the field. ▪ Any sterile, non-waterproof wrapper that encounters moisture becomes nonsterile • Keep all surfaces dry. • Discard any sterile packages that are torn, punctured, or wet. ➢ Sterile Filed set up: ▪ First  open flap or wrapper of packaging AWAY from you ▪ Next  open SIDE flaps ▪ Last  open last flap TOWARD your body NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ▪ Administer antiviral agents- acyclovir can shorten the course ▪ Monitor for complications of Postherpetic neuralgia- pain lasting longer than 1 month ❖ Isolation Guidelines- ATI Fundamentals Ch. 11 ➢ Isolation guidelines are a group of actions that include hand hygiene and the use of barrier precautions ➢ Must be used whenever there is anticipation of contacting infectious material ➢ Change PPE: ▪ After contact with each client ▪ In between procedures with the same client ▪ If in contact with large amounts of blood and body fluids ➢ Clients in isolation are at higher risk for depression and loneliness- provide sensory stimulation ❖ Health Care Associated Infections- ATI Fundamentals Ch. 11 ➢ HAI’s are infections acquired while receiving care in the health care setting. ➢ Formerly called “Nosocomial Infections” ➢ Often occurs in the ICU ➢ Best way to prevent HAIs is frequent and effective handwashing ➢ Common sites: ▪ UTI- E-Coli, Staph aureus, enterococci ▪ Surgical wounds ▪ Respiratory tract ▪ Blood stream Practice Question: A client is 2 days postoperative following an appendectomy. While changing the linens on the client’s bed, the nurse notes drainage from an infected wound has soiled the bed sheet. The appropriate nursing action is to: ➢ A. carefully place the soiled sheet in a moisture-resistant plastic bag ➢ B. Spray the soiled sheet with a bleach solution ➢ C. Roll up the soiled sheet and toss it directly into the laundry chute ➢ D. Discard the sheet in an impervious trash bag ❖ Safe Medication Administration and Error Reduction- ATI Fundamentals Ch. 47 ➢ Providers Responsibilities: ▪ Obtain pt. medical history ▪ Perform physical exam ▪ Diagnosing ▪ Prescribe medication ▪ Monitor response to therapy ▪ Modify medication prescription to therapy ➢ Nomenclature: ▪ Chemical Name  chemical composition ▪ Generic Name  official or nonproprietary name ▪ Trade Name  brand name NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ➢ Unsafe prescription ➢ Appropriate/ priority actions following a medication error ➢ Routes of administration- intradermal, Z-track, TB test: ▪ IV Intermittent IV bolus ➢ IV catheter insertion: ▪ Selecting an IV site ➢ Medication reconciliation ➢ Manifestations of allergic reactions ➢ Mixing insulin ➢ Evaluating appropriate use of herbal supplements ➢ Priority action for handling defective equipment ❖ Client Safety – ATI Fundamentals Ch. 12 ➢ Fall precautions: ▪ Complete fall risk assessment on admission and regular intervals ▪ Adequate lighting ▪ Call light within reach ▪ Assistive devices, if needed ▪ Assign to nurses’ station ▪ Hourly rounding ▪ Frequently used item within reach ▪ Bed in lowest position with brakes locked ▪ Keep side rails up ▪ Nonskid footwear and bathmats ▪ Use gait belts ▪ Keep clear path to bathroom ➢ Seizure precautions: ▪ Make sure equipment is at bedside ▪ Maintain airway patency ▪ Inspect environment and remove items that can harm patient ▪ Assist with ambulation ▪ DO NOT PUT ANYTHING IN CLIENTS MOUTH!! ▪ Do not restrain patient ▪ Lower to floor, put them on one side with head flexed ▪ Wrap a blanket on all 4 sides of patient’s bed ▪ Stay with client and call for help ▪ Administer medication ▪ Determine mental status ▪ Measure VS and oxygenation ▪ Document seizure ➢ Home safety hazards ▪ Place “No Smoking” sign ▪ No smoking near oxygen  Do it outside ▪ Ensure electrical equipment is in good repair and well grounded NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ▪ Keep oxygen 8 feet away from gas stove ▪ Replace bedding that can generate static electricity w/ items made from cotton ▪ Keep flammable materials away from oxygen ➢ Ergonomics- prevention of injury when lifting ▪ Avoid injury when turning patients ➢ Needle disposal ➢ Handling defective equipment ➢ Home safety ▪ Older adult ▪ Teaching client about home safety ▪ Evaluating client understanding of home safety ➢ Seclusion and restraints- in general use seclusion or restraints for the shortest duration necessary and only if less restrictive measures are not sufficient ▪ Possible complications include- pneumonia, incontinence and pressure ulcers ➢ Fire safety ▪ R (rescue client), A (Alarm), C (Contain Fire), E (Extinguish) ➢ Fire Extinguishers: ▪ P (pull the pin), A (aim), S (squeeze), S (Sweep) ➢ Classes of fire extinguishers: ▪ Class A: combustibles such as paper, wood- trash fires ▪ Class B: for flammable liquids and gas fires ▪ Class C: electrical fires ❖ Seclusion/Restraints- ATI Fundamentals Ch. 12 ➢ Can be physical (vest, belt, etc.) or chemical (sedatives) ➢ Use only if less restrictive measures are not effective ➢ Inappropriate use of seclusion or restraints: ▪ Convenience of staff ▪ Client extremely physically or mentally unstable ▪ Punishment for the client ▪ Clients who cannot tolerate the decreased stimulation of a seclusion room ➢ Restraints should: ▪ Never interfere with treatment ▪ Restrict movement as little as necessary ▪ Fit properly and be discreet ▪ Be easily removed or changed ➢ Alternatives to restraints: ▪ Orientation to the environment ▪ Supervision of a family member or sitter ▪ Diversional activities ▪ Electronic devices ➢ Planning care for a client with a prescription for restraints: ▪ Provider must complete a face to face assessment NURS 342Fundamentals Study Guide LATEST UPDATED 2022. • Air bag in passenger seat  < 12 y/o in back seat • Use seat belts • Wear protective equipment (riding a bike, sports) • Road safety • Play in safe areas ▪ Firearms • Keep firearms unloaded, locked up, and out of reach • Teach to never touch and gun • Store bullets in different location ▪ Play injury • Teach not to run with candy or objects in mouth • Ensure bikes are appropriate size • Teach playground safety • Never swim alone • Wear protective helmets • Avoid strangers ▪ Burns • Reduce setting of water heater to no higher than 120 F • Teach dangers of matches, fireworks, and firearms • How to use a microwave • Apply SPF 30 or higher sunscreen ▪ Poisons • Teach about hazards of alcohol, cigarettes, illicit drugs • Keep potentially dangerous substances out of reach • Have the poison control hotline number available ▪ Begin sex education for school-aged child ➢ Adolescents: ▪ Motor vehicle injury • Complete driver’s education course • Educate on hazards of driving while distracted • Water safety • Protective equipment in sports • Be alert for manifestations of depression, anxiety, other behavioral changes ▪ Burns • Sunscreen (SPF 30 or higher) • Dangers of tanning beds and sunbathing ▪ Social Media • Discuss, monitor, and limit exposure to social networking and the Internet ➢ Young and middle adults: ▪ MVA  most common ▪ Adults- occupational injuries, alcohol, and suicide ➢ Older adults (cognitive, physical, and sensory changes) ▪ Falls, burns, home hazards (need modifications such as grab bars, etc.) ▪ Electrical cords behind furniture NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ▪ Monitor gait and balance ▪ Use nonskid mat in bathtub or shower ▪ Ensure adequate lighting ▪ Remove item that could cause client to trip ❖ Emergency Care- ATI Fundamentals Ch. 13 ➢ ABCDE Principle ▪ A – Airway/Cervical Spine ▪ B – Breathing ▪ C – Circulation ▪ D – Disability ▪ E – Exposure ➢ Basic first aid ▪ Bleeding • External bleeding- apply direct pressure to wound site • DO NOT remove impaling objects, instead stabilize the object • Internal bleeding will require IV volume replacement with fluid or blood products, or surgical interventions ▪ Fractures and splinting • Assess for swelling, deformity and skin integrity • Assess temperature, distal pulses and mobility • Apply splint to immobilize the fracture. • Cover open areas with sterile dressing • Reassess neurovascular status (5 Ps) ▪ Sprains • RICE • Refrain from weight bearing • Apply ice to decrease inflammation • Apply compression dressing to minimize swelling • Elevate the extremity ▪ Heat stroke • Body temperature greater than 104F- treat aggressively • S/S- hot dry skin, hypotension, tachypnea, tachycardia, anxiety, confusion, seizures, coma. • Client DOES NOT sweat • Rapid cooling- ice packs over major arteries • Cold water bath • Do not allow client to shiver- if so, cover with a blanket ▪ Frostnip and frostbite • Common sites  earlobes, tip of nose, fingers, and toes • Frostnip  no tissue injury, just treat by warming • Frostbite  tissue injury, white waxy areas • Warm the affected area in 98.6-108F water bath • Pain medication and tetanus NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ▪ Burns • Can be from electrical current, chemicals, radiation, or flames • Remove the agent (electrical current, radiation and chemical) • Smother flames and perform primary survey • Cover the client and maintain NPO • Elevate extremities if not contraindicated (like Fracture) • Assess thickness and areas of burns • IV fluids and tetanus ▪ Altitude-Related Illnesses • Client becomes hypoxic • Can progress cerebral and pulmonary edema – immediate treatment!!! • S/S: ◆ Throbbing HA, N/V, Dyspnea, Anorexia • Nursing Interventions: ◆ Administer O2 ◆ Descend to lower altitude ◆ Provide steroids and diuretics ◆ Promote rest ➢ CPR ➢ CAB ➢ Assess for response and breathing: ▪ If no breathing (or gasping)- call for help ▪ If alone activate emergency response system and get AED if available ▪ If a second person is there, send them for activate the emergency response system (911) ▪ Check pulse and begin CPR and alternate wit breaths if pulse not detected Practice Question: A nurse is caring for a client who 1-day postoperative following abdominal surgery. What is the first action the nurse should take after discovering that a client’s wound has eviscerated? ➢ A. Cover the incision with a moist sterile dressing. ➢ B. Have the client lie on his back with his knees flexed. ➢ C. Call the client’s surgeon ➢ D. Measure the client’s vital signs. ❖ Ergonomic Principles – ATI Fundamentals Ch. 14 ➢ Body mechanics: ▪ Center of gravity • To lower center of gravity, bend hips and knees • Spread feet apart to broaden base of support ▪ Pushing or pulling • Widen base of support • Pull objects to center of gravity instead of pushing away • If Pushing  move front foot forward • If Pulling  move your rear leg back to promote stability NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ▪ Close drapes  protect against shattering glass ▪ Lower bed to lowest position ▪ Move away from windows ▪ Close doors ▪ Do not use elevators ➢ Biological pathogens ▪ Be alert for appearance of disease that does not usually occur at a specific time or place ▪ Use recommended isolation measures ▪ Take measures to protect yourself and others ▪ Recognize indications of infection/poisoning ➢ Chemical Incidents ▪ Occur of an accident or due to a purposeful action (terrorism) ▪ Avoid contact ▪ Maintain ABCs ▪ Remove offending chemical – undress client ➢ Hazardous material Incident ▪ Contain material in one place ▪ Don PPE ▪ Water  Universal Antidote ▪ Place contaminated material into plastic bags and seal them ▪ Wash skin with water and antibacterial soap ➢ Radiological Incidents ▪ Wear water-resistant gown, double gloves, body fully cover ➢ Bomb Threat ▪ Listen for distinguishing background noises ▪ Bomb located – do not touch it ▪ Keep elevators available ▪ Remain calm and alert – try not to alarm the patient ➢ Active Shooter Situation: ▪ RUN • Evacuate • Leave belongings behind • Instruct others to follow ▪ HIDE • Stay out of shooters sight • Find a protective area • Block or lock doors • Silence phone and remain quiet ▪ FIGHT • If unable to run and hide, throw items, yell shooter to stop, wound the shooter ❖ Health Promotion/Disease Prevention – ATI Fundamentals Ch. 16 ➢ Screenings are for baseline and for clients who are asymptomatic: ▪ Routine physical  q 1-3 years (females), q 5 years (males) _ 20-40 years NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ▪ Dental  q 6 months ▪ TB screening  q 2 years ▪ BP  q 2 years, annually of elevated ▪ BMI  each routine visit ▪ Cholesterol  starting at age 20, min. q 5 years ▪ Glucose  starting at age 45, min. q 3 years ▪ Skin assessment  q 3 years (ages 20-40), annually > 40 years ▪ Digital rectal exam  during routine physical exam, continue after age 76 ▪ Colorectal screening  (every year between 50 and 75) ▪ Cervical cancer screening (PAP)  Ages 21-29 q 3 years, 30-65 q 5 years ▪ Breast cancer screening  (20-39 years, clinical exam q 3 years, mammogram annually after 40) ▪ Testicular exam  (start at age 20) ▪ Prostate specific antigen  (PSA) starting at 50 ➢ Primary: decreases risk of exposure ▪ Immunization programs ▪ Child car seat education ▪ Nutrition, fitness activities ▪ Health education in schools ➢ Secondary: prevent worsening of health ▪ Communicable disease screenings ▪ Early detection, treatment of DM ▪ Exercise programs for older adults who are frail ➢ Tertiary: prevent long term consequences of illness ▪ Begins after an injury or illness ▪ Prevention of pressure ulcers after spinal cord injury ▪ Promoting independence after traumatic brain injury ▪ Rehabilitation centers ❖ Client Education – ATI Fundamentals Ch. 17 ➢ Domains of learning: ▪ Cognitive- focuses on thinking • Client learns manifestations of hypoglycemia and can verbalize when to notify the HCP ▪ Affective- feelings, beliefs, and values • New diabetic discusses her feelings about her new diagnosis and the life changes necessary ▪ Psychomotor- require mental and physical activity • When client practices preparing insulin injections ➢ Factor that enhance learning: ▪ Perceived benefit ▪ Cognitive and physical ability ▪ Health and cultural beliefs ▪ Active participation ▪ Age and educational level appropriate methods NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ➢ Barriers to learning ▪ Fear, anxiety, and depression ▪ Physical discomfort, pain, and fatigue ▪ Environmental distractions ▪ Health and cultural beliefs ▪ Sensory and perceptual deficits ▪ Psychomotor deficits ❖ Health Assessment – ATI Fundamentals Ch. 26 ➢ Assessment Techniques ▪ 4 basic assessment techniques • Inspection, palpation, percussion, Auscultation • In the above order except where? Abdomen ▪ Equipment ▪ Older adult considerations ▪ Focused assessment: • focused assessment a highly specific assessment focusing on the system or systems involved in the patient's problem. ➢ General survey: appraisal of overall health ▪ Physical appearance • Ex: age, gender, LOC, color of skin, signs of distress ▪ Body structure • Ex: height, stature, nutritional status, symmetry of body parts, posture, gross abnormalities ▪ Mobility • Ex: gait, movements (tremors), ROM, motor activity ▪ Behavior • Ex: facial expressions, mood and affect, speech, dress, hygiene, grooming ▪ Vital signs • Temperature, Pulse, Respirations, BP, O2 ➢ Components: ▪ Patient ID ▪ Past Medical History ▪ Medications ▪ Allergies ▪ Social History ▪ Immunizations/Travel ▪ Family History ▪ Review of Systems (subjective) ▪ Physical examination (objective) ❖ System Assessment ➢ Neurological NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ➢ Blood Pressure ▪ Normal  less than 120/80 ▪ Assess complication and contributing factors ▪ BP CANNOT be less than 100/70 ❖ Physical Assessment – ATI Fundamentals Ch. 28-31 ➢ Head/Neck: Check for ▪ Head  bumps, lesion, alopecia, dry scalp ▪ Face  symmetry, color ▪ Neck  ROM, JVD, swollen lymph nodes goiter, trachea midline ▪ Eyes  visual acuity, PERRLA, double/blurred/no vision ▪ Ears  alignment, drainage deformities ▪ Nose  midline, patent naris, assess smell ▪ Mouth  cracked lips, bleeding gums, dry/moist mucus membranes, swollen tongue, ability the swallow, gag reflex, slurred speech ▪ Teeth  shiny, white, and smooth ➢ Thorax, Heart, and Abdomen: Check for ▪ Thorax and Lungs • Inspect (shape, symmetry, surgery scars, skin color) • Palpation (edema, masses, bulges) • Percussion (dullness or tympanic sounds) • Auscultation (abnormal respiratory patterns like crackles, wheezes, etc., assess for bronchial, bronchovesicular, and vesicular lungs sounds) ▪ Heart • S1  “lub” (contraction) • S2  “dub” (relaxation) • S3  ventricular gallop; in children and young adults, occurs after S2 • S4  atrial gallop, in athletes, occurs after S1 • Murmurs ◆ Systolic  occurs after S1 ◆ Diastolic  occurs after S2 • Thrills  palpable vibration • Bruit  Blowing, swishing sounds • Auscultatory sites of Heart: ◆ Aortic  Right 2nd ICS ◆ Pulmonic  Left 2nd ICS ◆ Erb’s Point  Left 3rd ICS ◆ Tricuspid  Left 4th ICS ◆ Apical/Mitral/PMI  Left midclavicular line 5th ICS - (closure of mitral valve) ▪ Abdomen • Inspection (lesion, scars, color, bruising, distention) • Auscultation (Bowel sounds_5-35 [hypo or hyper} start in RLQ • Percussion (high pitched tympany sounds) • Palpation (light or deep varies on tenderness) NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ➢ Skin ▪ Assess temperature – use dorsal part of hand ▪ Assess skin integrity – Braden scale ▪ Assess skin turgor – indication of dehydration if tenting occurs ▪ Color of skin: • Pallor (white appearance) • Cyanosis (Blue color – loss of O2) • Jaundice (yellow pigment – liver problems) • Erythema (redness) ▪ Nails • Check for clubbing – respiratory insufficiency • Capillary refill (<3 seconds) – greater than 3 seconds indicates arterial insufficiency ▪ Hair • Alopecia (bald spots) • Distribution • Hirsutism – hair growth on faces for females ▪ Peripheral Arteries Strength Pulses (carotid, radial, brachial, femoral, popliteal, posterior tibial, and dorsalis pedis) • 0 = Absent, unable to palpate • +1 = diminished, weaker than expected • +2 = brisk, expected – NORMAL!! • +3 = increased • +4 = Full volume, bounding ▪ Edema • 1+ = Trace, 2mm, rapid skin response -- NORMAL!! • 2+ = Mild, 4mm, 10-15 second skin response • 3+ = Moderate, 6mm, prolonged skin response • 4+ = Severe, 8mm, prolonged skin response ▪ Lesions • Primary: ◆ Macule  freckles, petechiae ◆ Papule  elevated nevus ◆ Nodule  wart ◆ Vesicle  blister, varicella, herpes zoster ◆ Pustule  acne ◆ Tumor  Epithelioma ◆ Wheal  insect bite • Secondary: ◆ Erosion  ruptured vesicle ◆ Crust  scab ◆ Scale  dandruff, moist surface, no bleeding ◆ Fissure  tinea pedis ◆ Ulcer  pressure ulcer, venous stasis ulcer ▪ Use A (asymmetry) B (Border) C (Color) D (Diameter) E (Evolving) system NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ➢ Musculoskeletal ▪ Assess: • Gait • Alignment (Kyphosis, Lordosis, Scoliosis) • Symmetry, muscle mass • Muscle tone ▪ Range of Motion • Flexion, extension, hyperextension, supination, pronation, abduction, adduction, etc. ➢ Neurologic ▪ Mental status • Alert  responsive • Lethargic  drowsy but able to open eyes • Obtunded  responds to light shaking but confused • Stuporous  requires painful stimuli • Comatose  no response ▪ Sensory function  light touch, temperature, pain sensation ▪ Motor Function  Romberg test, Heel-to-toe walk ▪ Cranial Nerves: • 1  olfactory (smell) • 2  Optic (sight) ◆ Snellen chart – visual acuity ◆ Rosenbaum – near vision or farsightedness ◆ Ishihara test - Color vision • 3  Oculomotor, 4  trochlear, 6  Abducens (PERRLA, 6 cardinal positions of gaze) • 5  Trigeminal (light touch sensation, jaw clench, chewing) • 7  Facial (taste 2/3 thirds of tongue, facial movements) • 8  Auditory (hearing and balance) ◆ Whisper test, Rinnes test, Weber tests • 9  Glossopharyngeal (taste 1/3 thirds of tongue, swallow, gag reflex) • 10  Vagus (gag reflex, speech) • 11  Spinal accessory (turning head, shrug shoulders) • 12  Hypoglossal (tongue movement) ❖ Therapeutic Communication -ATI Fundamentals Ch. 32 ➢ Levels of basic communication ▪ Intrapersonal communication  “self-talk” ▪ Interpersonal communication  b/w 2 people ▪ Public communication  b/w large groups of people ▪ Transpersonal communication  spiritual ▪ Small group communication  committees, research teams, support groups ➢ Non Verbal Communication : Nurses should be aware of how they communicate nonverbally and should determine the meaning of the clients’ nonverbal communication as well. ▪ Appearance, posture, gait NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ➢ Buddhism ▪ Vegetarians ▪ Avoid alcohol and tobacco ▪ Might fast on holy days ▪ Bran death – requirement ▪ Death is seen as a stage of life to occur at home ▪ Body prepared by male ▪ May use cremation ➢ Christianity ▪ Common belief – faith healing ▪ Organ donation generally allowed ▪ Practice holy communion ➢ Sikhism ▪ Female client often checked by other females ▪ Remove undergarments – can be distressing ▪ Use religious symbols or devotional prayer ▪ Might not permit cutting or shaving of the hair ➢ Navajo ▪ Correct poor health by stories, songs, rituals, prayers and paintings ➢ Hinduism ▪ Illness can be caused by past sins ▪ Clients want to lie on the floor while dying ▪ Care of body should those of same gender ▪ Cremation ▪ Use rituals for purity and prayer ▪ Use amulets or other symbols ➢ Islam ▪ Avoid alcohol and pork ➢ Jehovah witness ▪ Not accept blood transfusion ▪ Avoid foods prepared with blood ❖ Grief, Loss, and Palliative Care – ATI Fundamentals Ch. 36 ➢ Advanced Directives ▪ Living Will – document stating clients wishes ▪ Health Care Proxy aka Durable Power of Attorney -makes decision for client on their behalf ➢ Types of loss ▪ Necessary loss  related to a change that is part of the cycle of life and is anticipated but still cam be intensely felt ▪ Actual loss  of a valued person, item, or status ▪ Perceived loss  anything client defined as loss but that is not obvious or verifiable to others ▪ Maturational or developmental loss  any loss normally expected due to developments of life • Ex: a child leaving for college NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ▪ Situational loss  any anticipated loss caused by external event • Ex: a family loses their home during tornado ▪ Anticipatory loss  experienced before loss has happened ➢ Kubler-Ross Model of Grief ▪ Denial  difficulty believing in an expected or actual loss ▪ Anger  directs anger toward self and others ▪ Bargaining  negotiates for more time or a cure ▪ Depression  overwhelming saddened ▪ Acceptance  acknowledges what is happening and plans by moving forward ➢ Manifestations of Grief Reactions ▪ Normal grief • Considered “uncomplicated” • Some acceptance should be evident by 6 months • May have somatic complaints: chest pain, palpitations, headaches, change in sleep patterns ▪ Anticipatory grief • “letting go of an object the person before the loss” ▪ Complicated grief • Difficult progression through the expected stages of grief ▪ Disenfranchised grief • Experienced loss that cannot be publicly stated • Ex: suicide or abortion ➢ Postmortem Care ▪ Maintain privacy ▪ Remove all tubes (unless organs are to be donated) ▪ Remove personal belongings and give to the family ▪ Cleanse and align the body supine with a pillow under head, arms with palms down outside of the sheet, dentures in place and eyes closed. ▪ Apply fresh linens with absorbent pads ▪ Brush and comb the client’s hair- replace hair pieces if necessary. ▪ Remove excess equipment and supplies and soiled linens from room. ▪ Dim the lights to minimize noise and provide a calm environment ▪ Allows family to visit ▪ Put ID tag ❖ Hygiene – ATI Fundamentals Ch. 37 ➢ Bathing ▪ Assign to AP ▪ Allow rest periods ▪ Partial baths  cannot tolerate but cleaning of in uncomfortable areas ▪ Therapeutic baths  promote comfort ➢ Oral hygiene ▪ Place client head to the side ▪ Use soft toothbrush NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ➢ Foot care ▪ Prevent skin breakdown, pain, infection ▪ Caution with diabetic neuropathy ➢ Perineal care ▪ Maintain skin integrity and relive discomfort ➢ Cultural and social practices ➢ Bathing a client with Dementia ➢ Oral care for a client who is unconscious ▪ Place client head to the side ➢ Foot care for a client who has DM Practice Question: A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? ➢ A. Turn the client’s head to the side. ➢ B. Place two fingers in the client’s mouth to open. ➢ C. Brush the client’s teeth once per day. ➢ D. inject a mouth rinse into the center of the client’s mouth. Practice Question: A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client’s plan of care? ➢ A. Schedule rest periods during morning care. ➢ B. Discontinue morning care for 2 days. ➢ C. Perform all care as quickly as possible. ➢ D. Ask a family member to come in to bathe the client. ❖ Rest and Sleep – ATI Fundamentals Ch. 38 ➢ Stages of Sleep ▪ Stage 1 NREM • Light sleep; few minutes • Muscle relaxes • Loss of awareness • VS/metabolism decrease • Awakens easily • Feels relaxed and drowsy ▪ Stage 2 NREM • Deeper sleep; 10-20 minutes • VS decrease • Requires stimulation to wake ▪ Stage 3 NREM • Slow wave sleep or delta sleep • VS decrease • More difficult to awake ▪ STAGE 4 REM NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ▪ Observe bony prominences. ▪ Check skin turgor. ▪ Use a pressure ulcer risk scale such as Norton or Braden. ▪ Assess at least every 2 hr. ▪ Observe for urinary or bowel incontinence. ➢ NURSING INTERVENTIONS ▪ Identify clients at risk for pressure ulcer development. ▪ Position using corrective devices such as pillows, foot boots, trochanter rolls, splints, and wedge pillows. ▪ Turn every 1 to 2 hr. and use devices for support or per protocol. ▪ Teach clients who can move independently to turn at least every 15min. ▪ Provide clients who are sitting in a chair with a device to decrease pressure. ▪ Limit sitting in a chair to 1 hr. Instruct clients to shift their weight every 15 min. ▪ Use a therapeutic bed or mattress for clients in bed for an extended time. ▪ Monitor nutritional intake. ▪ Provide skin and perineal care. ▪ Preventing skin breakdown in immobile patients ▪ Assessing skin condition for immobile patients ▪ Evaluating a client use of a walker ▪ Application of anti-embolic stockings ▪ Preventing complications of immobility ▪ Presenting plantar flexion ➢ Crutches ▪ Do not alter crutches ▪ Hand grips with elbows flexed at 20-30 degrees ▪ Tripod position (6 inches in front) ▪ 2-3 finger-widths in axilla space • 2-point  partial weight bearing on both feet • 3-point  bear all weight on 1 foot (unaffected) while using both crutches • 4-point  bear weight on both legs, alternate with each crutch ▪ Going upstairs (Ascending) • Move unaffected leg up first  moves affected leg and crutches up ▪ Going downstairs (Descending) • Move crutches and affected leg down first  moves unaffected leg down ➢ Cane ▪ Maintain 2 points of support ▪ Keep cane on stronger side of body ▪ Move cane forward  move weaker leg  advance stronger leg ➢ Walker ▪ Put all 4 points on the floor before to putting weight on hand pieces ▪ Move walker forward  affected or weaker foot  move unaffected leg ❖ Airway Management- ATI Fundamentals Ch. 53 ➢ Monitoring O2 Saturation NURS 342Fundamentals Study Guide LATEST UPDATED 2022. ➢ Labs to report ➢ Teaching tracheostomy care at home ➢ Positioning for postural drainage ➢ Nasotracheal suctioning technique ➢ Teaching the use of the incentive spirometer ❖ Other Skills to Review ➢ Facilitating urinary catheter insertion ➢ Maintaining urinary catheter insertion ▪ Promoting voiding in a client postop ▪ Condom catheter ➢ NG tube insertion and preparing to administer feeding ➢ Verifying NG tube placement ➢ Central line dressing change ➢ Sterile technique ➢ Assisting the client to use a fracture pan ➢ Ear irrigation ➢ Obtaining a capillary blood glucose ➢ Cleaning a wound site ➢ Incentive spirometer