Foundations HESI Review
Foundations HESI Review
Maslow’s Hierarchy of Needs
- Physiologic: biologic needs for food, shelter, water, oxygen,
... [Show More] sleep, sleep expression
o Open airway
- Safety: avoiding harm; attaining security, order and physical safety
o Teaching an older client to remove throw rugs that pose a safety hazard when ambulating
o First priority is safety then coping skills
- Love and belonging: Giving and receiving affections; Esteem and recognition
o Assisting client in joining a support group
- Self-actualization; Aesthetic
o Continued growth and development and self care
Advanced Directives
- Include living wills, health care proxies and durable powers of attorney for health care
- Based on values of informed consent, patient autonomy over end-of-life decisions, truth- telling, and control over the dying process
- Patient Self-Determination Act: patient’s record needs to document whether or not the patient has signed an advance directive
o For living wills or durable powers of attorney for health care to be enforced, a patient must be declared legally incompetent or lack the capacity to make decisions regarding his or her own health care treatment
o Legal competency needs clarification, judge makes that determination
- Health care proxy/durable power of attorney = legal document that designates a person or people of one’s choosing to make health care decisions when a patient is no longer able to make decisions on his or her own behalf
Death with Dignity or Physician-Assisted Suicide
- A competent individual with a terminal disease could make an oral and written request for medication to end his or her life in a humane and dignified manner
o Terminal disease = incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within 6 months
- ANA believes that nurses’ participation in assisted suicide violates the code of ethics for nurses
Durable POA vs Medical POA
- Durable POA = written document that creates an agency relationship between person granting authority and an agent, or attorney
o Authorize another person to engage in specified business, financial, legal transactions on your behalf
- Medical POA = document that allows you to designate trusted family member or friend to make medical decisions for you in the event you become unconscious or mentaly incapable of making decisions yourself
Urine
- Urinary output: less than 30 mL/hr, nurse should immediately assess for signs of blood loss and notify HCP
o Patients who have not voided for longer than 3-6 hours and have had fluid intake recorded should be evaluated for urinary retention
o Less than 30 mL/hr for more than 2 consecutive hours or excessive urine output (polyuria) is a cause for concern and should notify HCP
- Lab/Diagnostic testing
o Urine specimens need to reach lab within 2 hours of collection or must be preserved
o Urine that stands in a container at room temperature without required preservative will grow bacteria resulting in changes that will affect the accuracy of the test
o Obtain urine that is fresh = ask patient to double void
▪ Second voided specimen is the one sent to the lab
o Clean-voided or midstream (culture and sensitivity)
▪ To obtain urine as free of bacterial contamination as possible, a mid- stream clean-catch urine specimen may be required; required for accurate measurement of the kidneys’ excretion of substances
▪ Have patient initiate stream into toilet, then pass container into stream and collect 30-60 mL
• Initial stream flushes out microorganisms that accumulate at urethral meatus and prevents transfer into specimen
▪ Remove specimen container before flow of urine stops and before releasing labia or penis
▪ Transport specimen to lab within 15-30 minutes or refrigerate immediately
o Timed urine specimens: measures bodily substances that may be excreted at higher levels at specific times of the day or over a specific period
▪ Timed period begins after the patient urinates and ends with a final voiding at the end of the time period
▪ In most 24 hour specimen collections, discard the first voided specimen and then start collecting urine
▪ Patient voids into a clean receptacle; and the urine is transferred to the special collection container, which often contains special preservatives
▪ Urine container may need to be kept cool by setting it in a container of ice
▪ Missed specimens make the whole collection inaccurate
▪ Educate patient about need to collect all urine voided during prescribed time period
Religious Dietary Restrictions
- Muslims: pork, alcohol, caffeine
- Christianity: alcohol, meatless days during Lent
- Hinduism: all meats, fish, shellfish with some restrictions
- Judaism: pork, shellfish (only eat fish with scales), rare meats, blood, mixing milk/dairy with meat, kosher food preparations
- Mormons: caffeine, teas, coffees, tobacco
- Seventh-Day Adventists: Pork, shellfish, fish, alcohol, caffeine
Medical Nutrition Therapy
- GI Diseases (peptic ulcers): Avoid foods that increase stomach acidity such as caffeine, decaf coffee, milk frequently, citric acid juices, hot chili peppers, black peppers,
o Discourage alcohol, smoking, aspirin, NSAIDs
o Eat 3 regular meals without snacks (several small meals) especially at bed time
o IBS/Crohn’s: vitamins and iron supplements to correct or prevent anemia.
Increase fiber, reduce fat, avoid large meals, avoid lactose
o Celiac: gluten free – no wheat, rye, barley, oats
o Short bowel syndrome: lifetime feeding with EN or PN
o Diverticulitis: moderate or low residue diet until infection subsides; then high fiber
- Diabetes Mellitus:
o Type 1: Insulin and dietary restrictions
o Type 2: exercise and diet therapy. Carbs from fruits, vegetables, whole grains, legumes and low fat milk. Monitoring carb consumption is a key strategy in achieving glycemic control
▪ Limit saturated fat to < 7%
▪ Cholesterol < 200 mg/day
▪ Fiber foods
▪ Avoid excess energy
- Cardiovascular disease:
o High fruits, vegetables, whole-grain high-fiber
o Eat fish at least 2x/week
o Limit food and beverages high in added sugar and salt
▪ Limit saturated fat to < 7%
▪ Trans fat < 1%
▪ Cholesterol < 300 mg/day
▪ Lean meats, vegetables, fat-free dairy, limit fats/sodium
- Cancer & cancer treatment
o Small frequent meals that are nutritious and easy to digest
- HIV
o Maximize kcal and nutrients
o Small, frequent, nutrient dense meals
o Cold foods and drier or saltier foods with fluids in between
Nutrition
- Physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and trace minerals zinc and copper
- Collagen is a protein formed from amino acids acquired by fibroblasts from protein ingested in food
- Vitamin C necessary for synthesis of collagen
- Vitamin A reduces the negative effects of steroids on wound healing
- Zinc = epithelialization and collagen synthesis
- Copper for collagen fiber linking
- Calories provide the energy source needed to support cellular activity of wound healing
o Protein needs especially are increased and essential for tissue repair and growth
o 30-35 kcal & mL of fluids/kg/day
o 1.25-1.5 g protein/kg
Braden Scale for Predicting Pressure Ulcer Risk
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and shear
Stages of Pressure Ulcers
- Stage I: Nonblanchable Redness
o Discoloration of skin, warmth, edema, hardness or pain
o Darkly pigmented skin may not have visible blanching but its coloring may differ from surrounding area. Area may be painful, firm, soft, warmer or cooler compared to adjacent tissue
- Stage 2: Partial-thickness
o Shallow open ulcer with red-pink wound bed without slough
o Intact or open/ruptured serum-filled or serosanguineous-filled blister
o Shiny or dry shallow ulcer without slough or bruising
- Stage 3: Full-thickness skin loss
o Subcutaneous fat may be visible, but bone, tendon and muscle are NOT exposed
o Slough may be present but does not obscure depth of tissue loss
o May include undermining and tunneling
- Stage 4: Full-thickness tissue loss
o Exposed bone, tendon, muscle, subcutaneous fat
Wound Classifications
- Acute: trauma/surgical incision. Wound edges are clean and intact
- Chronic: chronic inflammation, repetitive insults to tissue
- Healing process
o Primary intention: surgical incision, wound is sutured or stapled; healing occurs by epithelialization
o Secondary intention: wound edges not approximated – pressure ulcers. Wound heals by granulation tissue formation, wound contraction and epithelization
o Tertiary intention: wound left often for several days; then wound edges are approximated
Positioning
- Redistributing pressure and shearing force to skin: elevating HOB to 30 degrees or less decreases chance of pressure ulcer development from shearing forces
o 30 degree lateral position = prevents positioning directly over bony prominences
Wound Management
- Preventing infection = cleaning and removing nonviable tissues
o Clean pressure ulcers only with noncytotoxic wound cleaners = normal saline or commercial wound cleaners (Dakin’s solution/sodium hypochlorite solution, acetic acid, povidone-iodine, hydrogen peroxide)
▪ Don’t use these in clean, granulating wounds
▪ Noncytotxic cleaners do not damage or kill fibroblasts and healing tissue
- Irrigation: delivering wound-cleansing solution to wound
o Debrides necrotic tissue with pressure that can remove debris from wound bed without damaging healthy tissues
▪ 19 gauge angiocatheter and 35 mL syringe delivering saline at 8 psi
- Debridement: removal of nonviable necrotic tissue
o Removal of necrotic tissue is necessary to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing
o Analgesic 30 mins before
Cleaning Wound
- Irrigating wound, allow solution to flow from least to most contaminated area
o Flush area with constant low-pressure flow of solution
o Clean gloves
o Always irrigate a wound with syringe tip over but not ni the drainage site
o Make sure fluid flows directly into the wound and not over a contaminated area before entering wound
- Drain sites: source of contamination
Wound Culture
- Never collect wound culture sample from old drainage
- Clean wound first with normal saline to remove skin flora
- Quantitative swab procedure
o Clean, allow to dry
o Use a sterile swab from culturette tube
o Moisten swab with normal saline
o Rotate swab
Protecting Patients During Seizure
- Note time, stay with patient, call for help, track duration of seizure, notify HCP
- If standing or sitting, guide patient to floor and protect head by cradling in your lap or placing pad under head
- Do not lift patient from floor to bed while seizure is in progress
- Clear surrounding area of furniture
- If patient is in bed, remove pillows and raise side rails
- If possible turn patient onto one side, head tilted slightly forward
- Do not restrain; hold limbs loosely. Loosen clothing
Restraints
- After applying, evaluate every 15 minutes
- Release restraint at least every 2 hours
- After 24 hours, HCP must see and assess patient
Transmission-Based Precautions
- Airborne precautions (droplet nuclei smaller than 5 microns): Measles, chickenpox (varicella), disseminated varicella zoster, pulmonary or laryngeal tuberculosis
o Private room, negative-pressure airflow, mask or respiratory protection device
o N95 respiratory for all HCP
- Droplet precautions (droplet larger than 5 microns; being within 3 feet of patient): Diphtheria (pharyngeal), rubella, streptococcal pharyngitis, pneumonia or scarlet fever in infants and young children, pertussis, mumps, Mycoplasma pneumonia, meningococcal pneumonia or sepsis, pneumonic plague
o Private room or cohort patients
o Surgical mask or respirator required
- Contact precautions (direct patient or environmental contact): VRE and MRSA, C.Diff, major wound infections, herpes simplex, scabies
o Private room or cohort patients
o Gloves
o Gowns
o Patients may leave their room for procedure therapy is infectious material is contained or covered, placed in clean gown and if hands are cleaned
- Protective environment: allogeneic hematopoietic stem cell transplants
o Private room
o Positive airflow
Ventrogluteal injections
- Preferred and safest for adults, childrens and infants especially for medications that have larger volumes and are more viscous and irritating
- Volumes > 2 mL
- Supine/lateral, flex knee and hips to relax
o Place palm of your hand over greater trochanter of patient’s hip with the wrist perpendicular to femur
o Point thumb towards groin and index finger towards anterior superior iliac spine
o Expend middle finger along iliac crest toward buttock
- Z-track IM injections: minimizes local skin irritation by sealing the medication in muscle tissue
o Large and deep like ventrogluteal
o Needle remains inserted for 10 seconds
o Release skin after withdrawing needle – medication can’t escape muscle tissue [Show Less]