Nursing Professional Values
Pain
Assessment & Vital Signs
Infection Control & Isolation
Immobility
Misc.
100
Code of Ethics
Developed by the ANA, this document outlines rules for nurses about client privacy, nursing conduct, and nursing behaviors to protect clients and the profession.
100
PQRST
Provocation/Precipitating cause
Quality
Region (or Radiation): "Can you point to where you are having your pain?"
Severity(or Scale)
Timing
100
Assessment
Subjective: current complaint, history, medications, etc.
Objective: vital signs, intake & output of fluids, height/weight
100
What are the four most common HAI's?
1. Catheter-associated urinary tract infections (CAUTI)
2. Central line-associated bloodstream infections (CLABSI)
3. Surgical site infections
4. Ventilator-associated pneumonia
100
Gastrointestinal complications of immobility
Malnutrition, constipation, fecal impaction, GERD, heartburn.
100
Aspiration Precautions
Head of bed up
Thickened liquids
SLP for swallowing
Routine oral care
Chin to the chest when swallowing
200
Key Principles of the Code of Ethics
Advocacy
Responsibility
Accountability
Confidentiality
200
Numeric Rating Scale
The most frequently used pain scale is where the client is asked to rate the intensity of their pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain the client can imagine.
200
Diagnosis
RN's clinical judgment about actual or potential health problems to help priortize and plan care.
200
Standard Precautions
Type of precautions used on all patients
Gloves
200
Tissue integrity risk factors for immobility
pressure injuries
200
Post-Op Complications for Infection
Increased pain
Severe redness
Swelling
Warm to touch
Drainage
Low BP
Increase respiration
Fever
Increased WBC
300
Integrity
The quality of being honest and having strong moral principles. (Think my ‘INtention is to always be honest)
300
Wong-Baker FACES Pain Rating Scale
Scale with facial expressions to indicates level of pain. Appropriate to use in children ages 3 and older.
300
Planning
Goals and outcomes formulated, personalized, to individuals unique needs
300
Contact Precautions
Precautions used when a client has an infectious agent that can be transmitted by direct or indirect contact with body secretions
Requires a minimum of gown and gloves before client interactions
300
Circulation risk factors for immobility
Deep vein thrombosis (DVT) occurs when a thrombus or blood clot develops in one or more of the deep veins, typically in the arms, pelvis, thighs, or lower legs. Immobile clients are at a greater risk for developing a DVT due to their increased blood viscosity and the atrophy of muscles that normally assist the body in pumping blood.
The most serious complication of DVT is a pulmonary embolism, which occurs when part of the thrombus breaks off and travels into the lungs via the bloodstream.
300
Ergonomics
Study of body mechanics concerning the demand and design of the work environment and the equipment used.
400
Autonomy
The right to make his or her own decisions
(think All by myself)
400
Face, Legs, Cry, Consolability (FLACC) scale
This scale is an observational pain measurement tool designed to be used with children 2 months to 7 years and clients who are cognitively disabled.
400
Implementation
Carrying out interventions outlined like cardiac monitor or oxygen, medication, and standard protocols
400
PPE Removal for Contact Precautions
Always remove PPE inside the client’s room if the client is prescribed contact precautions to avoid contaminating surfaces outside the client’s room.
400
Immobility for bone density
Resistance to extension of an extremity
400
What can the use of ergonomics increase and decrease?
Increase work satisfaction
Maximize productivity
Decrease the risk of injury and fatigue
500
AlTRUism
To do something, or take action, for the sake of benefiting someone else.
(think “It's TRUE I don’t expect anything in return when I help others”)
500
Practice Question: How do you determine pain in a patient who is cognitively disabled?
Use the Face, Legs, Activity, Cry, Consolability (FLACC) Scale.
500
Evaluation
Evaluate implementation to ensure desired outcome has been met: continous reassessment may be needed
500
Droplet Precautions
Don a mask when entering the room or coming into close contact with the client.
500
Respiratory risks with immobility
Atelectasis:
Partial or complete collapse of the lung, including airways and small sections of lung tissue.
Rapid, shallow breathing
Treatment: Deep breathing exercises 1 to 2 hours, bronchodilators
500
Examples of Ergonomic Practices and Equipment in Health Care
Modifiable workstations and chairs
Keyboards with wrist supports
Adjustable IV stands and poles
Height-adjustable beds
Two-person lifts/transfers
Client transfer devices
Shower chairs
Toilet seat risers
Side-opening garbage and linen containers
Elimination of uneven floor surfaces
600
Accountability
Responsible for all actions( think I am ‘accountable’ for my actions)
600
Nonverbal Pain Scale
Designed for clients who are unable to verbalize their pain level. This is for client who may be unconscious.
600
Determining Client Priority
Airway
Breathing
Circulation
The client that may deteriorate very quickly
600
Airborne Precautions
Used when a client has an infectious agent that can be transmitted through the air. You should don an N95 mask or a high-level respirator when entering the room of a client.
Client should be placed in a negative pressure air room (also called an Airborne Infection Isolation Room)
600
Orthostatic Hypotension
A decrease in blood pressure that occurs upon standing, especially from a lying or sitting position. A significant drop in blood pressure is caused by a change in position.
600
Fecal Occult Blood Test
A fecal occult blood test (FOBT) checks the stool for the presence of blood.
Test: Uses two drops(samples) one on 'A' and 'B' of square.
30 seconds for results
700
Nursing Managers
Nurse managers are responsible for their staff and unit functioning well. Their responsibilities include hiring, orienting, scheduling, evaluating, problem-solving, managing budget needs such as supplies and staffing, ensuring workplace staff and client satisfaction, and providing oversight of the safety, care, and positive outcomes of the clients on the unit.
700
CRIES Scale
The Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) Scale is an observational scale used for infants who were born at 38 weeks of gestation or greater.
700
Adult BP
Expected: Systolic 90 to 119
Diastolic 60 to 79mm Hg
700
A nurse is caring for a patient who has airborne precautions. What PPE should they don?
N95 mask
700
No assistance
The client can stand, march or step in place, and walk without any help.
700
The three layers of skin
Epidermis compromised of epithelial cells
Dermis
Subcutaneous
800
Nursing Educator
provides health care information to clients or teaches nursing students
800
Adult Pulse
Expected: 60 to 100 bpm
800
Minimal assist
The client can rise from a seated position and sustain a steady stand.
Use a gait belt and ambulation assistive device.
900
Nurse researcher
develops evidence-based information for nursing practice
900
Adult Temp
96.8°F (36°C).-100.4°F (38°C)
900
Moderate assist
The client can maintain a seated position and has some upper extremity strength but lacks enough lower extremity strength to transfer safely.
- Use sit-to-stand powered lifts and assistive devices.
1000
Case managers
coordinates care for the client with all team members
1000
Maximum assist
The client cannot bear weight, assist, or maintain a seated position. Use a total mechanical lift or sling.
1100
Nurse leader
manages and motivates a group toward achieving a common goal.
1100
The nurse is preparing to conduct a mobility assessment for a client. What are the six steps?
Extend arm to shake hands with client’s farther upper extremity
Instruct the client to sit on the edge of the bed for at least 2 minutes
Instruct client to extend one leg, flex ankle, and point toes.
Request the client to stand at the bedside for at least 5 seconds.
Request the client to walk or march in place.
Ask the client to take a few steps forward and then backward.
1200
What is a change agent?
A change agent sees a need and takes action to make a change.
1200
Assistive Devices
Gait belt
Cane
Walker
Crutches
Slide board
Pivot disc
Mechanical sit-to-stand lift
1300
Advocacy
Speaking up for clients' needs when clients are unable to speak for themselves, and supporting clients to make choices for their health.