FUNDAMENTALS: NCLEXABCS

Better than 1,2,3—ABCs are always the first priority.

AIRWAY – Is it clear? If it isn’t, we’ll never get to the next letter:

BREATHING – If this isn’t possible oxygen won’t reach the lungs and be transported around the body in the blood, know as:

CIRCULATION – Without which hypoxia and cardiac arrest will ensue.

These are the basic lifesaving principals and they combine with that only slightly lesser known phrase, “look, listen, and feel.” Look in the mouth to make sure airway is clear, listen for breath, and feel for pulse. Whether in the ER, the OR, or on the floors this is nursing 101.

MASLOW’S HIERARCHY OF NEEDS

Human needs are ranked on an ascending scale according to how essential those needs are for survival. Abraham Maslow ranked human needs on five levels.

1.PHYSIOLOGIC NEEDS – Needs such as air,

food, water, shelter, rest, sleep activity, and

temperature maintenance, are crucial for survival.

2.SAFETY AND SECURITY NEEDS – The

need for safety has both physical and

psychological aspects. The person needs to feel safe, both in the physical environment

and in relationships.

3.LOVE AND BELONGING NEEDS – The

third level of needs includes giving and receiving affection, attaining a place in a group, and maintaining the feeling of belonging.

4.SELF-ESTEEM NEEDS – The individual needs both self-esteem (i.e., feelings of independence, competence, and self-respect)

and esteem from others (i.e., recognition, respect, and appreciation).

5.SELF-ACTUALIZATION – When the need for self-esteem is satisfied, the individual strives for self-actualization, the innate

need to develop one’s maximum potential and realize one’s abilities and qualities.

Human needs serve as a framework for assessing behaviors, assigning priorities to outcome criteria, and planning nursing interventions.

THE NURSING PROCESS

The nursing process is a systematic, rational method of planning and providing individualized nursing care. In the simplest terms the nursing process is:

1.ASSESSING – Collecting data.

2.DIAGNOSING – Figuring out what is the problem.

3.OUTCOME/PLANNING – How to best manage the problem.

4.IMPLEMENTING – Putting the plan into action.

5.EVALUATING – Did the plan work?

The five phases of the nursing processes are not singular entities. They often overlap, for example, assessment is often carried out while implementing and evaluating. The nursing process allows for RNs to use time and resources more efficiently, to both their own and their client’s benefit.

THE SIX RIGHTS

They are called the “rights” of medication administration. All medication errors can be linked, in some way, to an inconsistency in adhering to these “rights” when giving meds to patients.

1.RIGHT CLIENT – To identify a client correctly, the nurse must check the medication administration form against the client’s

identification bracelet and ask the client to state his or her name to ensure the ID band is correct.

2.RIGHT MEDICATION – This is a multi-step process. The medication should be check against the medication order and the

medication label. Nurses should only administer medications they prepare and verify. If an error occurs, the nurse who give the medication is the one responsible for the error.

If a client questions the medication a nurse is about to give it is important not to administer it until it can be rechecked against the prescriber’s order. An alert client will know if a medication is different from those received before.

3.RIGHT DOSE – The unit dose system is designed to minimize errors. If a medication must be prepared from a larger volume or

strength than needed or when the prescriber orders an amount different than what the pharmacy supplies, the chance for a

mistake multiplies. When performing medication calculations or conversions, have a colleague, another qualified RN check the calculated dose.

4.RIGHT TIME – The nurse must understand why a medication is ordered for certain times of day and whether that time schedule

can be altered.

5.RIGHT ROUTE – If a prescriber’s order does not designate a route of administration such as orally or by injection or IV

(intravenously) the nurse must consult the prescriber. If the prescribed route is not the recommended route the nurse should

double check with the prescriber.

6.RIGHT DOCUMENTATION – This is a fairly new addition to the traditional “Five Rights” but has been widely adopted by

facilities and caregivers. Many medication errors result from inaccurate documentation. The documentation should clearly reflect the patient’s name, the name of the ordered medication, the time the drug was given and the medications dosage, route

and frequency. After giving the medication the MAR must be completed per facility policy.

HEART

BASICS

PULMONARY CIRCULATION: Unoxygenated- R side of heart

Unoxygenated blood flows from inferior and superior vena cava

Right Atrium

Tricuspid Valve

Right Ventricle

Pulmonic Valve

Lungs

Through Pulmonary System

SYSTEMIC CIRCULATION: Oxygenated-L side of heart

Oxygenated blood flows from pulmonary veins

Left Atrium Mitral Valve Left Ventricle Aortic Valve Systemic Circulation

CARDIAC CYCLE: The actual time sequence between ventricular contraction and ventricular relaxation

SYSTOLE: Simultaneous contraction of the ventricles

DIASTOLE: Synonymous with ventricular relaxation; when ventricles fill passively from the atria to 70% of blood capacity

SOUNDS

S1 Tricuspid & Mitral Valve Closes

S2 Pulmonary & Aortic Valve Closes

S3 Ventricular Filling Complete

S4 Elevated Arterial Pressure (Atrial Kick)

WAVE REVIEW

IN-DEPTH

P WAVE: Small upward wave indicating atrial depolarization QRS COMPLEX: initial downward deflection followed by large upright wave, followed by small downward wave;

represents ventricular depolarization; masks arterial repolarization; enlarged R portion- enlarged ventricles; enlarged Q portion may indicate probable heart attack

T WAVE: Dome shaped wave; Indicates ventricular repolarization; flat when insufficient O2; elevated when ↑ K levels

P-R INTERVAL: Interval from beginning of P wave to R wave; represents conduction time from initial excitation to initial ventricular excitation; Good diagnostic tool; usually normal <0.25

S-T SEGMENT: Time from the end of S to beginning of T wave; represents time between end of spreading impulse through ventricles and ventricular repolarization; ↑in heart attack; ↓with insufficient oxygen

Q-T INTERVAL: Time for singular depolarization and repolarization of the ventricles. Conduction probs, myocardial damage, or congenital heart defects can prolong this.

ECG CHANGES WITH MI T wave inversion ST segment elevation Abnormal Q waves

ECG CHANGES WITH DIGITALIS

Inverts T wave

QT segment shorter

Decreases ST segment

P Wave: Atrial depolarization

PR Segment: AV node conduction

QRS Complex : Ventricular Depolarization

U Wave: Hypokalemia creates U-wave

ST Segment: Ventricles depolarized

T Wave: Ventricular repolarization

ECG CHANGES WITH QUINIDINE

Inverts T wave

Q segment longer

QRS segment longer

ECG CHANGES WITH K+ Hyperkalemia: Lowers P Wave; ↑ width of QRS Hypokalemia: Lowers T wave; causes “U”

ECG CHANGES WITH CA Hypercalcemia : makes a longer QRS segment Hypocalcemia : increases time of QT interval

BRAIN

PERSONAL PROTECTIVE EQUIPMENT (PPE)

Unless otherwise specified, assume that PPE includes: Gowns, Goggles, Mask, Gloves

The proper place for donning (putting on) PPE is outside of the room

The proper order for donning PPE is:1. Put on gown2. Put on mask3. Put on goggles4. Put on gloves

The proper place for removing (doffing) PPE is inside room

The proper order for removing PPE is:1. Gloves2. Goggles3. Gown4. Mask need to take mask off outside so you don’t breathe in contaminated air

In airborne precautions ONLY, the mask is removed outside of the room

PSYCHIATRIC NURSE TEST-TAKINGPRINCIPLESPhase SpecificityThe best psych answers are those answers that are most appropriate to the phase of the nurse-patient therapeutic relationship that you are in

If the question tells you the phase of the relationship, the phase will be the determinant of which answer is correctThe phases of the nurse-patient relationship:

The Pre-Interaction PhasePurpose: For the nurse to explore his/her own feelings. To prevent judgmental, intolerant reactions.Length: Begins when you learn you are going to be caring for someone and ends when you meet them.Correct Answer(s): “The nurse will explore her/his own feelings about…”

The Introductory PhasePurpose: To establish trust and explore/assessLength: Begins when you first meet the patient and ends when a mutually agreed-upon care plan is in placeKey Words: These phrases are designed to hint to you that you are in the introductory phase:

o 1. “During the initial interview…”o 2. “Upon admitting the patient..”o 3. “On admission…”o 4. “At your first few meeting with..”o 5. “While assessing…”o 6. “On the day of admission…”o 7. “ While formulating nursing diagnoses…”

Correct answers: Should be very tolerant, accepting, explorative, probing, “nosy.” Be warm and fuzzy

The Working Phase (Therapeutic Phase)Purpose: To implement the plan of careLength: From the finished care plan until dischargeKey Words: 1. “During the therapeutic interview…” 2. “While implementing the care plan..” 3. “While working on the care plan goals…” 4. “During treatment sessions..” 5. “During therapy..” 6. “In your weekly session..” 7. “Three days after admission…” 8. “After improving..”Correct Answers:Should be very focused, directive, “tough.” In some ways these answers will seem stern and slightly unfriendly. Set limits. Enforce proper communication.

The Termination PhaseThe only question asked here has been, “When does the termination phase begin?The answer “On admission”

GIFT GIVINGIn psych, do not give something of value to the patient. Conversely, do not accept something of value from the patient

A gift is something of tangible or intangible value given from one person to another.

Gifts include: hugs, kisses, compliments, opinions, holding hands, placing an arm around, etc

DO NOT do these behaviors in psych. (May be appropriate in med-surg)Difference between complimenting and observing progress

ADVICE-GIVINGDO NOT GIVE ADVICE. Let the patient formulate own solutions and alternatives.

Remember, giving advice and setting limits are not the same. The former is bad, the latter is good.

KEY WORDS TO AVOID:1. “Suggest that..”2.”Advise the patient to..”3. “Tell the patient to..”4. “If I were you, I would…”5. “You should do..”6. “You ought to..”7. “You should NOT do..”8. “Don’t do…”9. “Recommend that…”

Any words with these phrases violate this principle and are WRONG. RULE THEM OUT!Always say, “And what do you think you should do, Mr. Smith?”

GUARANTEE GIVINGDO NOT GIVE GUARANTEES IN PSYCH. You cannot predict the human mind of know another’s experience

Giving guarantees is okay in Med/Surg—if true

KEY WORDS:1. If you…then…”2. “You will improve if you..”3. “We can…”

A guarantee violates trust when the promised results do not appear

Only things can guarantee: 1) meds will work 2) you are safe

IMMEDIACYThe best psych answers communicate to the patient that the nurse is willing to deal with the patient’s problem right then and right there

Key Phrases:AVOID answers like these1. “Refer patient to…”2.” Have you spoken to your…about this?”3. “Why don’t you talk to your…about this?

Avoid changing the subject—unless you are refocusing a patient who is avoiding the subject of therapeutic session

CONCRETENESSThe best psych answers are those answers that say exactly what they mean in a literal sense—word for word

KEY PHRASES: Avoid slang, figurative speech, sayings, proverbs, verses, poetry, stories, parables, allegories, neologisms.

Tie-Breakers

1. “Why” questions are not as good2. Reflection is good.3. Open-ended is better than closed-ended.4. Answers with I, me, we, us in the subject are not good.5. Shortest answers are the best

HANDWASHING AND GLOVING

HandwashingHandwashing versus Scrubbing

Handwashing ScrubbingPosition Hands below elbows Elbows below handsLength Seconds MinutesHandles Yes; sink with handles No sink with handles

When Upon entry or leaving room before and after gloving, when soil hands

When patient is immunosuppressed for any reason

Use Soap and water Something with chloro in it

Use an Alcohol-Based Solution1. On entering or leaving a room2. Before putting on gloves, after taking off gloves3. Cannot after soil hands!!

What about after using the rest room? must use soap and water

Dry from cleanest (hand) to dirtiest (elbow)

Turn water off with new paper towel

Sterile GlovingGlove dominant hand first.Grasp outside of cuff.Touch only the inside of glove surface. Do not roll cuff.Fingers inside of second glove cuff.Keep thumb abducted back.Only touch outside surface of gloveSkin touches inside of gloveOutside of glove only touches outside of gloveRemove glove to glove Skin to skin

INTERDISCIPLINARY CARE

Identifying which patients need interdisciplinary care…different than prioritizing who would most benefit from a team working together on their care

Patients who do not need interdisciplinary care: Patients who need or have multiple doctors

Patient who DO need interdisciplinary care:1. Major Criteria

a. Patients with multi-dimensional needsi. For example:

1. Physical 2. Psychological

3. Social4. Spiritual5. Intellectual needs

b. Patients who need rehabilitation2. Minor Criteria [choosing between patients]

a. A patient whose current treatment is ineffectiveb. A patient who is preparing for discharge

EMPATHY

The best psych answers are those answers that communicate to the patient that the nurse accepts that patients feelings as being valid, real, and worthy of action.

Key Phrases: A low-empathy answer is always wrong

Avoid Saying:

1. “Don’t worry…”

2. “Don’t feel…”

3. “You shouldn’t feel…”

4. “I would feel…”

5. “Anybody would feel…”

6. “Nobody would feel…”

7. “Most people would feel…”

Four Steps to Answering Empathy Questions

1. Recognize that it is an empathy question

Empathy questions have a quote in the question, and each of the answers contains a quote.

2. Put yourself in the clients shoes. Say their words as if you really meant them.

3. Ask yourself, “If I said those words and really meant them, how would I be feeling right now?”

4. Choose the answer that reflects the feelings...not the answer that reflects their words.