Foundations HESI Review PDF

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Foundations HESI Review (from 9th ed. of Foundations text)

Basic Nursing Skills – Vital Signs – Chapter 30 

BP cuff size (review what happens with wrong cuff size)

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Technique for palpating systolic BP (when arterial pulsations too weak to detect Korotkoff sounds or to identify auscultatory gap). Box 30-9, p. 508. Palpate radial pulse. Inflate cuff 30 mmHg above point at which you can no longer palpate the pulse. Slowly release valve and deflate cuff… See documentation guidelines, as well.

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Technique for taking BP in the leg – popliteal artery. SBP usually 10-40 mmHg higher than using brachial. DBP remains same. Ch. 30, p. 508.

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Orthostatic BP readings – orthostatic hypotension also called postural hypotension; obtain supine, sitting, and standing (1-3 minutes between each); observe pt. for dizziness, fainting, lightheadedness. Record pts. position with each reading (remember pt. safety); don’t delegate this. Note when you should take postural hypotension readings.

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Know normal vital signs – techniques, ranges, assessment, etc. Findings on respiratory assessment?

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What is a pulse deficit? What do you do if you detect a pulse deficit during your assessment? See Clinical Decision, p. 519. What if pulse deficit is in lower extremities? Pedal pulse weak on one side? Assess next pulse up, e.g., posterior tibial. If that pulse is weak, move up to popliteal, etc. Compare one extremity to the other.

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Apical pulse is taken for a full minute; PMI (point of maximal impulse) located at 4th or 5th intercostal space (ICS), just medial or left of the midclavicular line (MCL).

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Elevated BP? Pt c/o headache? What may this indicate? What do you do? Reassess using other arm. Do not keep taking BP on same extremity. Reassess!!! May even need a manual cuff. See Electronic Blood Pressure Measurement Procedural Guidelines, Box 30-10, p. 509.

Hygiene 

Hygiene – self-care deficit/self-care deficit (see Orem’s theory, p. 44-45) Assessment of self-care ability, p. 826-827; p. 1247. Assess physical status and mental status. Assess for activity intolerance. Determine if family can help with care.

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Back rubs – Can be part of patient’s hygiene (after bath). Promotes relaxation, relieves muscle tension, can be used to help decrease patient’s pain (nonpharmacologic measure). Effleurage is associated with reduced anxiety, heart rate, and respiratory rate. Slow-stroke back massage of 3 minutes and hand Page 1

massage of at least 10 minutes can both significantly promote both physiological and psychological relaxation in older clients. Be aware of contraindications, such as heart surgery, fractured ribs, etc.). Pain and Sleep 

Exercise and Sleep – exercise 2 hrs before bedtime allows cool down period and fatigue that promotes relaxation (see Sleep Hygiene Habits, Box 43-9, p. 1006). Should not exercise closer to bedtime. See Factors Affecting Sleep, pp. 998-999.

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Sleep problems; altered sleep – pain. Treat pain first. See Box 43-5 Nursing Assessment Questions and Box 43-6 Questions to Ask to Assess for Specific Sleep Disorders.

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Be aware of CNS depression with benzodiazepines (lams and pams) and barbiturates (barbital). If taking a benzo for sleep, nurse needs to provide continued assessment for resp. depression. Antidote is flumazenil (Romazicon). Prioritize assessment in a variety of patients. Think ABC’s, acute/chronic, unstable/stable,

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Normal sleep patterns and interventions to help return pt. to normal sleep patterns; types of nonpharmacologic interventions (before giving meds). See Sleep History, pp. 1000-1002. Health Promotion, pp. 1005-1009. These all go together with sleep practices and sleep promotion.

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Insomnia – medications; client teaching for insomnia (older adult). Therapeutic communication techniques for patient with insomnia. See p. 996 re: insomnia. Older adults, p. 998. Ask if they have a sleep routine. If not, establish one. Do not drink alcohol at bedtime (it may help with sleep onset, but does not promote continued sleep and can increase risk for sleep apnea). *See last page for Promoting Sleep in Older Adults.

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Risk assessment for sleep apnea, see p. 996 (Two major risk factors are obesity & hypertension.) Other risk factors include smoking, heart failure, type 2 diabetes, alcohol, and a positive family history also greatly increases the risk of developing sleep apnea.

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Pain assessment – observe for nonverbal cues (grimacing, rigid body posture, limping, frowning or crying). (See Box 44-9 Behavioral Indicators of Effects of Pain, p. 1027). Know the difference in acute pain and chronic pain symptoms, pp. 1017-1018; Box 44-10, p. 1028. Management of chronic pain, pp. 1041-1043..

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Assess quality and quantity of pain. How? Reassess pt. after administering pain med. When? (peak)

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Chronic pain – assess abilities to perform ADLs, function on job, etc.

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Complementary and Alternative Therapies – acupuncture, etc. (We did not cover acupuncture on quiz. See p. 694). Acupuncturist inserts sterile needles into the skin in specific areas – modifies response of the body to pain and how pain is processed by central neural pathways and cerebral function. Effective for treating low back pain, myofascial pain (TMJ), hot flashes, migraines, etc. Caution use in Page 2

pregnancy, hx of seizures, immunosuppression. Contraindicated in patients with bleeding disorders and infection. Complementary and alternative therapies are now considered “integrative therapies,” and many health care practitioners participate in these integrative approaches. Have patient talk with HCP about using these therapies, especially when treating conditions that traditional medicines have proven ineffective. See p. 696. 

Breakthrough pain – how to manage breakthrough pain. See pp. 1041-1042. See Box 44-17, p. 1042. May need to include “rescue dose” of medication, such as adding an IR (immediate release) opioid in between doses of scheduled CR (continued release or sustained release) meds. Another option is decreasing both dose & frequency of scheduled opioid (so pt. gets it more often without getting OD).

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Management of pain with nonpharmacologic measures (Hesi book). See also pp. 1031-1035 (biofeedback, relaxation and guided imagery, distraction, music, cutaneous stimulation (TENS unit, massage, hot and cold therapy, acupressure, etc.), herbals, etc.

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Surgical patient – pain control with PCA, pp. 1038-1039 and Skill 44-1, pp. 1046-1049).

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Evaluation – pain outcome (quality and quantity; compare assessment to baseline assessment). Document.

Elimination 

Male catheter insertion (how far to insert catheter after visualizing urine in the tube?)

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Female catheter insertion (advance 1-2 inches after seeing urine); positioning (dorsal recumbent position with knees flexed. Alternative position is side lying (Sims) with upper leg flexed at hip and knee. Dorsal recumbent is not lithotomy.

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Assess allergies to latex and iodine (shellfish) – why?

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Indwelling catheter – ambulation; never raise drainage bag above level of bladder; prior to ambulation, drain all urine from tubing into drainage bag; prevent dependent loops and kinking of tubing (see Box 46-10 Preventing Catheter-Associated Urinary Tract Infections), p. 1122.

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No urine – check for kink. Irrigate indwelling urinary catheter (open and closed techniques; indications); evaluation after irrigation (should have more fluid returned than you used for irrigation).

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Removal of indwelling catheter (what happens when client has urinary retention?). If catheter removed earlier in the day, determine when patient voided after catheter removal. If bladder distended, will likely need to reinsert catheter. If no distention, may use bladder scan. Priority after catheter removal is when did patient void?

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Urinary diversion systems – ileal conduit; patient with cystectomy

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Obtaining a timed (6, 12, or 24-hour) urine specimen

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What do you do if specimen becomes contaminated? – start over (obtain new specimen). For example, if obtaining urine specimen that contains multiple colonies, it is likely contaminated. Obtain new specimen.

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How to obtain urine for C&S. See Table 46-3 Urine Testing for obtaining Clean-voided or midstream (culture & sensitivity) and Sterile specimen for culture and sensitivity. Skill 46-1 for Collecting Midstream (Clean-Voided) Urine Specimen.

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What to assess when obtaining urine specimen? Is client able to void?

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Residual urine (nursing problem) – what is potential problem when urine remains in the bladder?

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S/S of UTI and/or cystitis? (dysuria)

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Elimination – bedside chair/commode (best position, when possible)

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Interventions that promote normal elimination (fluid, fiber, exercise)

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Impaction removal (requires physician order)

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Obtaining stool specimen (wear gloves; does not have to have visible blood to be a sample for occult blood testing). See p. 1156.

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Fecal occult blood test (guaiac, Hemoccult) (Box 47-4, pp. 1157-1158). Repeat 3 times. What can affect results?

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Bowel training/bowel retraining – p. 1168. Bowel Retraining – Focus on Older Adults Box 44-13. Patients with chronic constipation or incontinence need bowel training.

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Colostomy – gas (vent the colostomy bag—do NOT poke holes in it)

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Purpose and technique of colostomy irrigation.

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Nursing diagnosis for patient with diarrhea? Primary is fluid volume deficit; impaired skin integrity is potential secondary problem.

Nutrition/Diets/Fluids 

NG placement – X-ray (KUB – abdomen) for verification (then agency policy for verifying before each feed) – auscultation over stomach or pH testing of gastric contents.

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Tube feeding – position (HOB minimum of 30 degrees—higher if tolerated)

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Nursing diagnosis for client with vomiting (especially very young and very old); fluid volume deficit. See pp. 951-954. See Concept Map and Nursing Care Plan.

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Assessment – weight with fluid retention (see below)

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Physical assessment – dehydration (renal) evaluate (turgor, urine output, BUN/creatinine); weight one of the best indicators for fluid retention or loss (1 kg [2.2 lb] = 1 liter fluid)

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Clear liquid diet – how to advance diets (see p. 1073), i.e., after surgery clear liquid, full liquid, soft, etc. What items are included in each diet category? (See Box 45-10, p. 1074). Consider culture and Page 4

dietary preferences (vegetarians and beef or chicken broth). Clear liquid includes anything that is clear: clear, fat-free broth/bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles. (p. 1074). Full liquid includes clear liquids, in addition: smooth textured dairy products (ice cream, custard), strained or blended soups, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt. See also Dysphagia Stages (Box 45-10). Remember thickened liquids for dysphagia, NOT thin liquids. 

Low sodium diet – food choices. Patient teaching. Read labels!!!

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Teach calcium-supplemented diet for patient with hypocalcemia. See Table 42-4, p. 941. Foods containing calcium include dairy products, canned fish with bones (e.g. canned salmon), broccoli, oranges. Requires vitamin D for best absorption. Undigested fat prevents absorption.

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High protein meal (including protein foods for vegetarians) – combine incomplete proteins.

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Foods to promote elimination (fiber, warm prune juice) – causes of constipation (opioid use, inactivity, decreased fluid/fiber, etc.)

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Constipation – interventions; constipation plan (fluid [warm prune juice], fiber, activities)

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Hypernatremia – client teaching (p. 940) – sodium restrictions (why? how?) – HTN, HF, etc.

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Dilutional hyponatremia (SIADH) – overproduction of antidiuretic hormone (ADH) causes water retention (produces dilutional hyponatremia, which makes sodium level go down). Do not increase sodium but restrict fluid intake. See below, including lab values for sodium (Na+).

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Water intoxication – restrict fluids, not add sodium. Assess sodium level (136-145 mEq/L).

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Low serum potassium (hypokalemia) – assess muscle strength (causes muscle weakness); dysrhythmias with ↑ or ↓; Antidote for hyperkalemia (too much potassium) is Kayexalate

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Oral care with NG tube – should be every 2 hours.

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Oral care – unconscious (see p. 841 and Skill 40-3, pp. 865-867); suction while providing care

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Teaching – stomatitis (POC). Avoid hot beverages and foods as well as salty, spicy, and citrus-based foods. Use pain relievers like acetaminophen or ibuprofen. Gargle with cool water (not ice water) or suck on ice pops if you have a mouth burn. For canker sores, drink more water. Rinse with salt water. Practice proper dental care. Apply a topical anesthetic (not for children under 6). See text, p. 841.

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Patient with dysphagia – thickened liquids (nectar-like or honey thickness, as well as spoon thick liquids, like pudding – not thin liquids or difficult to chew foods); feeding debilitated patient. Tuck chin to chest with each bite. Place food on strong side of mouth. (p. 1074 – Assisting Patients with Oral Feeding).

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Fat content of fruits and vegetables (low fat diet), even if fat is a healthy fat. Remember low fat diet means you need to know the amount of fat being ingested. Page 5

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Nutrition – teaching for weight reduction. ChooseMyPlate.gov. See Dietary Guidelines & Box 45-2, p. 1058.

Mobility/Immobility/Safety 

Proper technique for applying TED hose (antiembolitic stockings) – NAP can apply. Remember that TED hose, ACE wraps, other bandages should be wrapped from distal to proximal to promote venous return and reduce trapping of blood/pooling of blood)

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Use of SCDs – purpose (proper technique) for applying pneumatic compression devices

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Transferring pt. with hemiparesis; assisting to ambulate with hemiparesis. (p. 431, 804-805). Stand on affected side and support with gait belt. For transfers, have chair on strong side.

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Ambulation – assess pts activity tolerance, strength, VS, balance, orientation, and need for assistance, grimacing while ambulating. Assess for orthostatic VS (have patient dangle legs on side of bed 1-2 min. prior to rising if needed) to promote safety; evaluate environment – remove obstacles, have clean and dry floor, identify rest points, have pt wear supportive, nonskid shoes. Obese patient. Frail patient.

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Assisting to ambulate a patient with visual impairment (blind patient). See p. 1256.

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See pp. 431-432 for methods of assisting with ambulation; what to do if pt begins to fall (assist to the floor)

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Review crutch walking and crutch safety pp. 807-809 (know different gaits, up and down stairs); review safety for crutches, measuring for crutches (weight should not be on axilla but on hand grips (p. 806); 4-point crutch walking (must be able to bear weight on both lower extremities)

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Wheelchair safety, pp. 390391 (wheels locked, anti-tip bars, use of footrests, etc.); wheelchair transfer after CVA

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Logroll may be needed in pts who have had spinal cord injury, recovering from neck, back, or spinal surgery to keep spinal column straight and to prevent further injury. Pt turned as a unit. (p. 437)

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Immobility (potential problems such as edema of lower extremities, nursing interventions; ROM. See ch. 28 and 39. (Know various ROM positions). Have immobile patient dorsiflex and plantar flex feet, push against footboard, etc.

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Turning schedule for pt. with decreased mobility (impaired physical mobility); how often change position in chair?

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Shearing force – what is it? How to reduce it? Potential problems? “Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces.” p. 1204.

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Therapeutic mattresses, pp. 1205-1206 and Table 48-7. Don’t add any linens that will reduce the benefit of the aerated (special) mattress. Also, important to note: Box 48-8 Patient Teaching, p. 1207.

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Fire – RACE (rescue/remove clients, activate alarm, confine fire, extinguish fire); follow this order! Page 6

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Seizure – safety, see p. 393 and Box 27-14, p. 394. “Seizure precautions encompass all nursing interventions to protect a patient from traumatic injury, position for adequate ventilation and drainage of oral secretions, and provide privacy and support following the seizure.”

Standard Precautions/Isolation/Asepsis 

Donning and removing personal protective equipment (PPE): put on gown, surgical mask or respirator, goggles/ear protection, gloves; remove gloves first, then protective eyewear, gown, and mask last. Include putting on and removing “clean” gloves.

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Proper technique for putting on (donning) sterile gloves and removing contaminated gloves; teaching UAP proper gloving technique. What do you do if person applying gloves contaminates them? What about other supplies being used? Replace anything contaminated. Do not replace what isn’t.

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Preparing and maintaining sterile field (surgical asepsis principles), p. 467-469.

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Standard precautions (and know what to do in obtaining a specimen using standard precautions); see p. 465 text and Box 29-13. Also, see Table 29-6, p. 459. See also text p. 458.

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Isolation guidelines, p. 459-460. KNOW! Which isolation for which type of infectious agent. Table 29-6, p. 459. Contact precautions, droplet precautions, airborne precautions. Contact precautions includes putting on clean gloves when you enter the room. Certain organisms can remain viable for weeks in the environment.

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Caring for a patient with MRSA (contact precautions).

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C. difficile – gown and gloves; also requires washing with soap and water.

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Airborne precautions – private room, negative-pressure airflow (HEPA filtration), mask or respiratory protection device, N95 respirator (depending on condition). Measles, chickenpox (varicella), Herpes zoster, shingles (VZV), TB. Remember mnemonic: My Chicken Hez TB – Airborne (N95)

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Handwashing – home, teaching (proper technique).

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Acrylic (artificial nails) – evidence indicates artificial nails and nails with nail polish (can chip) harbor microorganisms. Health care workers should avoid acrylic nails and nail polish. ...