UCF ABSN Essentials of Nursing Practice - Exam 1 2 basic rules for restraints - Answer -Always attach to bed frame, NEVER side rails. 2 fingers should fit between the body and the restraint to not cut off circulation. 2 Nursing Interventions to combat immobility - Answer -Education - bone health, exercise (weight bearing), prevention of musculoskeletal injuries. Nutrition - high protein, high calorie, vitamin C for skin integrity, vitamin B for energy metabolism, fluid hydration. 3 Learning Styles - Answer -visual, auditory, kinesthetic 3 Steps in Concept Mapping - Answer -Step 1 - organize assessment data, put in clusters to find/form patterns, identify nursing diagnosis. Step 2 - Find cultural relevance in diagnosis, a flexible and individualized situation with specific problem solving. Step 3 - make the diagnosis more meaningful by creating a connection between the diagnosis and what you're going to do. 7 Principles of Surgical Asepsis - Answer -1. STERILE TO STERILE. 2. Only sterile objects in sterile field. 3. Objects falling below the waist (unattended objects, turning back on the field, crossing arms over sterile field). 4. Prolonged exposure to air contaminated field. 5. Moisture onto a sterile field causing contamination. 6. Fluid flow in the direction of gravity. 7. 1" border around field is contaminated/not sterile. A patient should always have access to their ________ . - Answer -Call bell. A patients bed should always be _____ and _____ . - Answer -Low and Locked. A Safe Environment - Answer -Basic needs are closely linked to safety - Oxygen and carbon monoxide levels, food safety, temperature swings. Vulnerable groups - age extremes, chronically ill, physically/mentally ill, illiterate, poor, homeless. A safe environment includes the patient and health care providers well -being. ADPIE aka The Nursing Process - Answer -A - assess (gather info about pt's condition) D- diagnose (identify the pt's problem) P - plan (set goals of outcomes and identify appropriate nursing actions) I - implement (perform the nursing actions identified during the planning stage) E - evaluate (determine if goals and expected outcomes were achieved or not) Adult learning factors - Answer -1. Adults are more self -directed to learn. 2. Stage of acceptance of diagnoses. 3. Physical capability of learner. 4. Sensory deficits? Pain? Tired? Affective Domain of Learning - what it includes and effective teaching strategies. - Answer -What you FEEL. - Receiving, Responding, Valuing, Organizing, and Characterizing. Effective Teaching Strategies - role play, group discussions, one -on-one discussions. Age groups and major safety concerns - Answer -1. Infants, toddlers, preschoolers - suffocation and choking. 2. School -aged children - drownings. 3. Adolescents and teenagers - unintentional poisonings. 4. Adults - work related hazards. 5. Elderly - MVC, falls, and burns. Airborne Precautions require what type of room and PPE? - Answer -A private room with NEGATIVE airflow, handwashing, N95 respirator. Alternatives to restraints - Answer -Identify the cause of the agitation/behavior! Instead use: bed/chair alarms, increase pt observations, frequent reorientation in bed, family visits, consistent caregiver present. Modify the environment by: reducing noise levels, relocate closer to nurse's station, call bell, fold towels!, re -evaluate medications!!! Anatomy of Nursing Diagnosis - NANDA Statements - Answer -NANDA statement... related to (r/t)... Symptoms/Actual Diagnosis... as evidenced by (AEB)... Subjective or Objective data Appropriate use of ______ and ______ can decrease the risk of transmission. - Answer -Personal Protective Equipment and Handwashing Assessing the Teaching Environment - Answer -1. Distractions/noise 2. Comfort of room (light, temp.) 3. Room facilities and equipment. Assistive Devices - Walkers, Canes, and Crutches - Answer -1. Walkers - measure the top of the walker should line with crease of inside of the wrist. The patient holds the handgrips on the upper bars, takes a step, moves the walker forward and then takes an other step. DO NOT let them pick up the walker and move. Disadvantages = can roll forward when weight is applied.
