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Mizzou NURSE 3170 - Exam 1 Study Guide

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Developmental considerationsLimitations in mobilitySensory perceptionKnowledgeThe individualThe environmentSpecific risk factorsRecognize manifestations of domestic violence or neglectNursing HistoryAssess for history of falls or accidentsNote assistive devices.Be alert to history of drug or alcohol abuse.Obtain knowledge of family support systems.Joint Commission Safety GoalsImprove patient identification.Improve communication among caregivers.Improve safety of high-alert medications.Eliminate wrong site, wrong patient, wrong procedure, and wrong surgery.Improve safety using infusion pumps.Improve effectiveness of clinical alarm systems.Patient Outcomes for SafetyIdentify real and potential unsafe environmental situations.Implement safety measures in the environment.Use available resources for safety information.Incorporate accident prevention practices into ADLs.Remain free of injuryCasting MaterialsNonplaster aka fiberglassLighter weightWater resistantStrongerDried with hair dryerWeight baring in 15-30 minutes after applicationPlasterHeavyBecomes warm during applicationEasily dented when wetTakes 24-72 hours to dryAssessment of an extremity in a cast6 P’sPulseParasthesiaPainPoikilothermiaPuffinessPallorCompartment SyndromeOccurs when there is increased pressure in the tissues which can compromise circulationTrueCaused by swelling of the soft tissue under the fasciaFasciotomyFalseSwelling of the soft tissue in the cast“Clam Shell” cast until swelling decreasesPatient Education Regarding CastsKeep extremity elevatedNothing inserted into the castIsometric exercisesNotify Health Care Provider:Foul odorsPain not relieved by prescribed medicationDrainageRough edgesSwelling6 p’sCast RemovalVibrating “saw”Appearance of extremityMuscle atrophySkinExercisesTractionApplication of a pulling force to a part of the body; counterweight systemUses:Minimize muscle spasmsReduce, align, and immobilize fracturesReduce deformityPrinciples of TractionMust be continuousWeights must be free hangingNothing should interfere with the pulleysPatient must aligned correctlyCheck orders for amount of weightsTypes of TractionSkin TractionBuck’s extension tractionHare TractionNursing CareAssess for the 6 P’sRemove the boot (with someone supporting extremity) to check for skin breakdownProvides back care and position change every 2 hoursMay need special mattressAssess for DVTsSkeletal TractionApplied directly to the bonePin CareCleanse area with sterile water every 4 hoursAssess for signs of infectionKeep crusting to a minimalDO NOT apply any ointment to siteNursing Skills Exam # 1 Study GuideFormat:50 questions, 1 select all that apply, ID + matching25% - infection control15% - vital signs20% - safety and mobility30% - skin and wound10% - hygieneWeek One Goals – Safety, Hygiene, Mobility, Infection Control, Skin Integrity:· Know Vital Sign Parameters and Terminology· Understand basic pathophysiology for abnormal vital signs· Know what equipment is required to obtain vital signs· Understand factors that may impact vital sign readings· Understand chain of infection and interventions to “break the chain”· Know the types of isolation precautions & what PPE is required for each (including standard body substance precautions)· Know when it is appropriate to use hand sanitizer vs soap and water for hand hygiene· Purpose of restraints / reason for use· Understand types of restraints and when they would be used· Nursing care related to restraint use· Unexpected outcomes related to restraints· Basic principles of patient hygiene· Peri-care principles· Know patient positions and their impact on patient· Interventions to protect skin integrity and the nurses’ role in the process· Know different assistive devices and indications for use· Know bony prominences and how to minimize risk of skin break down· Understand impact of mobility on body system functions· Fall risk indicators and interventions to reduce fall risk· Key components of environmental assessment· Purpose of the Braden score and impact on nursing careWeek Two Learning Objectives: Sterile Technique, Skin & Wound:· Rules of sterile technique· Difference between clean and sterile technique· What situations are appropriate for sterile technique· How to set up a sterile environment· What to do in cases of contamination· Wound Assessment and significance of findings (both normal and abnormal)· Nursing interventions related to wound care· Wound dressing types and when is it appropriate to use· Wound dressing techniques and nursing implications· Types of drains, purpose, expected & unexpected outcomes· Skin & Wound terminology· Lab values related to wound care and healing· Impact of nutrition on wound healingVital Signs Lecture Notes:- Terminologyo Hyper = Higho Hypo = Lowo Tachy = Fasto Brady = Slow- Temperatureo Factors Affecting Body Temperature Circadian Rhythms Age and Gender Environmental temperatures- Hypothalamus- Stress- Temperature Terminology:o Hypothermia- low body temperatureo Hyperthermia-high body temperature o Afebrile- without fevero Fever or Febrile- with a fevero Physical effects of fevero Increased may cause a loss of appetite with an increase in metabolic rateo Dehydrationo Increased oxygen requirementso Symptoms- tachycardia, hot skin, flushed appearance, delirium, seizureso Methods to reduceo Administer ordered medications- Tylenol or Ibuprofeno Cooling blanketo Removing clothingo Cooling the room temperature- Decreased body temperatureo Can be deadly to infants- Physical effectso Decreases metabolic demand for oxygen (except in newborns)- Assessingo Sites Tympanic Considered a core temperature Is readily accessible and results are rapid Not affected by ear wax or ear infections Should not be used if patient has ear drainage Hard to perform due to ear size in small infants- Oralo Patient must be able to keep mouth closed around the thermometero Should not use if someone has had surgery of the mouth, nose, or throato Should not take within 15 minutes of a patient eating or drinking fluids that were either cold or hot, smoking, or chewing gum - Rectalo Considered to be one of the most


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Mizzou NURSE 3170 - Exam 1 Study Guide

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