Final Exam Blue Print Essay

Gowns: prevent soiling clothing during contact with patient Masks: should be worn when you anticipate splash or spray of blood or body fluid and satisfy droplet/airborne precautions. Protective eyewear: should be worn for procedures that generate splashes or splatters Gloves: prevent the transmission of pathogens by direct/indirect contact. This equipment protects you from waste materials such as wounds, blood, stool, and urine. Indwelling urinary catheters – causes of risk for infections An indwelling urinary catheter obstructs the normal flushing action of urine flow. The presence of a catheter in the urethra breaches the natural defenses of the body. Reflux of microorganisms up the catheter lumen from the drainage bag or backflow of urine in the tubing increases the risk of infection. Surgical asepsis uses verse medical asepsis Surgical asepsis is used during procedures that require intentional perforation of patient’s skin, when skin’s integrity is broken, or during procedures that involve insertion of catheters. * Sterile objects remains sterile only when touched by another sterile object * Place only sterile objects on sterile field * Sterile object/field out of the range of vision or held below waist is contaminated * Sterile object/field becomes contaminated by prolonged exposure to air. * When sterile surface comes in contact with a wet, contaminated surface, the sterile object/field becomes contaminated by capillary action * Sterile object becomes contaminated if gravity causes contaminated fluid to flow over the objects surface * The edges of sterile field/container are considered to be contaminated. Medical asepsis, or clean technique, includes procedures for reducing the number of organisms present and preventing the transfer of organisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis. Nursing intervention when assessing bradycardia radial pulse Can cause pulse deficit. To assess a pulse deficit 2 nurses are needed to assess radial and apical pulse simultaneously and compare rates. The difference between apical and radial pulse is the pulse deficit. Assess the ability of the heart to meet the demands of body tissue for nutrients by palpation a peripheral pulse or using a stethoscope to listen to heart sounds (apical rate) Pulse sites Temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, Dorsalis pedis Critical Thinking- chapter 15 Examples of application of critical thinking (you may have to scan the chapter, no specific section to apply to the question) Know what would be considered critical thinking * Critical thinking involves recognizing that an issue exists, analyzing information about the issue, evaluating information, and making conclusions. * Critical thinking is a continuous process characterized by open-mindedness, continual inquiry, and perseverance. * Diagnostic reasoning: determining a patient’s health status after you have assigned meaning to the behaviors and symptoms presented. * Inference: process of drawing conclusions from related pieces of evidence. * Clinical decision making: careful reasoning so the best options are chosen for the best outcomes. * Nursing process: five-step clinical decision-making approach. Five components of critical thinking. * Knowledge base * Experience * Critical thinking competencies * Attitudes * Standards Professional standard for critical thinking * Intellectual: the intellectual standard is a guideline or principle for rational thought. * Professional: the professional standard refers to evidence-based ethical criteria for nursing judgments used for evaluation and criteria for professional responsibility. Patient Safety- chapter 27 Patient safety during seizures * Seizure precautions encompass all nursing interventions to protect the patient from traumatic injury, position for adequate ventilation and drainage of oral secretions, and provide privacy and support following the seizure. * Seizure precautions are nursing interventions to protect patient from traumatic injury, positioning for adequate ventilation and drainage/oral secretions, and providing privacy and support after event. Fall risk prevention and interventions The plan for a patient who has high risk for falls. 1. Select nursing interventions to promote safety according to patient’s developmental and health care needs. 2. Consult with OT and PT for assistive devices 3. Select interventions that will improve the safety of patients home environment Interventions * Nursing interventions for promoting safety are individualized for patients’ developmental stage, lifestyle, and environment. * Note the safety locks and anti-tip bars on the wheelchair. * Nurses contribute to a safer environment by helping patients meet basic needs related to oxygen, nutrition, and temperature. * Adequate lighting and security measures in and around the home, including the use of nightlights, exterior lighting, and locks on windows and doors, enable patients to reduce the risk of injury from crime. * Modifications in the environment will easily reduce the risk of falls. To reduce the risk of injury in the home, remove all obstacles from halls and other heavily traveled areas. * Prevention of accidental fires and poisons requires awareness of precautions such as not smoking in bed and keeping hazardous substances out of reach of children. * Safety bars provide excellent prevention against falls. Safety risk-Risk at developmental stages * Children younger than 5 years of age are at greatest risk for home accidents that result in severe injury and death. * The school-aged child is at risk for injury at home, at school, and while traveling to and from school. * Adolescents are at risk for injury from automobile accidents, suicide, and substance abuse. * Threats to an adult’s safety are frequently associated with lifestyle habits (smoking, drinking, hazardous work, etc.). * Risks for injury for older patients are directly related to the physiological changes of the aging process. Risk * 16-19 : car accident * 75 and up: falls and car accident * Older adults have decreased vision acuity and hearing loss making them at risk for MVA and hearing sirens or horns. Decrease reflexes occur with aging. * Lead can be in paint, soil, water and can be inhaled or swallowed. * 64 years and older; decreased vision, orthostatic hypotension, gait and balance problems, urinary incontinence, use of walking aids, effects of various medications (sedatives, anticonvulsants, hypnotics, analgesics. * Falls occur due to inadequate lighting, barriers along walk paths and stairways, and lack of safety devices in home. * Patients most at risk of injury are those with bleeding tendencies (disease or medications), and osteoporosis (results in fractures). Every developmental age involves specific safety risks: * Children younger than 5 years of age are at greatest risk for home accidents that result in severe injury and death. * The school-aged child is at risk for injury at home, at school, and while traveling to and from school. * Adolescents are at risk for injury from automobile accidents, suicide, and substance abuse. * Threats to an adult’s safety are frequently associated with lifestyle habits (smoking, drinking, hazardous work, etc.). * Risks for injury for older patients are directly related to the physiological changes of the aging process. Priority planning patient care (this is using your critical thinking skills and wouldn’t be found in a section of the book) * In many situations, patients present with multiple nursing diagnoses. Use a concept map to visualize how nursing diagnoses interrelate. * Establish goals with the patient’s self-care abilities and resources in mind, and focus on maintaining or improving the condition of the skin and oral cavity. * Patient’s skin is clean, dry, and intact without signs of inflammation. * Patient’s skin remains elastic and well hydrated. * Patient’s skin is free from areas of pressure. * Timing is also important in planning hygiene care. * In hospital or extended care settings, work closely with nursing assistive personnel, who often provide hygiene care. * Collaborate with other health team members as indicated (e.g., work with physical therapy and occupational therapy to enhance the patient’s independence with self-care activities). * When a patient needs assistance as a result of a self-care limitation, the family often becomes a valuable resource to the nurse an d helps with hygiene measures.