MDC I Exam 1 Outline
1. Herbal supplements
a. Aloe: wound healing.
b. Chamomile: anti-inflammatory.
c. Echinacea: strengthen body’s immune system, prevention against cold and flu.
d. Feverfew: used for migraine headaches, as well as for menstrual cramps.
e. Garlic:used for cardiovascular conditions, including high cholesterol and
triglyceride levels associated with the risk of atherosclerosis.
f. Gingko Biloba:used for many conditions with aging, including poor circulation
and memory loss.
g. Ginseng:used as a general tonic to increase overall body tone, ginseng is
considered helpful in elevating energy levels and improving resistance to stress.
h. Valerian:promotes sleep and reduces anxiety.
2. Pain assessment (3)
a. Types of pain
i. Cutaneous Pain :arises from burning your skin.
1. Example – on a hot iron or from touching a hot pan on the stove.
ii. Visceral Pain: caused from deep internal disorders such as menstrual
cramps, labor pains, or gastrointestinal infections.
iii. Deep Somatic Pain: originates from the ligaments, tendons, nerves,
blood vessels and bones.
1. Example – fractures or sprains
iv. Radiating Pain: starts at an origin but extends to other locations.
1. Example – pain from a sore throat might extend to ears and head.
v. Referred Pain: occurs in an area distant from the site or origin.
1. Example – pain from a heart attack might be felt in the left arm or
jaw.
vi. Phantom Pain:pain that is perceived from an area that has been
surgically or traumatically removed.
1. Example – pain from an amputated limb.
vii. Neuropathic Pain: results from an injury of one or more nerves.
viii. Acute Pain: Short-duration, rapid onset, and associated with some kind
of injury.
ix. Chronic Pain: lasts 6 months or longer and interferes with ADL’s.
b. Pain Assessment: plays a role in the clients rest and comfort needs and in the
area of anxiety related to illness recovery. It is considered the 5thvital sign. Always
reassess as needed and provide medication before doing activity.
i. Step 1 : Explain what it is and how it is used.
“This is a pain rating scale that many of our patients use to help
us understand their pain and set goals for pain relief. We will ask
you regularly about pain, but any time you have pain you must let
us know so we can help control it. We don’t always know when
you hurt”
ii. Step 2: Show them how to rate their pain
“On this pain rating scale 0 means no pain, and 10 means the
worst pain possible pain. The middle of the scale, around 5,
means moderate pain. A 2 or 3 would be mild pain, but 7 or higher
means severe pain”
iii. Step 3: help them understand what pain is and what it could feel
like.
“Pain refers to any kind of discomfort anywhere in your body. Pain
also means aching and hurting. Pain can include pulling,
tightness, burning, knifelike feelings, and other sensations”
iv. Step 4: Ask about characteristics.
“I want to be sure that I’ve explained this clearly; so, would you
give me two examples of pain you’ve had recently?”. If the
patient's examples include various parts of the body and various
pain characteristics, it indicates that he or she understands as a
fairly broad concept. An example of what a patient might say is “I
have a mild, sort of throbbing headache now, and yesterday my
back was aching”.
v. Step 5. Ask them about pain now and how it feels when at its worst,
or how it normally is.
“Using the scale, what is your pain right now? What is it at its
worst?” OR “Using the pain rating scale and one of your examples
of pain, what is that pain usually? What is it at its worst?”
vi. Step 6. Explain complications and measures that might be taken for
acute and chronic pain.
1. Surgical patient
“I have explained the importance of coughing and deep
breathing to prevent pneumonia and other complications.
Now we need to determine the pain rating that will not
interfere with this so you may recover quickly”
2. Chronic pain or terminal illness
“What do you want to do that pain keeps you from doing?
Which pain rating would allow you to do this?”
c. Characteristics of Pain:
Location: ask the client to describe where on the body the pain is, with
landmarks.
Radiate: does the pain move anywhere else?
Quality: how the pain feels. Sharp, dull, achy, burning, stabbing,
pounding, throbbing, shooting, etc.
Intensity and Strength: how much pain does the person feel.
Duration: where did it start, how long does it last, when did it first, occur,
constant or intermittent.
Impact of the pain on daily life.
Things that make the pain better or worse
3. Falls: highest contributor of injury in healthcare fields, can cause injury, altered mental
state, and death.
a. Safety
1. Orient the client to the environment they live in.
2. Remove objects from the floor or area that may cause hazard.
3. Use a gait belt or assistive device when helping clients get up.
4. Never leave a client alone.
5. Provide constant monitoring for clients who are very high risk of
falling.
6. Use bed alarms, rails, fall mats, non slip socks to help the client.
7. Use signs to let staff know to help the client.
8. Go to the client when the call bell is rung quickly.
9. Have PT/OT/Provider do a through assessment to determine the
fall status for a client and what interventions should be done.
10. Do not get a client up if they feel dizzy
11. Be careful when giving clients who may fall harder tasks like
cleaning, trimming bushes.
12. Help the client walk up and down stairs at home, use handrails.
b. Prevention/ Interventions
i. Keep the bed in the lowest position with bed rails up and items in
easy reach, like their call light.
ii. Encourage the client to request assistance when needed, have
call bell in reach
iii. Use chair alarm when client in the chair
iv. Have the client wear well fitting slippers or shoes with nonslip
soles and low heels when walking.
v. Keep floor free of clutter and wipe up spills promptly
vi. Accompany the client during ambulation using a gait belt if they
are weak or dizzy.
vii. Perform actions to improve cardiac output, reduce dizziness,
syncope, agitation and confusion and to improve cerebral blood
flow.
viii. Perform actions to restore fluid and electrolyte balance reduce the
risk for mental status changes that may lead the client to get up by
themselves.
ix. Perform actions to increase strength and activity tolerance
x. Provide an assistive aid like a cane or walker if the client is
unsteady on their feet
xi. Instruct the client to ambulate in well lit areas and use handrails
xii. Give patience when completing activity and ambulation
xiii. Change positions slowly to reduce dizziness
xiv. Ensure there is a non slip bath and shower mat, shower chair, call
light, grab bars and lighting.
xv. Administer CNS depressants as needed
xvi. Reorient the confused client frequently to their surroundings
xvii. Supervise the clients at all times
xviii. Consult the doctor for use of temporary restraints if needed
xix. Give medications for anxiety and antipsychotics as needed
c. Risks for…
1. Older Adults: most at risk due to comorbid conditions and
deteriorating bodily functions
a. History of falls
b. Living Alone
c. Lower limb prosthesis
d. Use of assistive devices like a cane or walker
e. Wheelchair use
2. Children Less than 2 years old
a. Bed located near windows
b. Lack of automobile car seats
c. Lack of parental supervision
d. Male gender when less than a year old
e. No baby gates on stairs
f. No window guards
g. Unattended when on bed, changing table, sofa, or
elevated surface
3. Cognitive
a. Diminished mental status makes one more likely for a fall
b. Confusion, delirium, impaired reality
4. Environment
a. Cluttered Environment
b. No anti slip mats in bathroom or shower
c. Restraints
d. Throw or scatter rugs
e. Unfamiliar or dim rooms
f. Bad weather conditions like ice or puddles
g. Wet floors
h. Sidewalk cracks or stairs, or holes
5. Medications
a. ACE inhibitors
b. ETOH use
c. Antianxiety drugs
d. Antihypertensives
e. Diuretics
f. Hypnotics
g. Narcotics
h. Opiates
6. Physiological/ Diseases
a. Anemia
b. Arthritis
c. Decreased lower extremity strength
d. Diarrhea
e. Faintness when turning or extending neck
f. Foot problems
g. Gait difficulties
h. Hearing difficulties
i. Impaired balance
j. Neoplasms that cause difficulty
k. Neuropathy
l. Orthostatic hypertension
m. Post op conditions
n. Blood sugar changes after meals
o. Acute illness
p. Proprioception defects
q. Sleeplessness
r. Urgency
s. Incontinence
4. Fire safety
a. Fires are usually due to problems with electrical or anesthetic equipment or from
smoking.
b. Smoking is prohibited in healthcare facilities because it can interact with oxygen,
which is used a lot in healthcare.
c. Staff must know exactly how to protect clients and themselves: location of exits,
alarms, extinguishers, not blocking doors, policy protocol.
d. Code Red or Code Yellow
e. Never panic, always keep clients calm, protect clients from injury.
f. RACE: fire emergency response
i. R: rescue; protect clients and move them to a safer location.
ii. A: alarm; activate the facilities alarm system and report the fire and
location.
iii. C: contain; close doors and windows and turn off oxygen sources where
the fire is.
iv. E: extinguish; use the fire extinguisher to put out the fire.
g. PASS: operating the fire extinguisher
i. P: pull the pin
ii. A: aim at the base of the fire
iii. S: squeeze the handle
iv. S: sweep from side to side to cover the area of the fire
h. Types of Fire Extinguishers
i. Class A: for combustibles like paper, wood, trash fires
ii. Class B: for flammable liquids and gas fires
iii. Class C: for electrical fires
·
5. Safety
a. Priority actions across the lifespan
1. Infants
a. Drowning is the leading cause of death for children ages 1-4,
followed by motor vehicle accidents.
b. Falls, choking, sudden infant death syndrome (SIDS), and
ingesting poisons are other critical safety concerns.
c. Injury Prevention (ATI)
i. Aspiration
1. Avoid small objects (grapes, coins, and candy),
which can be lodged in their throat.
2. Provide age-appropriate toys
3. Check clothing for safety hazards (loose buttons)
ii. Bodily Harm
1. Keep sharp objects out of reach
2. Keep infants away from heavy objects they can pull
down.
3. Do not leave infants alone with animals.
4. Monitor for shaken baby syndrome
iii. · Burns
1. Check the temperature of bath water
2. Turn down the thermostat on the hot water heater
to 49 degrees Celsius (120 degrees Fahrenheit) or
below.
iv. Drowning
1. Always supervise the infant while in the body of
water, even the bathtub
2. Have the child wear floatation devices when in the
water
3. Never let young children into the deep end
4. Have the child wear seeable swimwear
v. Falls
1. Keep the crib mattress in the lowest position with
the rails all the way up.
vi. Poisoning
1. Lock or position all hazardous chemicals in a
cabinet away from the child
2. Do not let the child into the bathroom unsupervised
or into a room that has been cleaned
vii. ·Motor Vehicle Injuries
1. Ensure the infant rides in a tested car seat in the
back of the car
viii. Suffocation
1. Ensure the infant does not have access to any
plastic bags
2. School-age
a. Bodily Harm
i. Keep firearms in a locked cabinet or box
ii. Assist with identifying safe play areas
iii. Teach stranger safety
iv. Teach use of helmets when skating, skateboarding, biking,
scooters, skiing, and other activities that may account for
increased injury
v. Teach children to wear light reflective clothing at night
b. Burns
i. Teacher fire safety and elimination of potential burn
hazards
ii. Have working smoke and carbon monoxide detectors in
the home
iii. Wear sunscreen when outside
c. Drowning
i. Supervise children when they are near a body of water
ii. Teach swimming skills and safety
d. Motor Vehicle Accidents
i. Have children use a carseat until they are able to have
adult seat belts fit correctly
ii. Children younger than 13 should sit in the backseat
e. Substance abuse/Poisoning
i. Keep cleaners and chemicals in locked areas or out of
reach
ii. Educate children who are curious about the use of the
products
iii. Purchase items that have a child safe lid on them
iv. Teach children to say no to drugs
v. Teach children about dangers of smoking
b. Risks:
i. Middle-age adults
1. Avoid substances, including alcohol that can lead to substance
use disorders
2. Avoid drinking and driving or taking substances that impair motor
functions
3. Wear a seatbelt when operating or using a vehicle
4. Wear a helmet when doing recreational activities or sports
5. Install smoke detectors and carbon monoxide detectors in the
home
6. Secure guns in a safe location
c. Never Events
i. Serious injuries or death to a patient that should never happen in a
hospital.
ii. From: lack of communication, lack of attentiveness and monitoring, lack
of clinical judgement, inadequate measures to prevent health
complications, errors in medication administration, errors in interpreting
authorized provider prescriptions, lack of accountability and patient
advocacy, inability to carry out interventions in an appropriate manner,
lack of mandatory reporting.
iii. Examples include: falls, needlestick injuries, wrongful medication
administration, hospital acquired infections ,suicide, surgical procedures,
air embolisms, wrong transfusions, blood clots after procedures
iv. Prevent with being alert, monitoring, assisting patients, double checking
work and medications, use fall precautions, SCDs, complete line care as
directed, etc
v. Interventions
1. Respond to all monitors or alarms that go off on patients
2. Check and flush lines, IVs and catheters as protocol defines it
3. Use fall precautions on the fall risk patient
4. Double check medications with the 3 checks and have another RN
double check high risk medications
5. Complete peri-care or hygiene daily
6. Discard and cap needles when not being used
7. Mark surgical areas and triple check before allowing operations to
begin
8. Follow protocol by having another nurse read and check before
transfusions
d. Patient orientation
i. Have to do so at admission and transfers
ii. Helps client and family feel safer at the hospital
iii. Tell them where the:
1. Call light is and how to use it
2. Electric bed operation
3. Telephone and TV use
4. Room lighting
5. Smoking Policy
6. Bathroom location
7. Meal times
8. Waiting areas
9. Usual time for provider rounds
10. Dining and vending services
11. Visitor policies
iv. If determining patient orientation:
1. Ask them name, where they are, what time it is, and the situation
v. Provide a regular schedules and frequent orientation to clients that have
altered mental statuses
e. Transferring
i. Evaluate each situation and use an algorithm to determine the safest
method to transfer or move the client. Answer these questions: can the
client bear weight? Can they assist? Are they cooperative?
ii. Determine the client’s ability to help with transfers (balance, muscle
strength, endurance, and use of a trapeze bar.
iii. Evaluate the need for additional staff or assistive devices (transfer belt,
hydraulic lift, sliding board).
iv. Assess and monitor the use of mobility aids (canes, walkers, crutches).
v. Include assistance or mobility aids in the plan of care for safe transfers
and ambulation.
f. Body Mechanics
i. Understand location of center of gravity and base of support.
ii. Keep feet shoulder width apart.
iii. Plan work carefully to do it safely.
iv. Elevate work to a comfortable level.
v. Avoid twisting.
vi. Bend knees when lifting heavy objects.
vii. Carry objects close to the body with elbows bent.
viii. Push, pull, or slide heavy objects instead of lifting them.
ix. Get help when you need to move a patient.
6. Joint Commission
a. Regulates national patient goals to ensure safety and quality care is provided to
all patients
b. Helps ensure that protocol is being met in hospitals for safety
c. Will conduct random visits and audits for safety to ensure that the facility is safe
for patients and staff
d. Includes medication reconciliation,safe dosing, and communication
i. Speak Up: important to do so when something you feel is not right with
care, staff or policies
ii. Many facilities have councils to encourage improvements and safety of
care
iii. Encourage others to take control of their care and document all that you
do and report adverse events
iv. S - speak up if you have questions of concerns.
v. P - pay attention to the care you are receiving
vi. E - educate yourself about your diagnosis
vii. A - ask a trusted friend or family member to be your advocate
viii. K - know your medications and why you take them
ix. U - use a hospital, clinic, surgery center, or other type of healthcare organization that has
undergone a rigorous on-site evaluation against established state-of-the-art quality and
safety standards, such as that provided by The Joint Commission
x. P - participate in all decisions about your treatment
7. Hygiene:
a. Bathing: helps to cleanse body, circulation, relaxation, healing. Always give a
bath to clients who can handle it, give rest periods, partial baths can be used
when clients can't tolerate a complete bath. Therapeutic baths help itchy skin.
i. Shower: best with walkie talkie patients, can use shower chair if needed.
Always monitor water temperature and watch patients for safety.
ii. Tub bath: immerses the patient in water for thorough washing. Can use
different washes for therapeutic measures.
iii. Bed bath: done for immobile patients or bed bound, remember to use the
folding mitt technique, change sheets when done and do it daily to
promote integrity of skin. Start from top to bottom and be light with the
strokes and use lotion and powder.
b. Eye and Ear Care
i. Always use clean, moist washcloth without soap to wash eyelids in the
inner corner to outer corner.
ii. Rotate in the ear to gently clean the ear canal.
c. Oral care: decreases risk of infection. All client should have proper hygiene done
daily.
i. Check for aspiration risk and gag reflex
ii. Have suction set up at bedside
iii. Be gentle when cleaning mouth due to fragile oral mucosa
iv. Never place fingers in a unconscious clients mouth
v. Turn unconscious patient on side in semi fowlers
vi. All others must do it in high fowler's position
vii. Denture care: must be done daily for those who can't do it themselves,
with gloves on and careful, with tepid water, and brushing softly
d. Foot Care
i. Helps to prevent infection and pain that interferes with gait
ii. DM, PVD, immunosuppression.
iii. Inspect feet and toes, wear water to wash and dry feet
iv. Moisturize
v. No OTC products
vi. Wear clean socks and shoes that are safe.
vii. Be careful when cutting nails and calluses.
viii. Make sure shoes fit correctly
e. Perineal Care: helps to maintain skin integrity and prevent transmission of
organisms
i. Incontinence care, catheter care or regular
ii. Always give privacy, respect the client
iii. Remove fecal material and clean front to back
iv. Dry thoroughly
v. Change sheets and pad and dressing if soiled
vi. Clean around the catheter sites and skin contact when doing care
f. Toileting:
i. Should be offered every hour to 2 hours or 30 minutes after meals
ii. Always assist the client to the bathroom if they are at risk to fall
iii. Record when you take the patient to the bathroom and how much output
they have
iv. If incontient, change and wipe the patient down with clean wipes and
place barrier cream to preserve the skin.
g. Nail Care
i. Check the nails for integrity or infection signs
ii. Check for a prescription when doing nail care
iii. Be careful with clients with DM or PVD due to potential bleeding
iv. No lotion due to the breakdown on skin
h. Hair Care
i. Done to promote client esteem and appearance
ii. Brush or comb hair daily and massage the scalp to promote circulation
iii. Be careful when combing and choose right comb and be gentle when
combing
iv. Can use the sink to shampoo the scalp, use a shampoo cap or a shower
depending on patient status
v. Be careful with the neck of patients and provide comfort with a towel roll
i. Shaving
i. Use electric razors
ii. Be careful with diabetics and bleeding risk patients
iii. Shave in one direction softly
iv. Soak with warm water to soften the skin and use shaving cream
8. Developing professional and therapeutic boundaries
a. Using therapeutic communication techniques to help communication
b. Have respect for the patient, staff, and family
c. Identify rules and boundaries of the setting
d. Know what is right and not right to tell your patient- not age, birthday, sex,
politics,etc
i. No giving away social media accounts or tell anyone about who you
caring for
ii. HIPAA
e. Not a social boundary
i. Social boundary is present during a friendship or socialization
relationship, NOT therapeutic
f. Have a clear role when giving care
g. Inappropriateness of patient or staff should be reported to manager
h. Be competent and confident when giving care
i. Use empathy when creating relationships
9. Tissue integrity
a. Preservation of the intactness of the integumentary system, functions and
structures
b. Role: skin is the largest organ and protects from infections, preserves fluids and
controls temperature
c. Impaired integrity has risk for complications like wounds, infections, burns,
growths, lesions
i. Partial Thickness: damage extends to the epidermis and dermis
ii. Full-Thickness: damage extends to the subcutaneous tissue, and bone or
muscle
d. Risk factors: malnutrition, neurological damage, DM,PVD, incontinence, immune
suppression
i. Most common integrity issues: pressure injury
1. Stages 1-4
2. Stage 1: blanched redness that doesnt go away
3. Partial thickness into the dermis and epidermis
4. Full thickness: into fat tissue
5. Full thickness severe: to the bone
ii. Consequences: cellulitis, infection, sepsis, pain
10. Incident reports
a. Follows Root Cause Analysis Process
i. Define the problem
ii. Collect data
iii. Identify Factors
iv. Identify the causes
v. Recommend and implement solutions
b. Follow Facility protocol when reporting events, and document ALL these events,
no loopholes!
c. Includes: falls, codes, violence, injuries, needlestick injuries, wrongful dosing and
medication administration, not monitoring, surgical complications
11. Feeding patients: Safety
a. Different ways :oral, enteral ,paternal depending on patient status
b. The nurse can also assist patients with feeding who have weakness, confusion,
swallowing difficulties, etc
c. Different diets to help clients eat and swallow= minced,moist, chopped.
d. Help the client find what foods they like
e. Assist with preventing aspiration: high fowler's, tucked chin, no straws, small
bites, keep in position 1 hr post meals due to aspiration risk
f. Record how much you feed the client and their tolerance
12. Maslow’s hierarchy
a. Based on the needs of the client
b. Needs must be met in order before higher needs can be met.
c. Levels from BOTTOM to TOP
i. Physiological Needs
1. Basic Needs
2. Ex: Food, water, shelter, oxygenation ,circulation, elimination
3. Must have all met at this level before advancing.
ii. Safety Needs
1. Next level based on one being secure in their surroundings
2. Safety in the home, security
3. Intervention: the nurse or social worker may help one go home
after hospitalization to a home free from abuse
iii. Love and Belonging
1. Based on intimate relationships, friendships, etc
iv. Esteem
1. Feeling of Self Accomplishment
v. Self-Actualization
1. Highest level of achieving one's full potential
d. Prioritization: one must meet basic needs before advancing onto higher needs.
i. ABCs: airway, breathing, circulation used to help assess client needs
ii. Triage from most sick to least sick
e. Oxygenation and Perfusion
i. Interventions to Promote Adequate Oxygenation
1. Position the client to allow for maximal chest expansion
2. Encourage or assist clients with frequent changes in position,
every 2 hours.
3. Encourage deep breathing and coughing.
4. Encourage ambulation.
5. Promote comfort so clients can tolerate the above activities.
6. Incentive Spirometry
7. Chest Physical Therapy
8. Nasal Cannula
9. Mechanical Ventilation
10. Endotracheal tube
11. Tracheostomy
12. Closed chest drainage
13. Extubation
14. Continuous positive airway pressure
15. Positive end-expiratory pressure
13. Delegation
a. The process of transferring to a competent person the authority to perform a
selected nursing task or activity in a selected patient care situation
1. Requires PRECISE and ACCURATE communication.
2. Nurse is always accountable for the task or activity that is
delegated.
b.Five Rights of Delegation when you delegate an activity to a UAP:
1. Right Task: The task is within the UAP’s scope of practice and
competence.
2. Right Circumstance: The patient care setting and resources are
appropriate for the delegation.
3. Right Person: The UAP is competent to perform the delegated
task or activity.
4. Right Communication: The nurse provides a clear and concise
explanation of the task or activity, including limits and
expectations.
5. Right Supervision: The nurse appropriately monitors, evaluates,
intervenes and provides feedback on the delegation process as
needed.
6. Tasks a AP can do: feeding, bathing ,toileting, ambulating,
dressing and grooming, vitals on request, blood sugars
14. Bleeding precautions
a. Use an electric shaver
b. Use a soft-bristled toothbrush
c. Do not have dental work performed without consulting your health care provider
d. Do not take aspirin or any aspirin-containing products. Read the label to be sure
that the product does not contain aspirin or salicylates.
e. Do not participate in contact sports or any activity likely to result in your being
bumped, scratched, or scraped.
f. Use sensitive tape.
g. Limit needlesticks as much as possible.
h. Use pressure when cuts or bleeding occurs and wash out and protect with
bandage
15. Cultural competency:
a. Respecting patient’s beliefs
i. Consider each client as a unique individual, influenced but not defined by
his culture.
ii. Respect your clients regardless of cultural background, and never force,
pressure, manipulate or coerce them to participate in care that conflicts
with their values and belief.
iii. Be aware of your own cultural heritage
iv. Appreciate that the client is unique: influenced, but not defined by his
culture.
v. Learn about the client’s cultural group.
vi. Incorporate the client’s cultural values/behaviors into the care plan.
b. Jehovah’s Witness: Appropriate actions
i. A practice that can create medical concerns:
ii. Refusal to accept blood transfusions or blood products, which they view
as morally wrong.
1. As a nurse: educate the patient and advise them about the
outcome.
iii. Does not permit autologous blood transfusions or donation or receipt of
an organ through which blood flows. If blood is not involved (e.g., corneal
transplants) they may accept transplantation.
iv. Clients can choose burial or cremation.
c. Catholic: End of life-Appropriate actions
i. A Roman Catholic who is seriously ill might wish to receive the sacrament
of anointing the sick.
ii. This sacrament, once known as the last rites, can be repeated if the
person recovers and then becomes ill at a later time.
iii. Only a priest can hear the sacrament of reconciliation (confession),
during which God, through the agency of the priest, grants forgiveness for
past sins.
iv. The Eucharist (communion bread), consecrated at the mass (a religious
service), may be brought to hospitalized patients by a priest, deacon, or
designated lay Eucharistic minister.
v. Most believe in continuing hydration and nutrition therapies as long as
possible.
d. Mormonism: cultural norms
i. Many avoid alcohol, tobacco use, and caffeine
ii. Children are baptised by age 8 by immersion
iii. Clients who are near death may recite an affirmation
iv. They may have visit from elders for blessings
v. Wear temple undergarments
16. Vital signs:
a. Temperature
i. Measuring temperature orally is appropriate for most adults and for
children who are old enough to understand directions, usually by 3 or 4
years of age.
1. When measuring oral temperature, wait 20 or 30 minutes if the
patient has been eating, drinking, smoking or exercising, as these
activities can alter the temperature.
2. Avoid this route for patients who have mouth sores or facial
injuries or cannot keep the mouth closed around the thermometer
probe.
ii. Steps:
1. Provide privacy and explain the procedure to the patient.
2. Place the covered temperature probe under the patient’s tongue in
the posterior lingual pocket.
3. Instruct the patient to close the lip gently around the probe and to
keep the mouth closed until the temperature has been measured.
Remind the patient not to bite down on the probe.
4. When the audible signal indicates that the temperature has been
measured, remove the probe and read the display.
5. Discard the disposable cover and document the results.
iii. The rectum is the least preferred site for measuring temperature because
of the discomfort for the patient and the invasive nature of the procedure.
iv. To measure rectal temperature:
1. Wear gloves, cover the red-tipped probe with a disposable plastic
sheath, and lubricate the probe cover before inserting it into the
patient’s rectum.
2. For an adult, insert the probe 1 to 1 ½ inches into the rectum and
in the direction of the umbilicus.
3. If you feel any resistance, remove immediately.
v. The axilla is appropriate for temperature measurement of most adults
and children, including infants. However, this site is not as accurate as the
others and does not reflect core body temperature.
vi. Steps:
1. Provide privacy and explain the procedure to the patient.
2. Assist the patient to a sitting position and move the bed linens,
gown, or other clothing to expose the patient’s axilla. Dry the
axilla, if needed.
3. Place the covered temperature probe under the patient’s arm in
the center of the axilla.
4. Leave the thermometer probe in place until the audible signal
indicates that the temperature has been measured.
5. Discard the disposable cover and document the results.
vii. A tympanic thermometer:
1. Cover the tip at the external opening of the disposable plastic
sheath. Place the covered tip at the external opening of the ear
canal, and wait 2 to 5 seconds after you press the scan button for
the temperature display.
2. To obtain an accurate temperature, it is important to place the
probe at the proper angle for sealing the ear canal.
viii. Steps:
1. Provide privacy and explain the procedure to the patient.
2. Gently push the disposable plastic cover over the tip of the
electronic thermometer until the cover locks into place.
3. Gently pull the pinna, also called the auricle, back, up, and out,
and insert the tip of the covered thermometer probe into the
patient’s ear canal.
4. Leave the thermometer in place in place until the audible signal
indicates that the temperature has been measured.
5. Discard the disposable cover and document the results.
ix. A temporal thermometer is a hand-held device with a round, rubber-like
probe on the end that measures skin temperature over the temporal
artery.
1. While pressing the scan button, hold the probe flat against the
forehead while moving it gently across the forehead over the
temporal artery, and then touch the skin behind the earlobe.
2. Release the scan button to display the temperature reading.
3. Use disposable probe covers or clean the probe with a
disinfectant wipe between patients.
x. Steps:
1. Provide privacy and explain the procedure to the patient.
2. Remove the protective cap and wipe the lens of the scanning
device with an alcohol swab to make sure it is clean.
3. Position the probe flat on the center of the patient’s forehead at
midpoint between the hairline and the eyebrow.
4. Press the scan button and slowly slide the thermometer across
the forehead and just behind the ear.
5. Release the scan button and read the display.
b. Heart Rate
i. Assessment on how adequate the heart pumps blood to the body
ii. Rate: fast or slow
iii. Rhythm can be regular or irregular
iv. Quality: can be faint, normal, strong, bounding
v. Places Assessed
1. Carotid 1 at a time
2. Radial
3. Brachial
4. Femoral
5. Popliteal
6. Posterior Tibialis
7. Dorsalis Pedis
8. Monitor or telebox if applicable
9. Apical Pulse: most accurate, found at the 5th intercostal space L.
sternal border
vi. Range: 60-100 beats
vii. To Assess:
1. Palpate the pulse with first 2 fingers
2. Once felt, analyze for presence and rate of the pulse
3. If regular: count for 30 seconds and multiply by 2
4. Ir irregular: count for full 1 minute
viii. Pulse Grading:
1. 0=Absent
2. 1= weak
3. 2= Normal
4. 3=Strong
5. 4=bounding
c. Respirations
i. Assess the effort of breathing
ii. Can be deep, normal, shallow, intermittent
iii. Note effort such as nasal flaring and tripoding
iv. Adventitious lung sounds
1. Crackles
2. Rhonchi
3. Stridor
4. Wheezes
v. Can be altered by situation such as from anxiety or pain
vi. Assess 30 sec x2 or 1 min by counting
vii. 12-20 normal range
viii. Never tell them you are counting when you assess
d. O2 Saturation
i. Measure of oxygen binding capacity with red blood cells
ii. Noninvasive
iii. 95-100%
iv. You place the probe on a vascular area
v. Factors: movement, cold, vasoconstriction, edema, abnormal hemoglobin
e. Blood Pressure
i. Force of blood exerting on vessel walls.
ii. Systole and Diastole
iii. Blood volume can affect blood pressure
iv. Can measure with manual BP cuff, machine, A line
1. Manual: listen to the 5 korotkoff sounds, 1st is the systolic and 4th
is diastolic
2. Inflate till you don't feel a pulse.
3. Slowly!
4. Can use the lower extremities
5. Do not take a bp with a PICC line, central line, A line, mastectomy
v. 120/80 is normal
f. Interpreting/ Abnormals: Priority
i. Blood pressure:
1. Hypertension: 140/90
a. Giv BP medications and reassess in 1-2 hrs
b. Encourage dieting, exercise
2. Hypotension: 90/60
a. Hold BP medications
b. Potentially give fluid bolus
c. Assess for dizziness when rising
ii. Pulse
1. Tachycardia: HR above 100
a. Assess for pain
b. See if they are anxious or confused
2. Bradycardia HR below 60
a. Ask if it is there normal
iii. Respirations
1. Tachypnea: above 20 breathes
a. Are they anxious, do they have a clear airway? Infection,
copd
b. Apply o2 as needed or relaxation techniques
2. Bradypnea below 12 breaths
a. Look to see if they are on narcotics or opioids
b. Listen to breath sounds
c. Common when sleeping with sleep apnea
iv. Temperature
1. Fever: above 100.4
2. Sepsis: less than 96.8
v. O2 sat: less than 95 is concern
1. Apply o2
2. COPD: 88-92 is okay
17. Therapeutic communication-is client-centered communication directed at achieving
client goals. It is used to establish the therapeutic relationship, provide and obtain
healthcare information, and express interest, concern, and caring for the client and
family.
a. Displaying empathy
i. Desire to understand and be sensitive to feelings, beliefs and situation.
1. Place yourself in the patient situation.
b. Differentiate techniques for enhancing therapeutic communication
i. Active listening
ii. Using silence
iii. Establish trust
iv. Being assertive
v. Validation
vi. Exploring issues
vii. Reflecting
viii. Communicating with confused patients
1. Always be slowly, speak clearly, loudly, simple terms. Repeat if
needed
ix. Open-ended questions- specify a topic to be explored, but phrase it
broadly to encourage the patient to elaborate.
1. Tell me more things
2. Not yes or no
x. Personal space
c. Barriers to communication
a. Asking too many questions
b. Offering advice
c. Changing the subject
d. Expressing approval or disapproval
e. Providing false reassurance
f. Stereotyping
g. Using patronizing language
d. Communicating with physicians
i. SBAR
1. Situation: what is going on with the patient, why they came in
2. Background: past medical history, past surgical history, past
events, past medication
3. Assessment: vitals, physical, functional
4. Recommendation: what you think the best plan of action is for the
patient
5. Be respectful of everyone's opinions
18. 3 dosage(1 i&o)
a. Use dimensional analysis to solve
b. Always know what you are solving for
i. Like mL/hr or tablets,etc
c. Know your conversions!
i. mL to L
ii. Kg to g to mg
iii. Kg to lbs
iv. Oz to mL
v. Days to hrs to min
vi. 1 cup=8oz=240ml
vii. Cc is the same as mL
d. For I/Os add for intake, subtract for output, and always convert to mL
19. Healthcare Environmental Factors/ Sentinel Events
a. Never Events: serious injuries or death to a patient that should never happen in a
hospital.
i. Ex: air embolisms, wrong transfusions, falls, trauma, injury, DVT/PE,
CAUTIs,CLABSIs, HAPIs
ii. Prevent with being alert, monitoring, assisting patients, double checking
work and medications, use fall precautions, SCDs, complete line care as
directed, etc
b. Equipment Related Accidents: related to malfunction or improper use
i. Always be familiar with equipment before using it
ii. Contact biomed if the equipment is not working and do not use it, tag it
c. Falls: very high in the healthcare setting, are most reported incident, high risk
with poor vision, cognition, weakness, etc, occurs at night, weekends, or holidays
d. Fires:due often to smoking or malfunctioning equipment. Big because oxygen is
highly flammable and found at hospitals, always ensure family and patients stay
calm, and follow protocol.
e. Biological Hazards: based on having contact with fluids and contaminants. We
must ensure patient safety and reduce risk of cross contamination
i. Hand hygiene is important and number 1 defense against contaminants,
and always do it before entering, exiting and changing gloves.
20. Morse Fall Scale
f. Used to assess patients who are likely to fall
g. Based on
i. History of Falling, immediate or within 3 months
ii. Secondary diagnosis
iii. Do they use ambulatory aids, bedrest, need an assistive device or help
iv. Do they have a IV/ heparin lock, and is it capped or have a lot of lines
v. Are the able to transfer
vi. What is their mental status and are they alert and oriented
h. Scale:
i. 0-24: no risk
ii. 25-50: low risk, implement fall prevention interventions
iii. 51+: high risk, use high risk fall prevention interventions
21. Restraints
i. Methods used to restrict movement or access
j. Used in hospitals when the situation or other approaches have been tried without
success
k. Types
i. Physical: actual things you do like wrist restraints, bed alarms, etc
ii. Chemical: medications like haldol and ativan
l. Avoid use as much as possible by promoting commitment to reduce restraints
m. Educate on options
n. Have constant 1 to 1 view of the patients
o. Inform and have enough staff available to care for persons in restraints
p. Nonviolent: restricts the client from harming themselves
i. Ex: mitts used to keep a client from pulling out an NG tube
q. Violent: restricts client from harming staff
i. Ex: client hits or kicks staff and is placed in 4 point restraints
r. Need an MD order every 24 hrs and the MD to assess patient each time the
order is renewed or started
s. Types: bed alarms, railings (3-4), vests(caution at strapping in and choking) ,
waists, extremity (hands, ankles), mitts
t. Alternatives to restraints: chair, bed, leg monitors, soft devices, strategies (call
not fall, sitter, video monitoring, distraction, rec therapy)
u. Guidelines: obtain an MD order every 24 hrs with assessment, check on patient
every 30 mins, offer fluids, toileting, ensure 2 figer fit through restraints, remove
every 2 hours to check skin and neurological system, pad areas where restraint
comes in contact with bony prominences, secure restraints to bed frame with
quick release knot, document all actions
