NUR 112 HPS@ Nysim Responses PDF

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NUR 112 HPS@NYSIM 11/10/2020 Topics and Skills to be Reviewed: a. b. c. d. e. f. g. h. i.

Patient safety measures Therapeutic communication (Listening; therapeutic touch; silence) Basic health assessment Vital signs Intake and Output Fluid and electrolytes The 7 rights of medications administration Intravenous Therapy Heat exhaustion Fluid and electrolytes Student’ Preparatory Activities

Know the following and be ready to discuss with the instructor during the simulation day: 1. List 5 patient safety and infection control measures that must be implemented when caring for a patient in a healthcare facility. 1 – Hand Hygiene, depending on the level of contact precaution will either be sanitizer or physical antimicrobial soap and water. 2 – Proper PPE according to the level of contact precaution. 3 – Checking patients two identifiers. 4 – Decontamination of noninvasive shared equipment 5 – Cohort patients properly according to their infection precaution. 2. List the 7 Rights of medication administration 1 – Right Medication 2 – Right Dose 3 – Right Patient 4 – Right Route 5 – Right Time 6 – Right Documentation 7 – Right Indication 3. What is heat exhaustion? Heat exhaustion is a condition whose symptoms may include heavy sweating and a rapid pulse, a result of your body overheating. 4. List 5 important assessment findings for a client with fluid and electrolyte imbalance. LAB VALUES:

1 - BUN. BUN may be decreased in FVE due to plasma dilution. 2 - Hematocrit. Hematocrit levels in FVD are greater than normal because there is a decreased plasma volume. 3 - Physical examination. Physical exam is necessary to observe the signs and symptoms of the imbalances. 4 - Serum electrolyte levels. Measurement of electrolyte levels should be performed to check for presence of an imbalance. 5 - ECG. ECG changes can also contribute to the diagnosis of fluid and electrolyte imbalance. 6 - ABG analysis. ABG analysis may reveal acid-base imbalances. PHYSICAL MANIFESTATIONS: 

I&O. the nurse should monitor for fluid I&O at least every 8 hours, or even hourly.

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Daily weight. Assess the patient’s weight daily to measure any gains or losses.

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Vital signs. Vital signs should be closely monitored.

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Physical exam. Physical exam is needed to reinforce other data about a fluid or electrolyte imbalance.

5. List 3 priority nursing interventions for a client with fluid and electrolyte imbalance. Monitor turgor. Skin and tongue turgor are indicators of the fluid status of the patient. Urine concentration. Obtain urine sample of the patient to check for urine concentration. Oral and parenteral fluids. Administer oral or parenteral fluids as indicated to correct the deficit. Oral rehydration solutions. These solutions provide fluid, glucose, and electrolytes in concentrations that are easily absorbed. Central nervous system changes. The nurse must be alert for central nervous system changes such as lethargy, seizures, confusion, and muscle twitching. Diet. The nurse must encourage intake of electrolytes that are deficient or restrict intake if the electrolyte levels are excessive.

6. How can you evaluate the effectiveness of the interventions? Maintained fluid volume at a functional level. Displayed normal laboratory results. Demonstrated appropriate changes in lifestyle and behaviors including eating patterns and food quantity/quality. Reestablished and maintained normal pattern and GI functioning. 7. List 5 important considerations when administering IV fluids therapy. Document baseline data. Before infusion, assess the patient’s vital signs, edema status, lung sounds, and heart sounds. Continue monitoring during and after the infusion. Observe for signs of fluid overload. Look for signs of hypervolemia such as hypertension, bounding pulse, pulmonary crackles, dyspnea, shortness of breath, peripheral edema, jugular venous distention, and extra heart sounds. Monitor manifestations of continued hypovolemia. Look for signs that indicate continued hypovolemia such as, decreased urine output, poor skin turgor, tachycardia, weak pulse, and hypotension. Prevent hypervolemia. Patients being treated for hypovolemia can quickly develop fluid overload following rapid or over infusion of isotonic IV fluids. Elevate the head of the bed at 35 to 45 degrees. Unless contraindicated, position the client in semi-Fowler’s position. Elevate the patient’s legs. If edema is present, elevate the legs of the patient to promote venous return. Educate patients and families. Teach patients and families to recognize signs and symptoms of fluid volume overload. Instruct patients to notify their nurse if they have trouble breathing or notice any swelling. Close monitoring for patients with heart failure. Because isotonic fluids expand the intravascular space, patients with hypertension and heart failure should be carefully monitored for signs of fluid overload.

8. List 2 priority patient education topic for a client experiencing fluid and electrolyte imbalances.

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Diet. A diet rich in all the nutrients and electrolytes that a person needs should be enforced.

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Fluid intake. Fluid intake must take shape according to the recommendations of the physician.

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Follow-up. A week after discharge, the patient must return for a follow-up checkup for evaluation of electrolyte and fluid status.

Medications. Compliance to prescribed medications should be strict to avoid recurrence of the condition. The HPS Scenario: 

Patient - Tyler Graves admitted to the emergency department (ED) with Dehydration and Heat Stroke Dehydration occurs when more water and fluids leave the body than enter Heatstroke is a condition caused by your body overheating, usually as a result of prolonged exposure to or physical exertion in high temperatures. This most serious form of heat injury, heatstroke, can occur if your body temperature rises to 104 F (40 C) or higher. Communication techniques for a patient with F&E imbalance: Acknowledgment Active Listening Summarizing Focusing Open-ended questions Give ample time to answer questions Respectful of Culture and Ethnicity Patience Body Language Rapport Barriers and Limitations Ask the correct questions The TEAM LEADER will do selected assignments and delegate others. A. Provide clear instructions to the patient pertaining to what immediate actions will be taken. EPSLO#! – Providing Patient Centered Care.

1. A team of nurses, a doctor and I are usually in the room with you. After washing our hands, and putting on gloves, one of us will be asking you to provide your full name and will verify the names by checking the name band on your hand. We will be wearing gloves while caring for you as a means of Standard Precaution to protect you and also us. We all will be wearing a mask (A COVID-19 requirement). 2. Another nurse will take your Temp, Pulse, Breathing and Blood Pressure and report the findings to the doctor if necessary, and will also do a physical assessment. We will keep your family member informed at all times on your progress. Depending on the level of activity in the room during your care, a family member will be allowed to remain in the room. 3. We will keep the bed in a low position with the siderails in an upward position because you have been complaining of lightheadedness and having a headache. Let us know if you need pain medication for the headache. We will inform the doctor, and request pain medication for the headache. We will ask you to clarify statements you may make if we do not understand (such “sick to your stomach” and inform the doctor if necessary. 4. Another nurse will prepare and start and intravenous fluid that is ordered by the doctor, to help replenish the fluid and the electrolytes you have lost from the excessive heat and perspiration. We will also encourage you to drink water or other types of fluid, especially since your urine is concentrated. 5. We will monitor the amount of fluid we are giving to you, and also the amount you are putting out via urination. 6. We will keep the room as cool as possible. B. Implementing Patient Safety and Infection Control: a. Handwashing and patient verification - EPSLO #5 [Safety] C. Identifying patient’s signs and symptoms of F & E imbalance a. Thirst, dry skin, confusion, irritability EPSLO #1 [PCC] D. Basic physical assessment of the patient using data collection. [EPSLO#3 – Incorporating Evidenced-Based Practice a. An environment of trust, inspection, auscultation, palpation, percussion, observation, and questioning and listening. E. Identify normal and abnormal patient assessment findings [EPSLO#1] Normal findings: The patient verbalizes the use of prescribed diuretics daily. Working in the sun for long hours and not drinking sufficient fluid Abnormal findings: decreased skin turgor, oliguria, concentrated urine, orthostatic hypotension, a weak, rapid heart rate, increased temperature, thirst, decreased or delayed capillary refill, cool, clammy skin, muscle weakness, and cramps.

F. Identify patient care interventions for treating dehydration related to heat exhaustion based on current best practice guidelines [EPSLO #1 & #3] PCC & current EBP Eliminated excess clothing and covers Administer extra fluids and encourage at least 8-10 glasses of mixed fluid daily. Administer antipyretic as prescribed.

G. Identify IV fluid and electrolytes needs for the patient experiencing fluid and electrolyte imbalance [EPSLO #1 & 3] PCC & current EBP] a. 0.9% NaCl and NaCl, K+ electrolytes H. Perform and communicate effectively as a member of the team [EPSLO #2 & #7] Exhibit Teamwork & Collaboration & Exemplify Professional Behavior] a. Know your assigned roles b. Communicate clearly avoid jargons c. Comply with the scope of practice for the State in which you work and with the guidelines, and policy and procedure for the agency for which you work. I. Provide relevant patient/family education [EPSLO #1 & #3] PCC & Incorporating EBP Wear lightweight, loose, and light-colored clothing. Protect your head and neck with a hat or umbrella when you are outdoors. Drink lots of water or sports drinks. Avoid alcohol. Eat salty foods, such as salted crackers, and salted pretzels. Limit your activities during the hottest time of the day. This is usually late morning through early afternoon. Use air conditioners or fans and have enough proper ventilation. If there is no air conditioning available, keep your windows open so air can circulate. J. Recognize how appropriate nursing interventions impact positive patient outcomes (EPSLO #4] With compassionate and culturally sensitive care, patients are usually more compliant with care orders, and usually develop a sense of safety for healthcare providers....