NR226 / NR-226 Final Exam Review & Study Guide : Fundamentals [Patient Care] - Chamberlain

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NR-226 Fundamentals [Patient Care] Final Exam Review & Final Study Guide • Review your nursing process, priorities, and safety o ADPIE ▪ Assessment, Diagnosis, Planning, Implementation, Evalu... ation o Priorities ▪ First-level Priority ▪ ABC’s (Airway, Breathing, Circulation), and Vital Sign concerns ▪ Second-level Priority ▪ Requiring your prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security). ▪ Third-level Priority ▪ Problems with lack of knowledge, activity, rest, or family coping o Patient Safety First ▪ Ex. In case of fire, get patient out of the room first; keep patients with high fall risk near nursing station • Review calculations (ALL) o 1 oz = 30 ml o 1tbs = 15 ml o 1 tsp = 5 ml o 1 cup = 8 oz o 1 kg = 2.2 lb • Review pain management, PCA pumps o Patient-controlled analgesia (PCA) ▪ Medication delivery system that allows clients to self administer safe dose of opioids ▪ Small, frequent dosing ensures consistent plasma levels. ▪ Clients have less lag time between identified need and delivery of medication, which increases their sense of control and can decrease the amount of medication they need. ▪ Morphine, hydromorphone, and fentanyl are typical opioids for PCA delivery ▪ Clients should let the nurse know if using the pump does not control the pain ▪ To prevent inadvertent overdosing the client is the only person who should push the PCA button. • Review expected physiological changes for older adults o Integumentary ▪ Decreased skin turgor, subcutaneous fat, and connective tissue (dermis), which leads to wrinkles and dry, transparent skin ▪ Loss of subcutaneous fat, which makes it more difficult for older adults to adjust to cold temperatures. ▪ Thinning and graying of hair, as well as a more sparse distribution ▪ Thickening of fingernails and toenails o Cardiovascular/ Pulmonary ▪ Decreased chest wall movement, vital capacity, and cilia, which increases the risk for respiratory infection ▪ Reduced cardiac output ▪ Decreased peripheral circulation ▪ Increased blood pressure o Neurosensory ▪ Slower reaction time ▪ Decreased touch, smell, and taste sensations ▪ Decreased saliva production ▪ Decline in visual acuity ▪ Decreased ability for eyes to adjust from light to dark leading to night blindness, which is dangerous when driving. ▪ Inability to hear high-pitched sounds (Presbycusis) ▪ Reduced spatial awareness o GI ▪ Decreased digestive enzymes ▪ Decreased intestinal motility, which can lead to increased risk of constipation ▪ Increased dental problems o Neuromuscular [Show More]

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