NSG 200 ATI Review. Ryan Rickley, SN National University Nursing Peer Mentor Program. Fundamentals of nursing practice. Techniques to prevent personal injury when lifting clients. Use major muscle groups to prevent back strain, tighten abdominal muscles to prevent lower back strain
NSG 200 ATI Review Ryan Rickley, SN National University Nursing Peer Mentor Program
Techniques to prevent personal injury when lifting clients • Use major muscle groups to prevent back strain, tighten abdominal muscles to prevent lower back strain • When lifting from the floor flex the hips, knees, and back • Use assistive devices, and call for assistance if needed • Face the direction of movement when moving a client • Sliding, rolling, and pushing requires less energy than lifting
What about crutches?? • Assess • 2-3 finger breadths between axilla and top of crutch • Hands positioned on pads with elbows flexed • Nursing Interventions • Teach to maintain weight on unaffected leg • Upstairs: step up with unaffected leg first • Downstairs: step down with affected leg first
Which of the following statements about surgical asepsis and a sterile field are correct? (select all that apply) __The nurse should turn her back on the sterile field if she needs to cough. __The 1-inch edge around a sterile field is also considered sterile. __A sterile item can touch another sterile item without contaminating it. __Sterile items must remain above the waist. __Surgical asepsis is also called “sterile technique”
Nursing Interventions • Medical Asepsis • Frequent hand hygiene • Use PPE as indicated • Cleanse least soiled areas first • Place moist items in plastic bag • Surgical Asepsis • Avoiding coughing, sneezing, talking directly over sterile field • Only dry sterile items touch the field • Keep all objects above the waist
PPE • Gloves are removed and hand hygiene is completed between each client. • When do you use PPE? • What are the types of PPE? • What do you do if your PPE becomes contaminated? • Do you take your gown or gloves off first?
Handwashing! • The three essential components of handwashing include: • Soap • Water • Friction • All health care personnel must perform hand hygiene, either with an alcohol-based product or with soap and water, before and after every client contact, after removing gloves, after contact with body fluids, and after using the restroom. • When hands are visibly soiled, handwashing with soap and water is indicated. • Handwashing must be done for at least 15 seconds up to 2 minutes
ETS (endotracheal Suctioning) • Advance the catheter until resistance is met. The catheter should reach the level of the carina.Pull the catheter back 1 cm (0.5 in) prior to applying suction to prevent mucosal damage. • Apply suction intermittently by covering and releasing the suction port with the thumb for 10 to 15 seconds. • Apply suction only while withdrawing the catheter and rotating it with the thumb and forefinger. • Reattach the BVM or ventilator and supply the client with 100% inspired oxygen. • Allow time for the client to recover between sessions. • Repeat as necessary(normally no more than twice.)
Hypo & Hyperthermia • Hypothermia (Is <_____ degrees Celsius?) • Warming blanket (often a “Bear Hugger” which is NOT used with additional blankets! • Monitor Heart Rate/Rhythm (why?) • Hyperthermia (is > _____ degrees Celsius?) • Cooling Blanket • Assess WBC count. (why?) • Fluids, Rest, Minimize activity. • Provide antipyretics (which are?) • PREVENT shivering, offer blankets during chills. Cooling blanket when chills subside. • Provide dry clothes, linens • Control Environmental Temp
Skin Integrity • Maintain clean, dry skin and wrinkle-free linens. • Inspect the skin frequently and document the client’s risk using a tool such as the Braden scale. • Clean and dry the skin immediately following urine or stool incontinence. • Apply moisture barrier creams to the skin of clients who are incontinent. • Use tepid water (not hot), minimal scrubbing, and pat the skin dry.
Skin Integrity • Reposition the client in bed at least every 2 hr and every 1 hr in a chair. • Clients who can self turn, should do so every 15 minutes. • Limit chair time to 2 hours, and shift weight q15 while in the chair. • Maintain the head of the bed at or below a 30° angle (or flat) • Keep the client from sliding down in bed, as this increases shearing forces that pull tissue layers apart and cause damage. • Lift, rather than pull, the client up in bed or in a chair, because pulling creates friction that can damage the outer layer of skin (epidermis). • Raise the client’s heels off of the bed to prevent pressure on the heels. • Ambulate the client as soon as possible and as often as possible. • Implement active/passive exercises for immobile clients. • Do not massage bony prominences.
Skin Integrity • Provide adequate hydration (2,000 to 3,000 mL/day) and meet protein and calorie needs. • Note if serum albumin levels are low (below 3.5 g/dL), because a lack of protein puts the client at greater risk for skin breakdown, slowed healing, and infection. • Provide nutritional support as indicated, such as vitamin and mineral supplements, nutritional supplements, enteral nutrition, and parenteral nutrition.
Mobility & Immobility • Position using skin integrity techniques, as well as pillows, trochanter rolls, foot boots, and wedge pillows = Increase venous return, prevent foot drop, and promote skin integrity. • Avoid extremely long applications of either heat or cold, as they will result in a reaction opposite to the intended response. • Make sure the provider has written a prescription that includes: • Location. • Duration and frequency. • Specific type (moist or dry). • Temperature to use. • AND…. • Assess the site every 5 to 10 min • Discontinue the application if any adverse events occur, or remove the application at the predetermined time • (usually 15 to 20 min).
Contact precautions • Standard Precautions • ALL Patients • Transmission Precautions • Contact • Gowns & Gloves ; additional if warranted by intervention • Droplet • Surgical Masks • Airborne • N95 Masks + Negative Airflow • Reverse Isolation (When?)
Blood pressure • No smoking or caffeinated drinks 30 minutes within reading • Rest for 5 minutes before measurement • Sit in a chair with feet on the floor • 2cm above the armpit aligned with brachial artery • Inflate to 30mmHG above expected value • Release air at 2-3 mmHG per second • If you get an abnormal reading, and the situation allows, RETEST the reading after about 2-15 minutes • NEVER measure in the same arm as an IV with an infusion in progress • NEVER with a dialysis “ AV shunt” • NEVER on the same side as a mastectomy
Contact precautions Quiz! Standard, Contact, Droplet, Airborne, or Reverse? C Diff = ? HIV = ? Varicella (Chickenpox) = ? Pneumonia = ? Rubeola (Measles) = ? Rubella (German Measles) = ? Active TB = ? MRSA = ? Severely Immunocomprimised= ?
Medication orders • How do you take a telephone order? How is that transcribed in the MAR? • What does it mean to reconcile the medication list? When do we do this? What is the implication of a medication rec? • What is your patient safety goal for medication administration? • What are the components of a medication order? 350mgColacePOBIDP. Marsh, NP
Legal stuff • Incident Reports • When do we file these? • What do we document in the patient’s chart? • Informed Consent • What is the nurses role? • What is the doctors role? • When do we need these? • DNR/Advance Directives • What is it? • What is the nurses role?