Pre-Clinical Review

What are the elements to the infection chain?

- Infectious Agent
- Reservoir
- Portal of Exit
- Transmission
- Portal of Entry
- Host Susceptibility

C. Diff requires you to wash your hands with what?

Nonantimicrobial Soap

When do we put on PPE for transmission-based precautions?

Before entering the room and before leaving the room

Contact Precautions

Gloves and Gown

Examples of Contact Precautions include what?

MRSA, VRE, C. Diff

Droplet Precautions

Mask

Examples of Droplet Precautions include what?

Influenza, Diphtheria

Airborne Precautions

N95 Mask

Examples of Airborne Precautions include what?

TB, Measles, Varicella

Protected/Reverse Isolation

Also called "Neutropenic Precautions"
- Used when patient immune system is weak/compromised and can't fight pathogens

Order of Donning PPE

Gown, Mask, Goggles, Gloves

Order of Doffing PPE

Gloves, Goggles, Gown, Mask

How often do we assess VS?

- On admission
- As part of shift assessment
- Routine q 4 hours
- Anytime patient feels "funny/different"
- Any condition changes
- Before/after a procedure
- Before/during/after the admin of some meds
- Before/during/after blood transfusion

Normal Temperature

97.0-100.4 (Older Adults = 96.5-97.5)

Normal Pulse

60-100 bpm

Normal Respirations

12-20 breaths per minute

Normal BP

90/60-130/90 (120/80)

Normal O2 Saturation

93%-100% on room air (90% for COPD)

What is the 6th ("Extra") VS?

Pain Scale

What is the most reliable pulse?

Apical Pulse

Where is the apical pulse?

5th ICS MCL

Normal Blood Glucose

70-110 mg/dL

When do we check blood glucose?

AC&HS, q 6 hours, etc.

The 5 Steps of the Nursing Process

ADPIE"
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation

Maslow's Hierarchy of Needs (Bottom to Top)

- Physiological Needs
- Safety
- Love/Belonging
- Self-Esteem
- Self-Actualization

What are the 3 parts of a nursing diagnosis?

1. Nursing Diagnosis - Pt. response to problem
2. Related To - The etiology
3. As Evidence By - S/s that support the diagnosis

How many goals are in the Nursing Care Plan?

2-3

How many interventions are in the Nursing Care Plan

6

What does it mean for a nursing care plan goal to be SMART?

- Specific
- Measurable
- Attainable
- Realistic
- Time-Bound

What does SBAR stand for?

- Situation
- Background
- Assessment
- Recommendation

What do we sign after a chart entry?

First Initial, Last Name, Job Title

SOAPIE Documentation

- Subjective Data
- Objective Data
- Assessment
- Plan
- Intervention
- Evaluation

PIE Documentation

- Problem
- Intervention
- Evaluation

How do you document an error?

- One sing line
- "Error" written above
- Initials

Do not refer to Incident Reports where?

In the patient chart

When should a morse fall scale be completed?

Every patient during every shift

What are the categories within the Morse Fall Scale?

- History of Falling
- Secondary Diagnosis
- Ambulatory Aid
- IV or IV Access
- Gait
- Mental Status

What is considered a "No Risk" with the Morse Fall Scale?

0-24; Provide good basic nursing care

What is considered "Low to Moderate Risk" with the Morse Fall Scale?

25-45; Implement standard fall precautions

What is considered "High Risk" with the Morse Fall Scale?

46+; Implement high risk fall prevention interventions

What are the standard interventions used to reduce falls (Used in Low to Moderate Risk)?

- Call light and needs within reach
- Hourly rounds
- Well-lit/decluttered patient areas
- Bed/chair wheels locked and in low position
- Non-skid socks
- Clutter-free room
- Change positions slowly ("dangle")

What are interventions to reduce falls for high risk patients?

- Keep patient in room close to nursing station
- Sitter/family member available
- Bed-chair alarms

What does a green wristband mean?

Latex Allergy

What does a red wristband mean?

Patient has an allergy

What does a yellow wristband mean?

Patient is fall risk

What are the two main concerns of a seizing patient?

Airway and Safety

How do we secure the airway of a seizing patient?

- Turn patient on side
- Ensure nothing is in their mouth

What are the interventions of a seizing patient?

- Secure airway (Turn on side and empty mouth)
- Remove objects that could cause injury (Glass, tight clothes, etc.)
- Time the seizure
- Bed in low position
- Pad the bedrails
- Suction equipment set up in room
- O2 available

Why do we have suction set up for a seizing patient?

Aspiration Risk

What needs to be done before applying restraints?

Make sure this wasn't a go to; document what you have done to try and address the issue

What do you tie restraints to?

The bed frame, not the side rails

How long does a restraint order last?

24 hours

How often do we assess restraints to check circulation and other needs?

2 hours; one at a time for circulation

What do we check when assess restraints every 2 hours?

- Skin Integrity
- Pulses
- Skin Temp
- Color
- Sensation

What is the acronym for fire safety?

RACE"
- Rescue
- Activate Alarm
- Contain
- Evacuate/Extinguish

What is the acronym for operating a fire extinguisher?

PASS"
- Pull
- Aim
- Squeeze
- Sweep

Lowering a pt. to the ground is still considered what?

A fall

How do you lower a pt. to the ground?

- Straight back
- Bend legs
- Let pt. slide down your legs
- Gently lower to the ground

Supine Position

Prone Position

Right Lateral Recumbent Position

Left Lateral Recumbent Position

Low Fowler's Position

Supine with HOB elevated 15-30 degrees

Semi-Fowler's Position

Supine with HOB elevated 30-45 degrees

Fowler's Position

Supine with HOB elevated 45-60 degrees

High Fowler's Position

Supine with HOB elevated 90 degrees

Trendelenburg Position

Reverse Trendelenburg Position

Braden Scale

A tool for predicting pressure ulcer risk

What are the categories of the Braden Scale?

- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and shear

How often do you reposition a pt. to avoid pressure ulcers?

2 hours

What are the early pharm and non-pharm prophylaxis measures to avoid DVTs and deconditioning?

- Early Ambulation
- TED Hose
- SCD's/ALP's (Sequential Compression Device/Alternating Leg Pressures)
- Heparin

What needs to be considered before we help a pt. ambulate?

- Activity Order & WB Status
- Cognition
- Physical Ability
- Pain
- Medical Conditions

How do we clean the limbs when administering a bath?

Distal to proximal

In what order do we use the bath wipes?

1. Neck/Chest
2. Left Arm
3. Right Arm
4. Perineal Area
5. Leg Leg
6. Right Leg
7. Back
8. Buttocks

When would we use chlorhexidine wipes?

- ICU pt.
- Pre-op pt. (3 days before surgery)
- Central Lines

Where can you not use chlorhexidine?

Face

To provide oral care there must be what?

An order

What's the difference between oral care with a regular pt. snd then with an unconscious one?

An unconscious pt. requires two nurses.
- One to suction to avoid aspiration

What position do we provide oral care?

Side lying

What specific injuries/complications do we assess for before providing hair care?

Any neck problems and ROM

How do we shave a pt.?

- Acquire disposable razor
- Towel over chest
- Shaving cream
- 45 degree angle - pull skin taut
- Short, firm stroke with grain of hair
-Rinse with warm water

What pt. cannot receive foot care?

- Impaired sensation - Low healing
- High risk foot issues

In what direction do we provide eye care?

Inner to utter canthus

In what position do we provide eye care?

Side-lying to side of affected eye or supine for both

How do we pull the pinna in adults?

Up and back

How do we pull the pinna for children?

Down and back

What position is the pt. in for ear car?

Sitting or lying towards effected ear

How long do we leave the cotton ball in after ear care?

5-10 min

Aspiration

Misdirection of secretions into the lower larynx or respiratory tract

What are some techniques to prevent aspiration?

- Pt. in high-Fowler's
- No straw
- Thicken fluids

What are the risk factors for aspiration?

- Lying down
- Dysphagia
- Stroke
- Head/neck cancer
- Head trauma
- Dementia
- Parkinson's
- Medical interventions that compromise the gag reflex

What do you document when feeding a pt.?

- Type of diet
- Amount of food consumed (%)
- Amount of liquid consumed (mL)
- How pt. tolerated

Enteral Feeding

Feeding delivered via tube to GI tract

What tube has the least risk of aspiration?

Enteric tube

The most common complication with feeding tubes is improper placement where?

Esophagus or Pulmonary System

What do we assess for prior to NGT placement?

- Hx of deviated septum, nosebleeds, or oral facial sx
- Anticoagulant therapy
- Gag reflex
- Mental status
- Lung sounds
- Bowel sounds
- Physician order

What must we use to confirm tube feeding placement before administering feedings or meds?

CXR

How do we check the feeding tube for migration?

Check tape marker on tube

What position must the pt. stay in while with a feeding tube?

HOB at 30 degrees at all times

What position does the pt. sit for feeding tube insertion?

High-Fowler's

Why do we aspirate a pt. with a feeding tube?

- pH
- Amount
- Color
- Quantity

How often do we verify tube feeding placement?

- Before administering feedings and medications
- Every 4-6 hours

GI aspirate with a pH of 5.5 or less means what?

The tube is in the gastric area

GI aspirate with a pH of 6.0 or more means what?

The tube is in the small intestines or pulmonary system

Removing an NGT requires what?

An order

How do we remove an NGT?

- Disconnect line and clear with 20 mL of air
- Place towel on chest
- Have pt. hold breath while you pull out slow and steady

What do we inspect with the NGT after removal?

The tip of the tube is still intact

What are the different combination tubes?

PEG and PEJ

What's special about the PEGs and PEJs?

- Allow for jejunal and gastric decompression
- Has separate jejunum and gastric ports

How do we care for PEG/PEJ tubes?

- Soap and water
- Clean stoma outward
- Rinse and pat dry
- Dressing goes over disk

Enteral feeding bags and tubes are changed when?

Every 24 hours

How often do you perform residuals?

Every 4-6 hours

What ongoing assessments should you do every 4 hours with a pt. on tube feeding?

- Lungs
- Bowel
- Electrolytes
- Weight

What do you do with a residual of 0-250 mL?

Return and continue feeding

What do you do with a residual of 250-500mL?

Hold and reassess

What do you do with a residual of >500mL?

Do not return residual and stop feeding

Don't start feeding if what?

- Position not confirmed via CXR
- You suspect migration

How often do we irrigate a enteral feeding tube?

4-6 hours

When do we irrigate a feeding tube?

- Before, between, after meds
- Before and after feeding

How many mL of water do we push to irrigate the feeding tube?

30 mL

Salem Pump

Double-lumen and vented; clear lumen attached to suction to remove gastric contents and blue lumen is a vent

Levin

Single-lumen and not vented

Parenteral Nutrition

Provided for pt. with significant GI dysfunction

What do parenteral nutrition feedings provide?

Amino acids, glucose, lipids, electrolytes, minerals, etc.

How often do we monitor a pt. with PN?

- 8 hours I&O
- 4 hours VS
- Weights 3 times a week
- 6 hours FSBS

What are the risks of PN?

- Pneumothorax
- Air embolism
- Localized infection
- Sepsis
- Hyper or hypoglycemia

Peripheral Parenteral Nutrition (PPN)

- Through peripheral IV
- Short-term 4-7 days
- Less osmolality

Total Parenteral Nutrition (TPN)

- Through central line or PICC (peripherally inserted central catheter)
- Long-term
- Usually ordered with lipids

Hypoventilation

- Decrease ventilations
- Bradypnea, confusion, lethargy
- Retaining CO2

What causes hypoventilation?

- Shallow breathing (pain, immobility, medications)
- Diminished lung function (COPD, consolidation, mass, pneumothorax/hemothorax, etc.)

Hyperventilation

- Increased ventilation
- Tachypnea, dyspnea, tachycardia
- Putting out too much CO2

Putting out too much CO2 causes what symptoms?

Lightheadedness, dizziness, tingling in the mouth/fingertips

What causes hyperventilation?

- Anxiety, infection, fever, etc.
- Increased metabolic rate (body prompts increase in ventilation)

What is an early neuro/mental sign of hypoxia?

Lethargy, confusion, irritability, anxiety, restless

What is an late neuro/mental sign of hypoxia?

Decrease in LOC, syncope, decreased A&O

What is an early cardiac sign of hypoxia?

Increased HR, increased BP

What is an late cardiac sign of hypoxia?

Cardiac arrest, dysrhythmia, decreased BP

What is an early respiratory sign of hypoxia?

Decreased O2, increased RR, dyspnea

What is the late respiratory sign of hypoxia?

Decreased O2

What is an early integumentary sign of hypoxia?

Cool extremeties

What is the late integumentary sign of hypoxia?

Cyanosis

What does is mean to treat oxygen therapy as a medication?

It needs an order

Nasal Cannula

1-6 L, 24-44% O2

When do we use a humidifier for the nasal cannula?

4-6 L

When do we use a high flow nasal cannula?

Critical care with acute respiratory failure

High Flow Nasal Cannula

Up to 60 L; already humidified

What color is the tube for high flow nasal cannula?

Green

Oxymizer

1-15 L, 24-60% O2

Is humidification needed for the oxymizer?

No

Simple Face Mask

5-8 L, 40-60% O2

Venturi Mask

4-12 L, 24-60% O2

Partial Nonrebreather Mask

6-10 L, 60-100% O2

Nonrebreather Mask

6-15 L, 60-100% O2

Partial Nonrebreather Mask

An oxygen-delivery apparatus similar to a nonrebreather mask, but with a two-way valve allowing the patient to rebreathe exhaled air.

Nonrebreather Mask

A device used to deliver high concentrations of oxygen to patients in acute respiratory distress; has a reservoir bag and a one-way valve to prevent rebreathing.

Face Tent

8-12 L, 28-100% O2

Oxygen Hood

5-8 L, 28-40% O2

What age group typically used the O2 hood?

Infants

Endotracheal Tubes and Tracheostomies require constant what?

Humidification

What groups commonly use CPAP and BiPAP machines?

COPD and sleep apnea

What are the types of chest physiotherapy?

- Cough
- Chest wall percussion
- Vibration and shaking (CPT Vest)
- Postural Drainage

Flutter Valve

Used on expiration, vibrates to break up mucus

Insentive Spirometry (IS)

Used on inspiration; helps pt. deep breath to avoid post-op atelectasis/pneumonia

Peak Flow Meter

Used in exhalation, for asthma pt. to measure air that can be quickly forced from lungs

What are the interventions for proper airway management?

- High-Fowler's
- Mucus Clearance
- Medication
- Nebulizer
- Enteral Feeding
- Ambulation
- Push fluids
- Humidity
- Chest Physiotherapy

What may indicate a pt. needs upper airway suctioning?

- Gurgling on inspiration/expiration
- Restlessness
- Excessive oral secretion
- Emesis in mouth
- Pt. can cough but not clear secretion s

What do you do after suctioning the airway?

Clear the line with saline

What type of technique do we use for upper airway suctioning?

Clean technique

What type of technique do we use for artificial airway suctioning?

Sterile technique

What is included in artificial airway suctioning?

Endotracheal Tubes and Tracheostomy

What do you do before you start to suction an artificial airway?

Pre-oxygenate or Hyper-oxygenate
- 5-6 Deep breaths
- 30-60 seconds with 100% O2

How long can you suction at one time with artificial airways?

10 seconds

What direction do you suction with an artificial airway?

Suction going back up but not down

What indicates a pt. with an artificial airway needs suctioning?

- S/s of hypoxia
- Productive cough
- Ineffective cough
- Course crackles
- Acute distress

What are the risks of suctioning an airway?

- Hypoxemia
- Cardiac dysrhythmia
- Laryngeal spasm
- Bradycardia (stimulation of vagus nerve)
- Nasal trauma

How much time must pass between each suction of the airway?

1 minute

What position does a pt. sit for tract care?

Semi or High Fowler's position

When must you immediately stop suctioning?

- Pulse decreases 20 BPM
- Pulse increases 40 BPM
- O2 sat falls below 90% or 5% below baseline

How often do we provide tract care?

4-8 hours

When is the best time to get a sputum collection?

Morning Time

Constipation

>3 Days without a BM

What can occur with prolonged constipation?

Fecal Impaction
- N/V bloating, liquid around stool

Chronic constipation has the risk of what?

Hemorrhoid

What intervention can we do to ease constipation?

- Increase fluids
- Increase fibrous foods
- Hot/warm liquids
- Prunes
- Activity
- Stool softener/laxatives

What position must the pt. be in for digital disimpaction?

Left Lateral Sims

What must you monitor with digital disimpaction?

- Monitor baseline VS
- Monitor HR (Vagal Down)

What could cause a false positive guaiac test for occult blood?

Eating red meat within last 3 days

What could cause a false negative guaiac test for occult blood?

Taking vitamin C

Why might someone receive an enema?

- Treat constipation
- Prep/clean before procedure
- Administer meds

Cleansing Enemas

Water, saline, soap suds, fleet
- Stimulates peristalsis by irritation of the colon and causing intestinal distension

Oil Retension Enemas

Uses a small volume to soften stool making it easier to excrete

What's special about a fleet enema?

Uses a small volume, hypertonic solution

How do you administer and enema?

- Use warm solution
- Prime tube
- Left Lateral Sim's Position
- Insert tube 3-4"
- If unable to insert the enema diffuse a small amount
- If still unable to enema, digital disimpaction
- Infuse slowly (High=18in, Regular=12in, Low=3in)

Small intestine absorb what?

Nutrients

Large intestine absorb what?

Water

Colostomy

Output similar to regular stool (In large intestine)

Ileostomy and Jejunostomy

Output watery-to-thick (In small intestine)

When should you empty an ostomy bag?

1/3-1/2 full

When should you change an ostomy bag?

3-7 days

How much bigger should the gaffer be then the stoma?

1/8-1/16

A blanching wound means what?

Moisture related

A non-blanching wound means what?

Pressure related

Hemostasis Phase of Wound Healing

- Vasoconstriction and clotting
- Platelets attract to repair

Inflammatory Phase of Wound Healing

- Vasodilation so plasma and blood cells can increase edema, erythema, and exudate

Proliferative Phase of Wound Healing

- Epithelialization
- Granulation
- Decrease in wound size

Maturation Phase of Wound Healing

- Scar development

Primary Intention Healing

Wound purposely closed
- Sutures and staples
- Decrease scarring

Secondary Intention Healing

Wound heal on own
- Increase in scarring

Teritary Would Healing

Wound is left open to allow swelling to decrease and then the doctor goes back in to close

Dehiscence

Failure of wound to heal, wound breaks open
- occurs 4-14 days after surgery

Evisceration

Complete failure to heal, wound opens with organs visualized
- Requires OR
- Heals by secondary intention

Serous

Thin, watery plasma fluid
- Seen with swelling

Serosanguinous

Watery with some blood
- Sometime dr will insert a drain

Sanguinous

Frank red blood with some clots
- Expected in post-op

Purulent

Infection with possible odor
- Needs wound culture

An epithelial ridge around a would indicates what?

Good healing

What are the correct methods of wound healing?

- Clean most contaminated to least contaminated
- Irrigate from top to bottom with solution
- Don't let irrigation fluid pool in wound

Primary Dressing

Direct contact with wound

Secondary Dressing

A dressing that covers or holds a primary dressing in place

Damp-to-Dry Dressing

Debreeding wound

Damp-to-Damp Dressing

Keeps a wound moist
- Change 4-6 hours

Dry Dressing

For wound healing by primary intention, absorbs minimal drainage

Hemovac Drain

A closed drainage system in which a soft drain is attached to a springlike suction device
- Holds 500 mL
- Emptied when 1/2-2/3 full

JP Drain

Hollow bulb-like device used to collect drainage
- Holds 200 mL

Penrose Drain

A flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing

How do we apply bandage?

Distal to proximal

Wound VAC

A medical device that applies negative pressure to a wound to promote healing and prevent infections

Removal of staples required what?

An order

What can serum electrolytes tell you about pt. output?

- Hemoconcentration: Increased Output, Increased concentration of electrolytes
- Hemodilation: Decreased Output, Decreased concentration of electrolytes

What is the minimum UOP?

30 mL

Simple-Lumen Catheter

No balloon; for one time bladder emptying

Double-Lumen Catheter

Also called indwelling; uses a balloon to hold

Triple-Lumen Catheter

Continuous Bladder Irrigation, used post-surgery to cleanse bleeding

Coude Tip Catheter

For males with enlarged prostates

Mushroom and Wing-Tipped Catheter

For urostomies

What is the normal size of the balloon?

5cc-10cc for adults
30 mL for urologic surgery pt.

What are the normal catheter sizes?

14-16 French
- The greater the number the bigger the catheter

Once you get urine flow, how much farther do you insert the catheter?

1-2 inches

How often do you provide catheter care?

Every 8 hours

Postvoid Residual (PVR)

The amount of urine remaining in the bladder immediately after voiding
- Normal is <50 mL

How long must you clamp a catheter before taking a urine specimen?

15 minutes

Piston Syringe

Used for open irrigation
- Double lumen catheter
- 60 cc syringe
- Not ideal = Introduces bacteria