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NUR2356: Multidimensional Care I / MDC 1 Exam 1 Outline
- Herbal supplements a. Aloe : wound healing. b. Chamomile : anti-inflammatory. c. Echinacea : strengthen body’s immune system, prevention against cold and flu. d. Feverfew : used for migraine headaches, as well as for menstrual cramps. e. Garlic :used for cardiovascular conditions, including high cholesterol and triglyceride levels associated with the risk of atherosclerosis. f. Gingko Biloba :used for many conditions with aging, including poor circulation and memory loss. g. Ginseng: used as a general tonic to increase overall body tone, ginseng is considered helpful in elevating energy levels and improving resistance to stress. h. Valerian :promotes sleep and reduces anxiety.
Pain assessment (3) a. Types of pain i. Cutaneous Pain : arises from burning your skin.
- Example – on a hot iron or from touching a hot pan on the stove. ii. Visceral Pain: caused from deep internal disorders such as menstrual cramps, labor pains, or gastrointestinal infections. iii. Deep Somatic Pain : originates from the ligaments, tendons, nerves, blood vessels and bones.
- Example – fractures or sprains iv. Radiating Pain: starts at an origin but extends to other locations.
- Example – pain from a sore throat might extend to ears and head. v. Referred Pain: occurs in an area distant from the site or origin.
- Example – pain from a heart attack might be felt in the left arm or jaw. vi. Phantom Pain: pain that is perceived from an area that has been surgically or traumatically removed.
- Example – pain from an amputated limb. vii. Neuropathic Pain: results from an injury of one or more nerves. viii. Acute Pain: Short-duration, rapid onset, and associated with some kind of injury. ix. Chronic Pain: lasts 6 months or longer and interferes with ADL’s.
b. Pain Assessment : plays a role in the clients rest and comfort needs and in the area of anxiety related to illness recovery. It is considered the 5thvital sign. Always reassess as needed and provide medication before doing activity. i. Step 1 : Explain what it is and how it is used. “This is a pain rating scale that many of our patients use to help us understand their pain and set goals for pain relief. We will ask you regularly about pain, but any time you have pain you must let
us know so we can help control it. We don’t always know when you hurt” ii. Step 2: Show them how to rate their pain “On this pain rating scale 0 means no pain, and 10 means the worst pain possible pain. The middle of the scale, around 5, means moderate pain. A 2 or 3 would be mild pain, but 7 or higher means severe pain” iii. Step 3: help them understand what pain is and what it could feel like. “Pain refers to any kind of discomfort anywhere in your body. Pain also means aching and hurting. Pain can include pulling, tightness, burning, knifelike feelings, and other sensations” iv. Step 4: Ask about characteristics. “I want to be sure that I’ve explained this clearly; so, would you give me two examples of pain you’ve had recently?”. If the patient's examples include various parts of the body and various pain characteristics, it indicates that he or she understands as a fairly broad concept. An example of what a patient might say is “I have a mild, sort of throbbing headache now, and yesterday my back was aching”. v. Step 5. Ask them about pain now and how it feels when at its worst, or how it normally is. “Using the scale, what is your pain right now? What is it at its worst?” OR “Using the pain rating scale and one of your examples of pain, what is that pain usually? What is it at its worst?” vi. Step 6. Explain complications and measures that might be taken for acute and chronic pain.
- Surgical patient “I have explained the importance of coughing and deep breathing to prevent pneumonia and other complications. Now we need to determine the pain rating that will not interfere with this so you may recover quickly”
- Chronic pain or terminal illness “What do you want to do that pain keeps you from doing? Which pain rating would allow you to do this?”
c. Characteristics of Pain : Location: ask the client to describe where on the body the pain is, with landmarks. Radiate : does the pain move anywhere else? Quality : how the pain feels. Sharp, dull, achy, burning, stabbing, pounding, throbbing, shooting, etc. Intensity and Strength : how much pain does the person feel. Duration: where did it start, how long does it last, when did it first, occur,
xiii. Change positions slowly to reduce dizziness xiv. Ensure there is a non slip bath and shower mat, shower chair, call light, grab bars and lighting. xv. Administer CNS depressants as needed xvi. Reorient the confused client frequently to their surroundings xvii. Supervise the clients at all times xviii. Consult the doctor for use of temporary restraints if needed xix. Give medications for anxiety and antipsychotics as needed c. Risks for…
- Older Adults: most at risk due to comorbid conditions and deteriorating bodily functions a. History of falls b. Living Alone c. Lower limb prosthesis d. Use of assistive devices like a cane or walker e. Wheelchair use
- Children Less than 2 years old a. Bed located near windows b. Lack of automobile car seats c. Lack of parental supervision d. Male gender when less than a year old e. No baby gates on stairs f. No window guards g. Unattended when on bed, changing table, sofa, or elevated surface
- Cognitive a. Diminished mental status makes one more likely for a fall b. Confusion, delirium, impaired reality
- Environment a. Cluttered Environment b. No anti slip mats in bathroom or shower c. Restraints d. Throw or scatter rugs e. Unfamiliar or dim rooms f. Bad weather conditions like ice or puddles g. Wet floors h. Sidewalk cracks or stairs, or holes
- Medications a. ACE inhibitors b. ETOH use c. Antianxiety drugs d. Antihypertensives e. Diuretics f. Hypnotics
g. Narcotics h. Opiates
- Physiological/ Diseases a. Anemia b. Arthritis c. Decreased lower extremity strength d. Diarrhea e. Faintness when turning or extending neck f. Foot problems g. Gait difficulties h. Hearing difficulties i. Impaired balance j. Neoplasms that cause difficulty k. Neuropathy l. Orthostatic hypertension m. Post op conditions n. Blood sugar changes after meals o. Acute illness p. Proprioception defects q. Sleeplessness r. Urgency s. Incontinence
- Fire safety a. Fires are usually due to problems with electrical or anesthetic equipment or from smoking. b. Smoking is prohibited in healthcare facilities because it can interact with oxygen, which is used a lot in healthcare. c. Staff must know exactly how to protect clients and themselves: location of exits, alarms, extinguishers, not blocking doors, policy protocol. d. Code Red or Code Yellow e. Never panic, always keep clients calm, protect clients from injury. f. RACE: fire emergency response i. R: rescue; protect clients and move them to a safer location. ii. A: alarm; activate the facilities alarm system and report the fire and location. iii. C: contain; close doors and windows and turn off oxygen sources where the fire is. iv. E: extinguish; use the fire extinguisher to put out the fire. g. PASS: operating the fire extinguisher i. P: pull the pin ii. A: aim at the base of the fire iii. S: squeeze the handle iv. S: sweep from side to side to cover the area of the fire
or into a room that has been cleaned vii. ·Motor Vehicle Injuries
- Ensure the infant rides in a tested car seat in the back of the car viii. Suffocation
- Ensure the infant does not have access to any plastic bags
- School-age a. Bodily Harm i. Keep firearms in a locked cabinet or box ii. Assist with identifying safe play areas iii. Teach stranger safety iv. Teach use of helmets when skating, skateboarding, biking, scooters, skiing, and other activities that may account for increased injury v. Teach children to wear light reflective clothing at night b. Burns i. Teacher fire safety and elimination of potential burn hazards ii. Have working smoke and carbon monoxide detectors in the home iii. Wear sunscreen when outside c. Drowning i. Supervise children when they are near a body of water ii. Teach swimming skills and safety d. Motor Vehicle Accidents i. Have children use a carseat until they are able to have adult seat belts fit correctly ii. Children younger than 13 should sit in the backseat e. Substance abuse/Poisoning i. Keep cleaners and chemicals in locked areas or out of reach ii. Educate children who are curious about the use of the products iii. Purchase items that have a child safe lid on them iv. Teach children to say no to drugs v. Teach children about dangers of smoking
b. Risks: i. Middle-age adults
- Avoid substances, including alcohol that can lead to substance use disorders
- Avoid drinking and driving or taking substances that impair motor
functions
- Wear a seatbelt when operating or using a vehicle
- Wear a helmet when doing recreational activities or sports
- Install smoke detectors and carbon monoxide detectors in the home
- Secure guns in a safe location c. Never Events i. Serious injuries or death to a patient that should never happen in a hospital. ii. From: lack of communication, lack of attentiveness and monitoring, lack of clinical judgement, inadequate measures to prevent health complications, errors in medication administration, errors in interpreting authorized provider prescriptions, lack of accountability and patient advocacy, inability to carry out interventions in an appropriate manner, lack of mandatory reporting. iii. Examples include: falls, needlestick injuries, wrongful medication administration, hospital acquired infections ,suicide, surgical procedures, air embolisms, wrong transfusions, blood clots after procedures iv. Prevent with being alert, monitoring, assisting patients, double checking work and medications, use fall precautions, SCDs, complete line care as directed, etc v. Interventions
- Respond to all monitors or alarms that go off on patients
- Check and flush lines, IVs and catheters as protocol defines it
- Use fall precautions on the fall risk patient
- Double check medications with the 3 checks and have another RN double check high risk medications
- Complete peri-care or hygiene daily
- Discard and cap needles when not being used
- Mark surgical areas and triple check before allowing operations to begin
- Follow protocol by having another nurse read and check before transfusions
d. Patient orientation i. Have to do so at admission and transfers ii. Helps client and family feel safer at the hospital iii. Tell them where the:
- Call light is and how to use it
- Electric bed operation
- Telephone and TV use
- Room lighting
- Smoking Policy
- Bathroom location
do and report adverse events iv. S - speak up if you have questions of concerns. v. P - pay attention to the care you are receiving vi. E - educate yourself about your diagnosis vii. A - ask a trusted friend or family member to be your advocate viii. K - know your medications and why you take them ix. U - use a hospital, clinic, surgery center, or other type of healthcare organization that has undergone a rigorous on-site evaluation against established state-of-the-art quality and safety standards, such as that provided by The Joint Commission x. P - participate in all decisions about your treatment
- Hygiene: a. Bathing: helps to cleanse body, circulation, relaxation, healing. Always give a bath to clients who can handle it, give rest periods, partial baths can be used when clients can't tolerate a complete bath. Therapeutic baths help itchy skin. i. Shower: best with walkie talkie patients, can use shower chair if needed. Always monitor water temperature and watch patients for safety. ii. Tub bath: immerses the patient in water for thorough washing. Can use different washes for therapeutic measures. iii. Bed bath: done for immobile patients or bed bound, remember to use the folding mitt technique, change sheets when done and do it daily to promote integrity of skin. Start from top to bottom and be light with the strokes and use lotion and powder. b. Eye and Ear Care i. Always use clean, moist washcloth without soap to wash eyelids in the inner corner to outer corner. ii. Rotate in the ear to gently clean the ear canal. c. Oral care: decreases risk of infection. All client should have proper hygiene done daily. i. Check for aspiration risk and gag reflex ii. Have suction set up at bedside iii. Be gentle when cleaning mouth due to fragile oral mucosa iv. Never place fingers in a unconscious clients mouth v. Turn unconscious patient on side in semi fowlers vi. All others must do it in high fowler's position vii. Denture care: must be done daily for those who can't do it themselves, with gloves on and careful, with tepid water, and brushing softly d. Foot Care i. Helps to prevent infection and pain that interferes with gait ii. DM, PVD, immunosuppression. iii. Inspect feet and toes, wear water to wash and dry feet iv. Moisturize v. No OTC products vi. Wear clean socks and shoes that are safe.
vii. Be careful when cutting nails and calluses. viii. Make sure shoes fit correctly e. Perineal Care: helps to maintain skin integrity and prevent transmission of organisms i. Incontinence care, catheter care or regular ii. Always give privacy, respect the client iii. Remove fecal material and clean front to back iv. Dry thoroughly v. Change sheets and pad and dressing if soiled vi. Clean around the catheter sites and skin contact when doing care
f. Toileting: i. Should be offered every hour to 2 hours or 30 minutes after meals ii. Always assist the client to the bathroom if they are at risk to fall iii. Record when you take the patient to the bathroom and how much output they have iv. If incontient, change and wipe the patient down with clean wipes and place barrier cream to preserve the skin. g. Nail Care i. Check the nails for integrity or infection signs ii. Check for a prescription when doing nail care iii. Be careful with clients with DM or PVD due to potential bleeding iv. No lotion due to the breakdown on skin h. Hair Care i. Done to promote client esteem and appearance ii. Brush or comb hair daily and massage the scalp to promote circulation iii. Be careful when combing and choose right comb and be gentle when combing iv. Can use the sink to shampoo the scalp, use a shampoo cap or a shower depending on patient status v. Be careful with the neck of patients and provide comfort with a towel roll i. Shaving i. Use electric razors ii. Be careful with diabetics and bleeding risk patients iii. Shave in one direction softly iv. Soak with warm water to soften the skin and use shaving cream
- Developing professional and therapeutic boundaries a. Using therapeutic communication techniques to help communication b. Have respect for the patient, staff, and family c. Identify rules and boundaries of the setting d. Know what is right and not right to tell your patient- not age, birthday, sex, politics,etc i. No giving away social media accounts or tell anyone about who you
b. The nurse can also assist patients with feeding who have weakness, confusion, swallowing difficulties, etc c. Different diets to help clients eat and swallow= minced,moist, chopped. d. Help the client find what foods they like e. Assist with preventing aspiration: high fowler's, tucked chin, no straws, small bites, keep in position 1 hr post meals due to aspiration risk f. Record how much you feed the client and their tolerance
- Maslow’s hierarchy a. Based on the needs of the client b. Needs must be met in order before higher needs can be met. c. Levels from BOTTOM to TOP i. Physiological Needs 1. Basic Needs 2. Ex: Food, water, shelter, oxygenation ,circulation, elimination 3. Must have all met at this level before advancing. ii. Safety Needs
- Next level based on one being secure in their surroundings
- Safety in the home, security
- Intervention: the nurse or social worker may help one go home after hospitalization to a home free from abuse iii. Love and Belonging
- Based on intimate relationships, friendships, etc iv. Esteem
- Feeling of Self Accomplishment v. Self-Actualization
- Highest level of achieving one's full potential d. Prioritization: one must meet basic needs before advancing onto higher needs. i. ABCs: airway, breathing, circulation used to help assess client needs ii. Triage from most sick to least sick e. Oxygenation and Perfusion i. Interventions to Promote Adequate Oxygenation 1. Position the client to allow for maximal chest expansion 2. Encourage or assist clients with frequent changes in position, every 2 hours. 3. Encourage deep breathing and coughing. 4. Encourage ambulation. 5. Promote comfort so clients can tolerate the above activities. 6. Incentive Spirometry 7. Chest Physical Therapy 8. Nasal Cannula 9. Mechanical Ventilation 10. Endotracheal tube 11. Tracheostomy
- Closed chest drainage
- Extubation
- Continuous positive airway pressure
- Positive end-expiratory pressure
- Delegation a. The process of transferring to a competent person the authority to perform a selected nursing task or activity in a selected patient care situation
- Requires PRECISE and ACCURATE communication.
- Nurse is always accountable for the task or activity that is delegated. b. Five Rights of Delegation when you delegate an activity to a UAP:
- Right Task: The task is within the UAP’s scope of practice and competence.
- Right Circumstance: The patient care setting and resources are appropriate for the delegation.
- Right Person: The UAP is competent to perform the delegated task or activity.
- Right Communication: The nurse provides a clear and concise explanation of the task or activity, including limits and expectations.
- Right Supervision: The nurse appropriately monitors, evaluates, intervenes and provides feedback on the delegation process as needed.
- Tasks a AP can do: feeding, bathing ,toileting, ambulating, dressing and grooming, vitals on request, blood sugars
- Bleeding precautions a. Use an electric shaver b. Use a soft-bristled toothbrush c. Do not have dental work performed without consulting your health care provider d. Do not take aspirin or any aspirin-containing products. Read the label to be sure that the product does not contain aspirin or salicylates. e. Do not participate in contact sports or any activity likely to result in your being bumped, scratched, or scraped. f. Use sensitive tape. g. Limit needlesticks as much as possible. h. Use pressure when cuts or bleeding occurs and wash out and protect with bandage
- Cultural competency: a. Respecting patient’s beliefs i. Consider each client as a unique individual, influenced but not defined by his culture.
patient has been eating, drinking, smoking or exercising, as these activities can alter the temperature.
- Avoid this route for patients who have mouth sores or facial injuries or cannot keep the mouth closed around the thermometer probe. ii. Steps:
- Provide privacy and explain the procedure to the patient.
- Place the covered temperature probe under the patient’s tongue in the posterior lingual pocket.
- Instruct the patient to close the lip gently around the probe and to keep the mouth closed until the temperature has been measured. Remind the patient not to bite down on the probe.
- When the audible signal indicates that the temperature has been measured, remove the probe and read the display.
- Discard the disposable cover and document the results. iii. The rectum is the least preferred site for measuring temperature because of the discomfort for the patient and the invasive nature of the procedure. iv. To measure rectal temperature:
- Wear gloves, cover the red-tipped probe with a disposable plastic sheath, and lubricate the probe cover before inserting it into the patient’s rectum.
- For an adult, insert the probe 1 to 1 ½ inches into the rectum and in the direction of the umbilicus.
- If you feel any resistance, remove immediately. v. The axilla is appropriate for temperature measurement of most adults and children, including infants. However, this site is not as accurate as the others and does not reflect core body temperature. vi. Steps:
- Provide privacy and explain the procedure to the patient.
- Assist the patient to a sitting position and move the bed linens, gown, or other clothing to expose the patient’s axilla. Dry the axilla, if needed.
- Place the covered temperature probe under the patient’s arm in the center of the axilla.
- Leave the thermometer probe in place until the audible signal indicates that the temperature has been measured.
- Discard the disposable cover and document the results. vii. A tympanic thermometer:
- Cover the tip at the external opening of the disposable plastic sheath. Place the covered tip at the external opening of the ear canal, and wait 2 to 5 seconds after you press the scan button for the temperature display.
- To obtain an accurate temperature, it is important to place the probe at the proper angle for sealing the ear canal.
viii. Steps:
- Provide privacy and explain the procedure to the patient.
- Gently push the disposable plastic cover over the tip of the electronic thermometer until the cover locks into place.
- Gently pull the pinna, also called the auricle, back, up, and out, and insert the tip of the covered thermometer probe into the patient’s ear canal.
- Leave the thermometer in place in place until the audible signal indicates that the temperature has been measured.
- Discard the disposable cover and document the results. ix. A temporal thermometer is a hand-held device with a round, rubber-like probe on the end that measures skin temperature over the temporal artery.
- While pressing the scan button, hold the probe flat against the forehead while moving it gently across the forehead over the temporal artery, and then touch the skin behind the earlobe.
- Release the scan button to display the temperature reading.
- Use disposable probe covers or clean the probe with a disinfectant wipe between patients. x. Steps:
- Provide privacy and explain the procedure to the patient.
- Remove the protective cap and wipe the lens of the scanning device with an alcohol swab to make sure it is clean.
- Position the probe flat on the center of the patient’s forehead at midpoint between the hairline and the eyebrow.
- Press the scan button and slowly slide the thermometer across the forehead and just behind the ear.
- Release the scan button and read the display.
b. Heart Rate i. Assessment on how adequate the heart pumps blood to the body ii. Rate: fast or slow iii. Rhythm can be regular or irregular iv. Quality: can be faint, normal, strong, bounding v. Places Assessed
- Carotid 1 at a time
- Radial
- Brachial
- Femoral
- Popliteal
- Posterior Tibialis
- Dorsalis Pedis
- Monitor or telebox if applicable
- Apical Pulse: most accurate, found at the 5th intercostal space L.
f. Interpreting/ Abnormals: Priority i. Blood pressure:
- Hypertension: 140/ a. Giv BP medications and reassess in 1-2 hrs b. Encourage dieting, exercise
- Hypotension: 90/ a. Hold BP medications b. Potentially give fluid bolus c. Assess for dizziness when rising ii. Pulse
- Tachycardia: HR above 100 a. Assess for pain b. See if they are anxious or confused
- Bradycardia HR below 60 a. Ask if it is there normal iii. Respirations
- Tachypnea: above 20 breathes a. Are they anxious, do they have a clear airway? Infection, copd b. Apply o2 as needed or relaxation techniques
- Bradypnea below 12 breaths a. Look to see if they are on narcotics or opioids b. Listen to breath sounds c. Common when sleeping with sleep apnea iv. Temperature
- Fever: above 100.
- Sepsis: less than 96. v. O2 sat: less than 95 is concern
- Apply o
- COPD: 88-92 is okay
- Therapeutic communication-is client-centered communication directed at achieving client goals. It is used to establish the therapeutic relationship, provide and obtain healthcare information, and express interest, concern, and caring for the client and family. a. Displaying empathy i. Desire to understand and be sensitive to feelings, beliefs and situation.
- Place yourself in the patient situation. b. Differentiate techniques for enhancing therapeutic communication i. Active listening ii. Using silence iii. Establish trust iv. Being assertive v. Validation
vi. Exploring issues vii. Reflecting viii. Communicating with confused patients
- Always be slowly, speak clearly, loudly, simple terms. Repeat if needed ix. Open-ended questions- specify a topic to be explored, but phrase it broadly to encourage the patient to elaborate.
- Tell me more things
- Not yes or no x. Personal space c. Barriers to communication a. Asking too many questions b. Offering advice c. Changing the subject d. Expressing approval or disapproval e. Providing false reassurance f. Stereotyping g. Using patronizing language d. Communicating with physicians i. SBAR
- Situation: what is going on with the patient, why they came in
- Background: past medical history, past surgical history, past events, past medication
- Assessment: vitals, physical, functional
- Recommendation: what you think the best plan of action is for the patient
- Be respectful of everyone's opinions
- 3 dosage(1 i&o) a. Use dimensional analysis to solve b. Always know what you are solving for i. Like mL/hr or tablets,etc c. Know your conversions! i. mL to L ii. Kg to g to mg iii. Kg to lbs iv. Oz to mL v. Days to hrs to min vi. 1 cup=8oz=240ml vii. Cc is the same as mL d. For I/Os add for intake, subtract for output, and always convert to mL
- Healthcare Environmental Factors/ Sentinel Events a. Never Events: serious injuries or death to a patient that should never happen in a
