PCC-1 Exam 3

Question 1

Fall Prevention

Answer 1

Older adults often fall due to either intrinsic or extrinsic factors.
Intrinsic-gender (females are at a greater risk to fall than males), age, impaired sensory, function impairment, medical conditions.
Extrinsic- environmental hazards (poor lighting, throw rugs, etc.), medications, alcohol.
Preventions: screen for falls, ask patient if they have fallen more than once, gotten injured from said fall, been afraid of falling.

Acute or long term care interventions: 
scheduled screenings
environmental assessment 
maintain client mobility
educate caregivers and staff
individualized safety measures

Community:
annual screening
medication review 
home hazard assessment (throw rugs, slippery areas etc.)
address visual deficits

Question 2

Restraints

Answer 2

look over powerpoint and read through

Two types of restraints: Physical and Chemical

Physical: vest, belt, mitt, limb, mummy, side rails,

Chemical: medications designed to control socially disruptive behavior

Question 3

Requirements for Restraints

Answer 3

WRITTEN MD ORDER:

1. Must include the reason for and use and length of use and type of restraint
2. Valid for 24 hours
3. Pt must be evaluated face to face by a qualified health care provider before the order can be renewed

CONSENT:
1.) If the client cannot give permission legal proxy must after full disclosure of risks and benefits
2.) If client is too confused or mentally incapacitated to give permission this must be documented and the proxy contacted
3.) Emergency restraint needed- DOCUMENT clients behavior- the restraint may be applied and then orders should be written to cover the situation
Licensed staff must supervise for use
Consider client and choose restraint accordingly

Question 4

Interventions for Agitation when using restraints

Answer 4

Warm, non-stimulating drink
Treat pain
Stable staff assignments
Soft lights
Reduced environmental stimuli
Back rub, foot massage, walk
Music

Question 5

Vest (Physical Restraint)

Answer 5

Apply as manufacturer directs- choking

Tie with quick release knot at 45 degree angle to a non-moving part of the bed

Question 6

Belt (P.R)

Answer 6

(bed) should allow patient to roll

Question 7

Mitt (P.R)

Answer 7

May have rigid backing to prevent bending of hand

Question 8

Limb (P.R)

Answer 8

(elbow) often used for KIDS to protect IV site

- the padded handcuff like restraints we practiced with in clinicals

Question 9

Mummy (P.R.)

Answer 9

Used for procedures for KIDS and to immobilize PSYCH patients out of control
-looks like someone wrapped in a sleeping bag

Question 10

Veil beds (P.R.)

Answer 10

no longer being used, off the market

Question 11

Side Rails (P.R.)

Answer 11

Make sure the head can’t fit between the mattress and the rail
Mattress should be stable and will not allow head entrapment

Question 12

Short Term Complications with the use of restraints

Answer 12

Hyperthermia
New onset of incontinence
Pressure ulcers
Increased risk for nosocomial infections
Decreased appetite
Constipation

Question 13

Severe or Permanent Complications

Answer 13

Brachial plexus nerve injuries
Joint contractures
Hypoxic encephalopathy
Deconditioning
Psychological effects
DEATH from strangulation
Social isolation
confusion
anger
poor self image

Question 14

Effects of Immobility

Bed Rest

Answer 14

Can be temporary, permanent, sudden or slow onset
Bedrest- restriction of the client to the bed for therapeutic reasons
Reduce physical activity therefore reducing oxygen demands
Reduce/minimize pain to reduce the need for large doses of analgesics
All the client to rest and regain strength
Allow for uninterrupted rest
Usually written in the chart as BR(complete bedrest) or BR with BRP(bedrest with bathroom privileges)

Question 15

Effects of Immobility

Answer 15

Hazards of immobility- the individual of average height and weight (without chronic illness) loses 3% of muscle strength per day

- disuse atrophy – describes the tendency of cells and tissue to reduce in size and function in response to prolonged inactivity
- physiological, psychological, and social effects – longer the immobility the greater the effect
- older adults- important to limit “bed rest” and provide physical activity more than just bed-to-chair. Loss of walking independence= increased hospital stays, nursing home placement, & risk for falls.
	* older adults with chronic illness develop pronounced effects of immobility more quickly than a younger patient without chronic disease

Question 16

Effects of Immobility

Musculoskeletal

Answer 16

Exercise: maintains muscle size, shape, tone, & strength, joint mobility, and weight bearing maintains bone density

Immobility: decrease muscle endurance, muscle mass, muscle atrophy, decrease in stability & balance, impaired calcium metabolism, increase risk of joint contracture and decrease joint mobility

Question 17

Effects of Immobility

Cardiovascular

Answer 17

Exercise: increases HR and systolic pressure, shunts blood to heart and muscles, cardiac output increases

Immobility: orthostasis, decrease cardiac reserve & increase cardiac workload, increase use of Valsalva(straining), increase vasodilation & stasis, increased risk of thrombus formation

Question 18

Diagnoses from immobility that are musculoskeletal related

Answer 18

Osteoporosis – immobility accelerates bone loss from primary osteoporosis- one of the leading causes for bone fracture in men and women over the age of 50.

Joint contracture – abnormal and possibly permanent condition caused by the shortening of the connective tissue and characterized by decreased range of motion and/or fixation of the joint. Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. Ex- foot drop = Ankle is fixed in plantar flexion.

Question 19

Diagnoses that could result from immobility related to cardiovascular

Answer 19

Orthostatic hypotension – a drop in blood pressure greater than 20 mmHg in systolic pressure or 10mm Hg in diastolic pressure and symptoms of dizziness, lightheadedness, nausea, tachycardia, pallor, or fainting when the patient changes from supine to standing position. (decreased circulating fluid volume and decreased autonomic response)

Thrombus formation – an accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel. (Virchow’s triad- damage to the vessel, altered blood flow, increased clotting)

Question 20

Effects of Immobility Respiratory

Answer 20

Exercise: increased ventilation, prevents pooling of secretions, decreases breathing effort, improves diaphragmatic excursion
Decrease in cough response

Immobility: decreased respiratory movement and vital capacity, increased pooling and stagnation of secretions, increase risk of atelectasis, increase risk of pneumonia

Question 21

Effects of Immobility

Metabolic

Answer 21

Exercise: increased basal metabolism rate, increases use of triglycerides and fatty acids

Immobility: decreased metabolic rate, negative nitrogen balance, increase percentage of body fat and a decrease in percentage of lean body mass, anorexia, negative calcium balance

Question 22

Effects of Immobility

Urinary

Answer 22

Exercise: increase in efficiency of blood flow and better waste disposal, decrease stasis of urine in the bladder

Immobility: increased urinary stasis & urinary calculi, decrease bladder muscle tone, urinary retention, increase risk of overflow incontinence, increase risk of UTI

Question 23

Diagnoses from Immobility related to Respiratory

Answer 23

Atelectasis (collapse of alveoli) – secretions block large and small airways (bronchus & bronchiole) causing the collapse of the distal lung tissue (alveoli) as existing air is absorbed = hypoventilation and decreased ability to cough. Hypoventilation and decreased cough then allow additional mucus accumulation. When a patient is supine, prone, or lateral mucus collects in the bronchi.

Hypostatic pneumonia = bacterial infection of the lungs caused by accumulation of mucus in the dependent airways.

Question 24

Diagnoses from immobility related to metabolic

Answer 24

Negative nitrogen balance – The body is constantly synthesizing proteins and breaking then down into amino acids to form other proteins. When the patient is immobile (protein intake is low) the body excretes more nitrogen [the end product of amino acid breakdown] than it injects in proteins. This results in weight loss, decreased muscle mass, and weakness resulting from tissue catabolism (tissue breakdown).

Negative calcium balance – Immobility leads to calcium resorption (loss) from bones. Immobility causes the release of calcium into the circulation. Pathological fractures occur if calcium resorption continues as a patient remains on bed rest or continues to be immobile.

Question 25

Diagnoses from immobility related to Urinary

Answer 25

Urinary stasis – When a patient is recumbent or flat, the kidneys and ureters are on a more even plane. Peristalsis in the ureters is not sufficient to overcome gravity. The renal pelvis fills before the urine enters the ureters. This increases the risk or UTI and renal calculi (plus hypercalcemia).

Question 26

Effects of Immobility

Gastrointestinal

Answer 26

Exercise: increase appetite and GI tract tone, improves digestion and elimination

Immobility: slowing of peristalsis, weakened defecation muscles, increase constipation, risk of impaction or bowel obstruction if constipation is severe

Question 27

Effects of Immobility

Integumentary

Answer 27

Exercise: increases blood flow which results in an increase in nutrients to tissues and removal of waste from tissues

Immobility: decrease in skin turgor, increased risk of skin breakdown, delayed wound healing

Question 28

Effects of Immobility

Psycho-neurologic

Answer 28

Exercise: improves stress tolerance, produces relaxation, less risk of depression, improves body image and sleep, increases energy and appetite

Immobility: changes to self-esteem, emotional changes, decrease perception of time, decrease in problem-solving and decision-making ability, changes in sleep/rest pattern

Question 29

Diagnoses from immobility commonly related to integumentary

Answer 29

Pressure ulcer – an impairment of the skin as a result of prolonged ischemia (decreased blood supply) in tissues. Ischemia develops when the pressure on the skin is greater than the pressure inside the small peripheral blood vessels supplying blood to the skin. The longer the pressure is applied, the longer the period of ischemia and therefore the greater the risk of skin breakdown

Question 30

Diagnoses from immobility related to psycho-neurologic

Answer 30

Depression – an affective disorder characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness out of proportion to reality. Worrying quickly increases a patient’s depression, causing withdrawal. Withdrawn patients often do not want to participate in their own care.

Question 31

Assistive Devices

Walker

Answer 31

Elbows should be flexed 30 degrees
Never pull on the walker to stand up

Walkers – stability and security during walking. Used for weak patients of those patient who have balance problems. Line up the walker with the crease of the wrist. If a walker does not have wheels the walker is meant to be lifted in-between steps. Rolling walkers can cause falls.

Question 32

Assistive Devices

Cane

Answer 32

Hold can in opposite hand from the injured leg
In case of arm weakness place can in stronger hand regardless

Cane – Used when a patient has decreased unilateral leg strength. The cane is used on the strong side of the body. Two points of support are on the floor at all times.

C- Canes
O- Opposite
A- Affected
L- Leg

Question 33

Assistive Devices

Crutches

Answer 33

Gait is ordered by MD and typically taught by PT
Nurses reinforce the training
Monitor for safety
Know how to measure
4-point gait is used for partial weight bearing of both extremities
3-point gait used for no weight bearing on the affected leg
2-point gait used for partial weight bearing on both extremities
Swing-through gait used for paralyzed lower extremities

Crutches – 2-3 finger widths from the axilla. Pressure on the axilla increases the risk to underlying nerves, which sometimes results in partial paralysis of the arm.
Determine correct position of the hand grips with the patient upright, supporting weight by the handgrips with the elbows slightly flexed at 20-25 degrees.
Crutch gait – alternately bearing weight on one or both legs and on the crutches.

2 point and 4 point require at least partial weight bearing on both legs
3 point allows for no weight bearing on the affected leg
Swing-through is used for paralyzed lower extermities

Question 34

Transferring Patients

Answer 34

Safety
Preparation
Types
Moving toward the head of bed
Bed-to-chair & chair-to-bed
Bed to stretcher
Logrolling

Things to assess before moving a patient?
Physiological capacity (muscle strength, joint mobility, paralysis or paresis, bone continuity)
Weakness, dizziness, orthostatic hypotension
Activity tolerance
Posture and equilibrium
Sensory limitations
Pain
Vital signs
Cognitive status
Motivation
Fall risk
Previous transfer techniques used
Accessibility and familiarity with equipment

Study pages listed on slide 14 of Immobility powerpoint, also slide 15 for pictures of transference of patients

Question 35

Patient Positioning

Answer 35

What are barriers to safe patient handling and encouraging early mobility?
Box 39-1 p.791 & Table 39-1 p.804 P&P
Mechanical lifts and lift teams are essential when a patient is unable to assist.
When a patient is able to lift …. Wide stance, low center of gravity, equilibrium, face the direction of the movement, use arms and legs, leverage, reduce friction
* Notice if the patient is unable to assist and >200 lbs= 3 or more care givers
Figure 39-4 p.793 P&P Repositioning patient in bed
Figure 39-5 p.794 P&P To and from chair to other device
Figure 39-6 p.795 P&P lateral transfer

Question 36

Hip Precautions

Answer 36

Post op Total Hip Arthroplasty
Abduction pillow
Do Not bend hip above 90 degrees
Do not cross legs 
Do not bend forward to pick up objects
Do not rotate leg when standing 
TEDs & SCDs
Promote venous return
Procedure 

Box 28-7 Applying SCDs sequential compression devices and elastic stockings
Nurse must measure to determine the correct size of elastic stockings and assess for impaired circulation or DVT.
Assess for risks of Virchow’s triad = hypercoagulability, venous wall abnormalities, blood stasis
DVT = redness, warmth, swelling, pain, & Homan’s sign – pain in the calf upon dorsiflexion of the foot

Question 37

Cultural Competencies

Answer 37

1. Respecting a patient’s health beliefs and understanding the effect of the patient’s beliefs on health care delivery
2. Shifting a model of understanding a patient’s experience from a disease happening in the patient’s organ systems to that of an illness occurring in the context of culture
3. Ability to elicit a patient’s explanation of an illness and its causes
4. Ability to explain to a patient the health care provider’s perspective on the illness and its perceived causes
5. Being able to negotiate a mutually agreeable, safe, and effective treatment plan

Reiteration from Mrs. Campbell’s notes of the 5 competencies:

1. Respecting a patient’s health beliefs as valid and understanding the effect of the patient’s beliefs on health care delivery
2. Shifting a model of understanding a patient’s experience from a disease happening in his or her organ systems to that of an illness occurring in the context of culture (biopsychosocial context)
3. Ability to elicit a patient’s explanation of an illness and its causes (patient’s explanatory model)
4. Ability to explain to a patient in understandable terms the health care provider’s perspective on the illness and its perceived causes
5. Being able to negotiate a mutually agreeable, safe, and effective treatment plan

Question 38

Health Disparities

Answer 38

Health disparity (inequality/gap)
A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage

Health disparities are the differences among populations in the incidence, prevalence, and outcomes of health conditions, diseases, and related complications.
Health care disparities are differences among populations in the availability, accessibility, and quality of health care services (e.g., screening, diagnostic, treatment, management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their complications.

Addressing health disparities:
New standards
Focus on cultural competency, health literacy, and patient- and family-centered care
Recognize that valuing each patient’s unique needs improves the overall safety and quality of care and helps to eliminate health disparities.

African-Americans, Asians, & Hispanics less likely that non-Hispanic whites to see PCP regularly
Less care available to people in low- and middle-income groups compared with high-income groups
Uninsured people ages 0-64 years less likely to have regular PCP than those with private/public ins.
Subgroups of LGBT community have more chronic health conditions and a higher prevalence & earlier onset of disabilities than heterosexuals

Question 39

6 QSEN Competencies

Answer 39

1. ) patient centered care
2. ) teamwork and collaboration
3. ) evidence-based practice
4. ) quality improvement/assurance
5. ) safety
6. ) informatics

Question 40

Cultural Assessment models with explanation

Answer 40

Camphina-Bacote’s models of cultural competency has five interrelated components:
Cultural Awareness: an in depth self examination of one own’s background, recognizing biases, prejudices, and assumptions about other people

Cultural knowledge: : Sufficient comparative knowledge of diverse groups, including the values, health beliefs, care practices, world view, and bicultural ecology commonly found within each group

Cultural Skills:
Ability to assess social, cultural, and biophysical factors that influence patient treatment and care

Cultural encounters: Cross-cultural interactions that provide opportunities to learn about other cultures and develop effective intercultural communication

Cultural desire: The motivation and commitment to caring that moves an individual to learn from others, accept the role as a learner, be open to and accepting of cultural differences, and build on cultural similarities

Question 41

Cultural Competency

Answer 41

Defined as the enabling of health care providers to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients.
Culturally competent organizations:
Value diversity
Conduct a cultural self-assessment
Manage the dynamics of difference
Institutionalize cultural knowledge
Adapt to diversity

Expanding the original focus on interpersonal skills, many of the current approaches to cultural competency now also focus on:
All marginalized groups and not just immigrants
Prejudice, stereotyping, and social determinants of health
The health system, communities, and institutions.
You broaden your understanding of the world by learning about other people’s world views, which determines how people perceive others, how they interact and relate to reality, and how they process information. Cultural competency is dynamic and takes time to develop.

Question 42

Blanchet and Pepin on cultural competencies

Answer 42

Blanchet and Pepin: depends on experience & interactions with patients and fellow clinicians
Building a relationship with the other
Working outside the usual practice framework
Reinventing practice in action

Blanchet and Pepin have recently described the processes involved in the development of cultural competence among registered nurses and undergraduate student nurses. Clinical experience and interactions with patients and fellow clinicians help to build cultural competency.

Question 43

Cultural Competencies Cultural Responsive Care

Answer 43

Nurses should accommodate each client’s cultural beliefs and values whenever possible, unless they are in direct conflict with essential health practices. The goal is to provide culturally competent care.
Culturally sensitive – nurses are knowledgeable about the cultures prevalent in the area of practice.
Culturally appropriate – nurses apply their knowledge of the client’s culture to their care delivery
Culturally competent – nurses understand and address the entire cultural context of each client within the realm of the care they deliver.
Culturally responsive – should encourage client decision-making by introducing self-empowering strategies.
Culturally imposition – understanding and awareness of their own (nurses) culture and any culture biases that might affect care delivery.

Question 44

Linguistic Competencies

Answer 44

Linguistic competence is the ability of an organization and its staff to communicate effectively and convey information in a manner that is easily understood by diverse audiences. These audiences include people of limited English proficiency, those who have low literacy skills or are not literate, individuals with disabilities, and those who are deaf or hard of hearing.

Question 45

Mnemonics

Answer 45

LEARN: Listen, Explain, Acknowledge, Recommend, Negotiate
RESPECT: Rapport, Empathy, Support, Partnership, Explanations, Cultural Competence, Trust
ETHNIC: Explanation, Treatment, Healers, Negotiate, Intervention, Collaboration
C-LARA: Calm, Listen, Affirm, Respond, Add

Question 46

Factors of readiness to learn (motivation, ability, environment)

Answer 46

Motivation – a person’s desire or willingness to learn. Effected by previous knowledge, experience, attitudes, and sociocultural factors. *(Health Care providers make the worse patients)

Ability – depends on the physical and cognitive attributes, developmental level, physical wellness, and intellectual thought processes.

Environment- Effected by the # of people, need of privacy, temperature, lighting, noise, ventilation, furniture set up.

Pg. 14 in Powerpoint

Question 47

Health Literacy and knowledge assessment

Answer 47

Health literacy: the cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.
Health literacy includes patients’ reading and mathematics skills, comprehension, and decision-making and functioning skills with regard to health care.

Health Literacy is a strong predictor of a person’s health status. Results from a 2015 survey by the U.S. Department of Education, National institute of Literacy found that 32 million American adults have a below-basic level of health literacy. Studies show that patient with low literacy levels are 1.5 to 3 times more likely to expereicne adverse health outcomes and are at an increased risk for hospitalization that those at lower literacy levels. AT RISK = above the age of 65, minority populations, immigrant populations, low income, those with chronic mental of physical health conditions.

The nurse should provide client education at the 6th grade reading level or below. Assess by asking patient to read a medication label, explain back simple step by step plans, describe back instructions on a written hand out.

Question 48

Nursing Diagnosis: patient education-

Answer 48

Deficient knowledge (affective, cognitive, psychomotor)
Ineffective health maintenance
Impaired home maintenance
Ineffective family therapeutic regimen management
Ineffective self-health management
Noncompliance (with medications)

Nursing Diagnosis –
Deficient Knowledge = the diagnostic statement describes the specific type of learning needed and it’s cause
Ex. Deficient knowledge regarding (surgical procedure) related to lack of recall and exposure to information

Ineffective Health Management = used when you can eliminate health care problems through education
Ex. Ineffective Health Maintenance related to deficient knowledge regarding scheduling of medications

Question 49

Learning Domains

Answer 49

Cognitive Learning – acquiring knowledge and skills. Includes all intellectual behaviors and requires thinking

Affective learning – development of values, attitudes, and beliefs. Deals with expression of feelings and acceptance of attitudes, opinions, or values.

Psychomotor learning – acquiring motor skills (client must “physically do something”). Involves acquiring skills that require integration of mental and muscular activity.

Question 50

Learning Domains Continued

Answer 50

Different teaching methods are appropriate for each domain of learning.
Cognitive: discussion (one-on-one or group), lecture, question-and-answer session, role play, discovery, independent project, field experience- typical classroom type learning
Affective: role play, discussion (one-on-one or group)
Psychomotor: demonstration, practice, return demonstration, independent projects, games

Question 51

Teaching Methods

Answer 51

• Telling – limited info, when client is anxious, specific task, no feedback
• Participating – discussion, feedback, mutual goal setting, revision of plan
• Entrusting- client self manages care and the nurse observes and assists
• Reinforcement – use of a stimulus (positive or negative) Timing is essential so a clear correlation is made between the behavior and the stimulus.

Incorporating teaching – Teach more effectively while delivering nursing care. Ex. Medication teaching while administering medication

Question 52

Teaching Methods Continued

Answer 52

• One-one-One – most common at bedside, give info, client can ask questions, use models and diagrams, can be unstructured
  
  • Group – economical, learn from experiences of others, discussion, share ideas, review common experiences. Leader guides participation.
  • Preparatory instruction – (tests or procedures) reduce anxiety. Describe common physical sensations and causes. When results will be available.
  • Demonstrations- psychomotor skills – use return demonstration (requires planning and organization)
  • Analogies = supplements verbal instructions with familiar images that make complex information more real and understandable.
    
    • be familiar with the concept
    • know the patient’s background, experience, culture
    • keep analogy simple and clear
  • Role Play – Patient learn a required skill by performing independently. The nurse offers feedback.
  • Simulation – teach problem solving, application, and independent thinking

Question 53

Learning Evaluations

Answer 53

Questions to ask when evaluating client education –

1. were the client’s goals or outcomes realistic and observable?
2. Is the client able to perform the behavior or skill in the natural setting (home)?
3. How well is the client able to answer questions about the topic?
4. Does the client continue to have problems understanding information or performing a skill? If so, how can you change the interventions to enhance knowledge or skill 	performance?

Teach back – is a closed loop communication technique that assesses that client retention of the information imparted during the teaching session. Ask the patient to explain the teaching provided. Client understanding is confirmed when the client can accurately restte the information in his or her own words.

See through the patient’s eyes.
Have the patient’s learning needs been met?
Evaluate a patient’s learning by observing performance of expected learning behaviors under desired conditions.
Discontinue, adjust, or amend the plan.
Patient outcomes:
Legal responsibility
Documentation

Question 54

Teaching Technique for patients with special needs or low literacy

Answer 54

Teaching a Patient with Literacy or Learning Disability
Literacy and other Disabilities - Impaired ability to analyze instructions, synthesize information, problem solve. Promote a safe, shame-free environment. Consider sensory deficits.
- Establish trust, speak slowly, encourage questions, short sessions, appropriate teaching materials, appropriate analogies, model appropriate behavior, visual aids, Teach back, positive reinforcement.
Teach Back – to determine understanding about a topic or ability to demonstrate a procedure. Determines level of understanding of instructional topic. Always revise you instruction or develop a plan for revised patient teaching if the client is not able to teach back correctly.

Cultural Diversity – Assess and determine a patient’s beliefs, values, and customs as they relate to health. Box 25-7 p.350 P&P
- use a trained and certified healthcare interpreter to provide health care information when a client can not understand english

Teaching tools- Table 25-3 p.352 P&P. Select the right tool depending on the instructional method, learning needs, and ability to learn.

- Printed Materials = easy to read, info accurate and current, use for complex concepts
- Physical objects = teach concepts or skills, allows for the manipulation of objects  used later in skill

Special needs – Developmental needs of children, physical and psychological needs of older adults (sensory, memory)
Assess family dynamics (high incidence of elder abuse)
Box 25-8 p. 352 P&P Focus on Older adults – casual, personalized, lighting, large font, eliminate noise, sufficient time, use of prosthesis, concrete examples, step-by-step, short sessions, summarize.

Question 55

6 Rights of Medication Administration

Answer 55

The right patient
The right medication
The right route
The right time
The right dose
The right documentation

Question 56

Components of a medication order

Answer 56

Patient’s Full Name & Medical Record Number
Date and Time order was written
Medication Name
Dosage
Route of Administration
Time and Frequency of Administration
Signature of prescribing health care provider

Patient’s with the same name need to be identified carefully with their medical record number. Labels for same name should be placed on the charts and prn medications to ensure patient safety.
Clarify start and stop dates
Medication Name – chemical name (molecular structure), Generic name (official publicized name), Trade name (marketed name) – Be familiar with Generic & Trade names
Dosage = the strength of the medication- Nurse must understand pharmacokinetics (absorption, distribution, metabolism and excretion)
Route – know accepted abbreviations, clarify orders, look it up * tPA Activace
Time & Frequency – achieve a therapeutic range of a medication occurs between the toxic concentration and minimum effective concentration. Figure 32-2 p.614 P&P
Signature – make sure the signature is legible so you can call for clarification.

Question 57

Error Prone Abbreviations

Answer 57

Pg. 622 in P&P

Question 58

Interventions to avoid medication error

Answer 58

Follow 6 Rights
Read the label 3 times comparing with MAR
Use at least 2 Pt Identifiers
Do not allow any other activity to interrupt medication administration
Double-check all calculations and verify with another RN
Do not interpret illegible handwriting; clarify with prescriber
Question unusually large or small doses
Document all medications as soon as they are given

Question 59

Nurse’s Response to a medication error

Answer 59

Client’s Safety is TOP Priority
Assess Client
Notify Physician
Report to Nurse Manager
Do not fear repercussions
Reflect
Opportunity to prevent future errors
File Incident Report
Do not document in medical record
Report near misses

Question 60

Telephone and verbal orders

Answer 60

Accepted only if the physician cannot attend the patient and if the order is:
Recorded in the medical record verbatim with date and time of the order
Verified by reading back to and confirming with the physician
Complete
Countersigned by the physician as soon as possible
If the nurse can not understand the order, a second nurse or supervisor should be asked to listen to the order

Question 61

Oral Medication Administration Skills

Answer 61

Oral – with or with out food? Risk for aspiration (BOX 32-13 p.635 P&P) – Self- administer, high-fowlers, assess after sipping water for voice change, cough, delayed swallowing, pocketing.
Interventions – strong side of mouth, one at a time, thicken liquids, crush pills in purred food, avoid straws, well rested

Contraindications/ Precautions – NPO (nothing by mouth), inability to swallow/ risk for aspiration (dysphagia), nausea, vomiting, bowel inflammation, recent GI surgery, gastric suction, decreased Level of consciousness. Determine if a medication can be crushed!!!! Ask the pharmacist or look it up!!!! **

Nursing intervention-
Contraindication - Temporarily hold the medication and notify the prescribing health care provider and possibly the pharmacist.
Safety – Medication reconciliation = check the accuracy and completeness of the MAR & the 6 patient rights, Check medication 3 times, avoid interruptions when administering medications, assess for allergies, hand hygiene, prepare medication one patient at a time. Position patient into a Fowlers, High Fowlers, or side lying position.

The pharmacist should split, even pre-scored, medications and send to the unit packaged and labeled. (ISMP & USFDA recommendations of best 	practice)

PCC – Assess client’s knowledge of medications, assess preferred beverages to take with medication, Place prepare unit-dose medications in medicine cup without removing wrapper. WHY? P.656 P&P. Assess the patient’s ability to self-administer medication. Explain the purpose, action, side effects and adverse effects of each medication. The patient has the right to refuse any medication or treatment. What should the nurse do if the patient refuses?

Outcomes – Assess to make sure the patient swallowed the medication. Assess for desired response or adverse effect based on medication peak, Use teach back method. Document. Document. Document.

Question 62

Topical Medication Administration Skills

Answer 62

Topical – wear gloves, clean skin, remove old lotions, ointments and transdermal patches before applying new. Use sterile technique with an open wound. Label and document location medication was removed and new medication applied.

Question 63

Ophthalmic (Eye) Medication Administration Skills

Answer 63

Eye- Age-related problems, including poor vision, hand tremors, and difficulty grasping or manipulating containers, affect the older adult’s ability to self- administer eye medications.

Assess level of consciousness to reduce combative behavior when administering ophthalmic medications and preventing accidental eye injuries

Warming eye drops to room temperature will reduce eye irritation

Rolling eye drop container ensures medication is mixed and shaking causes bubbles increasing difficulty of administration.

Instill ophthalmic ointment in a even this stream above the lower lid margin. This distributes medication evenly across the eye and lid margin.
Place the intraocular disk in the conjunctival sac between iris and lower lid then gently pull the lower eyelid over the disk. You should not be able to see the disk. This ensures accurate delivery of the medication.
-Can not be delegated to assistive personnel

Question 64

Ear Medication Administration Skills

Answer 64

Can not be delegated to assistive personnel.
Explain positioning and sensation to expect such as hearing bubbling or feeling water in the ear
Positioning
Side lying unless contraindicated
Straighten ear canal – pull pinna up and back (adults)
Client remains side lying for 2-3 minutes
Clean procedure

Ear – Only use sterile solutions if the ear drum is suspected of or is ruptured. What may indicate ear drum rupture? Room temperature to prevent vertigo, dizziness, or nausea

Question 65

Nasal Medication Administration Skills

Answer 65

Nasal – often self-administered. Caution overuse to avoid the rebound effect of worsening nasal congestion.

Can not be delegated to Assistive personnel.
Assess condition of nose and sinuses
Instruct the client to clear or blow nose before administration unless contraindicated
Administer nasal drops and spray with patient supine and head tilted appropriately
Point nozzle of nasal spray to side and away from center of nose while gently closing other nostril.
The client should hold their breath for a few seconds then breath from the mouth and avoid blowing nose for several minutes

Question 66

Rectal Medication Administration Skills

Answer 66

Rectal – Often used to promote defecation or reduce nausea. Rectum is very vascular leading to systemic absorption.

Can not delegate to assistive personnel.
Review medical history for hemorrhoids, anal fissures, rectal surgery, or bleeding and allergies.
Clean procedure
Sims position
Use water-soluble lubricating jelly
Client should take slow deep breaths to relax the anal sphincter
Insert suppository gently through anus, past the internal sphincter and against the rectal wall (4 inches in adults)
Client should lie flat for 5 minutes to prevent expulsion

Question 67

Inhalation Medication Administration Skills

Answer 67

Can not be delegated to assistive personnel.
Assess ability to self-administer medications
Medication schedule and # of inhalations prescribed
Provide patient education as needed and tolerated
Important steps of medication administration
Shake inhaler vigorously 5-6 times
Have client sit up and take one deep breath in and out
Client should tilt head slightly back and slowly and deeply inhale medication for 3-5 seconds
Client should hold breath after administration for 10 seconds
Exhale through pursed lips
Wait 20-30 seconds between inhalations
Wait 2-5 minutes between different inhaled medications

Explain what metered dose is and warn the patient about overuse of inhaler, including medication side effects. This is because excessive inhalations increase risk of serious side effects.

Inhalation administration – Shaking inhaler 5-6 times ensures fine particles are aerosolized. Having the client sit up and take a cleansing breath empties the lungs and prepares the airway to receive the medication. Inhaling slowly for 3-5 seconds with head slightly tilted distributes the medication into the airways through the mouth. The client should then hold their breath for 10 seconds to allow the tiny drops of aerosol spray to reach deeper branches of airways. The client should exhale through pursed lips to keep small airways open during exhalation. Medications should be inhaled sequentially. Always give bronchodilators before steroids. First inhalation opens airways. Second and third inhalation reduces inflammation and/or penetrates deeper airways

Question 68

Essential Nutrients

Also look on pages 5 and 6 for additional information on nutrients on Nutrition powerpoint.

Answer 68

Carbohydrates
Complex and simple saccharides
Main source of energy

Proteins
Amino acids
Necessary for nitrogen balance

Fats
Saturated, polyunsaturated, and monounsaturated
Calorie-dense

Water
All cell function depends on a fluid environment

Vitamins
Essential for metabolism
Water-soluble or fat-soluble

Minerals
Catalysts for enzymatic reactions
Macrominerals; trace elements

Question 69

Anabolic vs. Catabolic

Answer 69

Anabolism
Building of more complex biochemical substances by synthesis of nutrients
Catabolism
Breakdown of biochemical substances into simpler substances; occurs during physiological states of negative nitrogen balance

Nutrient metabolism consists of three main processes:

1. Catabolism of glycogen into glucose, carbon dioxide, and water (glycogenolysis).
2. Anabolism of glucose into glycogen for storage (glycogenesis).
3. Catabolism of amino acids and glycerol into glucose for energy (gluconeogenesis).

Question 70

Nutritional Subjective Assessment

Answer 70

Eating patterns identify self-care ability and health vs. unhealth habits. Alternative diets are not supported.
Usual weight – excess weight carries risk of hypertension, diabetes, heart disease, and cancer
Changes – Interfere with adequate nutrient intake
Recent conditions – increased caloric and nutrient needs (2-3 X)
Chronic illness – cancer and chronic illness in crease risk for nutritional deficits
GI symptoms – interfere with nutrient intake and absorption
Allergies - peanut allergies on the rise Intolerances can cause deficiencies (intake or due to diarrhea)
Medications – can impact digestion, absorption, and metabolism. Vitamins, minerals, herbals can have harmful side effects or adverse effects
Patient centered care – poverty and lack of access to nutritious foods can lead to inadequate amount of all food groups and essential nutrients
Alcohol- “empty calories”, can block absorption, can cause birth defects
Exercise – caloric and nutrient needs increase with increased physical activity
Family history – long term nutritional impairment may present as heart disease, osteoporosis, cancer, gout, GI disorders, obesity, or diabeties

Question 71

Nutritional Objective Assessment

Answer 71

Nutritional screening is a quick and easy way to identify individuals at nutrition risk such as those with weight loss, inadequate food intake, or recent illness. Screening includes: weight, weight history, conditions associated with risk, diet information, routine lab work.
Malnutrition is estimated to occur in one third of hospitalized patients and is associated with adverse outcomes: impaired would healing, increased infection risk, suppression of immune system, functional loss with increased fall risk, increased risk of pressure ulcers, longer hospital stay, and increased mortality.
During hospitalization documentation of nutritional intake is achieved through calorie counts of nutrients consumed and/or infused.
24- hour recall – elicit specific information about dietary intake over a specific period of time. Disadvantages = (1) client may not be able to recall, (2) last 24 hours may not be typical intake, (3) client may alter the truth, (4) snacks and gravies/sauces/condiments may be underreported
Food frequency questionnaire- record how many times per day/week/month particular foods are eaten to estimate intake. Disadvantages = (1) does not always quantify amount of intake, (2) relies on memory
Food diary – write down everything consumed over a period of time. Must teach to record immediately after eating. Disadvantages= (1) noncompliant, (2) inaccurate, (3) atypical recording, (4) conscious altering of diet
Direct observation – of the feeding and eating process. Technology- photos of meals and tracking of meals

Question 72

Factors: Developmental State

Answer 72

Birth to 4 months is the most rapid period of growth in the life cycle. Breastfeeding is recommended for full-term infants for the first year of life. No Cows milk until 1 yr of age – poor source of iron and V-C&E Whole milk from 1yr-2yrs old (brain development)
Benefits of Breastfeeding
1. fewer food allergies and intolerances
2. reduced likelihood of overfeeding
3. less cost that infant formulas
4. increased mother-infant interaction
Adolescence - Caloric, protein, calcium, & iron requirements increase to meet the rapid physical growth and endocrine and hormonal changes than cause bone growth, increasing muscle mass, and onset of menarche in girls.
Pregnancy – national academy of sciences (NAS) recommends weight gain of 25-35 lbs for the normal weight woman. Increase of 28-40 lbs for underweight women, 15-25 lbs for overweight women, & 11-2- lbs for obese women.
Adulthood – obesity is the cardinal sign. This syndrome carries increased cardiac risk and is diagnosed when a person has 3/5 biomarkers. (1) elevated BP, (2) increased fasting plasma glucose, (3) elevated triglycerides, (4) increased waist circumference, (5) low HDL high density lipoprotein.
Aging Adult – Sarcopenia / sarcopenic obesity = age-related loss of muscle mass/ combined with increased body fat. It is attributed to a decrease in physical activity and a decreased protein intake with aging. Sarcopenic obesity results in a loss of muscle strength and function, decreased quality of life, physical frailty, and increased mortality rates. (resistance training)

Question 73

Factors: Cultural/Spiritual Influence

Answer 73

Consider risk factors for new immigrants– unfamiliar foods, food storage, food preparation, food buying habits
Consider cultural traditions- meal frequency and food quantity, ceremonial meals, fasting
Consider religious practices – (Table 11-1, p.184)
Should you assess a culturally diverse client using a 24 hour recall

Newly arriving immigrants may be at nutritional risk because they frequently come from countries with limited food supplies resulting from poverty, poor sanitation, war, or political strife. General undernutrition, hypertension, diarrhea, lactose intolerance, osteomalacia (soft bones), scurvy, and dental caries are among the more common nutrition related problems of new immigrants from developing countries.

Buddhism – do not eat meat
Catholicism- do not eat meat on ash Wednesday, good Friday, Fridays in Lent
Hinduism – do not consume alcohol, beef, pork, fowl, red colored foods
Islam – no pork, alcohol, fasting before sunset during Ramadan
Mormon – no alcohol, caffeine, fasting the first Sunday of each month,
Orthodox Judaism – no pork, no dairy and meat in the same meal, no leavened bread during Passover, no shellfish, Kosher preparation of meat
Seventh-Day Adventists – no pork, no shellfish, meat, dairy, eggs, alcohol, coffee, tea

Question 74

Types of Nutritional Assessments

Answer 74

Nutritional Screening:
-Malnutrition Screening Tool: Nutritional screening is a quick and easy way to identify individuals at nutrition risk such as those with weight loss, inadequate food intake, or recent illness. Screening includes: weight, weight history, conditions associated with risk, diet information, routine lab work.
Malnutrition is estimated to occur in one third of hospitalized patients and is associated with adverse outcomes: impaired would healing, increased infection risk, suppression of immune system, functional loss with increased fall risk, increased risk of pressure ulcers, longer hospital stay, and increased mortality.
Mini Nutritional Assessment: Like a 24 hour recall of what the patient had to eat

Question 75

Comprehensive Nutritional Assessment

Answer 75

Dietary History-
24- hour recall – elicit specific information about dietary intake over a specific period of time. Disadvantages = (1) client may not be able to recall, (2) last 24 hours may not be typical intake, (3) client may alter the truth, (4) snacks and gravies/sauces/condiments may be underreported
Food frequency questionnaire- record how many times per day/week/month particular foods are eaten to estimate intake. Disadvantages = (1) does not always quantify amount of intake, (2) relies on memory
Food diary – write down everything consumed over a period of time. Must teach to record immediately after eating. Disadvantages= (1) noncompliant, (2) inaccurate, (3) atypical recording, (4) conscious altering of diet
Direct observation – of the feeding and eating process. Technology- photos of meals and tracking of meals

Also Physical exam, anthropometric measures, laboratory tests

Question 76

BMI & waist-hip ratio

Answer 76

Calculate body mass index (BMI) by dividing the patient’s weight in kilograms by height in meters squared: weight (kg) divided by height2 (m2).
Waist-to-hip ratio >1.0 or greater in men and 0.8 or greater in women indicates android (upper body) obesity and increases the risk for obesity related disease and early mortality.
A waist circumference of >35 inches in a woman and >40 inches in a man increases the risk for heart disease, type 2 diabetes, and metabolic syndrome

Question 77

Malnutrition Classifications

Answer 77

Obesity = 120% of standard weight with obese appearance
BMI >30 waist- to-hip >1.0 in men & >0.8 in women
BMI >40 = extreme or morbid obesity

Marasmus – weight >80% standard weight with a starved appearance
MAMC 0 mid upper arm circumference <90%
Subcutaneous fat and muscle wasting

Kwachiorkor – weight >100% standard with a well-nourishes appearance/edematous
Caused by diets high in calories but little or no protein – Serum albumin <3.5 g/dL & Serum transferrin <150 mg/dL

Mixed – weight <70% with emaciated appearance
MAMC <60% , Serum albumin <2.8 g/dL & Serum transferrin <100 mg/dL
Caused by inadequate intake of calories and protein such as severe starvation and catabolic states. Muscle, fat and visceral protein wasting. High risk for morbidity and mortality.

Question 78

Medical Nutritional Therapy

Answer 78

Diabetes Mellitus:
Type 1 diabetes mellitus (DM) requires both insulin and dietary restrictions for optimal control, with treatment beginning at diagnosis (ADA, 2010). By contrast, patients often control type 2 DM initially with exercise and diet therapy. If these measures prove ineffective, it is common to add oral medications. Insulin injections often follow if type 2 DM worsens or fails to respond to these initial interventions.

Type 2: exercise and diet therapy initially
Individualized diet
Carbohydrate consistency and monitoring
Saturated fat less than 7%
Cholesterol intake less than 200 mg/dL
Protein intake 15% to 20% of diet

Question 79

Medical Nutrition Therapy Continued

Answer 79

Individualize the diet according to a patient’s age, build, weight, and activity level. Maintaining a prescribed carbohydrate intake is the key in diabetes management. The ADA recommends a diet that includes carbohydrates from fruits, vegetables, whole grains, legumes, and low-fat milk (American Dietetic Association, 2010b). Monitoring carbohydrate consumption is a key strategy in achieving glycemic control.
Limit saturated fat to less than 7% of the total calories and cholesterol intake to less than 200mg/day. In addition, varieties of foods containing fiber are recommended. Patients are able to substitute sucrose-containing foods for carbohydrates but need to make sure to avoid excess energy intake. Diabetics can eat sugar alcohols and nonnutritive sweeteners as long as they follow the recommended daily intake level.
Patients with diabetes and normal renal function should continue to consume usual amounts of protein (15% to 20% of energy).
The goal of MNT treatment is to have glycemic levels that are normal or as close to normal as safely possible; lipid and lipoprotein profiles that decrease the risk of microvascular (e.g., renal and eye disease), cardiovascular, neurological, and peripheral vascular complications; and blood pressure in the normal or near-normal range (ADA, 2010). Be aware of signs and symptoms of hypoglycemia and hyperglycemia.

Question 80

Medical Nutrition Therapy Cardiovascular Diseases

Answer 80

American Heart Association (AHA) dietary guidelines
Balance caloric intake and exercise.
Maintain a healthy body weight.
Eat a diet rich in fruits, vegetables, and complex carbohydrates.
Eat fish twice per week.
Limit foods and beverages high in sugar and salt.
Limit trans-saturated fat to less than 1%.

The goal of the American Heart Association (AHA) dietary guidelines is to reduce risk factors for the development of hypertension and coronary artery disease. Diet therapy for reducing the risk of cardiovascular disease includes balancing calorie intake with exercise to maintain a healthy body weight; eating a diet high in fruits, vegetables, and whole-grain high-fiber foods; eating fish at least 2 times per week; and limiting food and beverages that are high in added sugar and salt. The AHA guidelines also recommend limiting saturated fat to less than 7%, trans-fat to less than 1%, and cholesterol to less than 300mg/day. To accomplish this goal, patients choose lean meats and vegetables, use fat-free dairy products, and limit intake of fats and sodium.

Question 81

MNT HIV and AIDS

Answer 81

Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS)
Body wasting and severe weight loss
Severe diarrhea, GI malabsorption, altered nutrient metabolism
Hyper-metabolism as a result of cytokine elevation
Maximize kilocalories and nutrients
Encourage small, frequent, nutrient-dense meals with fluid in between

Patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) typically experience body wasting and severe weight loss related to anorexia, stomatitis, oral thrush infection, nausea, or recurrent vomiting, all resulting in inadequate intake. Factors associated with weight loss and malnutrition includes severe diarrhea, GI malabsorption, and altered metabolism of nutrients. Systemic infection results in hypermetabolism from cytokine elevation. The medications that treat HIV infection often cause side effects that alter the patient’s nutritional status.
Restorative care of malnutrition resulting from AIDS focuses on maximizing kilocalories and nutrients. Diagnose and address each cause of nutritional depletion in the care plan. The progression of individually tailored nutrition support begins with administering oral, to enteral, and finally to parenteral. Good hand hygiene and food safety are essential because of a patient’s reduced resistance to infection. For example, minimization of exposure to Cryptosporidium in drinking water, lakes, or swimming pools is important. Small, frequent, nutrient-dense meals that limit fatty and overly sweet foods are easier to tolerate. Patients benefit from eating cold foods and drier or saltier foods with fluid in between.

Question 82

MNT Cancer and treatment

Answer 82

Cancer and cancer treatment
Malignant cells compete with normal cells for nutrients.
Anorexia, nausea, vomiting, and taste distortions are common.
Malnutrition associated with cancer increases morbidity and mortality.
Radiation causes anorexia, stomatitis, severe diarrhea, intestinal strictures, and pain.
Nutrition management.

Malignant cells compete with normal cells for nutrients, increasing a patient’s metabolic needs. Most cancer treatments cause nutritional problems. Patients with cancer often experience anorexia, nausea, vomiting, and taste distortions. The goal of nutrition therapy is to meet the increased metabolic needs of a patient.
Malnutrition in cancer is associated with increased morbidity and mortality. Enhanced nutritional status often improves a patient’s quality of life.
Radiation therapy destroys rapidly dividing malignant cells; however, normal rapidly dividing cells such as the epithelial lining of the GI tract are often affected. Radiation therapy causes anorexia, stomatitis, severe diarrhea, strictures of the intestine, and pain. Radiation treatment of the head and neck region causes taste and smell disturbances, decreased salivation, and dysphagia. Nutrition management of a patient with cancer focuses on maximizing intake of nutrients and fluids. Individualize diet choices to a patient’s needs, symptoms, and situation.
Use creative approaches to manage alterations in taste and smell. For example, patients with altered taste often prefer chilled foods or foods that are spicy. Encourage patients to eat small frequent meals and snacks that are nutritious and easy to digest.

Question 83

Food Safety

Answer 83

Health care professionals not only need to be aware of factors related to food safety but also should provide patient education to reduce risks for foodborne illnesses.

Question 84

Aspiration Precautions

Answer 84

Ensure that suction equipment is readily available in the patient room prior to feeding
Position the patient in the upright position (Fowlers/high fowlers), stimulate salivation, begin with ¼ of a teaspoon, offer liquids and solids separately, observe the larynx after each food/fluid intake, feed slowly, place food in the stronger side of the mouth,
Have the patient tilt the head forward/chin down
Ensure you are using the appropriate food consistency (determined after the swallow study)
Avoid asking the patient to speak before swallowing

Question 85

Warning Signs of Dysphagia

Answer 85

Coughing during eating
Change in voice tone or quality after swallowing
Abnormal movements of the mouth, tongue, or lips
Slow, weak, imprecise or uncoordinated speech
Abnormal gag
Delayed swallowing
Incomplete oral clearance/pocketing
Regurgitation