HESI Fundamentals Study Guide

Foundations HESI Review Read all of chapters 1 and 2 in HESI book!!! Study this information for ALL HESI exams! Basic Nursing Skills – Vital Signs – Chapter 30  BP cuff size (review what happens with wrong cuff size) o False-high diastolic readings on BP cuff  Deflating cuff to slowly, inflating to slowly False-low readings on BP  Cuff to wide, arm above heart level o False-high readings on BP  Cuff to narrow/short, cuff to loose or uneven, arm not supported o  Technique for palpating systolic BP o (When arterial pulsations too weak to detect Korotkoff sounds or to identify auscultatory gap). Box 30-9, p. 508. Palpate radial pulse. Inflate cuff 30 mmHg above point at which you can no longer palpate the pulse. Slowly release valve and deflate cuff… See documentation guidelines, as well.  Technique for taking BP in the leg – o Popliteal artery.  SBP usually 10-40 mmHg higher than using brachial.   DBP remains same. Ch. 30, p. 508. Orthostatic BP readings – o orthostatic hypotension also called postural hypotension;  obtain supine, sitting, and standing (1-3 minutes between each);  observe pt. for dizziness, fainting, lightheadedness.  Record pts. position with each reading (remember pt. safety);  don’t delegate this.   Note when you should take postural hypotension readings. Know normal vital signs – techniques, ranges, assessment, etc. Findings on respiratory assessment? o RR: 12-20 o BP:<120/<80 o HR: 60-100 o Temp: 98.6F or 37C o Pain 5th vital sign Page Vital Signs – Guidelines  Nurse ultimately responsible for vitals but can be delegated in stable patients,  RN to interpret their significance and make decision about interventions;  Determine equipment functional and appropriate; o Know pt normal vitals;  Know history, therapies and meds that could affect vitals;  Control environmental factor that could affect vitals; o Be organized and use systematic approach to ensure accuracy; o Use vitals to determine indications for med administration;  Analyze measurements; communicate changes to HCP;  Advise pt and or pt family of results.  What is a pulse deficit? What do you do if you detect a pulse deficit during your assessment? o See Clinical Decision (If pulse is irregular do an apical/radical pulse assessment to detect a pulse deficit. Count apical pulse help patient to supine position or sitting position move aside bed linen and gown to expose sternum and let side of chest. While a colleague counts radial pulse begin apical pulse count out load to simultaneously assess pulses. If pulse differs by more than 2 a pulse deficit exists which sometimes indicates alternation in cardiac output.). o What if pulse deficit is in lower extremities? Pedal pulse weak on one side?   Assess next pulse up, e.g., posterior tibial.  If that pulse is weak, move up to popliteal, etc.  Compare one extremity to the other. Apical pulse is taken for a full minute; o PMI (point of maximal impulse) located at 4th or 5th intercostal space (ICS), just medial or left of the midclavicular line (MCL).  Elevated BP? Pt c/o headache? What may this indicate? What do you do? o Reassess using other arm. o Do not keep taking BP on same extremity. o Reassess!!! o May even need a manual cuff. Pain and Sleep  Exercise and Sleep – o Exercise 2 hrs before bedtime allows cool down period and fatigue that promotes relaxation (see Sleep Hygiene Habits, Box 43-9, p. 1006). Page o Should not exercise closer to bedtime. o See Factors Affecting Sleep, pp. 998-999.  Sleep problems; o Altered sleep – pain. o o Treat pain first. See Box 43-5 Nursing Assessment Questions and Box 43-6 Questions to Ask to Assess for Specific Sleep Disorders.  Be aware of CNS depression with benzodiazepines (lams and pams) and barbiturates (barbital). o If taking a benzo for sleep, nurse needs to provide continued assessment for resp. depression.  Antidote is flumazenil (Romazicon).  Prioritize assessment in a variety of patients.   Think ABC’s, acute/chronic, unstable/stable, Normal sleep patterns and interventions to help return pt. to normal sleep patterns; o types of nonpharmacologic interventions (before giving meds). See Sleep History, pp. 1000-1002. Health Promotion, pp. 1005-1009. o These all go together with sleep practices and sleep promotion.  Insomnia – o Symptom pts experience when they have chronic difficulty failing asleep, frequent awakenings from sleep or a short sleep or nonrestorative sleep. o DifÏculty falling asleep and staying asleep;  PROMOTING SLEEP- maintain a regular bed time and awake time, eliminate naps or limit to 20 mins or less twice a day, go to bed when sleepy, use warm bath to relax, if can't go to sleep in 15-30 min get out of bed, avoid stimulating activities, keep noise to a minimum, use meds, limit alcohol, caffeine and nicotine in late afternoon/ evening, o Medications; client teaching for insomnia (older adult).  Therapeutic communication techniques for patient with insomnia. See p. 996 re: insomnia. Older adults, p. 998. o Ask if they have a sleep routine. o If not, establish one. Page  Do not drink alcohol at bedtime (it may help with sleep onset, but does not promote continued sleep and can increase risk for sleep apnea).   *See last page for Promoting Sleep in Older Adults. Risk assessment for sleep apnea, see p. 996 o (Two major risk factors are obesity & hypertension.) o Other risk factors include smoking, heart failure, type 2 diabetes, alcohol, and a positive family history also greatly increases the risk of developing sleep apnea.  Pain assessment – See pp. 1022-1028. Observe for nonverbal cues (grimacing, rigid body posture, limping, frowning or crying). (See Box 44-9 Behavioral Indicators of Effects of Pain, p. 1027).  Know the difference in acute pain and chronic pain symptoms. o Acute pain  Temporary  Occurs after an injury to the body  Includes postoperative pain, labor pain, renal calculus pain. o Chronic pain   Nonmalignant (low back pain, RA)  Intermittent (migraine Headache)  Malignant, associated with neoplastic disease. Assess quality and quantity of pain. o How? Reassess pt. after administering pain med. When? (peak) o pain scale 1-10, reassess 30 minutes.  Chronic pain – assess abilities to perform ADLs, function on job, etc.  Complementary and Alternative Therapies – o Acupuncture, etc. (We did not cover acupuncture on quiz. See p. 694).  Acupuncturist inserts sterile needles into the skin in specific areas – modifies response of the body to pain and how pain is processed by central neural pathways and cerebral function. o Effective for treating  low back pain, myofascial pain (TMJ), hot flashes, migraines, etc. Caution use in pregnancy, hx of seizures, immunosuppression. o Contraindicated in patients with bleeding disorders and infection. Page  Complementary and alternative therapies are now considered “integrative therapies,” and many health care practitioners participate in these integrative approaches. o Have patient talk with HCP about using these therapies, especially when treating conditions that traditional medicines have proven ineffective. See p. 696.  Breakthrough pain – how to manage breakthrough pain. See pp. 1041-1042. See Box 44-17, p. 1042. May need to include “rescue dose” of medication, such as adding an IR (immediate release) opioid in between doses of scheduled CR (continued release or sustained release) meds. Another option is decreasing both dose & frequency of scheduled opioid (so pt. gets it more often without getting OD). o Incident pain predictable and elicited by specific behaviors or triggers such as a voluntary act (walking) or involuntary (coughing) or treatments (wound dressing) o End of dose pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesia o Spontaneous pain- pain that is unpredictable and not associated with any activity or event. o Treatment  Lifestyle changes, management of reversible causes, modification of pathological processes, nonpharm management, pharm management rescue dose, interventional techniques.  Management of pain with nonpharmacologic measures (Hesi book). o See also pp. 1031-1035 (biofeedback, relaxation and guided imagery, distraction, music, cutaneous stimulation (TENS unit, massage, hot and cold therapy, acupressure, etc.), herbals, etc.  Surgical patient – o  Pain control with PCA, pp. 1038-1039 and Skill 44-1, pp. 1046-1049). Evaluation – pain outcome (quality and quantity; 1-10 scales. compare assessment to baseline assessment). Document. Elimination  Male catheter insertion o  (how far to insert catheter after visualizing urine in the tube?) Bifurcation Female catheter insertion o (advance 1-2 inches after seeing urine); o positioning (dorsal recumbent position with knees flexed. Alternative position is side lying (Sims) with upper leg flexed at hip and knee. o Dorsal recumbent is not lithotomy. Page  Assess allergies to latex and iodine (shellfish) – why? CT scans, foleys  Indwelling catheter – o ambulation; never raise drainage bag above level of bladder; o prior to ambulation, drain all urine from tubing into drainage bag; o prevent dependent loops and kinking of tubing (see Box 46-10 Preventing CatheterAssociated Urinary Tract Infections), p. 1122.  No urine – o check for kink. o Irrigate indwelling urinary catheter (open and closed techniques; indications); o Evaluation after irrigation (should have more fluid returned than you used for irrigation).  Removal of indwelling catheter (what happens when client has urinary retention?). o If catheter removed earlier in the day, determine when patient voided after catheter removal.  If bladder distended, will likely need to reinsert catheter.  If no distention, may use bladder scan?  Priority after catheter removal is when did patient void?  Urinary diversion systems – ileal conduit; patient with cystectomy  Obtaining a timed (6, 12, or 24-hour) urine specimen  What do you do if specimen becomes contaminated? – o start over (obtain new specimen). For example, if obtaining urine specimen that contains multiple colonies, it is likely contaminated. Obtain new specimen.  How to obtain urine for C&S. See Table 46-3 Urine Testing for obtaining Clean-voided or midstream (culture & sensitivity) and Sterile specimen for culture and sensitivity. Skill 46-1 for Collecting Midstream (Clean-Voided) Urine Specimen.  What to assess when obtaining urine specimen? o Is client able to void?  Residual urine (nursing problem) – what is potential problem when urine remains in the bladder?  S/S of UTI and/or cystitis? (dysuria)  Elimination – Page o  bedside chair/commode (best position, when possible) Interventions that promote normal elimination o (fluid, fiber, exercise)  Impaction removal o (requires physician order)  Obtaining stool specimen o (wear gloves; does not have to have visible blood to be a sample for occult blood testing). See p. 1156.  Fecal occult blood test (guaiac, Hemoccult) o (Box 47-4, pp. 1157-1158). Repeat 3 times. What can affect results?  Bowel training/bowel retraining – p. 1168. Bowel Retraining – Focus on Older Adults Box 44-13. Patients with chronic constipation or incontinence need bowel training.  Colostomy – gas (vent the colostomy bag—do NOT poke holes in it)  Purpose and technique of colostomy irrigation.  Nursing diagnosis for patient with diarrhea? Primary is fluid volume deficit; impaired skin integrity is potential secondary problem. Nutrition/Diets/Fluids  NG placement – X-ray (KUB – abdomen) for verification (then agency policy for verifying before each feed) – auscultation over stomach or pH testing of gastric contents.   Tube feeding – position (HOB minimum of 30 degrees—higher if tolerated) Nursing diagnosis for client with vomiting (especially very young and very old); fluid volume deficit. See pp. 951-954. See Concept Map and Nursing Care Plan.  Assessment – weight with fluid retention (see below)  Physical assessment – dehydration (renal) evaluate (turgor, urine output, BUN/creatinine); weight one of the best indicators for fluid retention or loss (1 kg [2.2 lb] = 1 liter fluid)  Clear liquid diet – how to advance diets (see p. 1073), i.e., after surgery clear liquid, full liquid, soft, etc. What items are included in each diet category? (See Box 45-10, p. 1074). Consider culture and dietary preferences (vegetarians and beef or chicken broth). Clear liquid includes anything that is clear: clear, fat-free broth/bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles. (p. 1074). Full liquid includes clear liquids, in addition: smooth textured dairy products (ice cream, custard), strained or blended soups, refined cooked cereals, vegetable juice, Page pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt. See also Dysphagia Stages (Box 45-10). Remember thickened liquids for dysphagia, NOT thin liquids.  Low sodium diet – food choices. Patient teaching. Read labels!!!  Teach calcium-supplemented diet for patient with hypocalcemia. See Table 42-4, p. 941. Foods containing calcium include dairy products, canned fish with bones (e.g. canned salmon), broccoli, oranges. Requires vitamin D for best absorption. Undigested fat prevents absorption.   High protein meal (including protein foods for vegetarians) – combine incomplete proteins. Foods to promote elimination (fiber, warm prune juice) – causes of constipation (opioid use, inactivity, decreased fluid/fiber, etc.)  Constipation – interventions; constipation plan (fluid [warm prune juice], fiber, activities)  Hypernatremia – client teaching (p. 940) – sodium restrictions (why? how?) – HTN, HF, etc.  Dilutional hyponatremia (SIADH) – overproduction of antidiuretic hormone (ADH) causes water retention (produces dilutional hyponatremia, which makes sodium level go down). Do not increase sodium but restrict fluid intake. See below, including lab values for sodium (Na+).  Water intoxication – restrict fluids, not add sodium. Assess sodium level (136-145 mEq/L).  Low serum potassium (hypokalemia) – assess muscle strength (causes muscle weakness); dysrhythmias with ↑ or ↓; Antidote for hyperkalemia (too much potassium) is Kayexalate  Oral care with NG tube – should be every 2 hours.  Oral care – unconscious (see p. 841 and Skill 40-3, pp. 865-867); suction while providing care  Teaching – stomatitis (POC). Avoid hot beverages and foods as well as salty, spicy, and citrusbased foods. Use pain relievers like acetaminophen or ibuprofen. Gargle with cool water (not ice water) or suck on ice pops if you have a mouth burn. For canker sores, drink more water. Rinse with salt water. Practice proper dental care. Apply a topical anesthetic (not for children under 6). See text, p. 841.  Patient with dysphagia – thickened liquids (nectar-like or honey thickness, as well as spoon thick liquids, like pudding – not thin liquids or difficult to chew foods); feeding debilitated patient. Tuck chin to chest with each bite. Place food on strong side of mouth. (p. 1074 – Assisting Patients with Oral Feeding).  Fat content of fruits and vegetables (low fat diet), even if fat is a healthy fat. Remember low fat diet means you need to know the amount of fat being ingested.  Nutrition – teaching for weight reduction. ChooseMyPlate.gov. See Dietary Guidelines & Box 45-2, p. 1058. Mobility/Immobility/Safety Page  Proper technique for applying TED hose (antiembolitic stockings) – NAP can apply. Remember that TED hose, ACE wraps, other bandages should be wrapped from distal to proximal to promote venous return and reduce trapping of blood/pooling of blood)  Use of SCDs – purpose (proper technique) for applying pneumatic compression devices  Transferring pt. with hemiparesis; assisting to ambulate with hemiparesis. (p. 431, 804-805). Stand on affected side and support with gait belt. For transfers, have chair on strong side.  Ambulation – assess pts activity tolerance, strength, VS, balance, orientation, and need for assistance, grimacing while ambulating. Assess for orthostatic VS (have patient dangle legs on side of bed 1-2 min. prior to rising if needed) to promote safety; evaluate environment – remove obstacles, have clean and dry floor, identify rest points, have pt wear supportive, nonskid shoes. Obese patient. Frail patient.  Assisting to ambulate a patient with visual impairment (blind patient). See p. 1256.  See pp. 431-432 for methods of assisting with ambulation; what to do if pt begins to fall (assist to the floor)  Review crutch walking and crutch safety pp. 807-809 (know different gaits, up and down stairs); review safety for crutches, measuring for crutches (weight should not be on axilla but on hand grips (p. 806); 4-point crutch walking (must be able to bear weight on both lower extremities)  Wheelchair safety, pp. 390391 (wheels locked, anti-tip bars, use of footrests, etc.); wheelchair transfer after CVA  Logroll may be needed in pts who have had spinal cord injury, recovering from neck, back, or spinal surgery to keep spinal column straight and to prevent further injury. Pt turned as a unit. (p. 437)  Immobility (potential problems such as edema of lower extremities, nursing interventions; ROM. See ch. 28 and 39. (Know various ROM positions). Have immobile patient dorsiflex and plantar flex feet, push against footboard, etc.  Turning schedule for pt. with decreased mobility (impaired physical mobility); how often change position in chair?  Shearing force – what is it? How to reduce it? Potential problems? “Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces.” p. 1204.  Therapeutic mattresses, pp. 1205-1206 and Table 48-7. Don’t add any linens that will reduce the benefit of the aerated (special) mattress. Also, important to note: Box 48-8 Patient Teaching, p. 1207.  Fire – RACE (rescue/remove clients, activate alarm, confine fire, extinguish fire); follow this order! Page  Seizure – safety, see p. 393 and Box 27-14, p. 394. “Seizure precautions encompass all nursing interventions to protect a patient from traumatic injury, position for adequate ventilation and drainage of oral secretions, and provide privacy and support following the seizure.” Standard Precautions/Isolation/Asepsis  Donning and removing personal protective equipment (PPE): put on gown, surgical mask or respirator, goggles/ear protection, gloves; remove gloves first, then protective eyewear, gown, and mask last. Include putting on and removing “clean” gloves.  Proper technique for putting on (donning) sterile gloves and removing contaminated gloves; teaching UAP proper gloving technique. What do you do if person applying gloves contaminates them? What about other supplies being used? Replace anything contaminated. Do not replace what isn’t.  Preparing and maintaining sterile field (surgical asepsis principles), p. 467-469.  Standard precautions (and know what to do in obtaining a specimen using standard precautions); see p. 465 text and Box 29-13. Also, see Table 29-6, p. 459. See also text p. 458.  Isolation guidelines, p. 459-460. KNOW! Which isolation for which type of infectious agent. Table 29-6, p. 459. Contact precautions, droplet precautions, airborne precautions. Contact precautions includes putting on clean gloves when you enter the room. Certain organisms can remain viable for weeks in the environment.  Caring for a patient with MRSA (contact precautions).  C. difficile – gown and gloves; also requires washing with soap and water.  Airborne precautions – private room, negative-pressure airflow (HEPA filtration), mask or respiratory protection device, N95 respirator (depending on condition). Measles, chickenpox (varicella), Herpes zoster, shingles (VZV), TB. Remember mnemonic: My Chicken Hez TB – Airborne (N95)   Handwashing – home, teaching (proper technique). Acrylic (artificial nails) – evidence indicates artificial nails and nails with nail polish (can chip) harbor microorganisms. Health care workers should avoid acrylic nails and nail polish. Keep nails trimmed.  Bathing patient with hepatitis A – hep A transmitted through feces (“vowels bowels” – hepatitis A, hepatitis E) – wear gloves Oxygenation/Tissue Perfusion   Oxygen – safety; disconnect; humidified if over 4 liters (1-3L/min. for COPD); cannula pressure Oxygen flowmeter – loose/disconnect (see skill, Box 41-9 Procedural Guidelines Applying a Nasal Cannula or Oxygen Mask, pp. 900-901). Page  When using nasal cannula oxygen, have personnel provide skin care around patient’s ears and nose (tubing can cause skin breakdown).  Priorities with orthopnea; priority assessment for hypoxia (early S/S?; later S/S?). Priority is elevating HOB and providing oxygen, if needed. See p. 877 Hypoxia (note clinical signs and symptoms).  Obtaining pulse oximetry (what to do if low reading?). Change to a different site, for example in the perfect Hesi world, you can change from a digit (finger) to the ear (requires different probe).  If patient has O2 ordered for oxygen saturation below 90% (or whatever is ordered) and pulse ox reading is low, try changing sites (once). If O2 sat remains below desired level, apply the oxygen as ordered. Don’t keep changing sites. Having patient take deep breaths is only a temporary fix. It will not really raise their oxygen saturation.   Assessment – respiratory findings (include vital signs, pulse, resp., etc.) Peripheral cyanosis (fingers, toes) may indicate just that the patient is cold – check their pulse first. If patient’s lips are cyanotic, this is central cyanosis – apply O2 at 2L and notify HCP.  Assessment with nasopharyngeal suction (check patency of nostril/naris first); O2 saturation [see clinical decision, p. 859]  Oropharyngeal suctioning (Yankauer) – safety Skill 41-1. Nonsterile procedure. Have patient cough to clear airway first (brings up mucus to back of oropharynx). “Insert Yankauer catheter into patient’s mouth. With suction applied intermittently, move catheter around mouth, including pharynx and gum line, until secretions are cleared.” (from Evolve/Hesi study packet). Be ready to apply O2 if SpO2 drops below 90% or 5% below baseline. Monitor oxygen saturation (pulse ox). Apply O2 if drops. Do NOT enter trachea. This is oral suction only.  Nasotracheal suctioning – safety (see skill above)  Respiratory – infection control (biohazard bags). See Control of Transmission, pp. 457-458.  Assessing pedal pulse – use light pressure to prevent obliterating the pulse Skin Integrity/Hygiene  Nursing diagnosis for patient with diarrhea (think!), particularly the elderly.  Older adult and skin care  Nursing interventions for pts. with impaired skin integrity; skin care for immobile client  Hygiene – self-care deficit (see Orem’s theory, p. 47-48) Assessment of self-care ability, p. 826827; bottom p. 830-831; NCP p. 834-835.  Soaking feet – part of routine pt. hygiene. Can delegate to NAP, but NAP cannot trim nails. Soak feet for 10-20 minutes in warm water (not hot); rewarm water after 10 minutes. Dry thoroughly, apply Page lotion. Nurse can trim nails using clippers straight across and even with fingertips. It is not necessary to soak the feet of an unconscious patient (wash feet, but do not soak).  Do NOT soak feet of pts. with diabetes or other peripheral vascular disorders. Do not trim in pts. with circulatory problems. Usually done by nail care specialist (such as podiatrist).  Safety – heat application (hot and cold therapy). Assess for sensation and cognition.  IV site pain – assessment? interventions? What if it is potassium (KCl) in IV? IV pump alarms? Wound Care  Braden scale – risk assessment tool for pressure ulcers; interpretation of Braden score (lower score is greater risk for pressure ulcers). If pt. condition changes (change in LOC, incontinence, etc.), reassess risk.  Wound drainage – abnormal (purulent). Remember that an increase in serosanguineous drainage may precede dehiscence.  Cleanse wound with drain in circular fashion from drain outward (from least contaminated to most contaminated). If linear wound, cleanse down incision first, then next wipe away from incision, etc. See p. 1213-1214. Do NOT scrub a wound. Cleanse gently, using one swab for each wipe.  Wound irrigation fluid – wound cleansing (routinely use normal saline if no order for specific fluid), see p. 1208.  Pressure ulcer assessment; stages of pressure ulcers; pressure ulcer cleansing, Ch. 48, Skill 48-2, pp. 1224-1226.  Laboratory assessment for patients with pressure ulcers? – protein (albumin, prealbumin). If wound not healing, check albumin level.  Stasis ulcer – inflammation  Skin rash – assessment?  Hydrogel, hydrocolloid dressings (what type of dressings and/or solutions for granulating wounds?  Hemovac or other vacuum drain (Jackson-Pratt) – postop care with the drain (compress, close seal)  If dressing saturated and no order to change, can reinforce dressing Legal/Ethical/Professional Issues  Safety – Use of restraints. Also see HESI book (secure on bed frame, not bed rail); procedure and delegation, etc. See Skill 27-2, pp. 399-403. See step 6, p. 402, regarding quick release buckle.  Battery, assault, libel, negligence, malpractice. Also see HESI book. Page  Consent. Also see HESI. NOTE: “It is important to note that nursing students cannot and should not be responsible for or asked to witness consent forms because of the legal nature of the document.”  Basic terms in health ethics: autonomy, beneficence, nonmaleficence, justice, fidelity.  Professional nursing code of ethics: advocacy, responsibility, accountability, confidentiality (also HESI book)  Confidentiality with eMAR (electronic medication administration record) – informatics, pp.359-361.  Nurses can have a voice in making of health care laws/legislation; can be lobbyists; contact state representatives   Know specific situations in which you can and cannot delegate to a nursing assistive personnel (NAP) Know what can be assigned to an LPN vs. a CNA (licensed nsg. personnel) – see above and HESI handout  RN’s only can do patient teaching (see HESI book); RN’s should assess VS on unstable pts. (not CNA)  Role of HIPAA  Narcotic medication refused – must have witness to waste the medication  Placebo administration End of Life Issues  Hospice – also see HESI book “End of Life Care” (pp. 350-352); client must desire hospice, pp. 760761; end-of-life and pain issues. Evaluation – pain outcome. See Table 37-3, p. 763 for promoting comfort in the terminally ill patient (pain, nausea, corneal irritation, noisy breathing, etc.); communication with client (See ch. 44 for managing cancer pain and pain management in hospice [MS infusion], pp. 1043, 1044-1045)  Terminally ill – anger (see p. 753 Stages of Dying). See Use Therapeutic Communication, pp. 761762. Very important – read!!!  Palliative care request. Palliative care is not just for patients with no hope of cure. Help patients and family understand focus is comfort and improved quality of life. Can be used in patients still receiving aggressive treatment for their condition—NOT just for end-of-life. See pp. 760-761. Read!!!  Euthanasia – medically assisted suicide (against Florida Nurse Practice Act)  Advanced directives/DNR (pp. 305-306) – including documentation of same (if patient wants to complete advanced directives, who should you contact?)  DNR – pt. on ventilator? If living will shows up, must consult with prescriber, not just take patient off the ventilator. See Advanced Directives, p. 305 and Kaplan handout. Page  Power of attorney (see Durable Power of Attorney for Health Care [DPAHC], p. 305, and Kaplan handout). A legal document that designates a person (or persons) that the client chooses to make health care decisions on behalf of the client. “This agent makes health care treatment decisions on the basis of the patient’s wishes.” This person makes the HC decisions, not the son, husband, etc., unless they are the DPAHC.  Legal/ethical – family dynamics Communication/Psych.  Therapeutic communication and listening (being silent); see chapter 7 HESI book (review therapeutic communication, coping styles, anxiety). Open-ended questions. Don’t ask why. Don’t give your opinion. Don’t make judgments. Don’t interrupt. Don’t say “don’t.” Remember: Acknowledge and reflect (client feelings). [See You Tube video “It’s not about the nail.”). Don’t assume you know why someone is crying. Offer self. Maybe just be silent and “there” (present), or maybe ask if patient just wants to talk. Don’t assume you know why they are crying. Therapeutic responses include: “This must be difficult…” “It must be very frustrating to not be able to…” “Tell me about…” See Communication Handout and pp. 327-331. You really need to review this—the suggested responses will be very helpful to you.  Communication evaluation. See pp. 331-332.  Communication/culture – language barrier. (What do you do?) Teaching/learning with language barrier, see Cultural Diversity (p. 350-351). See Box 24-9, p. 332. See Box 9-6 Working with Interpreters, p. 110. Also note Teach Back for evaluating effectiveness of communication and/or teaching to clients of different cultures (pp. 110-111).  Therapeutic communication. Consider patient’s cultural practices, such as foods, hygiene, spiritual practices (such as praying), etc. Do not schedule therapies at times that interfere with client’s spiritual practices. Medication Administration  Proper method for identifying patient (2 identifiers); Priority with med administration (six rights)  Remember D/H x Q (dosage ordered divided by dosage on hand/available, multiplied times quantity available.) Read problems carefully!!! Insert only what is being asked for in the question.  PO meds liquid mg/mL – calculate dosage in mL and/or tsp as directed. Remember to note if dosage is in more than 1 mL (e.g. 500 mg/5 mL). Don’t forget to multiply!!!  (when to use oral or “needleless” syringe) – less than 5 mL or unusual dose, i.e., 6.3 mL (can’t measure with med cup)  IM – mg/mL calculate dosage; (syringe size for different meds and different age groups) Page  PO tablet g and mg (po tabs/day/duration)  PO – tablespoons, ounces and mL  IM reconstitute medication  IM injections – when and why aspirate; what do you do if blood appears?  See Skill 32-5, pp. 672-673. For IM injection, gently massage area after removing needle; don’t need to apply bandage unless some oozing occurs. Luer-Loc syringe, p. 643.   IM – mL (how much for each site, age group); med dose resource Oral liquid medication – if less than 5 mL, use oral syringe (needleless syringe or calibrated spoon (not medicine cup)  Giving medications through an enteral tube (NG tube, PEG tube, G tube, etc.). Teaching. See Box 3214, pp. 636-637.  Skin preparation for ointment (see topical administration of med, pp. 637-638) – wash area gently with soap and water prior to med application   Teach re: vaginal application of med (like inserting a tampon) Instilling eye drops (review skill); gentle pressure over lacrimal duct but don’t blot up drops with tissue; don’t let dropper touch eye; wash hands before and after  Instilling ear drops – Adult? Child? Press or gently massage tragus. Client teaching. Under age 3 is child (pull auricle down and back); 3 and above follow adult procedure. See Box 32-17, Procedural guidelines for Administering Ear Medications. Step 11. c. states “Straighten ear canal by pulling auricle down and back (children younger than 3 years) or upward and outward (children 3 years of age an older and adults.” See Teach Back Step 15.  Electronic documentation of med administration (See p. 624-625 and Box 32-4 Steps to Take to Prevent Medication Errors, Box 32-5 Informatics and Medication Safety. Read Critical Thinking, pp. 626-629. What happens if power goes out?  Refusal of opioid/narcotic requires witness of waste.  Calculation of heparin bolus and drip; maintenance rate on pump (units/kg)  Calculation of IV drip rates with and without pump  Preparation of vial and ampule for parenteral med administration.  Ventrogluteal site preferred for IM injections o to avoid damage to major nerves and blood vessels (ALL age groups). “Recommended for IM sites greater than 2 mL.” p. 649. o Deltoid used for immunizations/vaccinations. Do not administer more than 1 mL in deltoid. See specific guidelines, pp. 649-651. Page  How do you assess for side effects? When? What are you looking for?  Medication error action o (priority is assessment of patient)  Priorities (med administration in 2 pts. with pain) – o acute vs. chronic, unstable vs. stable, sudden onset chest pain vs. other pain, etc. Miscellaneous  Grief, death – o family support (see Death and Grief, HESI)  Grief – mastectomy  Anxiety, spiritual, hopelessness (loss of hope) o – see NCP on hopelessness, p. 758; also see p. 754; Box 37-5, p. 757.  Discharge teaching – what can affect this? Who can do discharge teaching? How do you know your teaching was successful? Elderly? Anxious? o Needs clearly written and readable instructions.  Teaching – o affective learning (role play); special considerations for elderly (see Box 25-8, p. 352)  Patient/family teaching  Patient education needs to be at o o  – evaluation 5th grade reading level (unless you know client is educated) Sexuality questioning o – ch. 35, specifically p. 723 Box 35-6. Sexuality – geriatrics; see Box 35-1, p. 718 and text p. 717-718. Unless health or physical issues, older adults remain sexually active; at risk of STIs.  Understanding the role of nursing process and critical thinking in prioritization (important concept) – process of prioritizing problems. o Nursing action for confused patient (safety). Discuss sundowning.  Nursing process – o particularly establishing goals and outcome statements; o identifying correct nursing diagnoses (pain, mobility, elimination, wounds, etc.)  Culture – spiritual (Hispanic, Navajo/Native, Muslim, American/Buddhist) – end of life issues – see Box 37-3, pp. 766-767 Cultural Aspects of Care. Cultural diversity. Atheist and Agnostic – p. 734. Page o Atheist does not believe in the existence of God, and an Agnostic believes that there is no known ultimate reality. However, spirituality is still important regardless of patient’s religious beliefs. o “Atheists search for meaning in life through their work and their relationships with others. o Agnostics discover meaning in what they do or how they live because they find no ultimate meaning for the ways things are. They believe that people bring meaning to what they do.” o Spirituality represents the totality of one’s being… it unifies the various aspects of an individual.” “It spreads through all dimensions of a person’s life, whether or not the person acknowledges or develops it.”  Dietary restrictions for various cultural groups o (see handout and Table 45-3, as well as Box 45-5 Cultural Aspects of Care, p. 1063); consider even clear liquids (beef broth, etc., for client who avoids certain meats).  Herbal folk medicine/home remedies  Documentation of verbal and/or telephone orders. See p. 367 text and Box 26-4. Also, see Box 32-3, o (can interact with meds) p. 621.  SBAR reporting o (Hand-off report, notifying physician, etc.); what do these letters represent? What do you include in your SBAR communication? Situation background assessment recommendations (identifying yourself is not part of the SBAR)  Hourly rounding – o 4 P’s – see handout (pain, potty, position, possessions) Promoting Sleep in Older Adults (from Fundamentals of Nursing, 8th ed., p. 955)Sleep-Wake Pattern  Maintain a regular bedtime and wake-up schedule  Eliminate naps unless they are a routine part of the schedule  If naps are taken, limit to 20 minutes or less twice a day Page  Go to bed when sleepy  Use warm bath and relaxation techniques  If unable to sleep in 15 to 30 minutes, get out of bed  Avoid stimulating activities before bedtime such as exercise or watching television Environment  Sleep where you sleep best  Keep noise to minimum; use soft music to mask it if necessary  Use nightlight and keep path to bathroom free of obstacles  Set room temperature to preference; use socks to promote warmth  Listen to relaxing music  Increase exposure to bright light during the day Medications  Use sedatives & hypnotics with caution as last resort and then only short term if absolutely necessary  Adjust medications being taken for other conditions and assess for drug interactiosn that may cause insomnia or excessive daytime sleepiness Diet  Limit alcohol, caffeine, and nicotine in late afternoon and evening  Consume carbohydrates or milk as a light snack before bedtime  Decrease fluids 2-4 hours before sleep Physiological/Illness Factors  Elevate head of bed and provide extra pillows as preferred  Use analgesics 30 minutes before bed to ease aches and pains  Use therapeutics to control symptoms of chronic conditions as prescribed Page