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Comprehensive Predictor Study Guide (Download to Score 100%)

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Comprehensive Predictor Study Guide 1. Professional Responsibilities: Durable Power of Attorney for Health Care 2. Professional Responsibilities: Educating Staff About Client Advocacy NURSING ROLE ... IN ADVANCE DIRECTIVES 3. Professional responsibilities: Client Advocacy 4. Cultural and Spiritual Nursing Care: Working With an Interpreter 5. Overview of Community Health Nursing: Adhering to Ethical Principals 6. Cultural and spiritual nursing care: Appropriate use of an Interpreter 7. Managing Client Care: Assigning a Task to an Assistive Personnel TO AP 8. Managing Client Care: Decision Making About Delegation 9. Managing Client Care: Delegating Tasks to a Licensed Practical Nurse 10. Managing Client Care: Delegating Tasks to Assistive Personnel: Considerations for selection: 11. Managing Client Care: Effective Time Management Time savers A. Documenting nursing interventions as soon as possible after completion to facilitate accurate and thorough documentation B. Grouping activities that are to be performed on the same client or are in close physical proximity to prevent unnecessary walking C. Estimating how long each activity will take and planning accordingly D. Mentally envisioning the procedure to be performed and gathering all equipment prior to entering the client’s room E. Taking time to plan care and taking priorities into consideration F. Delegating activities to other staff when client care workload is beyond what can be handled by one nurse G. Enlisting the aid of other staff when a team approach is more efficient than an individual approach H. Completing more difficult or strenuous tasks when energy level is high I. Avoiding interruptions and graciously but assertively saying “no” to unreasonable or poorly timed requests for help J. Setting a realistic standard for completion of care and level of performance within the constraints of assignment and resources K. Completing one task before beginning another task L. Breaking large tasks into smaller tasks to make them more manageable M. Using an organizational sheet to plan care N. Using breaks to socialize with staff Time wasters A. Documenting at the end of the shift all client care provided and assessments done B. Making repeated trips to the supply room for equipment C. Providing care as opportunity arises regardless of other responsibilities D. Missing equipment when preparing to perform a procedure E. Failing to plan or managing by crisis F. Being reluctant to delegate or under delegating G. Not asking for help when needed or trying to provide all client care independently H. Procrastinating: delaying time-consuming, less desirable tasks until late in the shift I. Agreeing to help other team members with lower priority tasks when time is already compromised J. Setting unrealistic standards for completion of care and level of performance within constraints of assignment and resources K. Starting several tasks at once and not completing tasks before starting others L. Not addressing low level of skill competency, increasing time on task M. Providing care without a written plan N. Socializing with staff during client care time 12. Managing Client Care: Organizing Workload to Manage Time Effectively TIME MANAGEMENT A. Organize care according to client care needs and priorities. B. What must be done immediately (administration of analgesic or antiemetic, assessment of unstable client)? C. What must be done by a specific time to ensure client safety, quality care, and compliance with facility policies and procedures (routine medication administration, vital signs, blood glucose monitoring)? D. What must be done by the end of the shift (ambulation of the client, discharge and/or discharge teaching, dressing change)? o What can the nurse delegate? o What tasks can only the RN perform? E. What client care responsibilities can the nurse delegate to other health care team members, such as practical nurses (PNs) and assistive personnel (APs)? F. Use time-saving strategies and avoid time wasters. (1.2) G. Good time management o Facilitates greater productivity. o Decreases work-related stress. o Helps ensure the provision of quality and appropriately prioritized client care. o Enhances satisfaction with care provided. H. Poor time management I. Impairs productivity. J. Leads to feelings of being overwhelmed and stressed. K. Increases omission of important tasks. L. Creates dissatisfaction with care provided. Time management is a cyclic process. A. Time initially spent developing a plan will save time later and help to avoid management by crisis. B. Set goals and plan care based on established priorities and thoughtful utilization of resources. C. Complete one client care task before beginning the next, starting with the highest priority task. D. Reprioritize remaining tasks based on continual reassessment of client care needs. E. At the end of the day, perform a time analysis and determine if time was used wisely. TIME MANAGEMENT AND SELF-CARE A. Take time for yourself. B. Schedule time for breaks and meals. C. Take physical and mental breaks from work and the unit. 13. Managing Client Care: Responding to an Incomplete Delegated Task SUPERVISION A. Occurs after delegation. A supervisor oversees a staff member’s performance of delegated activities and determines if: B. Completion of tasks is on schedule. C. Performance was at a satisfactory level. D. Unexpected findings were documented and reported. E. Assistance is needed to complete assigned tasks in a timely manner. Assignment should be reevaluated and possibly changed 14. Managing Client Care: Utilizing the Five Rights of Delegation Right task A. Identify what tasks are appropriate to delegate for each specific client. B. Delegate to appropriate team members (AP, LPN) o RIGHT TASK: Delegate an AP to assist a client who has pneumonia to use a bedpan. o WRONG TASK: Delegate an AP to administer a nebulizer treatment to a client who has pneumonia Right circumstance A. RIGHT CIRCUMSTANCE: Delegate an AP to measure the vital signs of a client who is postoperative and stable. B. WRONG CIRCUMSTANCE: Delegate an AP to measure the vital signs of a client who is postoperative and received naloxone to reverse respiratory depression. Right person A. The task must be within the team member’s scope of practice. B. The team member must have the necessary competence/training. C. Continually review the performance of the team member o RIGHT PERSON: Delegate an PN to administer enteral feedings to a client who has a head injury. o WRONG PERSON: Delegate an AP to administer enteral feedings to a client who has a head injury. Right direction/communication A. Communicate either in writing or orally. B. Data that needs to be collected C. Method and timeline for reporting, including when to report concerns/findings D. Specific task(s) to be performed; client-specific instructions E. Expected results, timelines, and expectations for follow-up communication o RIGHT DIRECTION AND COMMUNICATION: Delegate an AP to assist Mr. Martin in room 312 with a shower before 0900. o WRONG DIRECTION AND COMMUNICATION: Delegate an AP to assist Mr. Martin in room 312 with morning hygiene. Right supervision/evaluation A. The delegating nurse must: o Provide supervision, either directly or indirectly (assigning supervision to another licensed nurse). o Provide clear directions and expectations of the task to be performed (time frames, what to report). o Monitor performance. o Provide feedback. o Intervene if necessary (unsafe clinical practice). o Evaluate the client and determine if client outcomes were met. o Evaluate client care tasks and identify needs for quality improvement activities and/or additional resources. § RIGHT SUPERVISION: Delegate the ambulation of a client to an AP. Observe the AP to ensure safe ambulation of the client, and provide positive feedback to the AP after completion of the task. § WRONG SUPERVISION: Delegate the ambulation of a client to an AP without supervision to determine the need for intervention and failing to provide feedback to the AP. 15. Managing Client Care: Providing Cost-Effective Care Cost-effective A. Strategies that achieve optimal results in relation to the money spent to achieve those results. In other words, cost-effective means “getting your money’s worth.” o Example: Spending increased money on staf f training for transmission-based precautions resulting in the increased and effective use of PPE for client care. These actions have the result of a decrease in infection transmission and an overall savings in the cost of caring for clients who would have acquired these infections. COST-EFFECTIVE CARE STRATEGIES A. Providing clients with needed education to decrease or eliminate future medical costs associated with future complications. o Example: Teaching a client who has a new diagnosis of diabetes mellitus how to adjust the dosage of insulin depending on activity level reducing the risk of hypoglycemia resulting in the need for medical care. B. Promoting the use of evidence-based care resulting in improved client care outcomes. o Example: Implementing the use of evidence-based techniques to care for clients who have indwelling catheters resulting in a decreased incidence of catheter-acquired urinary tract infections. C. Promoting cost-effective resource management. o Example: Using all levels of personnel to their fullest when making assignments. Delegating effectively to members of the nursing care team. o Example: Providing necessary equipment and properly charging clients. o Example: Returning uncontaminated, unused equipment to the appropriate department for credit. o Example: Using equipment properly to prevent wastage. o Example: Providing training to staff unfamiliar with equipment. o Example: Returning equipment (IV pumps) to the proper department (central service, central distribution) as soon as it is no longer needed. This action will prevent further cost to clients. D. Patient should not be compromised quality of care **** 16. Managing Client Care: Delegating to an Assistive Personnel 17. Managing Client Care: Delegating Tasks to an Assistive Personnel 18. Managing Client Care: Delegating a Task to a Float Nurse A. Make sure nurse has the knowledge/skill to complete task B. Negotiate new assignment w/ charge nurse 19. Managing Client Care: Steps of the Delegation Process 20. Managing Client Care: Tasks to delegate to an Assistive Personnel 21. Managing Client Care: Delegating care to an Assistive Personnel 22. Cultural and Spiritual Nursing Care: Working with an Interpreter 23. Infection Control: Caring for a Client Who Has Clostridium Difficile A. Contract precautions B. Wash hands with soap and warm water, don’t use gel C. Clean equipment with bleach D. Water soluble, yellow bag for disposing 24. Care of Specific Populations: Priority Action for Family in Grieving A. Assess risk for suicide B. Stay with family C. Allow to express feeling/ allow time to grief D. Provide extra hard (resources – therapy) E. Assess coping mechanism/social support F. GRIEF COUNSELING 25. Managing Client Care: Strategies for Conflict Resolution CONFLICT RESOLUTION STRATEGIES PROBLEM-SOLVING Actions nurses can take to promote open communication and de-escalate conflicts A. Use “I” statements, and remember to focus on the problem, not on personal differences. B. Move a conflict that is escalating to a private location or postpone the discussion until a later time to give everyone a chance to regain control of their emotions. NEGOTIATION · Each party agrees to give up something Example · One nurse offers to care for Client A today if the other will care for Client B tomorrow. Strategy: Avoiding/Withdrawing · Both parties know there is a conflict, but they refuse to face it or work toward a resolution. · Can be appropriate for minor conflicts or when one party holds more power than the other party or if the issue can work itself out over time. Strategy: Smoothing · One party attempts to “smooth” another party by trying to satisfy the other party. · Often used to preserve or maintain a peaceful work environment. Strategy: Competing/Coercing = throwing people under the bus · One party pursues a desired solution at the expense of others. · Managers can use this when a quick or unpopular decision must be made. · The party who loses something can experience anger, aggravation, and a desire for retribution. Strategy: Cooperating/ Accommodating · One party sacrifices something, allowing the other party to get what it wants. This is the opposite of competing. · The original problem might not actually be resolved. · Can contribute to future conflict. Strategy: Compromising/Negotiating · Each party gives up something. · To consider this a win/lose-win/lose solution, both parties must give up something equally important. If one party gives up more than the other, it can become a win-lose solution. Strategy: Collaborating · Both parties set aside their original individual goals work together to achieve a new common goal. · Requires mutual respect, positive communication, and shared decision-making between parties. 26. Coordinating Client Care: Information to Include in Change-of-shift Report A. Code status B. Allergies C. Current medications o When the next ones are due o Are they on pain medication? D. Pertinent labs E. Current condition/status of patient F. IV fluids/rate G. Any change in care needed H. Any wounds/dressings I. Previous assessment J. Abnormal findings K. If they are going to surgery or a procedure L. If they need blood sugar checked M. Diet (NPO?) N. Activity level O. Plan of care P. BLOOD LOSS* 27. Gastrointestinal Therapeutic Procedures: Priority Findings Following a Colostomy A. If the stoma appears black or purple in color, this indicates a serious impairment of blood flow and requires immediate interventionà EMERGENCY NURSING ACTIONS · Assess the type and fit of the ostomy appliance. Monitor for leakage (risk to skin integrity). · Assess peristomal skin integrity and appearance of the stoma. The stoma should appear pink and moist. · Evaluate stoma output. Output should be more liquid and more acidic the closer the ostomy is to the proximal small intestine. · Empty the ostomy bag when it is ¼ to ½ f full of drainage. · Assess for fluid and electrolyte imbalances, particularly with a new ileostomy. · Evaluate ability of the client or support person to perform ostomy care. Stomal ischemia/necrosis · Stomal appearance should normally be pink or red and moist. · Signs of stomal ischemia are pale pink or bluish purple color and dry appearance. 28. Medications for depressive disorders: Priority Action for a client who has major depressive disorder A. Assess patient risk of harm to self and others B. Evaluate client’s use of drugs and alcohol C. Assess client history of depression and support system 29. Legal and Ethical Issues: Prioritizing the Delivery of Client Care A. Prioritize systemic before local (“life before limb”). o A client in shock over interventions for a client who has a localized limb injury B. Prioritize actual problems before potential future problems. o Administration of medication to a client experiencing acute pain over ambulation of a client at risk for thrombophlebitis C. Recognize and respond to trends vs. transient findings. o Recognizing a gradual deterioration in a client’s level of consciousness and/or Glasgow Coma Scale score D. Recognize indications of medical emergencies and complications vs. expected findings. o Recognizing indications of increasing intracranial pressure in a client who has a new diagnosis of a stroke vs. the findings expected following a stroke E. Apply clinical knowledge to procedural standards to determine the priority action. o Recognizing that the timing of administration of antidiabetic and antimicrobial medications is more important than administration of some other medications F. Maslow's Hierarchy of needs G. Airway, Breathing Circulation D: disability (neurological deficits, stroke in evolution) E: Exposure (Remove clothing for assessment or resuscitation) 30. Managing Client Care: Coordinating Care Following Report A. Set priorities know whom you can delegate to. B. Use priority setting framework to set priorities in management of client care after report (ABCDE, Maslow’s) 31. Managing Client Care: Prioritizing care 32. Managing Client Care: Prioritizing client care 33. Legal Responsibilities: Nursing Role in Informed Consent A. The nurse’s role in the informed consent process is to witness the client’s signature on the informed consent form and to ensure that the provider has obtained the informed consent responsibly. B. EX. Patient understands PICC line** 34. Information Technology: Appropriate Documentation A. Factual: Subjective and objective data B. Nurses should document subjective data as direct quotes, as the client’s statement. C. Subjective data should be supported by objective data so charting is as descriptive as possible. D. Objective data should be descriptive and should include what the nurse sees, hears, feels, and smells. Document the client’s behavior accurately. Instead of writing “client is agitated,” write “client pacing back and forth in his room, yelling loudly.” E. Accurate and concise: Document facts and information precisely (what the nurse sees, hears, feels, smells) without any interpretations of the situation. F. Complete and current: Document information that is comprehensive and timely. Never pre-chart an assessment, intervention, or evaluation. G. Organized: Communicate information in a logical sequence 35. Diabetes Mellitus Management: Providing Appropriate Information Resources A. The American Diabetes Association can provide national and regional support and resources to clients with diabetes and their families. B. My plate C. Provide appropriate resources per clients need 36. Professional Responsibilities: Teaching About Legal Issues in Health Care A. Good Samaritan laws, which vary from state to state, protect nurses who provide emergency assistance outside of the employment location. The nurse must provide a standard of care that is reasonable and prudent. B. State laws vary as to when an individual may begin practicing nursing. Some states allow graduates of nursing programs to practice under a limited license, whereas some states require licensure by passing the NCLEX® before working. 37. Professional Responsibilities: Recognizing and Intervening for a Tort Unintentional torts A. Negligence: A nurse fails to implement safety measures for a client who has been identified as at risk for falls B. Malpractice: Professional negligence (a nurse administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies). Quasi-intentional torts A. Invasion of privacy: Intrusion into a client’s private affairs or a breach of confidentiality (a nurse releases the medical diagnosis of a client to a member of the press). B. Defamation: False communication or communication with careless disregard for the truth with the intent to injure an individual’s reputation. C. Libel: Defamation with the written word or photographs (a nurse documents in a client’s health record that a provider is incompetent). D. Slander: Defamation with the spoken word (a nurse tells a coworker that she believes a client has been unfaithful to the spouse). Intentional torts A. Assault: The conduct of one person makes another person fearful and apprehensive (threatening to place a nasogastric tube in a client who is refusing to eat). B. Battery: Intentional and wrongful physical contact with a person that involves an injury or offensive contact (restraining a client and administering an injection against his wishes) C. False imprisonment: A person is confined or restrained against his will (using restraints on a competent client to prevent his leaving the health care facility). Managing Client Care: Priority Quality Improvement Action Referrals QUALITY IMPROVEMENT PROCESS: A. Information gathering is called: Root cause analysis o Focuses on variables that surround the consequence of an action or occurrence. o Is commonly done for sentinel events (client death, client care resulting in serious physical injury) but can also be done as part of the quality improvement process. o Investigates the consequence and possible causes. o Analyzes the possible causes and relationships that can exist. o Determines additional influences at each level of relationship. o Determines the root cause or causes B. The quality improvement process begins with identification of standards and outcome indicators based on evidence C. Outcome (clinical) indicators reflect desired client outcomes related to the standard under review. D. Structure indicators reflect the setting in which care is provided and the available human and material resources. E. Process indicators reflect how client care is provided and are established by policies and procedures (clinical practice guidelines). F. Benchmarks are goals that are set to determine at what level the outcome indicators should be met. 38. Continuity of Care: Identifying Community Resources for Client A. Assess need B. Referrals for individuals in acute care settings typically are based on the medical diagnosis or other relevant clinical information. Resources assist in restoring, maintaining, or promoting health. C. Health care services: acute care settings, health dpt, rehab services, home care services, PT, OTC D. Specialty service agencies: Support services, psychological services, churches, meal delivery services E. HOSPICE 39. Pressure Ulcers, Wounds, and Wound Management: Revising the Plan of Care A. Reassessing plan of care o Turning pt more often o Needs for different intervention B. DIETIAN REFERRAL 40. Professional Responsibilities: Reporting client abuse A. Discuss escape plan B. Mandatory Reporting 41. Coordinating Client Care: Appropriate action when a client leaves against medical advice A. Notify provider B. Explain risks C. Sign AMA form 42. Professional Responsibilities: Advocating for a safe use of alternative therapies A. Ask provider if therapy is okay 43. Legal Responsibilities: Clients Right to Privacy 44. Care of special populations: Addressing Rural Health Issues A. No tertiary care B. Less likely to seek care 45. Managing client care: Effective negotiation strategies A. Each party gives up something. B. To consider this a win/lose-win/lose solution, both parties must give up something equally important. If one party gives up more than the other, it can become a win-lose solution. 46. Professional Responsibilities: Addressing a Breach of client confidentiality A. Invasion of privacy 47. Coordinating Client care: Giving Change-Of Shif t Report on a client A. Communication hand-off tools: · I-SBAR, PACE, I PASS the BATON, Five P’s · Informs the next shift of pertinent client care information. · Describes the current health status of the client. B. Report to the Dr: · Assessment data integral to changes in client status · Recommendations for changes in the plan of care · Clarification of prescriptions 48. Safe Medication Administration and Error Reduction: Transcribing Verbal Prescriptions · Have a second nurse listen to a telephone prescription. · Repeat it back, making sure to include the medication’s name (spell if necessary), dosage, time, and route. · Question any prescription that seems inappropriate for the client. · Make sure the provider signs the prescription in person within the time frame the facility specifies, typically 24 hr. 49. Preoperative Nursing Care: Evaluating laboratory Values A. LIVER BIOPSY PTT TIME: 20-35; 60-70 50. Assessment and Management Newborn Complications: Identifying reportable findings A. RR:40-60 B. Hr:12-160 C. Temp. 36-37.5 D. Hypoglycemia E. Cold stress * F. Hyperbilirubinemia 51. Practice Settings and Aggregates: Priority action before a home visit A. CLARIFY THE SOURCE 52. Managing client care: Prioritizing Client Care 53. Medical Conditions: Prioritizing Care for Antepartum Clients A. Fundus B. Hemorrhage 54. Medical Conditions: Prioritizing Care of Multiple Clients A. Who are you going to see first 55. Managing Client Care: Prioritizing Care of clients 56.Professional Responsibilities: Informed Consent A. Witnesses informed consent. B. This means the nurse must o Ensure that the provider gave the client the necessary information. o Ensure that the client understood the information and is competent to give informed consent. o Have the client sign the informed consent document. o Notify the provider if the client has more questions or appears not to understand any of the information. § The provider is then responsible for giving clarification. o Document questions the client has, notification of the provider, reinforcement of teaching, and use of an interpreter Legal Responsibilities: Nursing Role in Informed Consent A. The nurse’s role in the informed consent process is to witness the client’s signature on the informed consent form and to ensure that the provider has obtained the informed consent responsibly. 57. Coordinating Client Care: Referral for Client Who has dysphagia A. SPEECH LANGUAGE pathologist 58. Nutrition and Oral hydration: Priority finding following an ischemic stroke A. Prevent aspiration B. Fowlers position C. TUCK CHIN SWALLOWING D. No straw E. Pureed/clear liquids 59. Nursing Care and Discharge Teaching: Car Seat Safety A. Keep infants in rear-facing car seats until age 2 or until the child reaches the maximum height and weight for the seat. B. The shoulder harnesses are placed in the slots at or below the level of the infant’s shoulders. The harness should be snug and the retainer clip placed at the level of the infant’s armpits. 60. Acute Neurological Disorders: Planning Care for a Child A. Meningitisà Isolate Droplet o Presence of petechiae or purpuric rash needs immediate medical attention o Monitor vitals, I&O, fluid status, pain level and neuro status o Monitor head circumference in newborns and assess fontanels o Correct fluid deficits then restrict fluids until no evidence of increased ICP and increased sodium o DROPLET PRECAUTION and PRIVATE ROOM o Administer antibiotics for bacterial infection ASAP o Corticosteroids o Analgesics for pain control § Acetaminophen with codeine § NO aspirin · REPORT TO PUBLIC HEALTH DEPARTMENT · Cooling blanket · Decrease stimuli · Seizure precautions B. Reye Syndrome o Maintain hydration while preventing cerebral edema § Monitor I&O o Monitor coagulation and prevent hemorrhage o Monitor pain o Assist with intubation and maintain ventilator if required o Implement seizure precautions 61. Adverse Effects, Interactions, and Contraindications: Priority Action to an Allergic Response A. EPI FIRST B. Diphenhydramine treats mild rashes and hives. C. Treat anaphylaxis with epinephrine, bronchodilators, and antihistamines. D. Provide respiratory support and notify the provider. 62. Medications Affecting Blood Pressure: Priority Adverse Effect of Losartan A. Respiratory distress B. Angioedema: *** o Skin wheals o Swelling of tongue and pharynx C. Fetal injury D. Hypotension E. Dizziness, lightheadedness 63. Safe Medication Administration and Error Reduction: Acceptable Client Identification A. Client’s name, an assigned identification number, telephone number, birth date, or another person-specific identifier, such as a photo identification card. 64. Facility Protocols: Responsibility of the Unit Nurse During a Disaster Identify people that can be discharged, basically helping with triage Tetanus shots, AID 65. Mobility and Immobility: Evaluating Client Understanding of Crutch Safety COAL: CANE Opposite Affected Leg WWAL: WALKER WITH AFFECTED LEG Crutch Instructions: A. Support body weight at the hand grips with elbows flexed at 30°. B. Position the crutches on the unaffected side when sitting or rising from a chair. CRUTCHES: Non-weight bearing · Begin in the tripod position, maintain weight on the “unaffected” (weight-bearing) extremity · Advance both crutches and the affected extremity · Move the unaffected weight-bearing foot/leg forward (beyond the crutches) · Advance both crutches, and then the unaffected extremity CRUTCHES: Weight bearing · Move crutches forward about one step’s length · Move “affected” leg forward; level with the crutches tips · Move the “unaffected” leg forward · Continue sequence making steps of equal length Walking up stairs · Hold onto tail with one hand and crutches with the other hand · Push down on the stair rail and the crutches and step up with the other hand · If not allowed to place weight on the affected leg, hop up with the unaffected leg. · Bring the affected leg and the crutches beside the unaffected leg · Remember, the GOOD leg goes up first and the crutches move with the affected leg Walking down stairs · Place the affected leg and the crutches down on the step below; support weight by leaning on the crutches and the stair rail · Bring the unaffected leg down · Remember, the BAD leg goes down first and the crutches move with the affected leg 66. Ergonomic Principles: Evaluating Lifting Techniques A. When the human body is in the upright position, the center of gravity is the pelvis. B. When an individual move, the center of gravity shifts. C. The closer the line of gravity is to the center of the base of support, the more stable the individual is. D. To lower the center of gravity, bend the hips and knee STRAIGHT BACK E. Spread your feet apart to lower your center of gravity and broaden your base of support. This results in greater stability and balance. F. KEEP OBJECTS CLOSE TO THE BODY 67. Ergonomic Principles: Lifting Objects Safely A. Tighten the abdominal muscles to increase support to the back muscles B. When lifting an object from the floor, flex your hips, knees, and back. C. Bring the object to thigh level, bending your knees and keeping your back straight. D. Stand up while holding the object as close as possible to your body, bringing the load to the center of gravity to increase stability and decrease back strain 68. Cancer Treatment Options: Caring for a Client Who Has a Radiation Implant · Brachytherapy describes internal radiation that is placed close to the target tissue. This is done via placement in a body orifice (vagina) or body cavity (abdomen) or delivered via IV such as with radionuclide iodine, which is absorbed by the thyroid. · Waste products are radioactive until the isotope has been eliminated from the body. Waste products should not be touched by anyone. NURSING CONSIDERATIONS A. Place the client in a private room away from other clients when possible. Keep door closed as much as possible. B. Place a sign on the door warning of the radiation source. C. Wear a dosimeter film badge that records personal amount of radiation exposure. D. Limit visitors to 30-min visits, and have visitors maintain a distance of 6 feet from the source. E. Visitors and health-care personnel who are pregnant or under the age of 18 should not come into contact with the client or radiation source. F. Wear a lead apron while providing care keeping the front of the apron facing the source of radiation. G. Keep a lead container in the client’s room if the delivery method could allow spontaneous loss of radioactive material. Tongs are available for placing radioactive material into this container. H. Follow protocol for proper removal of dressings and bed linens from the room. I. CLIENT EDUCATION J. Inform the client of the need to remain in an indicated position to prevent dislodgement of the radiation implant. K. Instruct the client to call the nurse for assistance with elimination. L. Instruct the client and family about radiation precautions needed in health care and home environments. 69. Home Safety: Needle Disposal in Home Settings Dispose of needles: puncture‐resistant receptacles. A. Milk Container B. NON-CRUSH PROOF PLASTIC CONTAINER C. Laundry Detergent Container D. COFFEE CONTAINER ON TOPSHELF 70. Safe Medication Administration and Error Reduction: When to Complete an Incident Report · Complete an incident report within the specified time frame, usually 24 hr. · Include the client’s identification, the time and place of the incident, an accurate account of the event, who you notified, what actions you took, and your signature. · Do not reference or include this report in the client’s medical record. 71. Facility Protocols: Client Evacuation in Response to a Fire R: rescue (priority) A: Alarm C: Confine E: Extinguish 72. Communicable Diseases, Disasters, and Bioterrorism: Chlamydia · Direct contact · Most common STI in women · If left untreated can lead to PID · All pregnant women should be screened at the first prenatal visit and rescreened in the third trimester if younger than 25 years and/or at high risk. · Must report to the CDC 73. Communicable diseases: Understanding Transmission of Varicella Airborne · infectious agents smaller than 5 mcg (measles, varicella, TB) · Negative airflow room · Keep door closed N95 · Incubation: 2 to 3 weeks · Duration of precautions: until lesions crust over 74. HIV/AIDS: Infection Control in the Client's Home A. Instruct the client to avoid cleaning pet litter boxes to reduce the risk of toxoplasmosis. B. Encourage the client to keep the home environment clean and to avoid being exposed to family and friends who have colds or flu viruses. C. Instruct the client to wash dishes in hot water using a dishwasher if available. D. Encourage the client to bathe daily using antimicrobial soap. E. Environmental clean with 1/100 10% bleach 75. Medical and Surgical Asepsis: Maintaining Aseptic Technique · Wash for at least 15 seconds to remove transient flora and up to 2 min when hands are more soiled. After washing, dry hands with a clean paper towel before turning off the faucet · alcohol-based product: (usually 3 to 5 mL) in the palm of the hand PROTECTIVE CLOTHING: · To put on: · To take off: 76. Legal and Ethical Issues: Appropriate Nursing Action When Caring for a Client in Seclusion · The provider must prescribe the seclusion or restraint in writing. Limits for seclusion: · Age 18 years and older: 4 hr · Age 9 to 17 years: 2 hr · Age 8 years and younger: 1 hr · If the need for seclusion or restraint continues the provider must reassess the client and rewrite the prescription, specifying the type of restraint every 24 hr or the frequency of time specified by facility policy · The nurse can use seclusion or restraints without first obtaining The facility protocol should identify the nursing responsibilities, including how often the client should be: · Assessed (including for safety and physical needs), and the client’s behavior documented · Offered food and fluid · Toileted · Monitored for vital signs · Monitored for pain Complete documentation every 15 to 30 minutes (or according to facility policy) includes a description of the following. · Precipitating events and behavior of the client prior to seclusion or restraint · Alternative actions taken to avoid seclusion or restraint · The time treatment began · a provider’s written prescription if it is an emergency situation. If this emergency treatment is initiated, the nurse must obtain the written prescription within a specified period (usually 15 to 30 min) 77. Mobility and Immobility: Pressure Ulcers A. Turn patients every 2 hrs., 78. Mobility and Immobility: Preventing Contractures A. Maintain body alignment B. Active ROM 79. Medical and Surgical Asepsis: Protecting Clients who have Latex Sensitivities A. Avoid bananas, apricots, cherries, grapes, kiwis, passionfruit, avocados, chestnut, peaches, tomatoes 80. Seizures: Nursing Interventions for an Adolescent who has Hyperthermia A. administer oxygen B. Administer cooling measuresà 0.9 chloride, cooling blanket, and place ice bags 81. Health Promotion of Infants (2days to 1 year): Car Seat Safety A. Keep infants in rear-facing car seats until age 2 or until the child reaches the maximum height and weight for the seat. B. The shoulder harnesses are placed in the slots at or below the level of the infant’s shoulders. The harness should be snug and the retainer clip placed at the level of the infant’s armpits 82. Heart Failure and Pulmonary Edema: Appropriate prescriptions A. Diuretics B. Ace inhibitors 83. Preoperative Nursing Care: Evaluating Client Understanding of Latex A. Complete latex allergy form B. If unable to obtain IV tubing without latex ports, cover latex ports with tape. C. Latex allergy: bananas, apricots, cherries, grapes, kiwis, passionfruit, avocados, chestnut, peaches, tomatoes 84. Mobility and Immobility : Contraindications for using heat therapy A. PACEMAKER 85. Communicable disease, disasters, and bioterrorism: Emergency Department Triage A. Emergent category (class I) - Highest priority is given to clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized. B. Urgent category (class II) - Second-highest priority is given to clients who have major injuries that are not yet life-threatening and usually can wait 45 to 60 min for treatment. C. Nonurgent category (class III) - The next highest priority is given to clients who have minor injuries that are not life-threatening and do not need immediate attention. D. Expectant category (class IV) - The lowest priority is given to clients who are not expected to live and will be allowed to die naturally. Comfort measures may be provided, but restorative care will not. 86. Communicable Diseases , Disasters, and Bioterrorism: Disaster Preparedness A. Report to local health department 87. Client Safety: Sequence of Steps in responding to fire R: Rescue (priority) A: Alarm C: Confine E: Extinguish 88. Cancer Treatment Options: Caring for a client who has a sealed radiation implant A. Brachytherapy describes internal radiation that is placed close to the target tissue. This is done via placement in a body orifice (vagina) or body cavity (abdomen) or delivered via IV such as with radionuclide iodine, which is absorbed by the thyroid. B. Waste products are radioactive until the isotope has been completely eliminated from the body. Waste products should not be touched by anyone. NURSING CONSIDERATIONS A. Place the client in a private room away from other clients when possible. Keep door closed as much as possible. B. Place a sign on the door warning of the radiation source. C. Wear a dosimeter film badge that records personal amount of radiation exposure. D. Limit visitors to 30-min visits, and have visitors maintain a distance of 6 feet from the source. E. Visitors and health-care personnel who are pregnant or under the age of 18 should not come into contact with the client or radiation source. F. Wear a lead apron while providing care keeping the front of the apron facing the source of radiation. G. Keep a lead container in the client’s room if the delivery method could allow spontaneous loss of radioactive material. Tongs are available for placing radioactive material into this container. H. Follow protocol for proper removal of dressings and bed linens from the room. CLIENT EDUCATION A. Inform the client of the need to remain in an indicated position to prevent dislodgement of the radiation implant. B. Instruct the client to call the nurse for assistance with elimination. C. Instruct the client and family about radiation precautions needed in health care and home environments. 89. Practice settings and Aggregates: Planning an Initial Home visit A. CLARIFY THE SOURCE 90. Report of Incident/Event/Irregular Occurrence/ Variance : Safe Medication Administration and Error Reduction: When to Complete an Incident Report A. Complete an incident report within the specified time frame, usually 24 hr. B. Include the client’s identification, the time and place of the incident, an accurate account of the event who you notified, what actions you took, and your signature. C. Do not reference or include this report in the client’s medical record. 91. Facility Protocols: Appropriate Action for a suspected Incident · A. Report to charge nurse if any suspected illegal activity is taking place on the unit o Drunk employee o Employee stealing medications o Abuse o Neglect 92. Pain Management: Safe Use of Patient-Controlled Analgesia A. Controlled by patient 93. Enuresis and Urinary Tract Infections: Obtaining Urine Culture A. Suprapubic → less than 2 yrs old; need an informed consent B. Avoid having child drink large fluids before urinalysis C. Clean catch method→ pee, pause, pee in urine cup 94. Communicable Disease, Disasters,and Bioterrorism: Nationally Notifiable Infectious Disease A. Gonorrhea B. Hep A,B, C C. HIV D. Malaria E. Meningococcal F. Mumps G. Pertussis H. Polio I. Smallpox J. Syphilis K. TB L. Chlamydia 95. Medical and Surgical Asepsis: Setting up a sterile field A. UNSTERILE→ below the waist, 6 inches above field B. Top flap away from body 1st 96. Complications related to the labor process: Client positioning a C-section Birth A. Position the client in a supine position with a wedge under one hip to prevent compression of the vena cava. 97. Medical Conditions: Prioritizing Care of Multiple Clients A. Who are you going to see first 98. Nursing Care of Newborns: Evaluating Client's Understanding of Bulb Syringe Use A. Routine suctioning of the mouth first, then the nasal passages with a bulb syringe B. Compress bulb before insertion into one side of the mouth. C. Avoid center of the mouth to prevent stimulating gag reflex. D. Aspirate mouth first, one nostril, then second nostril. 99. Health Promotion of Infants (2 Days to 1 Year): Expected Gross Development GROSS MOTOR SKILLS A. 1 MONTH Demonstrates head lag B. 2 MONTHS Lifts head off mattress when prone C. 3 MONTHS Raises head and shoulders off mattress when prone, Only slight head lag D. 4 MONTHS Rolls from back to side E. 5 MONTHS Rolls from front to back F. 6 MONTHS Rolls from back to front G. 7 MONTHS Bears full weight on feet, Sits, leaning forward on both hands H. 8 MONTHS Sits unsupported I. 9 MONTHS Pulls to a standing position, Creeps on hands and knees instead of crawling J. 10 MONTHS Changes from a prone to a sitting position K. 11 MONTHS Cruises or walks while holding onto something, walks with one hand held L. 12 MONTHS Sits down from a standing position without assistance 100. Guidelines for Healthy Eating: Understanding Nutritional Food Labels A. Food labels must include single serving size, number of servings in the package, percent of daily values, and the amount of each nutrient in one serving. B. The Percent Daily Values information is typically based on a 2,000 calorie/day diet, but for certain nutrients and food components can be based on 2,500 calorie/day. C. Teach clients to read food labels properly to ensure individual nutritional needs are met, and healthy choices are made. D. GREATEST WEIGHT IS LISTED 1ST E. NUTRIENTS INCLUDED ON THE FOOD LABEL: · Calories & Calories from fat · Total fat, Saturated fat, Trans fat · Cholesterol · Sodium · Total carbohydrates · Dietary fiber · Sugars · Protein · Vitamin A & C · Calcium · Iron 101. Nutrition Across the Lifespan: Adolescent Nutritional Needs A. The rate of growth during adolescence is second only to the rate in infancy. Nutritional needs for energy, protein, calcium, iron, and zinc increase at the onset of puberty and the growth spurt. B. The female adolescent growth spurt usually begins at 10 or 11 years of age, peaks at 12 years, and is completed by 17 years. Female energy requirements are less than that of males, as they experience less growth of muscle and bone tissue and more fat deposition. C. The male adolescent growth spurt begins at 12 or 13 years of age, peaks at 14 years, and is completed by 21 years. D. Eating habits of adolescents are often inadequate in meeting recommended nutritional intake goals. NUTRITIONAL CONSIDERATIONS A. Energy requirements average 2,000 cal/day for a 12- to 18-year-old female and 2,200 to 2,800 cal/day for a 12- to 18-year-old male. B. The USDA reports that the average U.S. adolescent consumes a diet deficient in folate, vitamins A and E, iron, zinc, magnesium, calcium, and fiber. This trend is more pronounced in females than males. C. Diets of adolescents generally exceed recommendations for total fat, saturated fat, cholesterol, sodium, and sugar. D. IRON 15MG IN FEMALES DUE TO MENSTRUATION & 1 MG IN MALES ; ZINC E. CALCIUM: 1300G 102. Prenatal Care: Client Teaching About Immunizations During Pregnancy a. No live vaccinations (MMR, Varicella, Hep A, HPV). b. Can give IM influenza 103. Nursing Care of Newborns: Evaluating Parental Understanding of Sudden Infant Death Syndrome A. Newborns are positioned supine, “safe sleep,” to decrease the incidence of sudden infant death syndrome (SIDS). B. No bumper pads, loose linens, or toys should be placed in the bassinet. C. Mothers should sleep in close proximity but not in a shared space. Higher incidence rates are noted for SIDS and suffocation with bed sharing/co-sleeping. D. Educate parents about the need for immunizations as a measure to prevent SIDS. E. USE PACIFIER WHEN SLEEPING; BREASTFEED 104. Musculoskeletal Congenital Disorders: Screening for Idiopathic Scoliosis a. Observe the child, who should be wearing only underwear, from the back. b. Have the child bend over at the waist with arms hanging down and observe for asymmetry of ribs and flank. c. Measure truncal rotation with a scoliometer. 105. Health Promotion of Infants (2 Days to 1 Year): Finding to Report Expected Findings: A. Newborns will lose up to 10% of their birth weight by 3 to 4 days of age. This is due to fluid shifts, loss of meconium, and limited intake, especially in infants who are breastfed. The birth weight is usually regained by the tenth to fourteenth day of life, depending on the feeding method used. B. Posterior fontanel closes by 6 to 8 weeks of age→ 2 months C. Anterior fontanel closes by 12 to 18 months of age* D. Infants gain approximately 680 g (1.5 lb) per month during the first 5 months of life. The average weight of a 6 month old infant is 7.26 kg (16 lb). Birth weight is at least doubled by the age of 5 months, and tripled by the age of 12 months to an average of 9.75 kg (21.5 lb). E. Infants grow approximately 2.5 cm (1 in) per month the first 6 months of life. Growth occurs in spurts after the age of 6 months, and the birth length increases by 50% by the age of 12 months. F. Six to eight teeth should erupt in infants’ mouths by the end of the first year of age. The first teeth typically erupt between the ages of 6 and 10 months G. Laughs and squeals by 4 months. H. Makes single vowel sounds by 2 months. I. By 3 to 4 months the consonants are added. J. Begins speaking two-word phrases and progresses to speaking three-word phrases. K. Says three to five words by the age of 1 year. L. Comprehends the word “no” by 9 to 10 months and obeys single commands accompanied by gestures. 106. Musculoskeletal Congenital Disorders: Recognizing Manifestations of Scoliosis A. Asymmetry in scapula, ribs, flanks, shoulders, and hips B. Improperly fitting clothing (one leg shorter than the other) C. LATERAL CURVATURE OF SPINE 107. Overview of Community Health Nursing: Secondary Prevention for Substance Use A. Early detection through health surveillance and screening o Community assessments o Disease surveillance (communicable diseases) o Screenings o Cancer (breast, cervical, testicular, prostate, colorectal) o Diabetes mellitus o Hypertension o Hypercholesterolemia o Sensory impairments o Tuberculosis o Lead exposure o Genetic disorders/metabolic deficiencies in newborns→ heel stick done within 24 hrs after birth(must be fed before screening) o Control of outbreaks of communicable diseases o 16 weeks→ AFP 108. Medical Conditions: Finding to Report to the provider 109: Nursing care and Discharge Teaching: Circumcision A. Explain to the parents that the newborn will not be able to be bottle feed for up to 2-3 hr prior to the procedure to prevent vomiting and aspiration based on the preferences of the provider. Newborns who are breastfed can nurse up until the procedure. B. Explain that the newborn is restrained on a special board during the procedure. C. Teach the parents to keep the area clean. Change the newborn’s diaper at least every 4 hr, and clean the penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the diaper from adhering to the penis. D. Avoid wrapping the penis in tight gauze, which can impair circulation to the glans. E. A tub bath should not be given until the circumcision is healed. Until then, warm water should be trickled gently over the penis. F. Notify the provider if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying from the newborn. G. Tell the parents that a film of yellowish mucus can form over the glans by day two, and it is important not to wash it off. H. Teach the parents to avoid using pre moistened towelettes to clean the penis because they contain alcohol. I. Inform the parents that the newborn can be fussy or can sleep for several hours after the circumcision. J. Provide comfort measures for 24 to 48 hr, to include acetaminophen as prescribed. K. Inform the parents that the circumcision will heal completely within a couple of weeks. 110. Newborn Nutrition: Teaching a Client who has Hepatitis C about Breastfeeding A. YES AS LONG AS NO CRACKED NIPPLES 111. Postpartum Disorders: Performing the Appropriate Assessment A. DVT: Swelling, redness, hardened veins, calf tenderness B. Pulmonary embolism: chest pain, Tachypnea, edema, heart murmur C. Coagulopathies: bleeding D. Uterine atony: retained placental fragments, overdistention 112. Nursing care and discharge teaching: Cord care A. Keep the cord dry and keep the top of the diaper folded underneath the belly B. Avoidsumbering NB in water until cord falls 10-14 days → sponge bath C. Report purulent, redness at cord site 113. Health Promotion of Toddlers(1-3 yrs): Developmental Tasks for 24 months A. 24 MONTHS 1. Walks up and down stairs placing BOTH FEET ON STEP 2. RUNS W/ WIDE STANCE 3. KICKBALLS FORWARD 4. 6-8 BLOCK TOWER 5. TURNS PAGES OF A BOOK ONE BY ONE 6. OBJECT permanence developed 7. Memory develops 8. Preoperational thought allows the toddler to use symbols to represent objects 9. Uses 2-3 word sentences 10. Autonomy vs shame and doubt 11.Solitary play (parallel play) 12. Fill/empty containers 13. Look at books 14. Push-pull toys 15. Scribble with crayon 114. Care of special populations: Nutrition Teaching for a client who has diabetes and is pregnant A. MONITOR THE AMOUNT OF CARBOHYDRATES IN THE DIET B. Limit sweets/desserts C. Meet with a registered dietitian 115. Nutrition across the lifespan: Monitoring Client weight loss 116. Health promotion of Adolescents(12-20) : Education about tobacco A. Assessment and screening tools B. Prevention C. Support system 117. Overview of Community Health Nursing : Primary Prevention of Abuse A. Education B. Teach alternative methods of conflict C. Educate on community services D. Teach no one has the right to touch or hurt another person, make sure they know how to report a case 118. Sources of Nutrition: Dietary Causes of Constipation A. Low fiber B. Iron supplements 119. Osteoporosis: Dietary Recommendations for Health Promotion A. Increase Calcium→ MILK PRODUCTS, GREEN VEGETABLES, ORANGE JUICE/CEREALS, RED/WHITE BEANS, & FIGS. B. Increase vitamin D→ FISH, EGG YOLKS, FORTIFIED MILK, CEREAL 120. Contraception : Contraindication for oral contraceptives A. St. John's wort B. Colesevelam C. Hypertension 121. Electrote imbalnces: Priority Assessment for suspected Hypocalcemia A. Convulsions B. Arrhythmias C. Tetany D. Spasms/stridor 122. Psychosocial Issues of Infants, Children, and Adolescents: Caring for a Child Following Abuse A. Identify abuse as soon as possible. Conduct detailed history and physical examination→ SANE EXAM B. Assess for unusual bruising on the abdomen, back, and buttocks. Document thoroughly with size, shape, and color. Use diagrams to represent location. C. Assess the mechanism of injury, which might not be congruent with the physical appearance of the injury. Many bruises at different stages of healing can indicate ongoing beatings. D. Observe for bruises or welts in the shape of a belt buckle or other objects. E. Observe for burns that appear glove- or stocking-like on hands or feet, which can indicate forced immersion into boiling water. Small, round burns can be caused by lit cigarettes. Document detailed descriptions of all findings. F. Note fractures that have unusual features, such as forearm spiral fractures, which could be caused by twisting the extremity forcefully. The presence of multiple fractures is suspicious. G. Check the child for head injuries. Assess the child’s level of consciousness, making sure to note equal and reactive pupils. Monitor for nausea/vomiting. H. The nursing priority is to have the child removed from the abusive situation. I. Mandatory reporting is required of all health care providers, including suspected cases of child abuse. There are civil and criminal penalties for not reporting. J. Clearly and objectively document information obtained in the interview and during the physical assessment. K. Photograph and detail all visible injuries. L. Conduct the interview with the client and parents individually. M. Be direct, honest, and professional. N. Use language the child understands O. Be understanding and attentive. P. Client circumstances are case-sensitive, and referrals are made to always keep the client safe. When applicable, explain the process if a referral is made to child or adult protective services Q. Assess safety and reduce danger for the victim. R. Use open-ended questions that require a descriptive response. These questions are less threatening and elicit more relevant information. S. Provide support for the child and parents. T. Demonstrate behaviors for child-rearing with the parents and child. U. Provide consistent care to the child. V. Avoid asking the child probing questions. W. Promote self-esteem. X. Assist with alleviating feelings of shame and guilt. Y. Assist the child with grieving the loss of parents, if indicated. Z. Discharge can begin once legal determination of placement has been decided 123. Crisis Management: Priority Actions During a Situational Crisis A. The initial task of the nurse is to promote a sense of safety by assessing the client’s potential for suicide or homicide. B. Provide for client safety. C. Initiate hospitalization to protect clients who have suicidal or homicidal thoughts. D. Prioritize interventions to address the client’s physical needs first E. LOST A GRANDPARENT IN A MVC F. Initial interventions include the following. o Identifying the current problem and directing interventions for resolution o Taking an active, directive role with the client. o Helping the client to set realistic, attainable goals G. Use strategies to decrease anxiety. o Develop a therapeutic nurse-client relationship. o Remain with the client. o Listen and observe. o Make eye contact. o Ask questions related to the client’s feelings. o Ask questions related to the event. o Demonstrate genuineness and caring. o Communicate clearly and, if needed, with clear directives. o Avoid false reassurance and other non therapeutic responses. H. Teach relaxation techniques. I. Identify and teach coping skills (assertiveness training and parenting skills). J. Assist the client with the development of the following type of action plan. o Short-term, no longer than 24 to 72 hr o Focused on the crisis o Realistic and manageable 124. Mental Health Issues of Children and Adolescents: Priority Assessment for a Client Who Has Conduct Disorder a. Use a calm, firm, respectful approach with the child. b. Provide a safe environment for the child and others. c. Use modeling to show acceptable behavior. d. Obtain the child’s attention before giving directions. Provide short and clear explanations. e. Set clear limits on unacceptable behaviors and be consistent. f. Plan physical activities through which the child can use energy and obtain success. g. Assist parents to develop a reward system using methods, such as a wall chart or tokens. Encourage the child to participate. h. Focus on the family and child’s strengths, not just the problems. i. Support the parents’ efforts to remain hopeful. j. Provide the child with specific positive feedback when expectations are met. k. Identify issues that result in power struggles l. Assist the child in developing effective coping mechanisms. m. Encourage the child to participate in group, individual, and family therapy. n. Administer medications, such as antipsychotics, mood stabilizers, anticonvulsants, and antidepressants; monitor for side effects. 125. Sexual Assault: Priority Intervention A. Perform a self-assessment. It is vital that the nurse who works with the client who has been sexually assaulted be empathetic, objective, and nonjudgmental. If the nurse feels emotional about the assault due to some event or person in his own past, it can be better to allow another nurse to care for the client. B. Perform an initial and ongoing assessment of the client’s level of anxiety, coping mechanisms, and available support systems. The nurse should also assess for indications of emotional and/or physical trauma. C. Provide a private environment for an examination with a specially trained nurse-advocate, if available. A sexual assault nurse examiner (SANE) is a specially trained nurse who performs such examinations and collects forensic evidence. D. Provide for client safety. E. Obtain informed consent to collect data that can be used as legal evidence (photos, pelvic exam). The rape survivor has the right to refuse either a medical examination or a legal exam, which provides forensic evidence for the police F. Treat any injuries, and document care given. G. Assist the SANE with the physical examination and the collection, documentation, and preservation of forensic evidence. Sexual assault evidence collection kits are used for collecting blood, oral swabs, hair samples, nail swabs, or scrapings, and genital, anal, or penile swabs. Document physical injuries in narrative and pictorial form, using body maps or photographs. Also document subjective data, using the client’s verbatim statements. H. Support the client while legal evidence is being collected (samples of hair, skin, semen). Avoid minimizing the client’s level of emotional suffering, as psychological responses can be subtle or not easily identifiable. Refrain from asking “Why” questions. I. Assess for suicidal ideation. J. Call the client’s available personal support system, such as a partner or parents, if the client gives permission. K. Assist the client during the acute phase of rape-trauma syndrome to prepare for thoughts, manifestations, and emotions that can occur during the long-term phase of the syndrome. L. Encourage the client to verbalize her story and emotions M. Listen and let the client talk. Use therapeutic techniques of reflection, open-ended questions, and active listening. N. ASSESS ANXIETY 126. Cultural, Ethnic, and Religious Influences: Assessing a Client's Dietary Acculturation A. Acculturation is the process of a cultural, ethnic, or religious group’s adopting of the dominant culture’s behaviors, beliefs, and values. B. Provide food choices and preparation consistent with cultural beliefs. When possible, allow the client’s family/caregiver to bring in food (as long as it meets the client’s dietary restrictions), and allow clients to consume foods that they view as a treatment for illness. Communicate ethnicity‐related food intolerances/ allergies to the dietary staff. 127. Cultural, Ethnic, and Religious Influences: Food Selection for a Client Who Follows Buddhist Dietary Practices A. Practice of vegetarianism by some Buddhists B. Individuals following a pure vegan diet do not consume animal products of any type, including eggs and milk products. These diets are often adequate in protein due to the intake of nuts and legumes (dried peas and cooked beans). C. A pure vegan diet requires that a variety of plant materials be consumed in specific combinations in order to ensure essential amino acid intake. D. Lacto vegetarian: Individuals following this diet consume milk products in addition to plant-based products. E. Ovo-lacto vegetarian: Individuals following this diet consume milk products and eggs in addition to plant-based products F. Ovo vegetarian: Individuals following this diet consume eggs in addition to plant-based products. 128. Grief, Loss, and Palliative Care: Identifying Types of Grief A. Normal grief · This grief is considered uncomplicated. · Emotions can be negative, such as anger, resentment, withdrawal, hopelessness, and guilt but should change to acceptance with time. · Some acceptance should be evident by 6 months after the loss. · Somatic complaints can include chest pain, palpitations, headaches, nausea, changes in sleep patterns, and fatigue. B. Anticipatory grief · This grief implies the “letting go” of an object or person before the loss, as in a terminal illness. · Individuals have the opportunity to start the grieving process before the actual loss. C. Complicated grief · Unresolved or chronic grief is a type of complicated grief. · This grief involves difficult progression through the expected stages of grief. · Usually, the work of grief is prolonged. The manifestations of grief are more severe, and they can result in depression or exacerbate a preexisting disorder. · The client can develop suicidal ideation, intense feelings of guilt, and lowered self-esteem. · Somatic complaints persist for an extended period of time. D. Disenfranchised grief · This grief entails an experienced loss that cannot be publicly shared or is not socially acceptable, such as suicide and abortion. 129. Bipolar Disorders: Recognizing Manifestations of the Manic Phase A. Labile mood with euphoria B. Agitation and irritability C. Restlessness D. Dislike of interference and intolerance of criticism E. Increase in talking and activity F. Flight of ideas: rapid, continuous speech with sudden and frequent topic change G. Grandiose view of self and abilities (grandiosity) H. Impulsivity: spending money, giving away money or possessions I. Demanding and manipulative behavior J. Distractibility and decreased attention span K. Poor judgment L. Attention-seeking behavior: flashy dress and makeup, inappropriate behavior M. Impairment in social and occupational functioning N. Decreased sleep O. Neglect of ADLs, including nutrition and hydratioN P. Possible presence of delusions and hallucinations Q. Denial of illness 130. Neurocognitive Disorders: Documenting Dementia Findings A. Functional Dementia Scale: This tool will give the nurse information regarding the client’s ability to perform self-care, extent of the client’s memory loss, mood changes, and the degree of danger to self and/or others 131. Neurocognitive Disorders: Managing a Client Who Has Dementia A. Focus on protecting from injury, as well as promoting client dignity and quality of life. B. Provide for a safe and therapeutic environment. o Assess for potential injury, such as falls or wandering. o Assign the client to a room close to the nurses’ station for close observation. o Provide a room with a low level of visual and auditory stimuli. o Provide for a well-lit environment, minimizing contrasts and shadows. o Have the client sit in a room with windows to help with time orientation. o Have the client wear an identification bracelet. Use monitors and bed alarm devices as needed. o Assess the client’s risk for injury and ensure safety in the physical environment, such as a lowered bed C. Cognitive Support o Provide compensatory memory aids, such as clocks, calendars, photographs, memorabilia, seasonal decorations, and familiar objects. Reorient as necessary. o Keep a consistent daily routine. o Maintain consistent caregivers. o Cover or remove mirrors to decrease fear and agitation. D. Physical Needs o Monitor neurological status. o Monitor vital signs. Tachycardia, elevated blood pressure, sweating, dilated pupils can be associated with delirium. o Monitor the client’s level of comfort and assess for nonverbal indications of discomfort. o Ensure adequate food and fluid intake E. Communication o Communicate in a calm, reassuring tone. o Speak in positively worded phrases. Do not argue or question hallucinations or delusions. o Reinforce reality and reinforce orientation to time, place, and person. o Introduce self to client with each new contact. o Establish eye contact and use short, simple sentences when speaking to the client. Focus on one item of information at a time. o Encourage reminiscence about happy times. Talk about familiar things. o Break instructions and activities into short timeframes. o Limit the number of choices when dressing or eating. o Minimize the need for decision-making and abstract thinking to avoid frustration. o Avoid confrontation. o Approach slowly and from the front. Address the client by name. 132. Personality Disorders: Antisocial Personality Disorder A. Characterized by disregard for others with exploitation, lack of empathy, repeated unlawful actions, deceit, and failure to accept personal responsibility; sense of entitlement, manipulative, impulsive, and seductive; nonadherence to traditional morals and values; verbally charming and engaging B. Limit-setting and consistency are essential with clients who are manipulative, especially those who have borderline or antisocial personality disorders. 133. Sensory Perception: Communicating With a Client Who Has Hearing Loss A. Sit and face the clients. B. Avoid covering your mouth while speaking. C. Encourage the use of hearing devices. D. Speak slowly and clearly. E. Do not shout. F. Try lowering vocal pitch before increasing volume. G. Use brief sentences with simple words. H. Write down what clients do not understand. I. Minimize background noise. J. Ask for a sign-language interpreter if necessary. 134. Stress Management: Teaching Relaxation Techniques A. Meditation includes formal meditation techniques, as well as prayer for those who believe in a higher power. B. Guided imagery: The client is guided through a series of images to promote relaxation. Images vary depending on the individual. For example, one client might imagine walking on a beach, while another client might imagine himself in a position of success C. Breathing exercises are used to decrease rapid breathing and promote relaxation. D. Progressive muscle relaxation: A person trained in this method can help a client attain complete relaxation within a few minutes. E. Physical exercise (yoga, walking, biking) causes release of endorphins that lower anxiety, promote relaxation, and have antidepressant effect F. Use nursing judgment to determine the appropriateness of relaxation techniques for clients who are experiencing acute manifestations of a psychotic disorder. 135. Care and specific populations: identifying Risk for Infant abuse A. Low income parents B. Low education and low self esteem family C. Substance abuse D. Unwanted, hyperactive, mentally disabled E. Crowded living conditions 136. Anxiety Disorders: Identifying Mild Anxiety A. Irritable B. Restless C. Fidgeting 137. Group and therapy: Facilitating Participation in a group A. If angry member→ Focus on the group members who have a positive outlook B. Remind the group that everyone should have a chance to participate C. If a member is silent, divide the groups into pairs and give extra time for member to compose thoughts before expressing 138. Substance use and addictive disorders: Finding of recent cocaine use A. Maladaptive behavior→ uphoria, fighting, persecutory ideation, agitation B. Tachycardia C. Pupillary dilation D. Elevated BP E. Perspiration/chills F. N/V G. Visual/tactile hallucination 139. Baby-friendly Car: Sibling Bonding A. Give a gift to give to newborn sibling B. Have older sibling help 140. Care of Clients who are dying and/or grieving: Expected Findings of the Grieving process A. Normal grief · This grief is considered uncomplicated. · Emotions can be negative, such as anger, resentment, withdrawal, hopelessness, and guilt but should change to acceptance with time. · Some acceptance should be evident by 6 months after the loss. · Somatic complaints can include chest pain, palpitations, headaches, nausea, changes in sleep patterns, and fatigue. B. Anticipatory grief · This grief implies the “letting go” of an object or person before the loss, as in a terminal illness. · Individuals have the opportunity to start the grieving process before the actual loss. C. Complicated grief · Unresolved or chronic grief is a type of complicated grief. · This grief involves difficult progression through the expected stages of grief. · Usually, the work of grief is prolonged. The manifestations of grief are more severe, and they can result in depression or exacerbate a preexisting disorder. · The client can develop suicidal ideation, intense feelings of guilt, and lowered self-esteem. · Somatic complaints persist for an extended period of time. D. Disenfranchised grief · This grief entails an experienced loss that cannot be publicly shared or is not socially acceptable, such as suicide and abortion. 141. Neurocognitive Disorders: Assessing Remote Memory A. Have patient state a verifiable fact (e.g. birthdate) 142. Psychotic Disorders: Assessment Findings 143. Depressive Disorders: Caring for a client who has Depression and Anorexia 144. Psychotic disorders: Priority Response for a client experiencing hallucinations A. Ask what the voices are saying B. Do not tell them they aren’t real C. Try to calm patient D. Assess for harm of self or patients 145. Neurocognitive Disorders: Teaching Family members of a client who has dementia 146. Effective communication : Therapeutic Response to the partner of a client who has bipolar 147. Effective communication: Therapeutic Response to a worried family member 148. Cognitive and Sensory Impairments: Identifying a Need for a hearing evaluation: INFANTS A. Lack of startle reflex B. Failure to respond to noise C. Absence of vocalization by 7 months D. Lack of response to the spoken word OLDER CHILDREN A. Using gestures rather than talking after 15 month B. Failure to develop understood speech by 24 months C. Yelling to express emotion D. Irritability due to inability to gain attention E. Seeming shy or withdrawn F. Inattentive to surroundings G. Speaking in monotone H. Need for repeated conversation I. Speaking loudly for situation 149. Gastrointestinal Therapeutic Procedures: Stoma Care A. Stoma should appear moist, shiny, and pink. The peristomal area should be intact, and the skin should appear healthy. B. Use mild soap and water to cleanse the skin, then dry it gently and completely. C. Apply barrier paste if necessary. D. Measure and mark the desired size for the skin barrier. E. Cut the opening 0.15 to 0.3 cm (1⁄18to 1⁄8in) larger, allowing only the stoma to appear through the opening. F. Apply the skin barrier and pouch. G. Fold the bottom of the pouch and place the closure clamp on the pouch. H. Dispose of the used pouch. Remove the gloves and perform hand hygiene Empty pouch when ⅓ to ½ full Avoid taking enteric-coated medications to reduce risk of blockage caused by the coating Change entire pouch every 3-7 days Use caution when eating high fiber foods as they can lead to diarrhea, constipation or obstruction I. Filters, deodorizers, or a breath mint can be placed in the pouch to minimize odor while the pouch is open. 150. Postpartum Physiological Adaptations: Interventions to Promote Client Ability to Void A. Encourage client to empty bladder every 2-3 hr. B. Encourage client to increase fluid oral intake C. Run water D. Catheterize if necessary for bladder distention if the client is unable to void to ensure complete emptying of the bladder and allow uterine involution E. Assess bladder for distention. Insert an indwelling urinary catheter to assess kidney function and obtain an accurate measurement of urinary output. F. Maintain or initiate IV fluids to replace fluid volume loss with IV isotonic solutions, such as lactated Ringer’s or 0.9% sodium chloride; ensure uterus is not deviated to one side G. Crede method: pressing gently on the bladde 151. Vitamins, Minerals, and Supplements: Contraindications for Nutritional Supplement in the Client Who is Preoperative A. Ginkgo biloba • Can interfere with coagulation B. St. John’s wort • Decreases effectiveness of oral contraceptives, cyclosporine, warfarin, digoxin, calcium channel blockers, steroids, HIV protease inhibitors, and some anticancer medications C. Saw palmetto • Can interact with antiplatelet and anticoagulant medications Valerian • It is not known if valerian potentiates effects of CNS depressants • Discontinue Saw Palmetto & Valerian Root 1-2 weeks prior to surgery. 152. Gastrointestinal Therapeutic Procedure: Evaluating a Client 153. Gastrointestinal Therapeutic Procedures : Manifestations of Early dumping syndrome A. Cramps B. Diarrhea C. Tachycardia D. Dizziness, fatigue) E. The client can report: o Full sensation o Weakness o Diaphoresis o Palpitations o Dizziness o Diarrhea. Vasomotor symptoms that can occur 10 to 90 min following a meal are: o Pallor o Perspiration o Palpitations o Headache o Feeling of warmth o Dizziness o Drowsiness 154. Acute Infectious Gastrointestinal Disorders: Manifestations of Dehydration A. Mild dehydration 1. weight loss of 3% to 5% in infants 2. Capillary refill greater than 2 seconds 3. Possible slight thirst B. Moderate 1. Weight loss of 6% to 9% 2. Capillary refill between 2 and 4 seconds 3. Possible thirst and irritability 4. Pulse slightly increased with normal to orthostatic blood pressure 5. Dry mucous membranes and decreased tears and skin turgor 6. Slight tachypnea 7. Normal to sunken anterior fontanelle on infants Severe 1. Weight loss greater than or equal to 10% 2. Capillary refill greater than 4 seconds 3. Tachycardia present, and orthostatic blood pressure can progress to shock 4. Extreme thirst 5. Very dry mucous membranes and tented skin 6. Hyperpnea 7. No tearing with sunken eyeballs 8. Sunken anterior fontanelle 9. Oliguria or anuria 155. Cardiovascular and Hematologic Disorders: Nutritional Recommendations for Heart Failure A. Heart failure is inability of the heart to maintain adequate blood flow which results in excess sodium, fluid retention, and edema. B. Reduce sodium intake to 2,000 mg/day or less. C. Monitor fluid intake (and possibly restrict 2 L/day). D. Increase protein intake to 1.12 g/kg. E. Small, frequent meals that are soft, easy-to-chew foods. 156. Nasogastric Intubation and Enteral Feedings: Confirming Placement of a Nasogastric Feeding Tube in the Jejunum A. Check placement by aspirating to collect gastric contents, testing pH (4 or less is expected), and assess odor, color, and consistency. B. After placement verification, secure the NG tube on the nose, avoiding pressure on the nares. C. ****Confirm placement with an x-ray. D. If the tube is not in the stomach, advance it 5 cm (2 in), and repeat the placement check. 157. Nutrition Across the Lifespan: Recommended Food Choices for a 2-Year-Old Toddler A. Limit 100% juice to 4 to 6 oz a day. B. Whole cow’s milk to provide adequate fat for the still-growing brain. C. Food serving size is 1 tbsp for each year of age D. Toddlers prefer finger foods because of their increasing autonomy. They prefer plain foods to mixtures, but usually like macaroni and cheese, spaghetti, and pizza. E. Regular meal times and nutritious snacks best meet nutrient needs. F. Snacks or desserts that are high in sugar, fat, or sodium should be avoided. G. Avoid foods that are potential choking hazard cut small, bite-sized pieces that are easy to swallow to prevent choking H. Iron deficiency anemia is the most common nutritional deficiency disorder in children. · - Lean red meats provide sources of readily absorbable iron. -Consuming vitamin C (orange juice, tomatoes) with plant sources of iron (beans, raisins, peanut butter, whole grains) will maximize absorption. -Milk should be limited to the recommended quantities (24 oz) because it is a poor source of iron and can displace the intake of iron-rich foods. I. Vitamin D is essential for bone development. J. Milk (cow, soy) and fatty fish are good sources of vitamin D. 158. Parkinson's Disease: Client Safety A. cutting up the food in small pieces and assessing swallowing B. maintain adequate nutrition and weight. Consult speech and language therapist to assess swallowing if the client demonstrates a risk for choking. C. Consult the client’s dietitian for appropriate diet, which often includes semisolid foods and thickened liquids. D. Provide smaller, more frequent meals. E. Sit the client upright to eat or drink F. Consult with occupational therapist for adaptive eating devices. G. Evaluate need for high-calorie, high-protein supplements to maintain the client’s weight. H. Teach the client to stop occasionally when walking to slow down speed and reduce risk for injury. I. Pace activities by providing rest periods. J. Provide a safe environment (no throw rugs, encourage the use of an electric razor). 159. Peptic Ulcer Disease: Dietary Teaching Following Gastric Resection A. Administer IV fluid replacement and maintenance as prescribed. B. Clamp NG tube as prescribed to assess the client’s tolerance prior to removal. C. Advance diet as tolerated when prescribed, beginning with clear liquids. Clamp tube after eating for 1 to 2 hr. D. Instruct client to report intolerance of intake following NG tube removal (nausea, vomiting, increasing distention). E. Monitor electrolytes, especially potassium levels. F. They need B12 vitamins. 160. Mobility and Immobility: Evaluating Client Understanding of Crutch Safety COAL: Coal Opposite Affected Leg WWAL: WALKER W/ AFFECTED LEG Crutch Instructions: • Support body weight at the hand grips with elbows flexed at 30°. • Position the crutches on the unaffected side when sitting or rising from a chair. CRUTCHES: Non-weight bearing • Begin in the tripod position, maintain weight on the “unaffected” (weight-bearing) extremity • Advance both crutches and the affected extremity • Move the unaffected weight-bearing foot/leg forward (beyond the crutches) • Advance both crutches, and then the unaffected extremity CRUTCHES: Weight bearing • Move crutches forward about one step’s length • Move “affected” leg forward; level with the crutches tips • Move the “unaffected” leg forward • Continue sequence making steps of equal length Walking up stairs • Hold onto tail with one hand and crutches with the other hand • Push down on the stair rail and the crutches and step up with the other hand • If not allowed to place weight on the affected leg, hop up with the unaffected leg. • Bring the affected leg and the crutches beside the unaffected leg • Remember, the unaffected leg goes up first and the crutches move with the affected leg Walking down stairs • Place the affected leg and the crutches down on the step below; support weight by leaning on the crutches and the stair rail • Bring the unaffected leg down • Remember, the affected leg goes down first and the crutches move with the affected leg 161. Disorders of female reproductive tissue: Teaching kegel exercises A. Tightening pelvic muscles for a count of 10. B. Relax slowly for a count of 10, pause for 10 to 15 seconds, repeat in sequences of 15. C. Perform while lying down, sitting, and standing. D. Perform 4 times daily. E. Contract the circumvaginal and/or perirectal muscles. F. Keep abdominal muscles relaxed during contractions. 162. Postpartum physiological adaptations: Promoting Urination after childbirth A. Encourage the client to empty her bladder frequently (every 2 to 3 hr) to prevent possible displacement of the uterus and atony. B. Measure the client's first few voidings after delivery to assess for bladder emptying. C. Encourage the client to increase her oral fluid intake to replace fluids lost at delivery and to prevent or correct dehydration. D. Catheterize if necessary for bladder distention if the client is unable to void to ensure complete emptying of the bladder and allow uterine involution. 163. Postpartum Physiological adaptations: Evaluating urinary elimination A. Assess the pt's ability to void every 2-3 hours (perineal/urethral edema may cause pain and difficulting in voiding during the first 24-48 hours) B. Assess the pt's bladder elimination pattern (should be voiding every 2-3 hours). Excessive urine diuresis (1500-3000 mL/day) is normal within the first 2-3 days after delivery C. Assess for distended bladder 164. Pain Management: Teaching about nonpharmacological pain management 1. Relaxation 2. Distraction 3. Cutaneous stimulation (ie acupressure, massage, thermal therapy, contralat stimulation) 4. Guided imagery 5. Hypnosis 6. Biofeedback 7. Music therapy 8. Exercise 165. Pain management: Non Pharmacological pain management strategies 1. Relaxation 2. Distraction 3. Cutaneous stimulation (ie acupressure, massage, thermal therapy, contralat stimulation) 4. Guided imagery 5. Hypnosis 9. Biofeedback 10. Music therapy 11. Exercise 166. Complementary and Alternative Therapies: Contraindications for Aromatherapy A. Seizures B. High blood pressure C. Hypoglycemia D. Pregnant E. Kidney problems 167. Nutrition Assessment/Data Collection: Weight Loss calculation 168. Chronic obstructive pulmonary disease: Managing Nutrition A. High calorie foods to promote energy 169. Gastrointestinal Disorders: Dietary Guidelines for Celiac Disease A. AVOID: BARLEY, RYE, OATS, WHEAT, GLUTEN B. Can eat rice 170. Eating disorders: Expected Finds for Anorexia Nervosa A. Fine, downy hair (lanugo) on face and back B. Yellowed skin C. Mottled, cool extremities D. Poor skin turgor E. .Decreased BP F. Decreased pulse G. Bloating 171. Medications for Depressive Disorders: Food and medication Interaction 172. Gastrointestinal Disorder: Peptic Ulcer Disease A. Administer IV fluid replacement and maintenance as prescribed. B. Clamp NG tube as prescribed to assess the client’s tolerance prior to removal. C. Advance diet as tolerated when prescribed, beginning with clear liquids. Clamp tube after eating for 1 to 2 hr. D. Instruct client to report intolerance of intake following NG tube removal (nausea, vomiting, increasing distention). E. Monitor electrolytes, especially potassium levels. F. They need B12 vitamins 173. Medications for Children and Adolescents Who Have Mental Health Issues: Client Teaching for Methylphenidate A. Instruct clients to take the last dose of the day no later than 4 p.m. B. Advise clients to decrease caffeine consumption. C. Clients should not take methylphenidate within 14 days of taking a MAOI. 174. Antilipemic Agents: Adverse Effects of Simvastatin A. Hepatotoxicity 1. Evidenced by increase in aspartate transaminase (AST) greater than 35 Units/L 2. Advise clients to observe for indications of liver dysfunction (anorexia, vomiting, nausea, jaundice), and to notify the provider if manifestations occur. 3. Advise clients to avoid alcohol. B. Myopathy 1. Evidenced by muscle aches, pain, and tenderness 2. Can progress to myositis or rhabdomyolysis 3. Advise clients to report muscle aches, pain, and tenderness 175. Antilipemic Agents: Medication Interactions A. HMG-CoA reductase inhibitors (statins) 1. Fibrates (gemfibrozil, fenofibrate) and ezetimibe increase the risk of myopathy. 2. Medications that suppress CYP3A4, such as erythromycin and ketoconazole, along with HIV protease inhibitors, amiodarone, and cyclosporine can increase levels of some statins when taken concurrently. 3. Grapefruit juice suppresses CYP3A4 and can increase levels of statins. B. Cholesterol absorption inhibitor (ezetimibe) 1. Bile acid sequestrants, such as cholestyramine, interfere with absorption. 2. Statins, such as atorvastatin, can increase the risk of liver dysfunction and myopathy. 3. Concurrent use with fibrates, such as gemfibrozil, increases the risk of cholelithiasis and myopathy. 4. Levels of ezetimibe can be increased with concurrent use of cyclosporine. C. Bile-acid sequestrants (Colesevelam) 1. Bile-acid sequestrants interfere with absorption of many medications, including levothyroxine; second-generation sulfonylureas, such as glipizide; phenytoin; fat-soluble vitamins (A, D, E, K); and oral contraceptives. They also form insoluble complexes with thiazide diuretics, digoxin, and warfarin. D. Fibrates (gemfibrozil) A. With concurrent use, warfarin increases the risk of bleeding. B. Statins increase the risk of myopathy. E. Antisense oligonucleotide (mipomersen) 1. Acetaminophen, methotrexate, tetracyclines, and tamoxifen increase levels of mipomersen and can increase risk for liver damage. 176. Connective Tissue Disorders: Long-Term Therapy A. Antirheumatic drugs (DMARD) 177. Contraception: Findings to Report · Abnormal bleeding · Stroke · chest pain, · shortness of breath · leg pain from a possible clot, · Headache · hypertension. 178. Medical Conditions: Medications for Preeclampsia · Methyldopa · Nifedipine · Hydralazine · Labetalol · Avoid ACE inhibitors and angiotensin II receptor blockers. · Magnesium sulfate 179. Medications Affecting Coagulation: Enoxaparin · Prevent deep-vein thrombosis (DVT) in clients who are postoperative. · Treat DVT and pulmonary embolism. COMPLICATIONS · Hemorrhage, · Neurologic damage from hematoma formed during spinal or epidural anesthesia · Thrombocytopenia evidenced by low platelet count · Toxicity/overdose · Provide instruction regarding self-administration. Medications can be available in prefilled syringes. · For subcutaneous injections when a prefilled syringe is not available, use a 20- to 22-gauge needle to withdraw medication from the vial. Then, change to a small needle (25- or 26-gauge, ½ to ⅝ inches long). · Rotate sites between right and left anterolateral and posterolateral abdominal walls at least 2 inches from umbilicus. · Do not aspirate. · Pinch up an area of skin, inject at a 90° angle, and insert needle completely. Do not aspirate. Inject entire contents of syringe. · Do not rub the site for 1 to 2 min after the injection. · monitor for indications of bleeding, such as bleeding gums, bruising, abdominal pain, nose bleeds, coffee-ground emesis, and tarry stools. · avoid the use of OTC NSAIDs, aspirin, or medications containing salicylates. · Advise client to use an electric razor for shaving and to brush with a soft toothbrush. 180. Medications Affecting Urinary Output: Recognizing Complication Caused by a Medication Interaction A. Potassium-sparing diuretics 1. Concurrent use of ACE inhibitors, angiotensin receptor blockers, and direct renin inhibitors increases the risk of hyperkalemia. 2. Concurrent use of potassium supplements, salt substitutes, and another potassium sparing diuretic increases the risk of hyperkalemia. B. Osmotic diuretics 1. Increase risk for hypokalemia with cardiac glycosides. 181. Medications for Depressive Disorders: Dietary Teaching MAOIs (Phenelzine) · Avoid tyramine rich foods include aged cheese, pepperoni, salami, avocados, figs, bananas, smoked fish, protein, some dietary supplements, some beers, and red wine. Medical Conditions: Medications for Preeclampsia · Methyldopa · Nifedipine · Hydralazine · Labetalol · Avoid ACE inhibitors and angiotensin II receptor blockers. Magnesium sulfate 182. Medications for Psychotic Disorders: Adverse Effects of Clozapine A. Metabolic syndrome 1. New onset of diabetes mellitus or loss of glucose control in clients who have diabetes 2. Dyslipidemia with increased risk for hypertension and other cardiovascular disease 3. Weight gain B. Orthostatic hypotension C. Anticholinergic effects D. Agitation, dizziness, sedation, sleep disruption E. Mild EPS, such as tremor F. Sexual dysfunction · Anorgasmia, impotence, low libido 183. Medications for Psychotic Disorders: Adverse Effects of Conventional Antipsychotics Extrapyramidal Side Effects Acute dystonia: · Severe spasm of the tongue, neck, face, and back Pseudoparkinsonism · Bradykinesia, Rigidity, Shuffling gait, Drooling, Tremors Akathisia: · Inability to sit or stand still, Continual pacing and agitation Tardive dyskinesia (TD) · Involuntary movements of the tongue and face, such as lip smacking and tongue fasciculations, and involuntary movements of the arms, legs, and trunk Neuroendocrine effects · Gynecomastia, Weight gain, Menstrual irregularities Neuroleptic malignant syndrome · Sudden high fever, Blood pressure fluctuations, Diaphoresis, Tachycardia, decreased LOC, tachypnea, muscle rigidity Sexual dysfunction Skin effects · Photosensitivity that can result in severe sunburn, Also: Orthostatic hypotension, Sedation, Seizures, Severe dysrhythmias, Liver impairment 184. Medications for Psychotic Disorders: Reportable Findings in a Client Taking Clozapine ·1. Report to MD infection (fever, sore throat, mouth lesions) 2. Risk for fatal agranulocytosis 3. Advise clients to observe for galactorrhea, gynecomastia, and amenorrhea, and to notify the provider if these occur. 4. Agitation, dizziness, sedation, sleep disruption are adverse effects to report to provider Physiological Adaptation Nursing Process: Assess the needs of a client who has an NG tube: A. ABCs; always assess patients airway. B. Elevate patient’s head before, during and after adm. of Any medications. To prevent aspiration C. Monitor tube for displacement (decrease in drainage, increased nausea, vomiting, distention). D. Provide frequent oral and nares care (every 2 hrs) E. Assess pertinent lab results (electrolytes, hematocrit). F. Assess nasal skin for irritation G. The NG tube is irrigated every 4 hr to maintain patency Cancer Treatment Options: Adverse Effects of Radiation Therapy: A. Adverse effects on tissue within the radiation path include skin changes, hair loss, and debilitating fatigue. B. Adverse effects depend on which part of the body is being exposed to the radiation and how much radiation is being administered. C. Skin: blanching, erythema, desquamation, sloughing, hemorrhage D. Mouth: mucositis, xerostomia (dry mouth) E. Neck: difficulty swallowing F. Abdomen: gastroenteritis fatigue G. Internal radiation causes body fluids to be contaminated with radiation, and body wastes should be disposed of appropriately, as directed by the facility. Head injury: Monitor for intracranial Pressure Complications A. Severe headache, nausea, vomiting B. Deteriorating LOC, restlessness, irritability C. Dilated or pinpoint nonreactive pupils D. Cranial nerve dysfunction E. Alteration in breathing pattern (Cheyne-Stokes respirations, central neurogenic hyperventilation, apnea) F. Deterioration in motor function, abnormal posturing (decerebrate, decorticate, flaccidity) Cushing’s triad is a late finding characterized by severe hypertension with a widening pulse pressure (systolic – diastolic) and bradycardia. G. Seizures H. Stroke Infections: Caring for a client who has Herpes Simplex Virus A. Treatment includes O Spirits of camphor, corticosteroid cream, mild antiseptic mouthwash, viscous lidocaine; removal or control of predisposing factors, antiviral agents (e.g., acyclovir [Zovirax], famciclovir [Famvir], penciclovir [Denavir], valacyclovir [Valtrex]). O Abstinence from sexual contact while lesions are present B. Herpes simplex infection: symptoms consisting of painful blisters and tender lymph nodes C. HSV initially presents with lesions and tender lymph nodes. Fetal consequences include miscarriage, preterm labor, and intrauterine growth restriction. A cesarean section is recommended for all women in labor who have active genital herpes lesions or early symptoms of impending outbreak, such as vulvar pain and itching Infections: Nursing Care of a Client who is Pregnant and has Gonorrhea A. Identify and treat all sexual partners. B. Ceftriaxone IM or doxycycline orally for 7 days is prescribed for the treatment of gonorrhea. C. Administer erythromycin to all infants following delivery. This is the medication of choice for ophthalmia neonatorum. This antibiotic is both bacteriostatic and bactericidal, and thus provides prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis. D. Gonorrhea is a commonly reported condition. (Depends on State) E. It is the responsibility of the provider to report cases of these diseases to the local health department. Prenatal Care: Interventions for Urinary Frequency During Pregnancy: A. The client should empty her bladder frequently, decrease fluid intake before bedtime, and use perineal pads. B. The client is taught how to perform Kegel exercises (alternate tightening and relaxation of pubococcygeal muscles) to reduce stress incontinence (leakage of urine with coughing and sneezing). Acute Infectious Gastrointestinal Disorders: Assessment of Dehydration in 3-month-old infant A. Failure to gain weight and signs of dehydration, such as dry and/or pale skin, cool lips, dry mucous membranes, decreased skin turgor, diminished urinary output, concentrated urine, thirst, rapid pulse, sunken eyes and fontanels B. Depressed fontanelle can indicate dehydration. C. Urine output less than 1 mL/kg/hr D. Urine-specific gravity greater than 1.015 E. Weight loss F. Dry mucous membranes G. Absent skin turgor Electrocardiography and Dysrhythmia Monitoring: Identify Arrhythmias A. Obtain a 12-lead ECG and prove antidysrhythmics and fluids Electrocardiography and Dysrhythmia Monitoring: Identifying Cardiac Dysrhythmias: A. Strip Expected Physiological Changes During Pregnancy: Positioning for Optimal Cardiac Output A. Encourage the client to engage in maternal positioning on the left lateral side, semi-Fowler’s position, or, if supine, with a wedge placed under one hip to alleviate pressure to the vena cava Cardiovascular Disorders: Interventions for Decreased Cardiac Output A. Provide medications to increase output (inotropic agents - milrinone, dobutamine) and to decrease cardiac workload. B. Administer oxygen. Intubation and ventilation can be required. C. Administer IV morphine, diuretics, and/or nitroglycerin to decrease preload. Administer IV vasopressors and/ or positive inotropes to increase cardiac output and maintain organ perfusion. D. Maintain continuous hemodynamic monitoring. Electrocardiography and Dysrhythmia Monitoring: Purpose of Telemetry A. Telemetry allows the client to ambulate while maintaining proximity to the monitoring system. B. Continuous ECG monitoring Pacemakers: Teaching a Client who has an Implantable Cardioverter/Defibrillator: A. Carry a pacemaker identification card at all times. B. Prevent wire dislodgement. (Wear sling when out of bed. Do not raise arm above shoulder for 1 to 2 weeks.) C. Take pulse daily at the same time. Notify the provider if heart rate is less than the pacemaker rate. D. Report signs of dizziness, fainting, fatigue, weakness, chest pain, hiccupping, palpitations, difficulty breathing, or weight gain. E. When the device delivers a shock, anyone touching the client will feel a slight electrical impulse, but the impulse is not harmful. F. Follow activity restrictions as prescribed, including no contact sports or heavy lifting for 2 months. G. Avoid direct blows or injury to the generator site. H. Resume sexual activity as desired, avoiding positions that put stress on the incision site. I. Never place items that generate a magnetic field directly over the pacemaker generator. These items can affect function and settings. This includes garage door openers, burglar alarms, strong magnets, generators and other power transmitters, and large stereo speakers. The use of household items is not prohibited. J. Inform providers and dentists about the pacemaker. Some tests, such as magnetic resonance imaging and therapeutic diathermy (heat therapy), can be contraindicated. K. Pacemakers set off airport security detectors, and officials should be notified. The airport security device should not affect pacemaker functioning. L. Airport security personnel should not place wand detection devices directly over the pacemaker Acid Base Imbalances: Interpreting ABGs in Salicylism A. Tinnitus, vertigo, decreased hearing acuity B. Respiratory alkalosis (acute hyperventilation) C. RESULTS IN: O Decreased CO2 (Normal CO2: 35-45) O Decreased or normal H+ concentration (Normal H: 22-26) D. If PH is greater than 7.45, identify as alkalosis Cancer Disorders: Client Data to Report A. Report of change in appearance of mole or lesion B. Report and provide relief for adverse or toxic effects of chemotherapy. C. Report manifestations of infection or illness immediately to the provider. D. Monitor for report of bone pain. Monitor CBC twice weekly to check leukocytes. E. Report temperature greater than 37.8° C (100° F). F. Mouth lesions that do not heal within 2 weeks can be cancerous and should be reported to a provider. Emergency Nursing Principles and Management: Caring for a Client who has Abnormal Trauma A. Initial O Ensure patent airway. O Administer O2 via non-rebreather mask. O Control external bleeding with direct pressure or sterile pressure dressing. O Establish IV access with two large-bore catheters and infuse warm normal saline or lactated Ringer’s solution. O Obtain blood for type and crossmatch and CBC. O Remove clothing. O Stabilize impaled objects with bulky dressing—do not remove. O Cover protruding organs or tissue with sterile saline dressing. O Insert indwelling urinary catheter if there is no blood at the meatus, pelvic fracture, or boggy prostate. O Obtain urine for urinalysis. O Insert NG tube if no evidence of facial trauma. O Anticipate diagnostic peritoneal lavage. B. · Ongoing Monitoring O Monitor vital signs, level of consciousness, O2 saturation, and urine output. O Maintain patient warmth using blankets, warm IV fluids, or warm humidified O2. C. Monitor for internal bleeding (Measure abdominal girth and abdominal or flank pain) at least every 8 hrs once stable. Stroke: Managing an Ischemic Stroke A. Ischemic strokes (thrombotic or embolic) can be reversed with fibrinolytic therapy using alteplase, also known as tissue plasminogen activator (tPA), if given within 3 to 4.5 hr of the initial symptoms (unless contraindicated by factors such as presence of active bleeding). B. Antiplatelets (Aspirin) → Low-dose aspirin is given within 24-48 hr following a stroke to prevent further clot formation. C. Other antiplatelets, such as clopidogrel, are not recommended. Communicable Diseases, Disasters, and Bioterrorism: Identify a Communicable Disease: A. Community health nurse engages in communicable disease surveillance B. Can use disease surveillance to track the point of origin of some disease C. Surveillance also helps management of a disease outbreak 1) Anthrax 2) Botulism 3) Cholera 4) Congenital rubella syndrome (CRS) 5) Diphtheria 6) Giardiasis 7) Gonorrhea 8) Hep A, B, C 9) HIV Infection 10) Influenza- associated pediatric mortality 11) Legionellosis/Legionnaires’ Disease 12) Lyme disease 13) Malaria 14) Meningococcal disease 15) Mumps 16) Pertussis (whooping Cough) 17) Poliomyelitis, paralytic 18) Poliovirus infection, nonparalytic 19) Rabies human or animal 20) Rubella German measles 21) Salmonellosis 22) Severe acute respiratory syndrome-associated coronavirus disease (SARS-CoV) 23) Shigellosis 24) Smallpox 25) Tetanus/C. Tetani 26) Toxic shock syndrome (TSS) (Other than Streptococcal). 27) TB 28) Typhoid Fever 29) Vancomycin-Intermediate and vancomycin-resistant Staphylococcus aureus (VISA/VRSA) Gastrointestinal Structural and Inflammatory Disorders: Identifying Area of Pain in Appendicitis A. Right lower quadrant Blood Neoplasms: Interventions for Chemotherapy-induced Stomatitis ● Stomatitis → is the inflam. Of tissues in the Oral cavity, such as the gums, tongue, roof and floor of the mouth and inside the lips and cheeks. A. Examine the client’s mouth several times a day, and inquire about the presence of oral lesions. B. Document the location and size of lesions. Lesions should be cultured and reported to the provider. C. Avoid using glycerin-based mouthwashes or mouth swabs. Nonalcoholic, anesthetic mouthwashes are recommended. D. Administer a topical anesthetic prior to meals. E. Discourage consumption of salty, acidic, or spicy foods. F. Offer oral hygiene before and after each meal. Use lubricating or moisturizing agents to counteract dry mouth. G. Encourage the client to rinse the mouth with a solution of 0.9% sodium chloride, room-temperature tap water, or salt and soda water. H. Encourage gentle flossing and brushing using a soft-bristled toothbrush or foam swabs to avoid traumatizing the oral mucosa. I. Rinse the mouth before and after meals. J. Encourage the client to eat soft, bland foods and supplements that are high in calories (mashed potatoes, scrambled eggs, cooked cereal, milk shakes, ice cream, frozen yogurt, bananas, and breakfast mixes). K. Avoid spicy, salty, acidic food/ alcohol and tobacco use Acute and Infectious Respiratory Illness: Assessing for Postoperative Complications A. Monitor oxygen saturation using a pulse oximeter. B. Asses breath sounds Cancer Treatment Options: Treating Xerostomia Following Radiation A. Same as Stomatitis look up 2. Bowel Elimination: Ostomy Care → Pg 303-304 A. If the stoma appears black or purple in color, this indicates a serious impairment of blood flow and requires immediate intervention B. NURSING ACTIONS C. Assess the type and fit of the ostomy appliance. Monitor for leakage (risk to skin integrity). D. Assess peristomal skin integrity and appearance of the stoma. The stoma should appear pink and moist. E. Evaluate stoma output. Output should be more liquid and more acidic the closer the ostomy is to the proximal small intestine. F. Empty the ostomy bag when it is one-fourth to one-half full of drainage. G. Assess for fluid and electrolyte imbalances, particularly with a new ileostomy. H. Evaluate ability of the client or support person to perform ostomy care. I. Stomal ischemia/necrosis J. Stomal appearance should normally be pink or red and moist. K. Signs of stomal ischemia are pale pink or bluish purple color and dry appearance. NURSING ACTIONS: L. Notify the provider or surgeon of unexpected findings Cancer Treatment Options: Priority Findings Following Radiation Therapy: A. Skin: blanching, erythema, desquamation, sloughing, hemorrhage B. Mouth: mucositis, xerostomia (Dry mouth) C. Neck: Diff. swallowing D. Abdomen: gastroenteritis E. Monitor CBC: possible decreased platelets and WBCs F. Report any evidence of skin damage Cystic Fibrosis: Action to Take prior to Postural drainage: A. 1-2 hrs before meals and at bedtime to decrease likeliness of vomiting or aspiration B. Give bronchodilator or nebulizer prior postural drainage prn C. Offer emesis basis and facial tissues *Benign Prostatic Hyperplasia: Priority Assessment Following Transurethral Resection of the Prostate: A. Urinary drainage bag is filled with dark red fluid with obvious clots. B. Painful Bladder spasm Cardiovascular Diagnostic and Therapeutic Procedures: Pulmonary Artery Wedge Pressure A. Hemodynamic monitoring *Electrocardiography and Dysrhythmia Monitoring: ECG interpretation: A. Strip Fluid Imbalances: Fluid Volume Deficit: A. Hypovolemia- It's a isotonic loss in which water and electrolytes are lost from the ECF B. Dehydration- It's osmolar and it's a loss of water, but no loss of electrolytes from the ECF. This hemoconcentration results in increases in Hct, serum electrolytes, and urine specific gravity. C. Can lead to hypovolemic Shock Nursing Care A. Observe respiratory rate, symmetry, and effort. B. Monitor for shortness of breath and dyspnea. C. Check urinalysis, oxygen saturation (SaO2), CBC, and electrolytes. D. Administer supplemental oxygen as prescribed. E. Measure the client's weight daily at same time of day using the same scale. F. Observe for nausea and vomiting. G. Monitor vital signs. (Check for hypotension and orthostatic hypotension.) H. Check neurological status to determine LOC I. Assess heart rhythm (can be irregular or tachycardic). J. Initiate and maintain IV access. K. For fluid replacement, administer IV fluids as prescribed (isotonic solutions such as lactated Ringer's or 0.9% sodium chloride; blood transfusions). L. Monitor I&O. Encourage fluids as tolerated. Alert the provider to a urine output less than 30 mL/hr. M. Monitor level of consciousness and ensure client safety. N. Observe level of gait stability. O. Encourage the client to use the call light and ask for assistance. P. Encourage the client to change positions slowly (rolling from side to side or standing up). Q. Check capillary refill (expected reference range less than 2 seconds). R. Provide frequent oral care. S. Prevent skin breakdown. Vitals A. Hypothermia, B. tachycardia, C. thready pulse, D. hypotension, E. orthostatic hypotension, F. decreased central venous pressure, G. tachypnea (increased respirations), H. Hypoxia I. Labs: Hct is increased in both hypovolemic and dehydration unless hemorrhage Acute Infectious Gastrointestinal Disorders: Findings to Report A. Decreased electrolytes related to Vomiting/diarrhea→ Potassium less than 3.5 or greater than 5.0 B. Bloody emesis/stools C. Fever D. Confusion, decreased LOC Anemias: Laboratory Values to Monitor for Pernicious Anemia A. Vitamin B12 due to deficiency of intrinsic factor produced by gastric mucosa which is necessary for absorption of vitamin B12 Anesthesia and Moderate Sedation: Laboratory Values to report: A. ABGs B. CBCs C. Electrolytes D. Liver/Kidney function Cardiovascular Disorders: Planning Care for a Child who has Kawasaki Disease: A. Monitor vital signs and cardiac status. Maintain cardiac monitoring. B. Assess for heart failure (decreased urine output, gallop heart rhythm, tachycardia, respiratory distress). C. Monitor I&O. D. Obtain daily weight. E. Administer IV fluids to prevent dehydration. ● Ofer clear liquids and soft foods. F. Administer IV gamma globulin according to facility policy. G. Administer aspirin as prescribed. H. Provide care to promote comfort due to findings. ◯ Perform oral hygiene. ◯ Apply cool cloths to skin. ◯ Apply skin lotions to maintain hydration. ◯ Provide for a calm, quiet environment. ◯ Promote rest by clustering care. I. Teach the family about disease progression. J. Encourage the family to maintain K. follow-up appointments. L. Teach the family that the irritability can last 2 months. M. Teach the family that arthritic symptoms can last N. several weeks. O. Teach the family that the skin manifestations are painless but the skin could be tender. P. Encourage passive ROM exercises in the bathtub. Q. Avoid live immunizations for 11 months. R. Notify the provider of any fever. Hematologic Disorders: Planning care for a client experiencing a Vaso-Occlusive Crisis: A. Providing relief of pain B. Decrease Incidence of sickle cell crisis Burns: Priority Action for a Toddler who has burns: A. Fluid replacement B. Pain medication Burns Priority Intervention: A. Airway may result from steam or chemical inhalation, aspiration of scalding liquid B. Maintain airway and ventilation, and provide oxygen as Prescribed. C. Fluid replacement D. Increase food intake: hypermetabolic/hypercatabolic Personality Disorders: Histrionic Personality Disorder: A. Characterized by emotional attention-seeking behavior, in which the person needs to be the center of attention; often seductive and flirtatious. B. Cluster B personality Disorder C. Maintain professional boundaries and communication at all times, due the flirtatious nature of these clients. Cardiovascular Disorders: Findings Associated with Patent Ductus Arteriosus: A. hole in fetal circulation between pulmonary artery and aorta doesn't close B. Increased pulm flow C. L to R→ Increase pulmonary blood flow D. murmur (machine hum) E. wide pulse pressure, bounding pulses, asymptomatic (possibly), heart failure Thorax, Heart, and Abdomen: Assessing Heart Sounds: A. S1 heart sound, during systole B. S2 sound, during diastole C. S3 Sound, ventricular gallop, use bell to find it D. S4 Sound, atrial contraction can happen in older and athletic adults/children use bell to find E. Thrill; palpable vibration from a murmur or cardiac malformation, measure using palm of hand to check for vibrations Inflammatory Disorders: Auscultating a Friction Rub A. grating sounds from an inflamed visceral and parietal rubbing against each other during inspiration and expiration B. Patients may have pain when breathing in and out due to inflammation of pleural layer C. May be hear in pts w/ pleuritis Electrolyte Imbalances: Interpretation of Laboratory Findings: Ch. 58 A. Sodium 134-145 B. Potassium 3.5-5.0 C. Calcium 9-10.5 D. Magnesium 1.3- 2.1 Postoprative nursing Care: Complications Following Rhinoplasty A. Excessive Swallowing→ Bleeding B. [Show More]

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