Core Concepts for Local RN Exams

8/3/2019 Core Concepts for Local RN Exams

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Core Concepts for Local RN Examination

Suctioning Technique

STERILE Technique

CATHETER SIZEInfant = #5 #8Child = #8 #10Adult = #12 #18

POSITIONConscious = SEMI FOWLERSUnconscious = LATERAL

LENGTH OF INSERTIONmeasure distance from tip of NOSE to tip of EARLOBE (13 cm or 5 in)

OXYGENATEBEFORE suctioningBETWEEN suction ATTEMPTSat the COMPLETION of the procedure

LUBRICATE CATHETER TIPSTERILE NSS or H20

H20 SOLUBLE LUBRICANT (K Y Jelly)

Key PointsROTATE when withdrawing catheter

APPLY suction while WITHDRAWINGINTERMITTENT SUCTIONNO suction while INSERTING

Apply suction 5 10 sec

Suction attempt

10 15 secInterval 20 30 secDuration 5 minEFFECTIVENESS

CLEAR BREATH SOUNDS

Suctioning At Home


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CLEAN Technique

Care of Suction CatheterInside surface Flush by suctioning BOILED or DISTILLED H2O

followed by suctioning of AIR

Outside surface Wipe with ALCOHOL or HYDROGEN PEROXIDE

Care of Suction CatheterAllow to DRYStore in CLEAN DRY areaUse within 24 hours ONLY

Bathing

CategoriesCleansing Baths

Therapeutic Baths

Cleansing BathsComplete Bed Bath ENTIRE bodyPartial or Abbreviated Bath only ODOR producing parts of the

body

Key Points

43 C 46 C or 110 F - 115 FBed comfortable working heightClient move NEAR youSide rail LOWER on your sideEyes wash using WATER only wipe from INNER to OUTER canthusExtremities use LONG FIRM strokes

from DISTAL to PROXIMAL Increased VENOUS return

Back assist to PRONE or SIDE LYING facing away from you

Therapeutic BathsColloidal antipruritusMedicated Tars psoriasis and eczemaSaline widely disseminated lesionsSodium Bicarbonate coolingStarch soothing


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Key PointsAdult 37.7 C 46 C or 100 F - 115 FChild and Infant 40.5 C or 105 FDuration 20 30 minutes

Special Oral Care

Indication UNCONSCIOUS client

USE Normal Saline

AVOID Hydrogen peroxideLemon glycerine swabMineral oil

Nurses Priority Assess GAG reflexPosition Side lying with HOB lowered

Key Points Rinse mouth by drawing 10 ml of WATER or ALCOHOL FREE

mouthwash into syringe Inject it gently into EACH side of mouth Clean oral tissues with FOAM swab or GAUZE pad moistened with

NSS Use SEPARATE applicators for EACH area of mouth Clean oral tissues in ORDERLY progression

CheekRoof of mouthBase of mouth

Tongue Lubricate lips with PETROLEUM JELLY If client is on O2 therapy, use WATER BASED lubricant instead

Levels of Prevention

Primary PreventionPRE PATHOGENESIS

Health Promotion not disease orientedHealth Protection illness or injury specific

HEALTH EDUCATIONIMMUNIZATIONRisk Assessment


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Environmental SanitationFamily PlanningMarriage Counseling

Secondary PreventionPATHOGENESIS

Early DiagnosisPrompt TreatmentHealth Maintenance

Case FindingHealth CheckupsAssessmentOrder and TreatmentScreening Surveys and Procedures

Tertiary PreventionPOST PATHOGENESIS

ReferralRehabilitationReinforcement to prevent further complication

Making Referrals

Active Program of RehabilitationTeaching Clients with CHRONIC Disorders

Cancer Screening GuidelinesTSE 13 y/oPap Smear 18 y/o or when sexually activePelvic Examination 18 y/oBSE 20 y/oCBE 20 y/o

MammogramLow risk 35 39 y/oHigh risk 30 y/o

DRE 40 y/oGuaiac Test 50 y/oSigmoidoscopy 50 y/o

Rehabilitation To improve QUALITY of life


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CLIENT is primary rehabilitator

Begins on ADMISSION

Documentation Systems

Source Oriented RecordTraditional Client RecordEach person has separate section in clients recordNarrative Charting

Problem Oriented RecordData are arranged according to clients problems

4 Basic Componentsa. Databaseb. Problem Listc. Plan of Cared. Progress Notes

Focus Charting

Focuses on client needs

Three columns are used for recording:

a. Date and Timeb. Focusc. Progress Notes

Charting by Exceptiononly EXCEPTIONS to rule are documentedABNORMAL FINDINGS

Faxing Information

Secure CONSENTCHECK 3 timesa. Before dialingb. After dialingc. Before SENDING

Key Points Access to record is RESTRICTED to health professionals involved in

giving care


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Hospital is rightful OWNER of clients record Clients record is INADMISSIBLE as evidence when client OBJECTS COMPLETE CHARTING is best defense against malpractice Nursing care NOT recorded is NOT provided

Change of Shift Report

Purpose To provide continuity of careTool KardexBasis Clients health care needs

Telephone Order

Only RNs should take telephone ordersVERIFY Repeat it back to physicianCountersign within 24 hours

Physical Assessment

General GuidelinesPSYCHOLOGICAL PREPARATIONRoom WARM enoughEMPTY THE BLADDER ComfortProvide privacy DrapingAdequate lighting

Ready the equipment at the bedsideExpose ONLY body areas to be examined Avoid Hypothermia

Special ConsiderationsConvenient TIMEHEAD TO TOEInspection, Palpation, Auscultation, Percussion I P A PPlan SEVERAL ASSESSMENT times ElderlyStart from the LEAST INVASIVE Infant/Child

Methods

INSPECTIONVisual ExaminationSense of Sight

PALPATIONTactile Examination


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Sense of Touch

Types

Light/Superficialgentle pressure

less than 1 cm deep

Deepincreased pressuremore than 1 cm deep

Parts of the Hand

FINGERTIPS PulsationFINGER PADS Shape

MoistureConsistencyTexture

PALMAR Aspect VibrationDORSAL Aspect Temperature

General Guidelines

Hands Clean

WarmFingernails SHORTAreas of Tenderness Palpated LASTSuperficial Palpation Done FIRST

AUSCULTATIONprocess of LISTENING to sounds produced within the bodySense of Hearing

Types

DIRECT Unaided EARINDIRECT Stethoscope

Parts of a Stethoscope

DIAPHRAGM HIGH frequencyBreath sounds


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Bowel soundsFriction rubs

BELL LOW frequencyS3 and S4

Bruits

Venous hums

PERCUSSIONact of STRIKING BODYSense of HearingSense of Touch

Types of Sounds

Quality LocationFLATNESS very dull muscle

boneDULLNESS thud like heart

liverspleen

RESONANCE hollow NORMAL LungHYPER booming EMPHYSEMIC LungRESONANCE

TYMPANY drum like air filled stomach

Key Points

FLATNESS Most DENSELeast AIR

TYMPANY Least DENSEGreatest AIR

Key Points

Chest SITTING positionBack STANDING positionPalpation of thyroid gland Stand BEHIND clientOphthalmoscope DARKEN roomVaginal speculum Pour WARM water

Abdominal Assessment


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General GuidelinesVOID before the assessmentO = Zero Degree HOBWARM the HANDS and the STETHOSCOPESUPINE with knees flexed

Correct SequenceI A P PInspectionAuscultationPercussionPalpationRLQ RUQ LUQ LLQ

Isolation Precautions

2 Tiers of PrecautionsStandard Precautions

Transmission based Precautions

StandardAll patients regardless of diagnosis or presumed infection

Prevent Nosocomial Infection

Transmission based

Patients who are cases or suspects of a highly transmissible infection

Types of Transmission based

Airborne Precautionsdroplet nucleiless than 5 microns

remain in the airtravel more than 3 feet

RequirementsNegative pressure roomFrequent hand washingParticulate or N95 mask

IndicationsMeasles

Tuberculosis


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Varicella

Droplet Precautionsparticle dropletsgreater than 5 micronsdont remain in the air

travel less than or up to 3 feet

RequirementsPrivate roomFrequent hand washingMask when working within 3 feet of the client

IndicationsDiphtheriaInfluenza HI type BGerman MeaslesMeningitisMumpsPertussisPharyngitis Strep throatPneumonia

Contact Precautionsdirect contact clients skin

indirect contact contaminated articles

IndicationsDysenteryEnteritis C. difficileFood borne HepatitisHerpes simplex virusScabies

CohortingPreschooler SAME AGE RoommateSchool Age SAME SEX Roommate

Hand Washingmost effective way to prevent spread of infection

PreparationFingernails are kept short


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Assess hands for skin breaksRemove all jewelry

RequirementsRunning water WARMSoap Liquid: 2 4 ml/ 1 tsp

Tissue paper

Key Points10 15 seconds CIRCULAR movementFRICTION

Medical Hand Washing Hold hands LOWER THAN elbowsSurgical Hand Washing Hold hands HIGHER THAN elbows

Medications

Guidelines1. YOU are responsible for your own action2. If client VOMITS after taking oral medication, REPORT to nurse in

charge or doctor3. When medication is OMITTED, record fact and reason4. When medication ERROR is made, ASSESS client and REPORT tonurse in charge or doctor5. Administer ONLY medication personally prepared

6. Do NOT leave medications at bedside

Identify the Client1st Check clients identification bracelet2nd Ask client to state his/her name3rdAsk another nurse to identify client

Key PointDo NOT ask client by stating his/her name

Therapeutic Nurse Client Relationship

PreinteractionNurses SELF AWARENESSPlanning for FIRST INTERACTION with clientReviewing client data

Orientation


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TRUST buildingROLE CLARIFICATIONUpholding clients rightsSELF DISCLOSURETERMINATIONSetting CONTRACT

Maintaining CONFIDENTIALITY

WorkingFacilitating BEHAVIOR CHANGEEXPLORATIONWorking through RESISTANCEPROBLEM IDENTIFICATIONTransference and Counter transference

TerminationRecapitulating GOALS and OBJECTIVES achievedREFERRALSReinforcing NEW ADAPTIVE BEHAVIOR

Delegation

YOU DelegateStable clientsStandard procedures

Do NOT DelegateCare of invasive lines

AssessmentPatient teachingTriage

Administration of medicationInsertion of IV and NGTNursing process

Nursing Care Modalities

Functional NursingTask Oriented ApproachMANY Patients FEW Nurses

Total Care or Case NursingHolistic Approach


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Ratio is 1:1FEW Patients MANY Nurses

Team NursingGroup ApproachDecentralized

Heart is Team Conference

Primary NursingComprehensive ApproachAdmission to Discharge24/7 ModelRatio is 1:4 6 (Small Group)Secondary Nurse Take over when Primary Nurse is OFF DUTYHead Nurse Quality Control Expert

Informed Consent

TypesExpress written or verbal agreementImplied nonverbal agreement

Prerequisite for:Surgical proceduresEntrance into a body cavity

Radiological proceduresAnesthesia administration

General Guidelines1. Purposes2. What client can expect to feel or experience3. Intended benefits4. Possible risks or negative outcomes5. Advantages or disadvantages of possible alternatives

ElementsVoluntarinessInformationCapacity

Legal Age (over 18 y/o)OrientedConscious


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ExceptionsMinorsUnconsciousMentally incompetent

Emancipated Minors

4 MsMarried minorMinor who has a childMinor in military serviceMinor whos living away from home

RolesPhysician Consent TakerNurse Witness or AdvocatePatient Decision Maker

Key Points In emergency

NO consent is neededIMPLIED consent appliesPATERNALISM applies

Two physicians may sign Routine procedures are covered by consent signed at admission MOST nursing interventions rely on ORALLY expressed consent or

IMPLIED consent If client refused to sign consent form, have client fill out

RELEASE form If client refused to sign release form, have it noted in clients

chart In ELECTIVE sterilization, husband and wife must consentWhen sterilization is medically necessary, wifes consent is

enough If client has questions and nurse has doubts about clients

understanding, NOTIFY physician Consent is obtained BEFORE administering preanesthetic

medication

Incident Report

WHAT? Unusual Occurrence Report hospital record of accident or unusual occurrence


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Purposes1. To make ALL facts available to hospital personnel2. To contribute to STATISTICAL data3. To help hospital personnel PREVENT future incidents oraccidents

Content1. Clients name, initials and hospital or ID number2. Date, time and place of incident3. Facts of incident4. Clients account of incident5. Witnesses to incident6. Any equipment and medication

Key Points IR should be COMPLETED within 24 hours FACTS of incident should be noted in clients record IR is NOT part of clients record Do NOT record in clients record that IR has been completed

because facts are already documented in chart ANYONE who identifies that incident occurred should complete IR IR is reviewed by hospital risk management committeeWhen accident occurs, you should first ASSESS client

Triage

TriageSystem of client evaluation to establish priorities and assignappropriate treatment or personnel

Determination of Priority

Emergency situations

GREATEST RISK receives priority

Major disastersclassification based on principles to benefit the LARGEST

numberthose requiring highly specialized care may be given MINIMAL

or NO carethose requiring minimal care to save their lives should be

treated FIRST


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Categories

EmergentLife threateningBe seen IMMEDIATELY

UrgentSerious but NOT life - threateningBe seen within 1 hour

Non UrgentEpisodic illnessBe addressed within 24 hours

Fast TrackRequire simple FIRST AID or basic PRIMARY CARE

Color Coded Tagging SystemImmediate

RedLife threatening injuries1st Priority

Delayed

YellowSignificant injuries2nd Priority

MinimalGreenMinor injuries3rd Priority

ExpectantBlackExtensive injuries4th Priority

Core Concepts for Local RN Exams

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