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What are the 4 LCCC ADN nursing concepts?
Human, Health, Nursing, Environment
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What are the 6 course threads?
- 1. Cultural/spiritual
- 2. Nursing Process
- 3. Teaching/Learning
- 4. Ethical/legal
- 5. Therapeutic communication
- 6. socialization to the role of a nurse
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Who is the LCCC nursing theorist and what theory is our program based on?
Sister Callista Roy's adaptation/systems theory
- -biopsychosocial
- -holistic
- -stressors
- -adaptation
- -stimulus
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When doing a skin assessment, what are some important things to remember?
- -Always palpate the skin and not just look at it
- -Difficult to see or touch areas need special care
- -Always check the feet and nails
- -->foot ulcerations in diabetics are serious problems!
- Check hair for critters
- check oral cavity
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What are the risk factors for Oral Problems?
- DM
- Chemotherapy
- Broad Spectrum Antibiotics
- Radiation
- Devices
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What are the risk factors for skin issues?
- Immobility
- decreased sensation (stroke, DM, SCI)
- decreased protein intake
- excessive wetness
- decreased blood flow (PVD)
- equipment added to body
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What are the risk factors for the peri area?
- scrotum
- female gyn parts
- rectal area
- certain patients
- -ob/gyn patients
- -childbirth
- -indwelling caths
- -uncircumcised
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What are some hygiene nursing diagnoses?
- bathing self care deficit
- risk for infection
- risk for impaired skin integrity
- impaired oral mucus membrane
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What are some ways to care (hygiene) for a confused patient?
- Get familiar with the patient
- eliminate triggers
- gentle, focused and unhurried manner
- focus on person, not task
- do not start with face
- bed in bad
- warm water
- privacy
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What are some nursing alerts for foot and nail care?
- DO NOT SOAK FEET OF PATIENT WITH DM
- DO NOT TRIM TOE NAILS ON PATIENT WITH DM
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Who are some people groups that are at risk for amputation?
- DM
- previous amputation
- PVD
- peripheral neuropathy
- decreased joint mobility (CVA, arthritis, fibromyalgia)
- pressure sores
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What are the ANA guidelines for foot care?
- Foot exam (at least yearly)
- Inspect feet daily
- Wash feet daily; dry completely
- shoes always; no bare feet
- clean, dry socks
- emollient notion (not inbetween toes!)
- trim nails flat with square edges
- do not cross legs
- keep feet in moderate temps
- Buerger-Allen exercises
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What are some negative effects of poor oral hygiene?
- poor nutrition
- stroke
- blood sugar swings
- pneumonia (esp in LTC institutions)
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What are some oral care interventions?
- Brush 2x daily (OD)
- Chlorhexidine for rinses if high risk
- floss once a day
- includes gently brushing tongue
- new tooth brush every 3 months
- new tooth brush after URI
- *no lemon glycerine or alcohol based mouth wash if high risk!
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How do you perform oral care for someone who is unconcious?
- *Check for gag reflex (CN IX)
- Aspiration precautions
- -turn patient to side lying position or HOB elevated if suction equipement
- -may be a two person job
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How do you perform oral care for someone who is vented?
- Main priority is maintaining the airway!
- ETT (endotracheal tube goes through the glottis)
- may be sedated
- increased risk for infection
- -VAP (ventilator associated pneumonia)
- -chlorhexidone
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How do you care for a patient with stomatitis?
- Frequent oral assessments
- check calorie count and fluid intake
- NSS rinses
- -when rising
- -after meals
- -at bedtime
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How do you care for dentures?
- Make sure you know how to remove and replace
- Take special care when brushing
- keep in moist water when not in use
- place in labeled container not on the over the bed table
- if musculoskeletal challenges, can get a large handled toothbrush
- encourage patients to wear their dentures to prevent warping and changing of mouth
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Who has special hair care needs for delousing medication?
- *These shampoos can contain a neurotoxic component
- -Organochloride lindane is contraindicated in the following:
- -seizure patients
- -pregnancy and breast feeding
- -over irritated skin
- -those under 110lbs
- -older adults
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What are things to be sure of when shaving a patient?
- Assess if the patient is on anticoagulants!
- -its a safety issue!
- -coumadin, heparin, lovenox, aspirin (ASA)
- Do not shave off a mole, wart, etc.
- Shave with the grain of the skin
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How do you perform eye care?
- First check for the blink reflex
- (check for and remove contacts, check for infection)
- clean from the inner canthus to the
- use different section of wash cloth for each eye
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What are the two main concepts of Ear Care?
- 1. Never put anything into the ear that can penetrate the ear drum
- (you can only irrigate ears with MD order)
- 2. Adults: Pull pinna up and back
- Child: down and back
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What are the different positions for a bed?
- Fowlers, High Fowlers, Flat, Trendelenburg, reverse Trendelenburg
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What is the process for making a bed?
- Bed to do when patient is OOB
- Asses patient's needs prior (br?)
- Get supplies
- Bed locks on (Safety!!!)
- Check armband and call name
- BED UP TO WORK AND DOWN WHEN YOU FINISH!
- Complete the task, siderails up on the side you are turning the patient towards
- ask patient if they need anything else?
- make sure call bell is at the bedside (safety)
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What is one main concept for bathing?
- Always promote venous return when possible
- -move from distal to proximal
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