PN1 Final Exam Review Module One & Two (FULL REVISED EXAM REVIEW).

PN1 Final Exam Review Module One & Two (FULL REVISED EXAM REVIEW). The nurse is responsible for all tasks that are delegated. 5 rights of delegation: • Right task: The task is within the UAP's scope of practice and competence. • Right circumstances: The patient care setting and resources are appropriate for the delegation. • Right person: The UAP is competent to perform the delegated task or activity. • Right communication: The nurse provides a clear and concise explanation of the task or activity, including limits and expectations. • Right supervision: The nurse appropriately monitors, evaluates, intervenes, and provides feedback on the delegation process as needed. Do not delegate what you can EAT: Evaluate Assess Teach Know the 6 ethical principals that nurses should use and examples of them: 1. Autonomy – self management (person suffers an accident and doesn’t want extra measures) 2. Beneficence – doing good for the patient (nurse & patient decide on post op care together) 3. Nonmaleficence – avoiding things that may cause harm 4. Fidelity – keeping the nurses promise to give care 5. Veracity – telling the truth (telling the truth when one makes an error) 6. Justice – ensuring the equal and fair treatment of all patients (If someone lies about an error) RESCUE ALARM CONFINE EXTINGUISH PULL PIN AIM HOSE SQUEEZE SWEEP SBAR Communication: Situation Background Assessment Recommendation Team STEPPS • CUS words: State “I’m concerned; I’m uncomfortable; I don’t feel safe” • Check backs: Restate what a person said to verify understanding by everyone. • Call outs: Shout out important information for all team members to hear at one time. • Two-challenge rule: State a concern twice; if ignored follow facilities chain of command. Mass Casualty Triage • RED – Emergent needing immediate attention (Class I) • YELLOW – Can wait short time for care (Class II) • GREEN – Non-urgent or “walking wounded” (Class III) • BLACK – Expected to die or are dead (Class IV) Common Complications of Decreased Mobility: Physiological - Pressure ulcers - Osteoporosis - Constipation - Weight loss/gain - Muscle atrophy - Atelectasis Psychological - Depression - Changes in sleep/wake cycle - Sensory deprivation Osteoarthritis: Progressive deterioration and loss of cartilage and bone in one or more joints *Most common arthritis and major cause of impaired mobility and disability Disease Process: Affects weight bearing joints, hands, spine S&S: pain, stiffness, immobility, enlarges nodular joints, Risk factors: (Primary) Aging, possible genetics, weight baring joints Secondary) obesity, trauma, occupation, metabolic diseases, blood disorders Diagnostics: ESR labs, Xrays, MRI, CT Interventions: NSAIDS, Muscle relaxants, opioids (tramadol), rest, exercise, hot/cold application, weight control, joint replacement surgery Gout: a systematic disease in which urate crystals deposit in the joints, causing inflammation S&S: swollen, painful joints Risk factors: (Primary) most common; purine metabolism errors, Xlinked trait (Secondary) Hyperuricemia; uric acid in the blood; caused by another risk factor such as renal failure Diagnostics: Serum Uric Acid Level (above 6.5 indicates gout) Interventions: (acute) Colchichine, NSAIDS (chronic) Allopurinol, Febuxostat Low purine diet (meat, shellfish) Avoid aspirin and diuretics Decrease stress Lyme’s Disease: systemic infectious disease caused by spirochete borrelia burgdorferi, results from a bite from a deer tick S&S: (stage 1) flu like, bulls’ eye lesion (stage 2) cardiac issues, dizziness (stage 3) chronic complications; arthritis Risk factors: Situations where a tick bite is likely; heavily wooded areas Diagnostics: ELISA and Western blot test Interventions: antibiotic therapy; doxycycline or amoxicillin Fibromyalgia: chronic pain syndrome S&S: fatigue, sleep disturbances, numbness/tingling, odor sensitivity, headaches, jaw pain Risk factors: most commonly seen in women ages 30-50 Interventions: regular sleep pattern, limit caffeine and alcohol, anticonvulsants, SNRI’s, Tricyclic antidepressants, Tramadol, NSAIDS, physical and integrative therapy Scoliosis: lateral spinal deformity S&S: uneven pant/shirt length, pain Diagnostics: Adam’s bending forward test Interventions: Milwaukee Brace, surgery Kyphosis: posterior curvature of the thoracic spine S&S: hunchback Interventions: brace, spinal infusion Osteoporosis: chronic bone loss diseases S&S: back pain, constipation, heigh decrease, humped back, fractures Risk factors: Alcohol Corticosteroid use Calcium low Estrogen low Smoking Sedentary lifestyle Diagnostics: DEXA Interventions: exercise, diet high in calcium Vitamin D Fiber and Protein, avoid alcohol and smoking, avoid fall risks, Biphosphates *40mg daily for 3 months, EMPTY stomach with 6-8oz water, no food 30 min after, do not lie down for 30 min Osteomyelitis: bone infection S&S: fever, malaise, swelling, purulent drainage, tachycardia Risk factors: Malnourished, elderly, overweight, injection drug use Diagnostics: bone culture, CBC, needle aspiration Interventions: IV antibiotic therapy, immobilize body part Piaget’s Disease: increased bone absorption leading to compensation by remodeling, leading to deformities S&S: hip pain, deep arching, warm to the touch Diagnostics: increase in ALP, x ray, bone scan Interventions: limiting complications Osteomalacia: metabolic disease causing poor and delated mineralization of bone cells S&S: generalized skeletal pain, waddling gait Risk factors: low vitamin D, malabsorption, biliary system disease Diagnostics: serum calcium, phosphate, vitamin D, BUN Interventions: sunlight exposure, Vitamin D supplements, ergocalciferol Assessing mobility: - Past medical history - Family history - Current medications Lifestyle behaviors/occupation Preventing decreased mobility: - AROM exercises every two hours - Help pump activites - Adequate fluids - Evaluation for need of ambulatory aids Interventions for decreased mobility: - PROM - Turn & reposition every 2 hours - Keep skin clean and dry - Adequate nutrition and fluid intake - Ambulate with aides - Encourage deep breathing - Educate the patient and their family A nurse is performing a neurovascular assessment. What should the nurse include in this assessment?