Final Exam

Patient-Controlled Analgesia

* Allows patient to self-administer with minimal risk of overdose * Maintains a constant plasma level of analgesic

Urinary System

Kidneys * Remove waste from the blood to form urine * Ureters * Transport urine from the kidneys to the bladder Bladder * Reservoir for urine until the urge to urinate develops Urethra * Urine travels from the bladder and exits through the urethral meatus

Nursing Knowledge Base: Pain Management

Knowledge, attitudes, and beliefs * Attitude of health care providers * Malingerer or complainer Assumptions about patients in pain * Biases based on culture, education, experiences * Acknowledge pain through patient's experiences * Limit your ability to help the patient

ABG

arterial blood gas

Orem's Self-Care Model

focuses on the patient's self-care capacities and the process of designing nursing actions to meet the patient's self-care needs - wanted the client to be seen as a soial, psychological and biological being that is capable of their own self-care

Glaucoma

increased intraocular pressure

MAR

medication administration record

Slough

necrotic fibrin

Eschar

necrotic soft tissue, black, loss of blood flow

Re-epithelialization

new skin growth

noc

night

Your patient is about to undergo a controversial orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patient's only treatment choice. This example describes the ethical principle of: []autonomy []fidelity []justice []nonmaleficence

nonmaleficence

NPO/npo

nothing by mouth

Pathological Influences on Mobility

Postural Abnormalities - Kyphosis (constantly leaning forward) - breathing decreases, can't fully expand lung space (increased risk of pneumonia) Muscle Abnormalities Damage to central nervous system (CNS) * Stroke Musculoskeletal trauma

indwelling catheter

one that remains inside the body for a prolonged time

proficient nurse

understands a patient situation as a whole rather than as a list of tasks, attends to an assessment data pattern, and acts without consciously labeling it

US

urinalysis

A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when: []you compare assessed pain w/baseline pain []body language is incongruent with reports of pain relief []family members report that pain has subsided []vital signs have returned to baseline

you compare assessed pain w/baseline pain

Nursing Point of View: Ethics and Values

* Nurses generally engage with patients over longer periods of time than other disciplines * Patients may feel more comfortable revealing information to nurses

Nurses' Attitudes Toward Older Adults

* Nurses must assess their own attitude toward older adults and their own aging Nurses need to gain knowledge about aging and health care needs of older adults: * Respect * Dignity * Involvement in care decision and activities

Acuity Rating Systems

* Nurses use acuity ratings to determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours * Based on type and number of nursing interventions required by a patient over a 24-hour period * The acuity level is a classification used to compare one or more patients to another group of patients

Summary of Theoretical Views

* Nursing caring theories have common themes * Caring is highly rational * Caring theories are valuable when assessing patient perceptions of being cared for in a multicultural environment * Knowing the context of a patient's illness helps you choose and individualize interventions that will actually help the patient

Scope and Standards of Practice

* Nursing definitions Nursing: Scope and Standards of Practice * 1960: Documentation began * Standards of Practice * Standards of Professional Performance Goal * To improve the health and well-being of all individuals, communities, and populations through the significant and visible contributions of registered nursing using standards-based practice

Nursing Process: Nursing Diagnosis: Infection Prevention and Control

* Nursing diagnoses for infection: Risk for Infection Imbalanced Nutrition: Less than Body Requirements Impaired Oral Mucous Membrane Risk for Impaired Skin Integrity Social Isolation Impaired Tissue Integrity Readiness for Enhanced Immunization Status

Assessment: Care of Surgical Patients

* Nursing history Medical history * Past illnesses * Surgeries * Reasons for surgery * Perceptions and knowledge Medication history * Prescription * Over the counter * Herbs * Street drugs Allergies * Drugs, latex, food, and contact Smoking * Cigarettes or packs per day Alcohol ingestion and substance use/abuse * Use per day or week * Recent immunizations (Flu or pneumonia) * Travel outside the US in the last 30 days Support sources * Family, friends, home environment * Who will be driving them home and staying with them for 24 hours after anesthesia

Standardized Nursing Diagnosis Language

* Nursing is in the beginning stages of developing language for the human conditions that are uniquely responsive to nursing care * Standardized language for nursing diagnoses means that all nurses are using the same words to describe the phenomena treated or managed by nurses * NANDA International (NANDA-I) is the organization officially sanctioned by the ANA as the body responsible for developing a system of naming and classifying nursing diagnoses

Career Development

* Nursing provides an opportunity for you to commit to lifelong learning and career development

Issues in Health Care Delivery

* Nursing shortage * Competency Quality and safety in health care * Pay for performance * Primary care providers get paid for the amount of patients they see per day * Patient satisfaction Magnet Recognition Program * Nursing-sensitive outcomes * Nursing informatics and technological advancements Globalization of health care * Vulnerable populations

Parenteral Nutrition

* Nutrients are provided intravenously Patients unable to digest or absorb enteral nutrition or are in highly stress physiological states: * Sepsis * Head injury * Burns * Peripheral or central line * Initiating parenteral nutrition * Preventing complications

Assessment: Preoperative Phase

* Occupation * Preoperative pain assessment Emotional health * Self-concept * Body image * Coping resources * Culture and religion

Medication Interactions

* Occur when one medication modifies the action of another * A synergistic effect occurs when the combined effect of two medications is greater than the effect of the medications given separately

Health Promotion and Maintenance: Psychosocial Concerns

* Therapeutic communication * Touch * Elder mistreatment/abuse * Reality orientation * Validation therapy * Reminiscence * Body-image interventions

Packing

* Used in wounds with tunnel, undermine, and fistula * Intention - prevent wound from closing and leaving access * Allows wound to heal from the bottom up (remember, with re-opened surgical wounds) * Wound must be irrigated

Nursing Care in PACU

* VS q 5 minutes on machine * Cardiac monitoring * Head to toe assessment orientation, lungs, heart, and, IV site and infusion, urinary output if Foley cath inserted. circulation to feet, ability to C & DB, pain, nausea, feeling of being cold, ice to any area * Aldrete score needed of 8 to be discharged to Acute Care

Negative-pressure wound therapy

* Vacuum Assisted Closure (VAC) Uses * Deep large wounds * Tunneling and undermining * Skin graft

A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she rounds on the patient? Select all that apply. The nurse asks the patient to rate his pain on a scale of 0 to 10. The nurse asks the patient what caused his fall. The nurse asks the patient if he has had pain in his back in the past. The nurse assesses the patient's lower-limb strength. The nurse asks the patient what pain medication is most effective in managing his pain.

The nurse asks the patient to rate his pain on a scale of 0 to 10, The nurse assesses the patient's lower-limb strength, Validation of assessment data is the comparison of data with another source to determine its accuracy. The nurse compares data reported by the previous nurse with data collected directly with the patient, including assessing pain on the rating scale and assessing the patient's lower limb strength. Asking the patient what caused his fall and about past back pain and experience with pain medications would offer the nurse new information about the patient.

Postoperative Convalescence: Assessment

* Airway and respiration * Circulation Temperature control * Malignant hyperthermia * Fluid and electrolyte balance * Neurological functions

A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? Select all that apply. "I usually go swimming with my family at the YMCA 3 times a week." "I need to ask my doctor if I should have a bone mineral density check this year." "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." "My lactose intolerance should not be a concern when considering my calcium intake."

"I usually go swimming with my family at the YMCA 3 times a week.", "I need to ask my doctor if I should have a bone mineral density check this year.", "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." Patients at risk for or diagnosed with osteoporosis have special health promotion needs. Encourage patients at risk to be screened for osteoporosis and assess their diets for calcium and vitamin D intake. Multivitamins do not always have the needed amount of calcium for every individual. A patient needs to know his or her requirement and make a decision based on that.

Which of the following statements about evidence-based practice (EBP) made by a nursing student would require the nursing professor to correct the student's understanding? "In evidence-based practice the patients are the subjects." "It is important to talk with experts and patients when making an evidence-based decision." "A nurse wanting to investigate the evidence to solve a problem starts by forming a PICOT question." "It is important to ask a librarian for help when searching for literature to help you answer your PICOT question."

"In evidence-based practice the patients are the subjects." Multiple research studies, expert opinion, personal experience, and patient preferences create the data source for EBP. Patients are not the subjects of EBP; they are typically the subjects in a research study.

Traditional Chinese Medicine

* "Life in balance" * Health promotion * Yin and yang are opposing complementary forces that exist in dynamic equilibrium Methods for evaluation of patient's condition * Observing * Hearing/smelling * Asking/interviewing * Touching/palpating Therapeutic modalities

ANA Code of Ethics

* #1 "The nurse, in all professional relationships, "practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual..." * 1.5 Principles of respect extend to all encounters, including colleagues, "This standard of conduct precludes any and all prejudicial actions, any form of harassment or threatening behavior, or disregard for the effect of one's actions on others"

Barriers to the EBP

* 'recipe' approach' * Insufficient Time * Funding information * Attitudes * No value placed on research * Difficulty in changing practice * Lack of awareness * Problems in reading/interpreting research for practice * Lack of leadership, motivation and vision

A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems? "I can tell that your eating habits have led to your diabetes. Is that right?" "It's been difficult for people to find jobs. Is that why you work part time?" "You have four children; do you have any concerns about going home and caring for them?" "I wish patients understood how overeating affects their health."

"You have four children; do you have any concerns about going home and caring for them?" This is the only assessment approach that is not biased or does not show judgment about the patient's weight or occupational status. With the other options, the nurse is reacting to the patient on the basis of personal stereotypes and biases.

Xerostomia

(dry mouth) lack of adequate saliva due to diminished secretions by the salivary glands

Implementation: Patient Safety and Quality

* Skills Health promotion * Developmental interventions * Lifestyle Environmental interventions * Basic needs General preventive measures * Lighting * Changing the environment

APA

* The words "Running head" will always fall on the title page followed by an abbreviated title of the paper * Title should be centered on page Body * The words "Running head" are no longer present * The title appears at the top of the page centered * In text citations should be used to reference literature used The page should read "references" rather than "works cited" All references should be hang indented and in alphabetical order.

Wound Etiology: Most Important Part of Wound Assessment

* Underlying factor that caused wound or is preventing it from healing * Etiology must be addressed to direct wound care * Each would type will follow specific pathways to healing Common wound types * Pressure * Venous * Arterial * Diabetic/Neuropathic * Surgical

How to report Elder Abuse

- 211 --- connect you to the correct number - Call Connie Grahovac, makes every attempt to keep those who report anonymous - Call the state: can be done anonymously

Dementia

- A gradual, progressive, irreversible, cerebral dysfunction - You need to rule out delirium whenever you suspect dementia - Nursing concerns; safety and physical psychosocial needs of older adult and their family.

Organ and Tissue Donation

- A specially trained professional (nursing supervisor, transplant coordinator) makes requests at the time of every death - The person requesting organ/tissue donation provides information of who can give consent legally, which organs/tissues can be donated, associated costs, and how the donation affects burial or cremation - Support the family to understand life support is preserving the organs for donation of their loved one. A live looking body confuses the family.

General Hygiene and Care

- Always go from clean to dirty! - Performing hygiene requires thorough physical and emotional assessment - Skin- anterior and posterior head to toe assessment - Make sure to shave if they would like you to

Kubler-Ross' Stages of Dying (DABDA)

- Denial - Anger - Bargaining - Depression - Acceptance

Factors Influencing Loss and Grief

- Human development - Personal relationships - Nature of loss - Coping strategies - Socioeconomic status - Culture and ethnicity - Spiritual and religious beliefs - Hope

Benefits of HIPPA

- Standardizes data, for the coordination of insurance benefits and payments - Health plan-specific reporting and filing requirements for hospitals and health care providers - Maintains patients' personal health information in a secure and confidential manner - It gives patients more control over their health information It sets boundaries on the use and release of health records - Gives patients the ability to request changes to their health information - You decide if you want to give your permission before your health information can be used or shared for certain purposes

Foley catheter care

-Keep the drainage bag below the level of your bladder and off the floor at all times. -Keep the catheter secured to your thigh to prevent it from moving. -Don't lie on your catheter or block the flow of urine in the tubing. -Shower daily to keep the catheter clean. -Clean your hands before and after touching the catheter or bag *Cleaning* -Wash your hands thoroughly with soap and water. -Using mild soap and water, clean your genital area. -Men should retract the foreskin, if needed, and clean the area, including the penis. -Women should separate the labia, and clean the area from front to back. -Clean your urethra (urinary opening), which is where the catheter enters your body. -Clean the catheter from where it enters your body and then down, away from your body. Hold the catheter at the point it enters your body so that you don't put tension on it. -Rinse the area well and dry it gently.

What is the correct order in which elastic stockings should be applied?1. Identify patient using two identifiers. 2. Smooth any creases or wrinkles. 3. Slide the remainder of the stocking over the patient's heel and up the leg 4. Turn the stocking inside out until heel is reached. 5. Assess the condition of the patient's skin and circulation of the legs. 6. Place toes into foot of the stocking. 7. Use tape measure to measure patient's legs to determine proper stocking size. 1, 5, 7, 4, 6, 2, 3 1, 7, 5, 4, 6, 2, 3 1, 5, 7, 4, 6, 3, 2 1, 5, 4, 7, 6, 3, 2

1, 5, 7, 4, 6, 3, 2 This is the correct order in which elastic stockings should be applied.

Whom does HIPPA cover?

1. All persons working in healthcare facility or private office 2. Students 3. Non-patient care employees 4. Health plans 5. Billing companies 6. Electronic medical record companies

Nurse's Presence: Loss, grief, bereavement

1. Become comfortable sharing silence with your patients 2. Communicate honestly and be open 3. Provide direction, repeat the direction, and thank the patient and family for following direction 4. Be authentic and know yourself 5. Instruct patient and family how to get a hold of you 6. Be in the moment-do not be thinking of what you have to do next

Steps of Evidence-Based Practice

1. Cultivate a spirit of inquiry 2. Ask a clinical question in PICOT format 3. Search for the most relevant evidence 4. Critically appraise the evidence you gather 5. Integrate all evidence with your clinical expertise and patient preferences and values - How to include patient with stage 4 Alzheimer's? Include the family. 6. Evaluate the outcomes of practice decisions or changes using evidence 7. Share the outcomes with others

24 Hours Post op call by RN

1. Have you had a fever? 2. Do you have a sore throat 3. Have you had any nausea or vomiting? 4. Do you have pain? If yes, what is your pain level score from zero to 10 5. Do you have any signs of wound infection 6. Did you need to call the surgeon's office, visit the office, or go to the emergency department for any reason? 7. Do you have any questions regarding your recovery?

Post mortem care

1. Patient pronounced dead, date and time recorded 2. HCP makes decision if autopsy is needed. If so, a consent form must be signed by next of kin 3. Validate status of organ donation 4. Identify patient with two identifiers according to facility policy 5. Provide respectful nursing care to patient 6. RN or LPN to remove intravenous lines-hold pressure over area until bleeding stops. Put Band-Aid on sites 7. Ask family if they would like to participate in preparing the body 8. Assemble cleaning equiptment (towels, wash cloths, clean gown) 9. Be aware that person, religious, or cultural practices determine whether or not to shake a males beard 10. Clean body head to toe, clean the room, deodorize if necessary 11. Offer family members time with the deceased 12. Provide privacy and offer to call for pastoral care of their choice 13. Give all personal belongings to family and have the person who receives the items sign the belongings list 14. Apply identifying tag to body per facility policy 15. Have family identify the funeral home to release body to and sign consent for release of body 16. Transport body to morgue covered with a sheet. 17. If an autopsy is to be performed, contact pathologist and ask if body should be put in refrigeration or not 18. If a funeral home is coming to pick up the body they may request you not refrigerate the body 19. Always follow facility policy and procedure in post mortem care

Termination of Pregnancy or Abortion Issues

1973 Roe v. Wade * U.S Supreme Court ruled that there is a fundamental right to privacy, which includes a woman's right to have an abortion 1989 Webster v. Reproductive Health Services * Some states require viability tests if the fetus is more than 28 weeks' gestational age

A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. What are the steps for making a nursing diagnosis in the correct order, beginning with the first step?1. Considers context of patient's health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical information 3. Clusters clinical cues that form a pattern 4. Chooses diagnostic label 2, 3, 4, 1 3, 2, 4, 1 2, 3, 1, 4 1, 4, 3, 2

2, 3, 4, 1 This is the correct steps for making a nursing diagnosis.

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. 1. "You say you've lost weight. Tell me how much weight you've lost in the last month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. Thank you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?" 4, 2, 1, 3, 5 2, 4, 3, 1, 5 4, 2, 5, 1, 3 2, 4, 1, 5, 3

2, 4, 1, 5, 3 This follows the correct order for the interview.

What is the appropriate order for the following steps of evidence-based practice (EBP)?1. Integrate the evidence.2. Ask the burning clinical question.3. Create a spirit of inquiry4. Evaluate the practice decision or change.5. Share the results with others.6. Critically evaluate the evidence you gather.7. Collect the most relevant and best evidence. 2, 3, 7, 6, 4, 1, 5 3, 2, 7, 1, 6, 5, 4 3, 2, 7, 6, 1, 4, 5 2, 3, 6, 7, 1, 4, 5

3, 2, 7, 6, 1, 4, 5

During the implementation step of the nursing process, a nurse reviews and revises a patient's plan of care. What is the correct order of steps for this?1. Modify care plan as needed. 2. Decide if the nursing interventions remain appropriate. 3. Reassess the patient. 4. Compare assessment findings to validate existing nursing diagnoses. 2, 1, 3, 4 3, 4, 2, 1 4, 3, 2, 1 3, 4, 1, 2

3, 4, 2, 1 Reassessment allows you to review a patient's care plan by validating the nursing diagnoses and determine whether the nursing interventions remain the most appropriate for the clinical situation. When changes are needed, you modify the plan of care.

Normal urine output

30 mL/hr

Normal cardiac output

4-6L-min

What are Jim's three "C"s of caring for dementia patients?

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What resources are available for you in terms of APA formatting?

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Nursing diagnosis

A decision or judgement about the nature of a client's problems or needs

Imagery

A mind-body therapy that uses the conscious mind to create mental images to stimulate physical changes in the body, improve perceived well-being, and/or enhance self-awareness Clinical applications * Pain control Limitations * Relatively few side effects

Depression

A mood disturbance characterized by feelings of sadness and despair Clinical = Diagnosed by psychiatrist

Atheist

A person who denies the existence of God

Braden Scale

A scale that predicts the risk for developing a hospital or facility acquired pressure ulcer/injury. The lower the number the more likely the patient is to develop a pressure ulcer. 19-23 = no risk 15-18 = mild risk 13-14 = moderate risk less than 9 = severe risk Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear are the six categories.

Nursing Clinical Information Systems

Allows nurses to access computerized information at the patient's bedside * Enables the nurse to share care plan immediately with the patient * Can check on laboratory results Designs * Nursing process * Protocol or critical pathway * Advantages

Alignment and balance

Also refers to posture

Anesthesia Patient Classification System

ASA Physical Status 1: A normal healthy patient ASA Physical Status 2: A patient with mild systemic disease ASA Physical Status 3: A patient with severe systemic disease ASA Physical Status 4: A patient with severe systemic disease that is a constant threat to life ASA Physical Status 5: A moribund patient who is not expected to survive without the operation ASA Physical Status 6: A declared brain-dead patient whose organs are being removed for donor purposes

A nurse is reading a research article. The nurse just finished reading a brief summary of the research study that included the purpose of the study and its implications for nursing practice. Which part of the article did the nurse just read? Abstract Analysis Discussion Literature Review

Abstract An abstract is a brief summary of the purpose of the article. It also includes the major themes or findings and the implications for nursing practice.

Elements of an article

Abstract Introduction Literature review or background * Manuscript narrative * Purpose statement * Methods or design * Results or conclusions * Clinical implications

Care Coordination

Accountable care organizations (ACOs) * Developed to coordinate medical care * Nurses act as leaders and care coordinators Patient-centered medical home (PCMH) * Coordinates care, gathers clinical data, monitors patient outcomes * Primary care providers function as the hub of the PCMH

Toxic effect

Accumulation of medication in the bloodstream. Hepatic or renal failure.

Nursing Diagnosis: Pain Management

Activity Intolerance - Fatigue - Impaired social interaction - Impaired physical mobility Anxiety - Insomnia - Ineffective coping - Impaired physical mobility

Maintenance and Promotion of Lung Expansion

Activity to decrease atelectasis (when alveoli collapse, puts patient at risk for pneumonia - can be caused by immobility, cough and deep breath as preventative measures) * Ambulation and time in chair * Positioning * Reduces pulmonary stasis, maintains ventilation and oxygenation Incentive spirometry * Encourages voluntary deep breathing * Inhale out of it keeping it as centered as possible Chest tubes * A catheter placed through the thorax to remove air and fluids from the pleural space or to prevent air from reentering or to reestablish intrapleural and intrapulmonic pressures

AMA

Against medical orders

Implementation: Mediation Administration

Acute care * Receiving, transcribing, and communicating medication orders * Accurate dose calculation and measurement * Correct administration * Recording medication administration Restorative care Special considerations * Infants and children (dosing, psychological prep) * Elderly * Polypharmacy

Older Adult and the Acute Care Setting

Acute care settings pose risks for adverse events: * Delirium * Dehydration * Malnutrition * Health care-associated infections * Urinary incontinence * Falls

What is delirium?

Acute confusional state

Delirium

Acute confusional state (in elderly, caused by UTI or pneumonia

Acute vs. Chronic

Acute wounds * Heal following a normal pattern Chronic * Fail to heal within 6 weeks * Does not progress to proliferative phase * Underlying factors prevent healing * Usually multiple factors stall progress * Diabetic foot ulcers * Reduced blood flow * High glucose

Types of Pain

Acute/transient pain * Protective, identifiable, short duration; limited emotional response Chronic/persistent noncancer * Is not productive, has no purpose, may or may not have an identifiable cause, lasts 6 months or more Chronic episodic * Occurs sporadically over an extended duration Cancer * Can be acute or chronic Idiopathic * Chronic pain without identifiable physical or psychological cause

A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? Select all that apply. The center needs to be clean, and rooms should look like a hospital room. Adequate staffing is available on all shifts. Social activities are available for all residents. The center provides three meals daily with a set menu and serving schedule. Staff encourage family involvement in care planning and assisting with physical care.

Adequate staffing is available on all shifts, Social activities are available for all residents, Staff encourage family involvement in care planning and assisting with physical care. Adequate staffing, provision of social activities, and active family involvement are essential. Meals should be high quality with options for what to eat and when it is served. A nursing center should be clean, but it should look like a person's home rather than a hospital.

Fidelity

Agreement to keep promises

A nurse who has recently graduated has been assigned to be a primary nurse on a geriatric unit. After completing a review of development aging, the nurse recalls that changes for the older adult include: []A transition from young adulthood []The ability of the older adult to achieve sexual arousal []A time when cognitive performance begins to peak. []Adjusting to decreasing health and physical strength

Adjusting to decreasing health and physical strength

Standing or routine

Administered until the dosage is changed or another medication is prescribed

Common Record-Keeping Forms

Admission nursing history form * Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems Flow sheets and graphic records * Help team members quickly see patient trends over time and decrease time spent on writing narrative notes * Patient care summary Standardized care plans or clinical care guidelines (CPGs) * Preprinted, established guidelines used to care for patients who have similar health problems * Discharge summary forms

A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with them. The nurse is acting as the patient's: Educator Advocate Caregiver Case manager

Advocate An advocate protects the patient's human and legal right to make choices about his or her care. An advocate may also provide additional information to help a patient decide whether or not to accept a treatment or find an interpreter to help family members communicate their concerns.

Administering via Inhalation

Aerosol spray, mist, or powder via handheld inhalers; used for respiratory "rescue" and "maintenance" * Pressurized metered-dose inhalers (pMDIs) * Need sufficient hand strength for use * Breath-actuated metered-dose inhalers (BAIs) * Release depends on strength of patient's breath. * Dry powder inhalers (DPIs) * Activated by patient's breath * Produce local effects such as bronchodilation * Some medications create serious systemic side effects Usually use sterile water, saline, or antiseptic solutions on * Eye * Ear * Throat * Vagina * Urinary tract * Use aseptic technique if a break is noted in the skin or mucosa * Use clean technique when the cavity is not sterile.

Critically Appraise the Evidence

After critiquing all articles for a PICOT question: * Synthesize or combine the findings * Consider the scientific rigor of the evidence and whether it has application in practice

Share the Outcomes with Others

After implementing an EBP change, it is important to communicate the results * Clinical staff on the unit * Nursing practice council or the research council * Clinicians * Professional conferences and meeting

Post-Procedure Care: Cath lab

Again...Nurses monitor and report vital signs, making sure they are stable * This is obviously VERY important! * Watch for signs of possible infection * Monitor for adverse side effects from medications and other complications associated with the procedure Adverse side effects from procedure could be: * Excessive bleeding * Fever * Allergic reactions * Stroke, Heart Attack, Death

The nurse is completing an admission assessment with an 80-yearold man who experienced a hip fracture following a fall. He is alert, lives alone, and has very poor hygiene. He reports a 20-pound weight loss in the last 6 months following his wife's death, as well as estrangement from his only child. He admits to falls before this most recent fall. What should the nurse suspect? Dementia. Elder abuse. Delirium. Alcohol abuse.

Alcohol abuse. Hallmarks of alcohol abuse include frequent falling, self-neglect, and poor nutrition, which could result in weight loss and may accompany depression and loss.

Sexuality is maintained throughout our lives. Which of the following answers best explains sexuality in an older adult? When the sexual partner passes away, the survivor no longer feels sexual. A decrease in an older adult's libido occurs. Any outward expression of sexuality suggests that the older adult is having a developmental problem. All older adults, whether healthy or frail, need to express sexual feelings.

All older adults, whether healthy or frail, need to express sexual feelings. Sexuality is normal throughout the life span, and older adults need to be able to express their sexual feelings.

The Relationship between EBP, Research, and QI

Although EBP, research, and QI are closely related, they are separate processed * EBP: Use of information from research and other sources to determine safe and effective nursing care with the goal of improving patient care and outcomes * Research: Systematic inquiry answers questions, solves problems, and contributes to the generalizable knowledge base of nursing; pay or may not improve patient care * QI: improves local work processes to improve patient outcomes and health system efficiency; results usually not generalizable

When a nurse conducts an assessment, data about a patient often comes from which of the following sources? Select all that apply. An observation of how a patient turns and moves in bed The unit policy and procedure manual The care recommendations of a physical therapist The results of a diagnostic x-ray film Your experiences in caring for other patients with similar problems

An observation of how a patient turns and moves in bed, The care recommendations of a physical therapist, The results of a diagnostic x-ray film There are many sources of data for an assessment, including the patient through interview, observations, and physical examination; family members or significant others, health care team members such as a physical therapist, the medical record (which includes x-ray film results, and the scientific and medical literature.

Evaluation

Analyze results of the study Use of findings

A nurse who works on a pediatric unit asks, "I wonder if children who interact with therapy dogs have reduced anxiety when they are in the hospital." In this example of a PICOT question, which of the following is the O? Children. Therapy dogs. The pediatric unit. Anxiety.

Anxiety. O stands for outcome; in this PICOT question, the outcome the nurse is concerned about is anxiety.

Apothecary Units

Apothecary units stand for some of the units that many of us may be familiar with: * Pounds, ounces And some that we are not so familiar with here in the United States * Grains, scruples, drams Instead, use metric units * Metric units are used worldwide and will not get confused * mg, kg, cm, L, dL

Collect the Best Evidence

Ask experts for help * Nursing faculty * Advanced practice nurses * Staff educators * Risk managers * Librarians A medical librarian can * Identify the databases that are available to you * Identify key words that will provide the best answer to your PICOT question

A nurse caring for a patient with heart failure instructs the patient on foods to eat for a low-sodium diet. The nurse will perform which of the following evaluation measures to determine success of her instruction? Patient weight Asking patient to identify three low-sodium foods to eat for lunch A calorie count of food Patient description of how food selections are made

Asking patient to identify three low-sodium foods to eat for lunch If the nurse is instructing patient on foods to eat, the goal and expected outcome would be knowledge based. Asking the patient to identify three low-sodium foods to eat for lunch is an evaluative measure for knowledge application.

An 18-year-old woman is in the emergency department with fever and cough. The nurse obtains her vital signs, listens to her lung and heart sounds, determines her level of comfort, and collects blood and sputum samples for analysis. Which standard of practice is performed? Diagnosis Evaluation Assessment Implementation

Assessment Assessment is the collection of comprehensive data pertinent to the patient's health and/or the situation.

Nursing Process: Patient Safety and Quality

Assessment * Through the patient's eyes * Nursing history * Health care environment * Risk for falls * Risk for medical errors * Disasters Patient's home environment * Perform hazard assessment * Walk through the home with the patient and discuss how he or she normally conducts daily activities and whether the environment poses problems * Help individuals focus on avoiding losses and reducing their risk for injury associated with disasters

Respiratory Immobility

Atelectasis * Secretions sit in lower part of the lungs, don't get cleared out, bacteria love it, high risk for pneumonia Hypostatic pneumonia * Because they can't fully extend lungs and expel secretions

A Few Procedures in the Cath Lab

Atherectomy: * Removal of hardened plaque in the artery. Plaque is pulverized and enters bloodstream harmlessly Balloon Angioplasty: * A catheter with a balloon attached, balloon inflates and splits plaque and stretches wall of artery, allowing better blood flow. Stenting: * Small, mesh tube that keeps artery open and prevents it from reclosing and collapsing Thrombectomy: * Removal of a blood clot from the blood vessels

Professional Roles

Autonomy and Accountability Caregiver Advocate Educator Communicator Manager

Nonmaleficence

Avoidance of harm or hurt

Nursing Diagnostic Statement

Basic format for 'risk' nursing diagnosis consists of two parts: the problem and the etiology * Problem -> response/to -> etiology * (NANDA-I label) -> r/t -> related factors * Risk for constipation -> r/t -> inadequate dietary fiber Three part: problem, etiology, symptoms * AEB (as evidence by) * Problem -> r/t -> etiology -> AEB -> Symptoms * NANDA-I label -> r/t -> (related factors) -> AEB -> Defining characteristics * Constipation -> r/t -> inadequate dietary fiber -> AEB -> Bloating no BM in 5 days

Evaluation: Urinary Elimination

Be specific as to the nature of the problem * Resolvable or ongoing Urinary inontinence * Ongoing * Clean, dry, comfortable, skin intact, hydrated * Resolvable * Given all available options * Appropriate teaching * Urinary diversion * Client's level of self-care * Care minimally disrupts client's preferred lifestyle

A with line above

Before

Justice

Being fair

Older Adults

Between 2015 and 2050 the proportion of the world's population over 60 years will nearly double from 12% to 22%. By 2020, the number of people aged 60 years and older will outnumber children younger than 5 years. The pace of population aging is much faster than in the past. All countries face major challenges to ensure that their health and social systems are ready to make the most of this demographic shift.

Requirments for Wound Healing

Blood Flow - Nutrients - Oxygen Cell migration Bacterial Management - Biofilm - Infection Wound Bed preparation - Moist environment - Debridement Management of Comorbidied - Disease - Medication - Nutrition

Preterm Labor: Oral Health

Bone loss more common in women with low-birth weight babies. Periodontitis contributing more towards lbwb than smoking or alcohol use. Risk associated with Gram-negative organisms

What is Ischemia? []An inadequate supply of blood to an organ or part of the body []Blood clotting []Irregular blood distribution []Both A and C

Both A and C

Sanguineous

Bright red: indicates active bleeding

What is the libraries online reference most useful for nurses?

CINAHL

Blood Flow Regulation

Cardiac Output * Amount of blood ejected from the left ventricle each minute * Normal 4-6L/min * SV x HR Stroke Volume * Amount of blood ejected from the left ventricle with each contraction Preload * End diastolic pressure * Less volume = less preload * Fluid overload = more preload Afterload * Resistance to left ventricular ejection * medications which dilate blood vessels will decrease afterload and vice versa

CPR

Cardiopulmonary resuscitation

Planning: Loss, grief, bereavement

Care plans for the dying patient focus on - Comfort - Preserving dignity and quality of life - Providing family members with emotional, social, and spiritual support - Give priority to a patient's most urgent physical or psychological needs while also considering his or her expectations and priorities

Contemporary nursing requires that the nurse has knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples? Select all that apply. Caregiver Autonomy and accountability Patient advocate Health promotion Lobbyist

Caregiver Autonomy and accountability Patient advocate Health promotion Each of these roles or skills includes activities for the professional nurse. Each of these is used in direct care or is part of professionalism that guides nursing practice.

The nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started noticing a glare in the lights at home. Her vision is blurred; and she is unable to play cards with her friends, read, or do her needlework. The nurse suspects that the woman may have: Presbyopia. Presbycusis Cataract(s). Depression.

Cataract(s). Cataracts normally result in blurred vision, sensitivity to glare, and gradual loss of vision. Presbyopia is a common eye condition resulting in a person having difficulty adjusting to near and far vision. The symptoms are not reflective of depression since her vision affects her ability to interact. She has not chosen to avoid her friends.

The Challenge of Caring

Challenges * Task-oriented biomedical model * Institutional demands * Time constraints * Reliance on technology, cost-effective strategies, and standardized, work processes If health care is to make a positive difference in patients' lives, health care must become more holistic and humanistic

Influences on Nursing

Changes in society lead to changes in nursing: * Health care reform * Demographic changes * Medically underserved * Threat of bioterrorism * Rising health care costs * Nursing shortage

Methods of Reporting

Charting by exception (CBE) * Focuses on documenting deviations Case management plan and critical pathways * Incorporate a multidisciplinary approach to care * Variances

A nurse checks an intravenous (IV) solution container for clarity of the solution, noting that it is infusing into the patient's left arm. The IV solution of 9% NS is infusing freely at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room the nurse inspects the condition of the dressing and notes the date on the dressing label. In which ways did the nurse evaluate the condition of the IV site? Select all that apply. Checked the IV infusion rate Checked the type of IV solution Confirmed from nurses' notes the time of dressing change Inspected the condition of the IV dressing at the site Checked clarity of IV solution

Checked the IV infusion rate, Inspected the condition of the IV dressing at the site The condition or status of the IV site is determined by checking the IV infusion rate and the condition of the IV site dressing. Checking the type of solution is important to ensure that correct therapy is being administered but is not a measure of the IV site condition. Confirming a dressing change or the appearance of the IV solution is not an indicator of the IV site status.

Which measures does a nurse follow when being asked to perform an unfamiliar procedure? Select all that apply. Checks scientific literature or policy and procedure Reassesses the patient's condition Collects all necessary equipment Delegates the procedure to a more experienced nurse Considers all possible consequences of the procedure

Checks scientific literature or policy and procedure, Reassesses the patient's condition, Collects all necessary equipment, Considers all possible consequences of the procedure The nurse does not delegate a procedure to a more experienced nurse. Instead the nurse has another nurse (e.g., staff nurse, faculty, nurse specialist) who has completed the procedure correctly and safely provide assistance and guidance.

Types of Ostomies

Colostomy: formed from the large intestine * Ascending * Transverse * Descending * Sigmoid colon * Ileostomy: made of the small intestine Urostomy: uses the ureters of the urinary tract * Ileal conduit * Double ureterostomy * Transureterostomy * Urinary diversion

Physiology of Sleep

Circadian rhythms * Affected by light, temperature, social activities, and work routines The biological rhythm of sleep frequently becomes synchronized from other body functions

What is the main reason a lot of fluid is used in diabetic patients undergoing cardiac catheterization? []Increase blood volume, which increases vessel diameter []Clear metformin and dye from the kidneys and body []To increase blood pressure allowing for better circulation []They do not use a lot of fluid in diabetic patients, because it is too harsh on the kidneys

Clear metformin and dye from the kidneys and body

The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: Cue. Reflection. Clinical inference. Probing.

Clinical inference. An inference is your judgment or interpretation of cues such as the shuffling gait and reduced leg strength. Any information gathered through your senses is a cue. Probing is a technique used in interviewing. Reflection is an internal process of thinking back about a situation.

Professional Nursing Code of Ethics

Code of nursing ethics * A set of guiding principles that all members of a profession accept * Helps professional groups settle questions about practice or behavior * Includes advocacy, responsibility, accountability, and confidentiality Social networking * Presents ethical challenges for nurses

Before consulting with a physician about a female patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? Cognitive Interpersonal Psychomotor Consultative

Cognitive This is an example of a cognitive skill, being used before consultation. It involves critical thinking and decision making so the nurse is able to deliver a relevant nursing intervention.

Assessment

Collect data that can be used to identify client needs that can be managed or treated with nursing care

Health perception-health management patternWhich of the following examples are steps of nursing assessment? Select all that apply. Collection of information from patient's family members Recognition that further observations are needed to clarify information Comparison of data with another source to determine data accuracy Complete documentation of observational information Determining which medications to administer based on a patient's assessment data

Collection of information from patient's family members, Recognition that further observations are needed to clarify information, Comparison of data with another source to determine data accuracy Assessment includes collection of data from secondary sources such as the patient's family. Recognizing that more observation is needed is an example of validation of data. Comparing data to determine accuracy is a feature of interpretation. Although complete documentation is an important step in communicating assessment data, it is not an assessment step.

Diet: Ostomies

Colostomy & Ileostomy * Divide meals and space them out * Low fiber, low residual Ileostomy * Requires more fluid * Thickening foods; applesauce, cheese, yogurt, mashed potato * Thinning foods: fruit juice, greasy and fried foods, green leafy and raw vegetables Urostomy * Maintain a regular diet

Autonomy

Commitment to include patients in decisions

A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the nursing diagnosis of Nausea related to effects of postoperative anesthesia. The nurse has been asking the patient to rate his nausea over the last several hours after administering antiemetics and using comfort measures such as oral hygiene. The nurse reviews the patient's responses over the past 10 hours and notes how the patient's self-report of nausea has changed. This review an example of: Comparing outcome criteria with actual response. Gathering outcome criteria. Evaluating the patient's actual response. Reprioritizing interventions.

Comparing outcome criteria with actual response. The key to this question is observation for change. The nurse compares the patient's actual self-report rating of nausea with the expected outcome of a reduction in nausea. Gathering outcome criteria simply involves having the patient rate nausea. Evaluating the behavior or self-report is the determination of the patient's actual response.

Implementation

Conduct the study

A nurse researcher is collecting data following approval from the institutional review board (IRB). In which part of the research process is this nurse? Analyzing the data Designing the study Conducting the study Identifying the problem

Conducting the study Conducting the study includes tasks such as obtaining necessary approvals and implementing the study protocol to guide data collection.

When recruiting subjects to participate in a study about the effects of an educational program to help patients at home take their medications as ordered, the researcher tells the subjects that their names will not be used and no one but the research team will have access to their information and responses. This is an example of: Bias. Anonymity. Confidentiality. Informed consent.

Confidentiality. Confidentiality guarantees that any information a subject provides will not be reported in any manner that identifies the subject and will not be accessible to people outside the research team.

Which of the following does a nurse perform when discontinuing a plan of care for a patient?

Confirms with the patient that expected outcomes and goals have been met When you discontinue a plan of care, you determine that expected outcomes and goals have been met, and you confirm this evaluation with the patient when possible. If you and the patient agree, you discontinue that part of the care plan. Reassessing how goals were met is not necessary if you confirm that discontinuation of a plan is appropriate. Talking with the patient about reprioritizing interventions in the plan of care and changing the frequency of the interventions provided are not appropriate when a plan is discontinued.

Consent

Consent form * Must be signed Informed consent * Agreement to allow care based on full disclosure of risks, benefits, alternatives, and consequences of refusal * The nurse's signature as a witness to the consent means that the patient voluntarily gave consent, the patient's signature is authentic, and the patient appears to be competent to give consent

Actions to Take

Contact a speech pathologist * They will do a 'swallow evaluation' * They may suggest further studies such as a: barium swallow or modified barium swallow * A recommendation for an appropriate diet will be suggested May want to implement 'aspiration precautions'. Some examples on the next slide!

A group of nurses have identified that the elderly patients on their unit have a high incidence of pressure ulcers after they have a stroke. During a unit meeting, they discuss different interventions they think may reduce the development of pressure ulcers. What is the nurses' next step to investigate this clinical problem further? Conduct a literature review. Share the findings with others. Conduct a statistical analysis. Create a well-defined PICOT question.

Create a well-defined PICOT question. In this case the nurses need to develop a PICOT question next to search for appropriate evidence that might offer answers to this clinical problem.

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend? Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert Hot dog on whole wheat bun with a side salad and an apple for dessert Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert Turkey salad on toast with tomato and lettuce and honey bun for dessert

Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert Teach patient and/or caregiver the current recommended dietary allowances for calcium and review foods high in calcium (e.g., milk fortified with vitamin D, leafy green vegetables, yogurt, and cheese).

A nurse researcher wants to know what factors are associated with a person's decision to exercise. The nurse distributes a survey to people who recently joined an exercise wellness program and analyzes the data to determine what factors and characteristics are most significantly linked to the decision to start exercising. What type of a research study is this?

Correlational In the correlational study the nurse researcher is correlating characteristics or factors with the decision to start exercising.

A nurse reviews all possible consequences before helping a patient ambulate such as how the patient ambulated last time; how mobile the patient was before admission to the health care facility; or any current clinical factors affecting the patient's ability to stand, remain balanced, or walk. Which of the following is an example of a nurse's review of this situation? Critical thinking Managing an adverse event Exercising self-discipline Time management

Critical thinking The process of reviewing consequences for a patient is an example of critical thinking and clinical decision making. Managing an adverse event occurs after consequences have occurred. Exercising self-discipline is a critical thinking attitude that guides you in reviewing, modifying, and implementing interventions, which occurs after reviewing consequences. This is not an example of time management.

Critical Thinking Defined

Critical thinking is: * The ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process * A continuous process characterized by open-mindness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant * Recognizing that an issue exists, analyzing information, evaluating information, and drawing conclusions

Surgical Debridement

Cutting into viable and dead tissue * Removal of necrotic, slough, or infected tissue Exposes wound base for topical treatments and assessment * *Removal of biofilm * *Stimulates the healing process - bleeding * Turns chronic wound back to acute Essential to healing * Outpatient clinic or operating room * Scalpel, curette, scissors * Experienced physician/NP/PA * Most effective debridement * Chronic wounds may need weekly Other Types * Enzymatic - topical products * Mechanical/selective - gauze * Autolytic - cellular

ug

DO NOT USE * This can be mistaken for "mg" of milligrams when it actually stands for micrograms * Instead, write out "micrograms" or "mcg" * This error used in medication administration can lead to a thousand times mroe medication then necessary

> and <

DO NOT USE * Instead, write out "greater than" or "less than" * In a hurry, these can be mistaken for letter L, the number 7 or mistaken for one another

cc

DO NOT USE Can be mistaken for the number 0 or "U" for units if poorly written or read in a hurry * Physician might order 10cc of a medication * Care provider may mistake for 1000 * Too high of dose for patient * Instead, use the metric system and milliliters * mL is the preferred may to write it

MS

DO NOT USE Can mean two different things * Morphine sulfate or magnesium sulfate * Often mistaken for one another * Instead, write out the terms completely Use of meds are completely different: * Magnesium sulfate, commonly known as Epsom salt, is used to replace magnesium in the body * Morphine sulfate is used to treat severe pain

A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: Collaborative data set. Diagnostic label. Related factors. Data cluster.

Data cluster. A data cluster is a set of cues (i.e., the signs or symptoms gathered during assessment).

A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: Select all that apply. Data collection. Data clustering. Data interpretation. Making a diagnostic statement. Goal setting.

Data collection, Data interpretation. This is an example of an error in interpretation and data collection. When making a diagnosis, the nurse must interpret data that he or she has collected by identifying and organizing relevant assessment patterns to support the presence of patient problems. In the case of the two diagnoses in this question, there can be conflicting cues. The nurse must obtain more information and recognize the cues that point to the correct diagnosis.

The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview? Orientation Working phase Data validation Termination

Data validation The gathering of information is the working phase of a patient-centered interview.

NSAIDS

Decrease inflammation

Heart and vascular Older Adult

Decreased contractile strength of the myocardium results in decreased cardiac output

Which of the following are physiological outcomes of immobility? Increased metabolism Reduced cardiac workload Decreased lung expansion Decreased oxygen demand

Decreased lung expansion Physiologic outcomes of immobility include decreased metabolism, increased cardiac workload, decreased lung expansion, and increased oxygen demand.

A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility: Decreased peristalsis Decreased heart rate Increased blood pressure Increased urinary output

Decreased peristalsis Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.

Older Adults

Decreased physical activity Hormonal changes Bone reabsorption

unstageable pressure ulcer

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

oliguria

Decreased urine output

The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? Select all that apply. Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs Allows physicians and allied health staff to communicate with nurses how they provide care among themselves Helps nurses focus on the scope of nursing practice Creates practice guidelines for collaborative health care activities Builds and expands nursing knowledge

Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs, Helps nurses focus on the scope of nursing practice, Builds and expands nursing knowledge The use of nursing diagnosis creates a common language for nurses to communicate patient care needs, allows nurses to focus on the realm and scope of nursing practice, and helps to develop nursing knowledge. It is not a language for physicians and allied health staff because they do not rely on providing nursing interventions. Terminology in nursing diagnosis may be familiar to other health care providers but not in a way for directing nursing interventions. Nursing diagnosis has the purpose of creating practice guidelines for nursing.

You are preparing a presentation for your classmates regarding the clinical care coordination conference for a patient with terminal cancer. As part of the preparation you have your classmates read the Nursing Code of Ethics for Professional Registered Nurses. Your instructor asks the class why this document is important. Which of the following statements best describes this code? Improves self-health care Protects the patient's confidentiality Ensures identical care to all patients Defines the principles of right and wrong to provide patient care

Defines the principles of right and wrong to provide patient care When giving care, it is essential to provide a specified service according to standards of practice and to follow a code of ethics. The code of ethics is the philosophical ideals of right and wrong that define the principles you will use to provide care to your patients. It serves as a guide for carrying out nursing responsibilities to provide quality nursing care and the ethical obligations of the profession.

Adolescents

Delayed in gaining independence and in accomplishing skills Social isolation can occur

Stage 4 Pressure Ulcer

Full thickness with exposed structures - Muscle, tendon, ligament

Planning: Research Process

Determine how study will be conducted

Diagnosis: Research Process

Develop research question(s)/hypotheses

Ask a Clinical Question

Developing a PICOT question * P = Patient population of interest * I = Intervention of interest * C = Comparison of interest * O = outcome * T = Time Example: What is the duration of recovery (O) for patients with total hip replacement (P) who developed a post-operative infection (I) as opposed to those who did not (C) within the first six weeks of recovery (T)?

Planning: Patient Safety and Quality

Goals and outcomes * Prevent and minimize safety threats * Are measurable and realistic * May include active patient participation * Setting priorities * Teamwork and collaboration

Dx

Diagnosis

Components of a Nursing Diagnosis

Diagnostic Label * The title or name of the nursing diagnosis * A concise word or phrase describing the client's health: ie: impaired physical mobility Definition * Described the characteristics of the human response identified Related factors * Causative or other contributing factors, eg., related to limited range of motion Risk factors * Risk for fall, pneumonia, pressure ulcer formation, renal calculi

Nutrition and Wound Healing

Dietary * *Protein intake - required for collagen * Calories - increased energy requirements for wound healing * Hydration - improves skin integrity, fluid loss from drainage Supplements * Protein shakes etc... * Vitamin C * Multivitamin Consult * *Nutrition or RD consult * *Diabetic educator Other considerations * May need tube feeding * Check labs - Albumin/Pre-albumin * Special considerations with Kidney disease and CHF etc...

Fluid and Electrolyte Changes with immobility

Diuresis (increased production of urine) occurs as a result of increased blood flow to kidneys, which causes loss of electrolytes (potassium and sodium). Also causes calcium resorption (loss) from bones which causes elevated serum calcium levels.

Types of Interventions

Direct care nursing interventions * "a treatment performed through interaction with the client" * Examples: ambulating, toileting, instilling hope Indirect care nursing interventions * A treatment performed away from the client but on behalf of a client or group of clients * Examples: shift report, telephone consultation Nurse-initiated interventions * An intervention initiated by a nurse in response to a nursing diagnosis. (helping a client dress) * Ex: turning a client every two hours Physician-initiated interventions * "a treatment initiated by a physician in response to a medical diagnosis by carried out by a nurse in response to a doctor's order" (administering a medication prescribed by a physician)

Alterations in Cardiac Functioning

Disturbances in conduction * Cased by electrical impulses that do not originate from the SA node (dysrhythmias) Altered cardiac output * Insufficient volume is ejected into the systemic and pulmonary circulation * L vs R sided HF Impaired valvular function * Is acquired of congenital disorder of a cardiac valve by stenosis or regurgitation Myocardial ischemia * Coronary artery flow to the myocardium insufficient to meet myocardial oxygen demands

A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format? Disturbed Sleep Pattern evidenced by frequent awakening Disturbed Sleep Pattern related to family caregiving responsibilities Disturbed Sleep Pattern related to need to improve sleep habits Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested

Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested A nursing diagnosis in a PES format includes the diagnostic label, related factor, and the defining characteristics by which the diagnosis is evidenced. The second nursing diagnosis is the correct format in the two-part format for writing a diagnosis. The first diagnosis has no related factor. The third diagnosis is an error, using a goal as a related factor.

Quality Documentation

Does: * Present information in an objective manner, chart what you see, hear, palpate * Use short succinct sentences * Present information chronologically Does not: * Use subjective language (except when in quotes), do not use words such as seems, appears, apparently * Use jargon and excessive abbreviations

Dry Wound

Dried wound bed Honey or hydrogel debridement

Breasts Older Adult

Droop

Pharmacological Concepts

Drug names: * Chemical - provides the exact description of medication's composition * Generic - the manufacturer who first develops the drug assigns the name, and it is then listed in the U.S Pharmacopeia * Trade - also known as brand or proprietary name. This is the name under which a manufacturer markets the medication Classification * Effect of medication on body system * Symptoms the medication relieves * Medication's desired effect Medication forms * Solid, liquid, other oral forms; topical, parenteral (injected); forms for instillation into body cavities

Factors Influencing Sleep

Drugs and substances * Hypnotics, diuretics, narcotics, antidepressants, alcohol, caffeine, beta-blockers, anticonvulsants Lifestyle * Work schedule, social activities, routines Usual sleep patterns * May be disrupted by social activity or work schedule Emotional stress * Worries, physical health, death, losses Environmental * Noise, routines Exercise and fatigue * Moderate exercise and fatigue cause a restful sleep Food and calorie intake * Time of day, caffeine, nicotine, alcohol

DPOA

Durable Power of Attorney- legal document allowing another person the authority to make medical decisions for you

Signs and Symptoms of Opioid Overdose

During an overdose, breathing can be dangerously slowed or stopped, causing brain damage or death. It's important to recognize the signs and act fast. Signs include: - Small, constricted "pinpoint pupils" - Falling asleep or loss of conciousness - Slow, shallow breathing - Choking or gurgling sounds - Limp body - Pale, blue, or cold skin

The nurse spends time with the patient and family reviewing the dressing change procedure for the patient's wound. The patient's spouse demonstrates how to change the dressing. The nurse is acting in which professional role? Educator Advocate Caregiver Case manager

Educator The nurse is demonstrating the role of educator. An educator explains concepts and facts about health, describes the reason for routine care activities, demonstrates procedures such as home care activities, reinforces learning or patient behavior, and evaluates the patient's progress in learning through return demonstration.

Non-rebreather

Emergency situations, patient is cyanotic, turn oxygen all the way up

Psychosocial Effects Immobility

Emotional and behavioral responses * Hostility, giddiness, fear, anxiety Sensory alterations * Altered sleep patterns Changes in coping * Depression, sadness, dejection Don't ever think you know what someone else is going through.

A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient? Encouraging use of an overhead trapeze for positioning and transfer. Frequent family visits Assisting the patient to a wheelchair once per day Ensuring that there is an order for physical therapy

Encouraging use of an overhead trapeze for positioning and transfer. The trapeze bar allows the patient to pull with the upper extremities to raise the trunk off the bed, aid in transfer from bed to wheelchair, or perform upper-arm exercises. It increases independence and maintains upper body strength to help in performing activities of daily living.

Preload

End diastolic pressure...the volume of fluid thats in your heart when it's resting less volume = less preload fluid overload = more preload

Metabolic Immobility

Endocrine, calcium, absorption, and GI function * Endocrine - blood sugars off * Calcium - pressure isn't on bones so calcium seeps into bloodstreams * GI - peristalsis slows (maybe even stops)

A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort?

Engage the patient in setting mutual outcomes for distance he is able to walk All goals and outcomes of care should be patient centered whenever possible. An approach for ensuring patient centered goals is having the patient involved so goals can be mutually set and realistic to the patient. Confirming with the physician and checking the medical record help the nurse understand the extent of exercise in which a patient can participate. But these approaches are not examples of mutual patient-centered goal setting. Having physical therapy assistance would not make a goal patient centered.

Florence Nightingale

English nurse remembered for her work during the Crimean War (1820-1910) - Improve hygiene practices to lower death rates

A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient? Achieving wound healing of the foot ulcer Enhancing patient knowledge about the effects of diabetes Providing a dietitian consultation for diet retraining Improving patient adherence to diabetic diet

Enhancing patient knowledge about the effects of diabetes The high priority for this patient is wound healing. If the ulcer is left untreated, it will cause more serious harm; an infection is likely, and it could spread. Providing a diet consultation is an intervention. Improving patient adherence to her diet is an intermediate outcome. Adherence to the diet is important but not life threatening when unmet. Since the patient has had diabetes for 10 years, enhancing knowledge is important because of her poor adherence but a lower priority than the others.

Skin Structure

Epidermis - exterior surface * Avascular - no blood vessels * Renewed every 15-30 days Dermis - capillaries and glands * Skins main support structure * Vascular Subcutaneous - fat and vasculature * Insulin injections * Up to 3cm thick * Shock absorber * Fatty tissue * Muscle, tendon, organ ligament, joint capsule, and bone found below * "Important when staging and grading wounds, as well as following their healing progress

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? Patient will be turned every 2 hours within 24 hours. Patient will have normal bowel function within 72 hours. Patient's skin integrity will remain intact through discharge. Erythema of skin will be mild to none within 48 hours.

Erythema of skin will be mild to none within 48 hours. Turning the patient every 2 hours in a 24-hour period is an intervention. Both "Patient will have normal bowel function within 72 hours" and "Patient's skin integrity will remain intact through discharge" are goals.

Interventions: Urinary Elimination

Establishing continence * Pelvic muscle exercises: Kegel exercises * Bladder retraining Maintaining dry and intact skin * External catheters * Managing urine elimination Cognitively impaired client * Schedules toileting and prompted voiding * Patterned urge response training * Environmental modifications To irrigate the bladder * To maintain patency * Closed irrigation system: 3-lumen catheter * Opening the system To manage a urinary diversion * Tracking the urine flow * Observing for signs of peritonitis or hemorrhage, decrease in vital signs * Assessment of stoma * Proper use of drainage bag To manage urinary tract infection * Increasing fluid intake * Instructing patient in preventative measures * Possible administration of antibiotics Intake and output * Extended care facility: done on selected patients when ordered * Hospital: generally done on all patients * Acute care: completed every shift * Critical care/OR/ER: may be done hourly Assessment of output * Color * Clarity * Odor * Amount

Diabetic Wounds

Etiology * Poorly controlled blood sugars * Healing process halts > 200 * Peripheral Neuropathy * Peripheral Arterial disease * Large and small vessel * Pressure - foot deformity * Typically on toes or planter surface of foot * High risk for Amputation! Treatment * Off-loading-Essential

Venous Ulcers

Etiology * Breaks in skin from edema or trauma result in ulceration * Typically found on calf region * Risk factors: Obesity, family hx, CHF, trauma * Hemosiderin Staining - blood cells are breaking up, pooling, and staining

Which of the following statements correctly describes the evaluation process? Evaluation is an ongoing process. Evaluation usually reveals obvious changes in patients. Evaluation involves making clinical decisions. Evaluation requires the use of assessment skills. Evaluation is only done when a patient's condition changes.

Evaluation is an ongoing process., Evaluation involves making clinical decisions, Evaluation requires the use of assessment skills. Evaluation is ongoing throughout the nursing process once nursing diagnoses or patient health problems have been identified. It is a process that involves clinical decision making and use of assessment skills as evaluative measures. Evaluation may reveal changes in patients that often are not obvious. It occurs after any intervention and not only when a patient's condition changes.

A patient has been febrile and coughing thick secretions; adventitious lung sounds indicate rales in the left lower lobe of the lungs. The nurse decides to perform nasotracheal suction because the patient is not coughing. The nurse inspects the mucus that is suctioned, which is minimal. The nurse again auscultates for lung sounds. Auscultation and mucus inspection are examples of: Evaluative measures. Expected outcomes. Reassessments. Reflection.

Evaluative measures. Auscultation of lung sounds and inspection of mucus after the intervention of suctioning are examples of evaluative measures. An outcome would be clear secretions or clear lung sounds. It is not a reassessment because the nurse has not yet compared findings with expected outcomes. Suctioning is a standard of care.

EBP

Evidence Based Practice

The Need for Evidence-Based Practice

Evidence-based care * Improves quality, safety, and patient outcomes * Increases nurse satisfaction * Reduces costs

When conducting preoperative patient and family teaching, you demonstrate proper use of the incentive spirometer. You know that the patient understands the need for this intervention when the patient states, "I use this device to []Help my cough reflex" []Expand my lungs after surgery" []Increase my lung capacity" []Drain excess fluid from my lungs"

Expand my lungs after surgery

Therapeutic effect

Expected or predicted physiological response

A patient is being discharged after treatment for colitis (inflammation of the colon). The patient has had no episodes of diarrhea or abdominal pain for 24 hours. Following instruction, the patient identified correctly the need to follow a low-residue diet and the types of food to include if a bout of diarrhea develops at home. These behaviors are examples of: Evaluative measures. Expected outcomes. Reassessments. Standards of care.

Expected outcomes. The absence of diarrhea and abdominal pain and the ability to identify the correct diet are expected outcomes. If outcomes had not been met, the nurse would reassess. The low-residue diet is a standard of care, but the patient's ability to describe it is an outcome. An evaluative measure is the nurse questioning the patient about symptoms.

Clinical nurse specialist

Expert clinician in a specialized area of practice such as adult diabetes care.

Nursing Knowledge Base: Dietary Needs

Factors influencing nutrition * Environmental factors * Developmental needs * Infants through school age * Breastfeeding, formula, solid foods * Adolescents * Rapid growth, eating disorders * Young and middle adults * Reduced nutrient demands * Pregnancy * Older adults * Decreased metabolic rate

Nursing Knowledge Base: Patient Safety and Quality

Factors influencing patient safety * Patient's developmental level * Are they a child, dementia? * Mobility, sensory, and cognitive status * Lifestyle choices * Knowledge of common safety precautions

Nursing Knowledge Base: Infection Prevention and Control

Factors influencing prevention and control: * Age * Nutritional status * Stress * Disease process * Treatments or conditions that compromise the immune response

Dressing Selection

Factors to consider * Frequency of change * Cost of supplies * Location - will the product stay * Protection from Pressure/sheering * Amount of drainage * Packing - tunnels and undermining need to heal from inside out * Moist wound environment - promotes granulation and healing

Acute and Restorative Care: Patient Safety and Quality

Fall prevention * Follow fall protocols * Patient-centered care * Assistive aids Restraints * Physical * Chemical * Ongoing assessment * Objectives * Patient safety Side rails * Increase patient mobility and/or stability * Most commonly used as restraint * Can cause falls or death

Implementation: Care After Death

Federal and state laws apply to certain events after death - Documentation - Organ and tissue donation - Autopsy - Postmorten care Federal and state laws require institutions to: - Request organ or tissue donation - Perform an autopsy - Certify and document the occurrence of a death - Provide safe and appropriate postmortem care

Medication Legislation and Standards

Federal regulations *Pure Food and Drug Act * Food and Drug Administration (FDA) * MedWatch program * State and local regulation of medication Health care institutions and medication laws Medication regulations and nursing practice (Nurse Practice Acts)

Perineal care (washing genitals) considerations

Female- * Clean from front to back * Clean anal area last * Do not clean from back to front Male-circumcised & Uncircumcised Circumcised- if patient can do this themselves, provide them with washcloth or cleaning wipe Uncircumcised - make sure foreskin is pulled back to clean Prevent paraphimosis

Which of the following might be a cause of stress for the older adult? []Financial security []Planned retirement []Housing []Adjusting to decreasing health and physical strength

Financial security Housing Adjusting to decreasing health and physical strength

First Nurse Theorist....

Florence Nightingale

A patient is admitted to a medical unit for a home-acquired pressure ulcer. The patient has Alzheimer's disease and has been incontinent of urine. The nurse inserts a Foley catheter. You will identify a link in the infection chain as: []restraints []poor hygiene []Foley catheter bag []improper positioning

Foley catheter bag

Friction

Force that occurs in a direction opposite to movement * Friction -sheet can cause friction when patient is pulled * Shearing - sliding down on bed, body weight being pushed against the sheet and moving forward, this force is much harder on the skin than friction

Iatrogenic

Form a procedure

Planning: Sleep

Goals and outcomes example * Follow professional standards * Create a concept map * Collaborate Setting priorities * Frequently sleep disturbances are the result of other health problems Teamwork and collaboration * Partner closely with the patient and sleep pattern

Older adults frequently experience a change in sexual activity. Which best explains this change? The need to touch and be touched is decreased. The sexual preferences of older adults are not as diverse. Physical changes usually do not affect sexual functioning. Frequency and opportunities for sexual activity may decline.

Frequency and opportunities for sexual activity may decline. As a result of loss of a loved one or a chronic illness in themselves or their partner, opportunities for sexual activity may decline. Aging does not change the need for touch, and older adults are diverse.

Exogenous

From microorganisms outside the individual

Stage 3 Pressure Ulcer

Full thickness - extends beyond the dermit into the subcutaneous tissue

Mobility

Gait (a particular manner or style of walking) * Are they balanced? Exercise (physical activity for conditioning the body, improving health, and maintaining fitness) Activity tolerance (very individualistic) * Physiological * Emotional * Developmental Body alignment is used for * Determining normal physical changes * Identifying deviations in body alignment * Patient awareness of posture * Identifying postural learning needs of patients * Identifying trauma, muscle damage, or nerve dysfunction * Obtaining information on incorrect alignment (i.e., fatigue, malnutrition, psychological problems) Standing - top of the body shouldn't be leaning forward or back Sitting - feet are flat on floor and back is straight Lying - are spine and hips in alignment?

Gatekeepers of Elder Abuse

Gatekeepers: Police, bank-tellers, mailmen, hospital staff, visitors

Introduction of Anesthesia

General * Loss of all sensation and consciousness (as an RN you are able to do consciousness sedation) * Induction, maintenance, and emergence Regional * Loss of sensation in one area of the body Local * Loss of sensation at a site Conscious sedation/moderate sedation * Used for procedures that do not require complete anesthesia

Critical Thinking Competencies

General critical thinking * Scientific method * Problem solving * Decision making Specific critical thinking * Diagnostic reasoning and inference * Clinical decision making Nursing process as a competency * Assessment * Diagnosis * Planning * Implementation * Evaluation

Dementia

Generalized impairment of intellectual functioning Slower onset

What is dementia?

Generalized impairment of intellectual functioning, slow onset

STAT

Given immediately in an emergency Asthma attack, anaphylactic shock, heart attack

Single (one-time)

Given one time only for a specific reason

prn

Given when the patient requires it ex; pain medication

Planning Immobility

Goals and outcomes * Stage 1 pressure ulcer, realistic goal would be to reverse it within a week * For someone who is dying, this is not realistic. * Setting priorities * Teamwork and collaboration

Grief

Grief = An emotional response to a loss, manifested in ways unique to an individual based on personal experiences, cultural expectations, and spiritual beliefs - Normal (uncomplicated) - Complicated: exaggerated, delayed, mased - Anticipatory - Disenfranchised (aka marginal or unsupported)

Clinical Preventive Services

Guidelines for primary care providers to use in screening and counseling patients to prevent or reduce the risk of heart disease, cancer, and infectious disease

HIPPA

Health Insurance Portability and Accountability HIPAA, also known as Public Law 104-191, has two main purposes: to provide continuous health insurance coverage for workers who lose or change their job, and to reduce the administrative burdens and cost of healthcare by standardizing the electronic transmission of administrative and financial transactions. Other goals include combating abuse, fraud and waste in health insurance and healthcare delivery and improving access to long-term care services and health insurance

Emphasis on Population Wellness

Health Services Pyramid * Managing health instead of illness * Emphasis on wellness * Injury-prevention programs

General Assessment: Urinary Elimination

Health history * Client's pattern * Past urinary difficulties * Physical examination Diagnostic tests * Urinalysis * Culture Blood chemistry * WBC, BUN, Creatinine * Cystoscopy: direct visualization of the bladder * Urodynamic test: measure function * Imaging: used to evaluate urinary lesions

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? Value-belief pattern Cognitive-perceptual pattern Coping-stress-tolerance pattern

Health perception-health management pattern The nurse's assessment covers the health perception- health management pattern, which is a patient's self-report of how he or she manages his or her health and his or her knowledge of preventive health practices. The coping-stress tolerance pattern includes questions focused on how a patient manages stress and sources of support. An assessment covering the value belief pattern leads a patient to describe patterns of values, beliefs, and life goals. An assessment of the cognitive-perceptual pattern includes questions that focus on the patient's language adequacy, memory, and decision-making ability.

Quantitative vs Qualitative

In a nutshell,quantitative research generates numerical data or information that can be converted into numbers. Qualitative Research on the other hand generates non-numerical data.

Which of the following Internet resources available can assist consumers when comparing quality care measures? Select all that apply. WebMD Hospital Compare Magnet Recognition Program Hospital Consumer Assessment of Healthcare The American Hospital Association's webpage.

Hospital Compare Both of these are Internet sites that collect patient data to document hospitals' quality of care and patient satisfaction. WebMD is an Internet source that is disease/condition specific. The Magnet Recognition Program is a hospital-initiated recognition that assesses quality of nursing care and patient safety. Hospital Consumer Assessment of Healthcare Both of these are Internet sites that collect patient data to document hospitals' quality of care and patient satisfaction. WebMD is an Internet source that is disease/condition specific. The Magnet Recognition Program is a hospital-initiated recognition that assesses quality of nursing care and patient safety.

A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? Select all that apply. How is your diabetic diet affecting you and your family? You seem to not want to follow health guidelines. Can you explain why? What worries you the most about having diabetes? What do you expect from us when you do not take your insulin as instructed? What do you believe will help you control your blood sugar?

How is your diabetic diet affecting you and your family?, What worries you the most about having diabetes? What do you believe will help you control your blood sugar? Asking "How is your diabetic diet affecting you and your family?" "What worries you the most about having diabetes?" and "What do you believe will help you control your blood sugar?" are open-ended and allow the patient to share his values and health practices. The statements "You seem to not want to follow health guidelines. Can you explain why?" and "What do you expect from us when you do not take your insulin as instructed?" both show the nurse's bias.

Integumentary Changes with immobility

Risk for pressure ulcers due to pressure and changes in metabolism

A nursing student is preparing to read the methods section of a research article. What type of information will the student expect to find in this section? Select all that apply. How the researcher conducted the study A description about how to use the findings of the study The number and type of subjects who participated in the study Summaries of other research articles that support the need for this study Implications for future research studies

How the researcher conducted the study, The number and type of subjects who participated in the study The methods section explains how a research study was organized and conducted to answer the research question or test the hypothesis and how many subjects or people participated in the study.

Alterations in Respiratory Functioning

Hyperventilation * Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism Hypoventilation * Alveolar ventilation inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide Hypoxia * Inadequate tissue oxygenation at the cellular level Cyanosis * Blue discoloration of the skin and mucous membranes

Respiratory Failure

Hypoxic: Decrease PaO2 or O2 sat * Teachypnic (abnormally rapid breathing) * Cyanotic * Use of accessory muscles * Labored breathing Hypercapnic (hypercarbia): Increase CO2 * Lethargic (difficulty arousing) * Confused * Obtunded (non-communicative/responsive) * Bradypnic (breathing slowly)

Respiratory Changes Immobility

Immobile patients are at high risk for developing pulmonary complications Atelectasis * Lack of movement within lung Hypostatic pneumonia

A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort? Engage the patient in setting mutual outcomes for distance he is able to walk Confirm with the patient's health care provider about ambulation goals Have physical therapy assist with ambulation Refer to medical record regarding nature of patient's physical problem

IV fluid administration Administering IV fluids required a health care provider's order. The other three interventions are independent nursing activities.

Assessment: Research Process

Identify area of interest or clinical problem

Which of the following is the first step of the research process? []Analyze data []Identify problem []Conduct study []Use the findings

Identify problem

A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement? Identifying the clinical sign instead of an etiology Identifying a diagnosis on the basis of prejudicial judgment Identifying the diagnostic study rather than a problem caused by the diagnostic study Identifying the medical diagnosis instead of the patient's response to the diagnosis.

Identifying the medical diagnosis instead of the patient's response to the diagnosis. Intestinal colitis is a medical diagnosis. The related factor in a nursing diagnostic statement is always within the domain of nursing practice and a condition that responds to nursing interventions. Nursing interventions do not change a medical diagnosis.

Postoperative Surgical Phase

Immediate postoperative recovery (phase 1) * Arrival * Hand-off: OR to PACU (post-anesthesia care unit) * Systems assessment * Discharge and hand-off: PACU to Acute Care Recovery in ambulatory surgery (phase 2) * Post anesthesia recovery score for ambulatory patients (PARSAP) * Observation-VS q 15 minutes * Discharge * Postoperative convalescence

Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. Select all that apply. Impaired Skin Integrity related to physical immobility Fatigue related to heart disease Nausea related to gastric distention Need for improved Oral Mucosa Integrity related to inflamed mucosa Risk for Infection related to surgery

Impaired Skin Integrity related to physical immobility, Nausea related to gastric distention The related factors in diagnoses "Fatigue related to heart disease" and "Need for improved oral mucosa integrity related to inflamed mucosa" are incorrect. The related factor of a medical diagnosis (in Fatigue related to heart disease) cannot be corrected through nursing intervention. In "Need for improved oral mucosa integrity related to inflamed mucosa" there is no diagnosis, but instead a goal of care. "Risk for infection related to surgery" is incorrect; risk nursing diagnoses do not have defining characteristics or related factors because they have not occurred yet.

Skeletal effects

Impaired calcium absorption Joint abnormalities

A patient in the emergency department has developed wheezing and shortness of breath. The nurse gives the ordered medicated nebulizer treatment now and in 4 hours. Which standard of practice is performed? Planning Evaluation Assessment Implementation

Implementation Implementation is completing coordinating care and the prescribed plan of care.

Nurses in an acute care hospital are attending a unit based education program to learn how to use a new pressure-relieving device for patients at risk for pressure ulcers. This is which type of education? Continuing education Graduate education In-service education Professional Registered Nurse Education

In-service education In-service education programs are instruction or training provided by a health care agency or institution. An in-service program is held in the institution and is designed to increase the knowledge, skills, and competencies of nurses and other health care professionals employed by the institution.

Urinary elimination effects of immobility

Increased risk for urinary stasis and renal calculi (kidney stones).

Infectious Process

Incubation period -> Prodromal stage -> Illness stage -> Convalescence - Localized versus systemic infection

Types of Care Plans

Individualized care plans * A care plan written specifically for each client Standardized care plans * A care plan written for a specific problem/nursing diagnosis which can be duplicated and individualized Computerized care plans * Created by a computer program * Easy to update and individualize Case management plans * Coordinated care Clinical pathways (Care or Concept maps) * A standardized multidisciplinary care plan that projects the expected course of the client's treatment and progress over their hospital stay

A critical care nurse is using a computerized decision support system to correctly position her ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? Patient-centered care Safety Teamwork and collaboration Informatics

Informatics Using decision support systems is one example of using informatics and gaining competency in informatics.

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient? Knowing the source of the guideline Reviewing the evidence used to develop the guideline Individualizing how to apply the clinical guideline for a patient Explaining to a patient the purpose of the guideline

Individualizing how to apply the clinical guideline for a patient Individualizing patient care is still the important principle for implementing care, even when a clinical guideline is used. Explaining any interventions in a guideline to the patient is important but not the most critical factor in implementing care. Reviewing the source of the guideline and applicable evidence do not directly benefit a patient.

Risk at Developmental Stages

Infant, toddler, and preschooler * Ingestion? * School-age child Adolescent * Car accidents * Adult Older adult * Falls?

Every health are organization gathers data on health outcomes. Examples of key quality-of-care or performance indicator include. []Discharges []Medications administered []Healthy births []Infection rates

Infection rates

The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? Select all that apply. Initial patient measurement is made around the calves Inflation pressure averages 40 mm Hg Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve. Stockings are removed every 2 hours during application. Yellow light indicates SCD device is functioning.

Inflation pressure averages 40 mm Hg, Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve, The most effective way to prevent deep vein thrombosis is through an aggressive program of prophylaxis. A properly functioning SCD inflates with a pressure around 40 mm Hg. Inflation pressure averages 40 mm Hg, and the patient's leg should be placed in the SCD sleeve with the back of knee aligned with the popliteal opening on the sleeve. Measurement involves length of leg, not calf. A green light indicates the SCD device is functioning.

Oropharyngeal Airway

Insertion procedure * Place in correct position once past the tongue with the flange flush with the teeth

Sleep Disorders

Insomnia * adjustment sleep disorder (acute insomnia) Inadequate sleep Sleep apnea * primary central sleep apnea, central sleep apnea caused by medical condition, obstructive sleep apnea syndromes, excessive daytime sleepiness Narcolepsy * cataplexy, sleep paralysis Sleep deprivation * emotional stress, medications, environmental disturbances, symptoms Parasomnias * somnambulism (sleepwalking), Night terrors, nightmares, nocturnal enuresis (bed-wetting), body rocking, Bruxism

A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error? Insufficient cluster of cues Disorganization Insufficient number of cues Evidence that another diagnosis is more likely

Insufficient number of cues It is likely the charge nurse suspects that the student has not collected enough cues to support the diagnosis. A change in blood pressure and mental status changes are significant findings that can be attributed to fluid volume excess and other diagnoses. The recommendation of the symptom cluster by the registered nurse would allow the student to have sufficient data to confirm a deficient fluid volume.

Stage 1 Pressure Ulcer

Intact skin with non-blanching redness

A researcher is studying the effectiveness of an individualized evidence-based teaching plan on young women's intention to wear sunscreen to prevent skin cancer. In this study, which of the following research terms best describes the individualized evidence-based teaching plan? Sample Intervention Survey Results

Intervention An intervention is an action or treatment performed by a researcher on a sample.

GI changes with immobility

Risk of constipation from decreased peristalsis and hypercalcemia. Can become a partial or complete bowel obstruction.

An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? Loss of appetite Gum soreness Difficulty swallowing Left-ankle joint stiffness

Left-ankle joint stiffness Patients whose mobility is restricted require range-of-motion (ROM) exercises daily to reduce the hazards of immobility. Temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. Two weeks of joint immobilization without ROM can quickly result in contractures.

Factors Affecting Urinary Elimination

Lifestyle factors * Nutrition and fluids (sodium encourages retention) * Diuresis: increased formation and excretion of urine * Drinks with caffeine (coffee, tea, some carbonated drinks) * Alcoholic beverages (especially beer) * Psychosocial * Activity and exercise Developmental factors * Childhood * Adolescents and young adults * Middle and older adults Physiological factors * Cognitive impairment * Neuromuscular disease * Impaired mobility

Factors Affecting Bowel Elimination

Lifestyle factors * Personal habits * Nutrition and fluids * Exercise * Positioning Cultural factors * May affect patient's likelihood to share abnormalities * Need for privacy Developmental factors * Infant: no control * Adolescent: growth and eating habits * Older adult: vulnerable to GI disturbances Psychosocial factors * Depression, anxiety, stress

The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? Select all that apply. Listen attentively to the patient's story. Use gestures that reinforce your questions or comments. Stand back away from the bedside. Maintain direct eye contact. Ask questions quickly to reduce the patient's fatigue.

Listen attentively to the patient's story, Use gestures that reinforce your questions or comments, Maintain direct eye contact. Ask questions quickly to reduce the patient's fatigue. Approaches for collecting an older-adult assessment include listening patiently, using nonverbal communication when a patient has a hearing deficit, and maintaining patientdirected eye gaze. Leaning forward, not backward, shows interest in what the patient has to say.

Musculoskeletal changes Immobility

Loss of endurance and muscle mass and decreased stability and balance * Balance is off, new susceptible to falls, hip fractures

Muscle effects

Loss of muscle mass Muscle atrophy * Important to do ROM every shift

Musculoskeletal changes-ROM-passive and active-contracture with immobility

Loss of strength and endurance, decreased muscle mass and decreased balance. Joint contractures such as foot drop is common, and disuse osteoporosis with risk of pathological fractures. ROM passive means you move the joint for the patient, active means they move the joint themselves

Wet Wound

Maceration - white boggy tissues More absorptive dressing Increase dressing frequency

Acute Postop Care: Implementation

Maintaining Respiratory Function: Patency, rate, rhythm, symmetry, breath sounds, color of mucus membranes Preventing Circulatory Complications: Heart rate, rhythm, BP, capillary refill, nail beds, peripheral pulses Achieving Rest and Comfort: Enhance the efficacy of pain control, minimize side effects of each modality Temperature Regulation: Malignant hyperthermia Maintaining Neurological Function: LOC, gag and pupil reflexes Maintaining Fluid and Electrolyte Balance: IV, I&O, compare baseline lab values Promoting Normal Bowel Elimination and Adequate Nutrition: Anesthesia slows motility Promoting Wound Healing: Check skin for rashes, petechiae, abrasions, or burns; wound for drainage Maintaining/Enhancing Self-Concept - Observe patients for behaviors reflecting alteration in self-concept

A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? Select all that apply. Providing mouth care every 4 hours Maintaining intravenous (IV) infusion at 100 mL/hr Administering prochlorperazine (Compazine) via rectal suppository Consulting with dietitian on initial foods to offer patient Controlling aversive odors or unpleasant visual stimulation that triggers nausea

Maintaining intravenous (IV) infusion at 100 mL/hr Consulting with dietitian on initial foods to offer patient Providing mouth care every 4 hours and controlling aversive odors or unpleasant visual stimuli that triggers nausea are both independent nursing interventions. Administering prochlorperazine via suppository is a dependent intervention.

Implementation: Health Promotion: Pain Management

Maintaining wellness * Help patient understand * Health literacy * Patients actively participate in their own well-being whenever possible Nonpharmacological pain-relief interventions * Cognitive and behavioral approach * Relaxation and guided imagery * Distraction * Music * Cutaneous stimulation - numbing cream * Cold and heat application * Transcutaneous electrical nerve stimulator (TENS) * Herbals * Reducing pain perception and reception Acute care: pharmacological pain therapies * Analgesics * Nonopiods - example: Tylenol, Aspirin, NSAIDS: Ibuprofen, Motrin * Opioids - example: Fentanyl, Morphine, Hydrocodone * Adjuvants/co-analgesics - mid together

A nurse is conferring with another nurse about the care of a patient with a stage II pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcer management. The use of a standardized guideline achieves which of the following? Select all that apply. Makes it quicker and easier for nurses to intervene Sets a level of clinical excellence for practice Eliminates need to create an individualized care plan for the patient Delivers evidence-based interventions for stage II pressure ulcer Summarizes the various approaches used for the practice concern or problem

Makes it quicker and easier for nurses to intervene, Sets a level of clinical excellence for practice, Delivers evidence-based interventions for stage II pressure ulcer Even though a standardized clinical practice guideline offers evidence-based solutions for clinical excellence that nurses can quickly and easily apply in practice, a nurse remains accountable for individualizing even standardized interventions when necessary. A guideline is not a summary of various approaches used by clinicians for a practice issue; it is a summary of the most relevant evidence-based information.

Impact of Abbreviations on Patient Safety

Many patients have difficulty understanding documents that they are given * Discharge information, consent forms, etc. * Affects their ability to care for themselves when they return home Difficulty understanding documents potentially increases when abbreviations are used * Example: take medication ac * How is he patient going to know what ac means? * Before meals KCO has banned use of medical abbreviations from all documents that patients and families receive from healthcare institutions

What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey? Measures a nurse's competency in interdisciplinary care Measures the number of adverse events in a hospital Measures quality of care within hospitals Measures referrals to a health care agency

Measures quality of care within hospitals HCAHPS is a survey that has become a standard for measuring and comparing quality of hospitals. It is a survey of patient perceptions.

Assessment: Medication Administration

Medical history * Allergies * Medications * Diet history * Patient adherence to therapy * Patient's perceptual or coordination problems * Patient's current condition * Patient's attitude about medication use * Patient's understanding of and adherence to medication therapy * Patient's learning needs

Prescriptions

Medication to be take outside of the hospital

Restorative and Continuing Care

Medications * Beta-blockers, ace inhibitors, diuretics, electrolyte replacement * Cardiopulmonary rehabilitation * Hydration * Coughing techniques * Purse Lipped-Breathing * Diaphragmatic breathing

Meditation and Breathing

Meditation * Any activity that limits stimulus input by directing attention to a single unchanging or repetitive stimulus, person becomes more aware of self Clinical application * Lowers oxygen consumption, reduces respiratory and heart rates, and reduces anxiety, lowers BP Limitations * May becomes hypertensive * May enhance effects of certain drugs

Candidates for Cath Lab

Men: * < 40 years of age: 2.5 mm in V2-V3 and 1mm in all other leads * > 40 years of age: 2 mm in V2-V3 and 1 mm in all other leads Women: * 1.5 mm in V2-V3 and 1 mm in all other leads Patients with: * Ischemia (an inadequate supply of blood to and organ or part of the body) * Example - The Heart not getting enough blood * nSTEMI Victims (Non-ST-elevation myocardial infarction) * Example - Heart Attack

Implementation: Acute Care Immobility

Metabolic * Provide high-protein, high-calorie diet with vitamin B and C supplements Respiratory * Cough and deep breath every 1 to 2 hours * Hold stomach and do a deep breath in and out * Take a deep breath in then cough hard - Provide chest physiotherapy

What are some of the interventions used to prevent and treat delirium?

Minimize risk factors - Make sure patients get high-quality sleep - Minimize environmental noise - Avoid physical restraints - Remove hazardous objects from room - Assess fall risk - Determine if they're at risk for wandering or suicide

A Critical Thinking Model for Clinical Decision Making

Model components: * Scientific knowledge base * Experience * Nursing process competency * Attitudes for critical thinking * Professional standards

A problem-oriented approachA nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor? Infant crying at breast Infant unable to latch on to breast correctly Mother's deficient knowledge Lack of infant weight gain

Mother's deficient knowledge In this scenario the related factor is the mother's deficient knowledge. A related factor is a condition, historical factor, or etiology that gives a context for the defining characteristics, in this case the infant crying, inability to latch on to breast, and absent weight gain.

Scientific Knowledge Base: GI System

Mouth * Digestion begins with mastication Esophagus * Peristalsis moves food into the stomach Stomach * Stores food; mixes food,liquid, and digestive juices; moves food into small intestines Small intestine * Duodenum, jejunum, and ileum Large intestine * The primary organ of bowel elimination Anus * Expels feces and flatus from the rectum

Health care reform will bring changes in the emphasis of care. Which of the following models is expected from health care reform? Moving from an acute illness to a health promotion, illness prevention model Moving from illness prevention to a health promotion model Moving from an acute illness to a disease management model Moving from a chronic care to an illness prevention model

Moving from an acute illness to a health promotion, illness prevention model Health care reform also affects how health care is delivered. There is greater emphasis on health promotion, disease prevention, and management of illness.

Musculoskeletal Changes Immobility

Muscle effects * Lean body mass loss * Muscle weakness/atrophy Skeletal effects * Disuse osteoporosis - Scandinavian decent, petite, at high risk for osteoporosis * Joint contracture

Cardiovascular Physiology

Myocardial pump * Two atria and ventricles * A healthy heart stretches in proportion to the strength of contraction (Starling's Law) Myocardial blood flow * Unidirectional through four valves * S1: mitral and tricuspid close * S2: aortic and pulmonic close Coronary artery circulation * Coronary arteries supply the myocardium with nutrients and removes wastes Systematic circulation * Arteries and veins deliver nutrients and oxygen and remove waste products

NANDA

NANDA International (NANDA-I) is the organization officially sanctioned by the ANA as the body responsible for developing a system of naming and classifying nursing diagnoses

ECG: Electrocardiogram

NSR (normal sinus rhythm) * SA node * AV node * Bundle of His * Right and left bundle branches * Purkinje fibers (dont needa memorize these) * Rate = 60-100 except heart rate, duh * PR 0.12-0.20 (atrial contraction) * QRS 0.06-0.12 (Ventricular contraction) * QT 0.12-0.43 (V de and repolarization) Alterations caused by: electrolytes imbalances (Hypokalemia/hyperkalemia), ischemia, DIB * Assess your patient * Determine if they are symptomatic

Ostomy

Names for their location * Ileostomy * Colostomy Types * Loop: transverse colon brought through the abdomen, supporting device used, sutures to abdomen, proximal end drains stool/distal end drains mucus, usually temporary * End Colostomy: proximal end of the bowel forms stoma, distal portion of GI tract removed or sewn closed * Double Barrel Colostomy: intestine divided and proximal and distal ends brought through abdomen. Proximal end has a small incision that drains stool.

Methods of Documentation

Narrative * The traditional method Problem-oriented medical record (POMR) * Database * Problem list * Care plan * Progress notes

Scientific Knowledge Base: Infection Prevention and Control

Nature of infection * Infection: the invasion of a susceptible host by pathogens or microorganisms; results in disease * Colonization: presence and growth of microorganisms within a host without tissue invasion or damage * Communicable disease: the infectious process transmitted from one person to another * Symptomatic: clinical signs of symptoms are present. * Asymptomatic: clinical signs and symptoms are not present

Nursing Diagnosis and Planning: Care of Surgical Patients

Nausea * Ineffective airway clearance * Deficient knowledge (specify) * Impaired physical mobility Anxiety * Delayed surgical recovery * Risk for infection * Risk for perioperative positioning injury Fear * Risk for deficient fluid volume * Acute pain * Risk for perioperative positioning injury

What do we do when we evaluate a care plan and the goal has not been accomplished?

Need to evaluate and make a new plan of care

Afib

No P-Wave! Atria is contracting all the way, just fluttering Cardiac output is lowered Can lead to stroke because blood is pooling in atria, can cause a clot, the clot moves to the brain

Jehovah's Witness

No blood products should be used Believe that blood houses the soul They can receive organ donations but all blood must be drained from them In an emergency situation if they do not have a bracelet saying no blood then give them blood Doesn't apply to children

Should you reorient dementia patients? Why or why not?

No, it's cruel and reminders don't work.

Defenses Against Infection

Normal flora * Microorganisms * Maintain a sensitive balance with other microorganisms to prevent infection. Any factor that disrupts this balance places a person at increased risk for acquiring a disease. Body system defenses * Organs Inflammation * Signs of local inflammation and infection are identical. * Vascular and cellular responses * Exudates (serous, sanguineous, or purulent) * Tissue repair * Serous - clear * Sanguineous - watery, bloody * Purulent - thick green yellow, pus

NS

Normal saline

Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? Select all that apply. Numbered order of diagnosis on the basis of severity Notion of urgency for nursing action Symptom pattern recognition suggesting a problem Mutually agreed on priorities set with patient Time when a specific diagnosis was identified

Notion of urgency for nursing action, Symptom pattern recognition suggesting a problem, Mutually agreed on priorities set with patient These three factors are considered in setting priorities for a patient's nursing diagnoses or collaborative problems. The other options are inappropriate because a numbering system and time of identification hold little meaning when a patient's condition changes.

Patricia Benner

Novice to Expert - Nurse can gain knowledge and skills without actually learning a theory - Nursing knowledge is made up of the extension of knowledge through research and understanding through clinical experience 5 Levels of Nursing Knowledge - Novice - Advanced beginner - Competent - Proficient - Expert

Community-Based and Institutional Health Care Services

Nurses encounter older-adult patients in a wide variety of community and institutional health care settings: * Private homes, apartments, retirement communities, adult day care centers, assisted-living facilities, and nursing centers Older adults need to help with decisions regarding which type of health care service is appropriate for them

Historical Influences

Nurses: * Respond to needs of patients * Actively participate in policy Knowledge of the history of the nursing profession increases your ability to understand the social and intellectual origins of the discipline.

Orthostatic Hypotension

Occurs after prolonged sitting or patients on bedrest due to blood pooling in the extremities; a SBP drop of 20mmHg or more a DPB drop of 10mmHg or more when a patient stands.

Inappropriate use or disclosure: HIPPA

Occurs when it is provided to a - Person not involved in the patient's treatment - Person who do not require the information to perform their treatment - Situations where disclosure is not in the best interest of the patient -Faxing data to incorrect party - Mailing information to the wrong recipient - Nurse discussing details of a patients information about patients, including patients assignment sheets, diagnostic reports and billing information should be shredded

Placebos

Only given with research

Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care? Probing Open-ended Problem-oriented Confirmation

Open-ended The best interview question for initially determining why a patient is seeking health care is by asking an open-ended question that allows the patient to tell his or her story. This is also a more patient-centered approach. Probing questions are asked after data are gathered to seek more in-depth information. Problem-oriented and confirmation are not types of interview questions.

Artificial Airways

Oral airway * Prevents obstruction of the trachea by displacement of the tongue into the oropharynx Endotracheal airway * Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions Tracheostomy * Long-term assistance, surgical incision made into trachea

Suctioning

Oropharyngeal and nasopharyngeal * Used when the client can cough effectively but is not able to clear secretions Orotracheal and nasotracheal * Used when the client is unable to manage secretions Tracheal * Used with an artificial airway * Ask patient to cough in order to get tube down

Cardiovascular Immobility

Orthostatic hypotension * Let them sit for about 5 minutes with legs flat on the floor * Feels like all the blood left their head, BP falls, feel faint Thrombus * Bloot clot

Idiosyncratic reaction

Over-reaction or under-reaction or different reaction from normal

Maintenance and Promotion of Oxygenation

Oxygenation therapy * To prevent or relieve hypoxia Methods of supply * Nasal cannula * Oxygen mask (several types) * ET tube

PICOT

P: Population/patient - age, gender, ethnicity, individuals with a certain disorder I: Intervention/indicator (Variable of Interest) - exposure to a disease, risk behavior, prognostic factor C: Comparison/control - could be a placebo or "business as usual" as in no disease, absence of risk factor, Prognostic factor B O: Outcome - risk of disease, accuracy of a diagnosis, rate of occurrence of adverse outcome T: Time - the time it takes for the intervention to achieve an outcome or how long participants are observed

A patient has just undergone an appendectomy. When discussing with the patient several pain-relief interventions, the most appropriate recommendation would be: []adjunctive therapy []nonopiods []NSAIDs []PCA pain management

PCA pain management

Serosanguineous

Pale, red, watery: mixture of serous and sanguineous

WHO Analgesic Ladder

Pain 1. - nonopioid +/- Adjuvant Pain persisting or increasing 2. - Opioid for mild to moderate pain +/- Nonopioid +/- Adjuvant Pain persisting or increasing 3. - Opioid for mild to moderate pain +/- Nonopioid +/- Adjuvant Freedom from cancer pain

Restorative and Continuing Care: Pain Management

Pain clinics, palliative care, and hospices * Pain centers treat patient on an inpatient or outpatient basis * The goal of palliative care is to learn how to live life fully with an incurable condition - living with chronic illnesses (COPD, Cancer, CHF) * Hospices are programs for end-of-life care * The American Nurses Association (ANA) supports aggressive treatment of pain and suffering, even if it hastens a patient's death.

Stage 2 Pressure Ulcer

Partial thickness, does not extend through dermis

A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient's bed and adjusts the room lighting to illuminate the work area. A patient care technician comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit? Environment Personnel Equipment Patient

Patient In preparing to administer the enema, the nurse did not prepare for the patient's physical and psychological comfort.

Federal Statutory Issues in Nursing Practice

Patient Protection and Affordable Care Act (PPACA) * Consumer rights and protections * Affordable health care coverage * Increased access to care * Stronger Medicare to improve care for those most vulnerable in our society Americans with Disabilities Act (ADA) * Protects rights of people with physical or mental disabilities Emergency Medical Treatment and Active Labor Act * When a patient presents to an emergency department, they must be treated Mental Health Parity Act as Enacted Under PPACA * Strengthens mental health services Advance directives * Living wills * Health care proxies or durable power of attorney for health care * Uniform Anatomical Gift Act * Health Insurance Portability and Accountability Act (HIPPA) * Health Information Technology Act (HITECH) * Restraints

The nurse writes an expected outcome statement in measurable terms. An example is: Patient will have normal stool evacuation. Patient will have fewer bowel movements. Patient will take stool softener every 4 hours. Patient will report stool soft and formed with each defecation.

Patient will report stool soft and formed with each defecation. Stool that is soft and formed at each defecation is measurable upon observation. "Patient will have normal stool evacuation" is a goal. Indicating that the patient will have fewer bowel movements is not specific enough for measuring improvement, and having a patient take a stool softener every 4 hours is an intervention.

A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: Patient's level of function. Patient's willingness to perform self-care. Patient's level of consciousness. Patient's health management values.

Patient's level of function. Observing a patient perform activities physical, socially, psychologically, and developmentally assesses his or her level of function. In the case of this question the nurse assesses physical functional level. Observation does not measure willingness to perform self-care but the ability to do so. Observing physical performance of self-hygiene is not a measure of level of consciousness nor does it reveal a patient's values.

Medication Administration

Pharmacist's role * Prepares and distributes medication Distribution systems (unit dose or automatic medication dispensing system [AMDS]) * Area for stocking and dispensing medication Nurse's role * Assess patient's ability to self-adminster, determine whether patient should receive, administer medication correctly, and closely monitor effects; do not delegate this task. Medication error

Adverse effect

Unintended, undesirable, often unpredictable. They have not been exposed to medication previously. Starts with tingling around lips, anxiety, throat closes up.

The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? Physical care technique Activity of daily living Indirect care measure Lifesaving measure

Physical care technique Administering a tube feeding is an example of a physical care, a direct care technique.

Physical Illness

Physical illness can cause pain, physical discomfort, anxiety, depression, and sleep disturbances: * Hypertension * Respiratory disorders * Nocturia * Restless leg syndrome (RLS) * American Academy of Sleep Medicine Classification of Sleep Disorders

Intraoperative Implementation

Physical preparation * Monitoring * Graded compression stockings * Latex sensitivity/allergy * Introduction of anesthesia * Positioning the patient for surgery * Documentation of intraoperative care

Acute Care: Surgical Patients

Physical preparation * Maintaining normal fluid and electrolyte balance * Reducing risk of surgical site infection * Preventing bladder and bowel incontinence * Promoting rest and comfort Preparation on day of surgery * Hygiene * hair and cosmetics * Removal of prostheses * Safeguarding valuables * Preparing the bowel and bladder * Vital signs * Documentation * Other procedures * Administering preoperative medications * Eliminating wrong site and wrong procedure surgery

Signs and Symptoms of Elder Abuse

Physical: Bruises, dehydration, malnutrition, over or under medicated (not giving Lasix so will not urinate, or giving meds to "snow" the patient, Haldol for problem behaviors), skin tears, tenderness Psychological: Withdrawn, fearful, flinching, family not allowing you to communicate directly to patient and not will to leave you alone with the patient

Adults

Physiological systems are at risk Changes in family and social structures

Planning, Intervening, and Evaluation

Planning phase * Planning is essential for determining and providing optimal nursing care * Expected goals/outcomes are identified in this phase. Goals/outcomes should be specific, measurable, and realistic - Bowel movement within 24 hours is a realistic outcome * Nursing interventions are treatment initiated by nurses, physicians, or other health care providers that are necessary to meet the expected goals/outcomes of each problem/nursing diagnosis * The nurse must decide the priorities of nursing diagnoses (ranked in the order of importance)

A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? Select all that apply. Policy for conducting hourly rounds Staffing level Interruption by staff nurse colleague RN's years of experience Competency of patient care technician

Policy for conducting hourly rounds, Staffing level, Interruption by staff nurse colleague Many factors within the health care environment affect your ability to set priorities, including model for delivering care, the workflow routine and staffing levels of a nursing unit, and interruptions from other care providers. Available resources (e.g., policies and procedures) also affect priority setting. The nurse's years of experience and the competency of the patient care technician are not part of the environment.

Urinary Elimination Changes Immobility

Urinary stasis * Sets them up for UTI * Renal calculi * Infection

Opioid Overdose Basics

Prescription opioids (like hydrocodone, oxycodone, and morphine) and illicit opioids (like heroin and illegally made fentanyl) have a potentially fatal risk of overdose. - Combining opioids with alcohol or certain other drugs - Taking high daily dosages of prescription opioids - Taking more opioids than prescribed - Taking illicit or illegal opioids, like heroin or illicitly - manufactured fentanyl, that could possibly contain unknown harmful substances. - Certain medical conditions, such as sleep apnea, or reduced kidney or liver function - Age greater than 65 years old

Integumentary

Pressure ulcer Ischemia * Lack of blood flow to an area

A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken: Myoclonus Pathological fractures Pressure ulcers Pruritus

Pressure ulcers Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore preventive nursing interventions are imperative.

Integumentary Changes Immobility

Pressure ulcers * Bony prominences are at risk, Occipital, hips, heels, elbows, spine, anywhere a tube is touching skin * Inflammation Ischemia * Loss of blood flow to the area * Older adults at greater risk

Musculoskeletal System: Nursing Care Immobility

Prevent muscle atrophy and joint contractures * positioning correctly with pillows & ROM

Preventative and Primary Health Care

Preventative Care * Reduces and controls risk factors for disease Primary care * Focuses on improved health outcomes * Requires collaboration Health promotion programs lower overall costs * Biggest in America: SMOKING! * Reduced incidence of disease * Minimizes complications * Reduces the need for more expensive resources

Pressure Ulcers Prevention

Prevention and Treatment * Key nursing responsibility Prevention * 24hr turning schedule * 2hr turning in bed * 15 min pressure release in wheelchair * Specialty air mattress and seat cushions * Incontinence mangement * Repetitive use of soap and water causes skin breakdown * Use special wipes and cleaning agents * Nutrition and hydration * Skin assessment Treatment - Same as prevention + wound care

Health Care Settings and Services -> Order of Pyramid

Preventive -> Primary -> Secondary -> Tertiary -> Restorative -> Continuing

The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n): Risk nursing diagnosis. Problem-focused nursing diagnosis. Health promotion nursing diagnosis. Wellness nursing diagnosis.

Problem-focused nursing diagnosis. This is an example of a problem-focused nursing diagnosis with a related factor, based on NANDA-I diagnostic terminology. Most health promotion diagnoses do not have established related factors based on NANDA-I; their use is optional. Wellness diagnoses are not one of the types of NANDA-I diagnoses.

Nurses in a community clinic have seen an increase in the numbers of obese children. The nurses who care for children are discussing ways to reduce childhood obesity. One nurse asks a colleague, "I wonder what the most effective ways are to help school-aged children maintain a healthy weight?" This question is an example of a/an: Hypothesis. PICOT question. Problem-focused trigger. Knowledge-focused trigger.

Problem-focused trigger. A problem-focused trigger is a clinical problem you face while caring for patients; the nurses in this question have identified a clinical problem that they want to investigate further.

Additional Functions of the Kidneys

Production of erythropoietin is a hormone essential to maintaining a normal red blood cell (RBC) volume. * Patients with kidney disease are prone to anemia * Production of Renin - angiotensin mechanism * Renin starts a chain of events that cause water retention, thereby increasing blood volume = increased BP * Kidneys affect calcium and phosphate regulation by producing a substance that converts vitamin D to it's active form.

Risk for DVT/Thrombosis-SCD's and TED's with immobility

Prolonged immobility can lead to pooling in the legs. Sequential Compression Device (SCD)'s and TED's (Thrombo-Embolic-Deterrent) are used to prevent clots.

Infants, Toddlers, Preschoolers

Prolonged immobility delays gross motor skills, intellectual development, or musculoskeletal development

Continuing Care: Nursing Centers or Facilities

Provide 24-hour intermediate and custodial care * Nursing, rehabilitation, diet, social, recreational, and religious services * Residents of any age with chronic or debilitating illness * Regulated by standards: Omnibus Budget Reconciliation Act of 1987 * Interdisciplinary functional assessment is the focus of clinical practice: MDS, RAIs

The examination for registered nurse (RN) licensure is exactly the same in every state in the United States. This examination: Guarantees safe nursing care for all patients Ensures standard nursing care for all patients Ensures that honest and ethical care is provided Provides a minimal standard of knowledge for an RN in practice

Provides a minimal standard of knowledge for an RN in practice RN candidates must pass the NCLEX-RN® to attain licensure. Regardless of educational preparation, the examination for RN licensure is exactly the same in every state in the United States.

Nurse anesthetist

Provides care and services under the supervision of an anesthesiologist

Nurse practitioner

Provides comprehensive care, usually in a primary care setting, directly managing the medical care of patients who are healthy or who have chronic conditions.

Nurse-midwife

Provides independent care including pregnancy and gynecological services

Suspected deep tissue injury

Purple or maroon areas of intact skin or blood-filled blisters caused by damage to the underlying soft tissues

Functions of Sleep

Purpose of sleep * Remains unclear * Physiological and psychological restoration * Maintenance of biological functions Dreams * Occur in NREM and REM sleep * Important for learning, memory, and adaptation to stress

Which of the following are warning signs of a MRSA infection? []Burning/tingling []Pus/Fluid []Bruising []Warmness []Skin lesions

Pus/Fluid Warmness Skin lesions

QI

Quality Improvement

Quality and Performance Improvement

Quality data * Quality improvement (QI) * Performance improvement (PI) * Quality improvement programs Models * Patient Self-Determination Act (PSDA) * Six Sigma or Lean * Rapid-cycle improvement or rapid-improvement event (RIE)

The nurses on a medical unit have seen an increase in the number of medication errors on their unit. They decide to evaluate the medication administration process based on data gained from chart reviews and direct observation of nurses administering medications. Which process are the nurses using? Evidence-based practice. Research. Quality improvement. Problem identification.

Quality improvement. Quality improvement studies evaluate how processes work in an organization. The nurses in this example are evaluating the medication administration process.

A nurse in a community health clinic has been caring for a young teenager with asthma for several months. The nurse's goal of care for this patient is to achieve self-management of asthma medications. Identify appropriate evaluative indicators for self-management for this patient. Select all that apply. Quality of life Patient satisfaction Use of clinic services Adherence to use of inhaler Description of side effects of medications

Quality of life, Use of clinic services, Adherence to use of inhaler Relevant and appropriate evaluative indicators of self-management include self-efficacy, health behavior or attitude, health status, health service use, quality of life, and psychological indicators. In this case the patient's quality of life, use of clinic services, and adherence (behavior) to use of an inhaler are all appropriate. Patient satisfaction is a perception and not an indicator of self-management. Ability to describe medication side effects is a measure of knowledge but does not necessarily equate with successful self-management.

Evaluation: Loss, grief, bereavement

Questiona to help validate achievement of patient foals and expectations - What is the most important thing I can do for you at this time? - Are your needs being addressed in a timely manner? - Are you getting the care for which you hoped? - Would you like me to help you in a different way? - Do you have a specific request that I have not met?

Additional Grief Theories

Rando's "R" Process Model: grief as a series of processes instead of stages or tasks - Recognizing the loss, reacting to the pain of separation, reminiscing, relinquishing old attachments, and readjusting to life after loss - Reminiscence is an important activity in grief and mourning - Dual process model: moving back and forth between loss-oriented and restoration-oriented activities - Post modern grief theories

The nurse is working with an older adult after an acute hospitalization. The goal is to help this person be more in touch with time, place, and person. Which intervention will likely be most effective? Reminiscence Validation therapy Reality orientation Body image interventions

Reality orientation Reality orientation is a communication technique that can help restore a sense of reality, improve level of awareness, promote socialization, elevate independent functioning, and minimize confusion.

Cardiovascular Nursing Care Immobility

Reducing orthostatic hypotension * Sit upright for 5 minutes, make sure they aren't dizzy/lightheaded * Reducing cardiac workload * Preventing thrombus formation * SCDs, thromboembolic disease (TED), hose, and leg exercises (tell patients when they're in bed ROM ankles, tighten thigh/calve muscles then let them go), ambulation (get them up and moving)

After caring for a young man newly diagnosed with diabetes, a nurse is reviewing what was completed in his plan of care following discharge. She considers how she related to the patient and whether she selected interventions best suited to his educational level. It was the nurse's first time caring for a new patient with diabetes. The nurse's behavior is an example of which of the following? Reflection-in-action Reassessment Reprioritizing Reflection-on-action

Reflection-on-action The nurse is performing reflection-on-action. This means that when you gather evaluative measures about a patient, reflection on the findings and the exploration about what the findings might mean improve your ability to problem solve. The other three measures occur during evaluation because the nurse is still actively intervening in the patient's care.

Developing Critical Thinking Skills

Reflective journaling * Define and express clinical experiences in your own words Meeting with colleagues * Discuss and examine work experiences and validate decisions Concept mapping * Visual representation of patient problems and interventions that shows their relationships to one another

Nervous System

Regulates movement and posture * Ex; stroke, quadriplegia

Nursing and the Scientific Approach

Research allows you to study nursing questions and problems in greater depth within the context of nursing - Quantitative * Experimental research * Nonexperiemtnal research * Surveys * Evaluation research - Qualitative * Ethnography * Phenomenology * Grounded theory

Afterload

Resistance to left ventricular ejection - so medications that dilate blood vessels will decrease the afterload and vice versa - leaves the aorta

An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? Select all that apply. B/P = 128/84 Respirations 26/min on room air HR 114 Crackles over lower lobes heard on auscultation Pain reported as 3 on scale of 0 to 10 after medication

Respirations 26/min on room air, HR 114, Crackles over lower lobes heard on auscultation Patients who are immobile are at high risk for developing pulmonary complications. The most common respiratory complications are atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions). Ultimately the distribution of mucus in the bronchi increases, particularly when the patient is in the supine, prone, or lateral position. HR 114

Prediction and prevention of pressure ulcers

Risk assessment - anyone can get * Braden scale * Impaired sensory perception * Impaired mobility - Bed and wheel chair bound patients, casts/splints * Incontinence * Alteration in LOC * Shear/Friction * Moisture Prevention * Prevention is much easier than healing * ICU and long-term care facilities Surgical patients * Economic consequences of pressure ulcers (KNOW THIS!!!) * Medicare and Medicaid: no additional reimbursement for car related to stage III and stage IV pressure ulcer

Sleep and Rest

Rest contributes to: * Mental relaxation * Freedom from anxiety * State of mental, physical, and spiritual activity Bed rest does not guarantee that a patient will feel rested

Heart Failure

Right sided * Blood backs up in peripheral vasculature * Weight gain * Hepatomegaly * Splenomegaly * Peripheral edema * Distended neck veins (JVD) Left sided * Blood backs up in lungs * Crackles * Hypoxia * SOB * Cough * Paroxysmal nocturnal dyspnea

Screening for Colon Cancer

Risk factors * Age > 50 years * Family history of polyps or colorectal cancer * History of inflammatory bowel disease * Living in an urban area * High-fat, low-fiber diet Warning signs * Change in bowel habits * Rectal bleeding Screening tests * Digital rectal examination * Guaiac test for occult blood * Colonoscopy

Methods of Documentation: Progress Notes

SOAP * Subjective, objective, assessment, plan SOAPIE * Subjective, objective, assessment, plan, intervention, evaluation PIE * Problem, intervention, evaluation Focus charting (DAR) * Data, action, response

Cardiac output =

SV x HR

Assessment: Dietary Needs

Screening a patient is quick method of identifying malnutrition or risk of malnutrition using sample tools: * Height * Weight * Weight change * Primary diagnosis * Comorbidites * Screening tools Anthropometry is a measure system of the size and makeup of the body * An ideal body weight (IBW) provides an estimate of what a person should weigh * Body mass index (BMI) measures weight corrected for height and serves as an alternative to traditional height-weight relationships Laboratory and biochemical tests * Fluid balance, liver/kidney function, albumin, iron, hemoglobin Dietary and health history * Health status; age; cultural background; religious food patterns; socioeconomic status; personal food preferences; psychological factors; use of alcohol or illegal drugs; use of vitamin, mineral, or herbal supplements; prescription or over-the-counter (OTC) drugs; and the patient's general nutrition * Physical examination - Refer to table 45-4 in text for signs of good/poor nutrition * Nursing specific assessment often involves calorie counts, monitoring daily weights, and assessment of wound healing

A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess? Health perception-health management pattern Value-belief pattern Cognitive-perceptual pattern Self-perception-self-concept pattern

Self-perception-self-concept pattern This is an example of assessment of a patient's feelings about his worth and body image, which is the self-perception- self-concept health pattern.

Standards of Practice

Six standards of practice * Assessment * Diagnosis * Outcomes identification * What do you want to happen? Ex; relief of headache to under pain scale of 4 * Planning * Establish interventions * Implementation * Evaluation * After a period of time determine the efficiency The nursing process is the foundation of clinical decision making

Classification of Surgery

Seriousness * Major or minor Major - going under anesthesia Minor - having a mole removed Urgency * Elective, urgent, emergency Elective - You don't have to have surgery, cosmetic Urgent - eventually you need to have it but you won't die today Emergent - if you don't get it done now you will die Purpose * Diagnostic, ablative, palliate, reconstructive/restorative, procurement for transplant, constructive, or cosmetic Diagnostic - invasive, determine stage in something Ablative - want to get rid of something Palliative - surgery to remove pain Reconstructive/restorative - Breast reconstruction surgery Procurement or transplant - keep alive on ventilator and take everything they possibly can, bone/tissue/organs Cosmetic - facelift, tucks, nose job * Moribound: at the point of death * American Society of PeriAnesthesia Nurses (ASPAN)

Planning

Set goals/outcomes and plan nursing care. Collaboration with the client is essential to successful planning

Abandonment and Assignment Issues: Legal Implications

Short staffing * Legal problems occur if an inadequate number of nurses will provide care Floating * Based on census load and patient acuities Health care providers' orders * Nurses follow orders unless they believe an order is given in error or is harmful

A nurse is caring for a complicated patient 3 days in a row. The nurse attends an interdisciplinary conference to discuss the patient's plan of care. In which ways can the nurse develop trust with members of the conference team? Select all that apply. Is willing to challenge other members' ideas because the nurse disagrees with their rationale Shows competence in how to monitor patients' clinical status and inform the physician of critical changes Asks a more experienced nurse to attend the conference Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly During the meeting focus on similar problems the nurse has had in delivering care to other patients.

Shows competence in how to monitor patients' clinical status and inform the physician of critical changes, Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly Showing competence and exercising effective communication are important for developing trust with interdisciplinary team members. Having another nurse attend the conference who might be less familiar with the patient would not promote trust. Challenging other ideas just because of disagreement does not foster trust. Changing the focus from the patient to the problems of the nurse will not foster trust.

Infection

Signs and symptoms * Foul smell * Redness to peri-wound (erythema) * Hot - (not warm) * Purulent drainage * Pain * Swelling Treatment * Culture - sensitivity * Systemic antibiotics * Antimicrobial dressings - broad spectrum * Debridement

Muscle Movement and Posture

Skeletal muscles are working elements of movement * If your not moving them for the patient they stop working * ROM exercises for bedridden patients - extremities can become contracted if they aren't exercised * Don't put IVs in contracted areas

Topical Medications

Skin * Use gloves * Use sterile techniques if the patient has an open wound * Clean skin first * Follow directions for each type of medication * Transdermal patches: * Remove old patch before applying new * Document the location of the new patch * Ask about patches during the medication history * Apply a label to the patch if it is difficult to see * Document removal of the patch as well

Integumentary system Older Adult

Skin * Loss of adipose tissue * Skin thins, becomes much more friable * Lesions

Stage 1 Pressure Ulcer

Sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose colour briefly when you press your finger on it and then remove your finger). In a dark-skinned person, the area may appear to be a different colour than the surrounding skin, but it may not look red. Skin temperature is often warmer. And the stage 1 sore can feel either firmer or softer than the area around it.

Legal Limits of Nursing

Sources of law: * Statutory law (Nurse Practice Act) * Criminal law (felonies or misdemeanors) * Civil law * Regulatory law (administrative law) * Common law (judicial decisions) Standards of care * Legal guidelines for defining nursing practice and identifying the minimum acceptable nursing care * Best known comes from the American Nurses Association (ANA) * Set by state and federal laws that govern where nurses work * Joint Commission requires policies and procedures (P&Ps).

Processing an Ethical Dilemma

Step 1: Ask if this is an ethical dilemma Step 2: Gather all relevant information Step 3: Clarify values Step 4: Verbalize the problem Step 5: Identify possible courses of action Step 6: Negotiate the outcome Step 7: Evaluate the action

Ageism

Stigmatism against a population

Diagnostic Tests

Stool analysis * Hemocult (guaiac), c-diff, ovum and parasites * Radiological examination of bowel * EGD- esophagogastoduodenoscopy visualise the stomach and esophagus Upper GI/Barium swallow * X-ray using contrast to examine structure and mobility of the GI tract Direct visualization of bowel * Colonoscopy * Flexible sigmoidoscopy * CT or MRI

* Your bladder scan your patient and find that they have 900mL of urine in their bladder. What would be your next intervention?

Straight Cath

SC or SQ

Subcutaneous

Oral Administration

Sublingual (under tongue) Buccal (cheek) * Easiest and most desirable route * Food may decrease therapeutic effect * Aspiration precautions Enteral or small-bore feedings * Verify that the tube location is compatible with medication absorption * Follow American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines * Use liquids when possible * If medication is to be given on an empty stomach, allow at least 30 minutes before or after feeding * Risk of drug-drug interactions is higher

The Wound Care Interdisciplinary Team

Surgeon * Cardiovascular * Reconstructive * Orthopedic * Podiatry * Nursing * Dietary Therapy * Physical, Occupational, lymphedema * Orthotist and prosthetics Specialists * Infectious diseases * Hyperbaric Medicine * Primary: manage comorbidites * Home health * Long term care facility * **Chronic wounds require specialist just like any other complex disease process

Beneficence

Taking positive actions to help others

Worden's Grief Tasks Model

Task I: Accept the reality of the loss Task II: Experience the pain of grief Task III: Adjust to a world in which the deceased is missing Task IV: Emotionally relocate the deceased and move on with life

A nursing student is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1° C (98.8° F). The student reports her recent assessment to the registered nurse (RN): the patient's temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend first? Tell the student that temporary confusion is normal and simply requires reorientation Tell the student to increase the patient's fluid intake since the urine is concentrated Tell the student that her assessment findings are normal for an older adult Tell the student that he will notify the patient's health care provider of the findings and recommend a urine culture

Tell the student that he will notify the patient's health care provider of the findings and recommend a urine culture The patient may have subtle symptoms of a urinary tract infection, as evidenced by a slight increase in body temperature, development of confusion, and the dark-colored urine. Temporary confusion is not a normal condition in older adults. Increasing the fluid intake is acceptable but not a recommendation for the set of symptoms the patient presents. The presenting set of symptoms is not normal.

Intraoperative Evaluation

The circulating nurse conducts an ongoing evaluation to ensure that interventions such as a patient position are implemented correctly during the intraoperative phase of surgery. * Circulating nurse - can go in and out of the OR * Scrub nurse - at bedside handing instruments to surgeon * Evaluate the patient's ongoing clinical status. Continuously monitor vital signs and intake and output

Nail care

The normal nail is transparent, smooth, and convex, with a pink nail bed and a translucent white tip

A group of nurses on the research council of a local hospital are measuring nursing-sensitive outcomes. Which of the following is a nursing-sensitive outcome that the nurses need to consider measuring? Select all that apply. Frequency of low blood sugar episodes in children at a local school The number of patients who develop a urinary tract infection from a Foley catheter Number of patients who fall and experience subsequent injury on the evening shift Number of sexually active adolescent girls who attend the community-based clinic for birth control Patient reported quality of life following coronary artery bypass graft surgery and cardiac rehabilitation

The number of patients who develop a urinary tract infection from a Foley catheter, Number of patients who fall and experience subsequent injury on the evening shift Nurse-sensitive indicators are outcomes that are sensitive to nursing practice; these outcomes will improve if the quantity or quality of nursing care improves.

A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient's expectations of care. Which statement is appropriate for evaluating a patient's expectations of care? On a scale of 0 to 10 rate your level of nausea. The nurse weighs the patient. The nurse asks, "Did you believe that you received the information you needed to follow your diet?" The nurse states, "Tell me four different foods included in your diet."

The nurse asks, "Did you believe that you received the information you needed to follow your diet?" Evaluating patient expectations of care involves measuring his or her perceptions of care (e.g., if this particular patient thinks that he or she had received sufficient information).

Intervention

The phase in which you execute the care plan. Interventions include counseling, providing comfort measures, teaching, offering emotional support, managing the environment and assessing

Stage 4 Pressure Ulcer

The pressure injury is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur.

A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? Select all that apply. The skin around the wound is tender to touch. Fluid intake for 8 hours is 800 mL. Patient has a heart rate of 78 beats/min and regular. Patient has drainage from surgical wound. Body temperature is 38.3° C (101° F). Patient states, "I'm worried that I won't be able to return to work when I planned."

The skin around the wound is tender to touch, Patient has drainage from surgical wound, Body temperature is 38.3° C (101° F). Tender skin around the wound, drainage from the surgical wound, and a temperature of 38.3° C (101° F) indicate a wound infection. Fluid intake of 800 mL over 8 hours and a heart rate of 78 beats/min and regular are normal assessment findings. A patient's expressed concern about returning to work is his or her subjective response about a separate issue and is insufficient to form a pattern.

The effects of immobility on the cardiac system include which of the following? Select all that apply. Thrombus formation Increased cardiac workload Weak peripheral pulses Irregular heartbeat Orthostatic hypotension

Thrombus formation, Increased cardiac workload, Orthostatic hypotension The three major changes are orthostatic hypotension, increased cardiac workload, and thrombus formation.

Evaluation: Patient Safety and Care

Through the patient's eyes * Are the patient's expectations met? * Are the family's expectations met? Patient outcomes * Monitor care by the health care team * Measure outcomes for each diagnosis * Continually assess needs for additional support

Assessment: Pain Management

Through the patient's eyes * Ask the patient's pain level * Use ABCs of pain management * Pain is not a number * In selecting a tool to be used with a patient, be aware of the clinical usefulness, reliability, and validity of the tool in that specific patient population * Be aware of possible errors in pain assessment Patient's expression of pain * Pain is individualistic Characteristics of pain * Timing * Location * Severity * Quality * Aggravating and precipitating factors * Relief measures Effects of pain on the patient * Behavioral effects * Influence on activities of daily living (ADLs) Concomitant symptoms * Usually increases pain severity

Evaluation: Nursing Care Immobility

Through the patient's eyes * It is essential to have the patient's evaluation of the plan of care Patient outcomes * Evaluate effectiveness of specific interventions * Evaluate patient's and family's understanding of all teaching provided

Evaluation: Pain Management

Through the patient's eyes * Patients help decide the best times to attempt pain treatments * They are the best judge of whether a pain-relief intervention works Patient outcomes * Evaluate for change in the severity and quality of the pain

HIPPA is broken down into V titles

Title I: Health Insurance Reform - Protects health insurance coverage for workers and their families when they change or lose their jobs - Limits new health plans ability to deny coverage due to a pre-existing condition Title II: Administrative Simplification - Prevents Health Care Fraud and Abuse - Is an Administrative Simplification that requires the establishment of national standards for electronic health care transactions and national identifiers for providers, employers, and health insurance plans Title III: HIPPA Tax Related Health Provisions - Guidelines for pre-tax medical spending accounts - Provides for certain deductions for medical insurance, and makes other changes to health insurance law Title IV: Application and Enforcement of Group Health Plan Requirements - Specifies conditions for group health plans regarding coverage of persons with pre-existing conditions - Provides modifications for health coverage Title V: Revenu Offsets _ Governs company-owned life insurance policies - Makes provisions for treating people without United States Citizenship and repealed financial institution rule to interest allocation rules

Purposes of the Nursing Outcomes Classification (NOC) include which of the following? Select all that apply. To identify and label nurse-sensitive patient outcomes To test the classification in clinical settings To establish health care reimbursement guidelines To identify nursing interventions for linked nursing diagnoses To define measurement procedures for outcomes

To identify and label nurse-sensitive patient outcomes, To test the classification in clinical settings, To define measurement procedures for outcomes The NOC classification offers a language for the evaluation step of the nursing process. The purposes of NOC are to (1) identify, label, validate, and classify nurse-sensitive patient outcomes; (2) field test and validate the classification; and (3) define and test measurement procedures for the outcomes and indicators using clinical data.

A nurse is participating in a health and wellness event at the local community center. A woman approaches and relates that she is worried that her widowed father is becoming more functionally impaired and may need to move in with her. The nurse inquires about his ability to complete activities of daily living (ADLs). ADLs include independence with: Select all that apply. Driving. Toileting. Bathing. Daily exercise. Eating.

Toileting, Bathing, Eating ADLs are self-care tasks that measure function and are markers for the ability to live independently. Although driving and daily exercise are important to quality of life and health maintenance, they would not necessarily impact a person's ability to live independently.

Pharmacological Pain Therapies

Topical analgesics * Creams, ointments, patches Local anesthesia * Local infiltration of an anesthetic medication to induce loss of sensation to a body part * Regional anesthesia * Perineurial local anesthetic infusion - Hooked to a pump Epidural analgesia * Regional * Administered into epidural space

receptive aphasia

inability to understand spoken or written words

Physiology of Pain

Transduction * Converts energy produced by these stimuli into electrical energy * Begins in the periphery when a pain-producing stimulus sends and impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential * Once transduction is complete, transmission of the pain impulse begins Transmission * Sending of impulse across a sensory pain nerve fiber (nociceptor) * Nerve impulses * Pain impulses Perception * The point at which a person is aware of pain * The somatosensory cortex identifies the location and intensity of pain whereas the association cortex, primarily the limbic system, determines how a person feels about it. There is no single pain center. Modulation * Inhibits pain impulse * A protective reflex response occurs with pain reception ***** Gate-control theory of pain (Melzack and Wall) * Pain has emotional and cognitive components, in addition to a physical sensation * Gating mechanisms in the central nervous system (CNS) regulate or block pain impulses * Pain impulses pass through when a gate is closed * Closing the gate is the basis for non-pharmacological pain relief interventions - example; meditation, yoga, heat, ice, holding a pillow, listening to music

Environmental Safety

Transmission of pathogens * Pathogens and parasites pose a threat to patient safety * Educate patients about hand hygiene * Immunization Pollution * Air, land, water * Noise

Tx

Treatment

Rx

Treatment (medications)

Treatment of Venous Ulcers

Treatment and Prevention * Edema control * Salt and fluid balances * Diuretics * Limb elevation 30min 3x per day above the heart * Ambulation - calf muscle pump * Advanced therapy * Venous ablation * Manual therapy and Pumps * Caution with CHF and arterial disease Compression Therapy * Standard of care * Check arterial status*

Positioning Techniques

Trochanter roll * Roll up blanket to support Hand roll * Roll up washcloth and place it in hand Trapeze bar * If patient is able to use them, encourage it * Supported Fowler's Supine * Lying flat on back Prone * On stomach Side-lying * Left/Right Lateral Recumbent * Sims'

Older Adults and Restorative Care

Types of ongoing care: * Continues recovery from acute illness * Addresses chronic conditions that affect daily functioning Goal * To regain or improve prior level independence, ADLs, instrumental activities and daily living (IADLs)

What are potential causes of delirium?

UTIs or pneumonia

Side effect

Unavoidable secondary effect

A nurse researcher wants to conduct historical research. Which of the following ideas for a study could the nurses conduct? Select all that apply. Determining the effect of unemployment on emergency room usage Understanding how Clara Barton shaped nursing in America Evaluating the effect of the Vietnam war on nursing leadership and practice Analyzing the evolution of nursing and patient care during recent disasters Investigating barriers to exercise in women who have become mothers in the past year

Understanding how Clara Barton shaped nursing in America, Evaluating the effect of the Vietnam war on nursing leadership and practice, Analyzing the evolution of nursing and patient care during recent disasters Historical studies are designed to establish facts and relationships concerning past events.

Allergic reaction

Unpredictable response to a medication, can turn into emergency quickly. Rash, hives, nausea - systemic

Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest? Isometric exercises Administration of low-dose heparin Suctioning every 4 hours Use of incentive spirometer every 2 hours while awake

Use of incentive spirometer every 2 hours while awake Incentive spirometry opens the airway, preventing atelectasis.

It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? Select all that apply. Using a standardized checklist for essential information Asking the wife to briefly leave the room Completing the hand-off without inviting questions Doing prework such as checking laboratory results before giving a report Including the wife in the hand-off discussion

Using a standardized checklist for essential information, Doing prework such as checking laboratory results before giving a report, Including the wife in the hand-off discussion Using standardized forms or checklists and doing thorough prework enhance the nurse's ability to communicate the plan of care effectively during a hand-off. It is also important to include patient and family when possible. The other two options are barriers to an effective hand-off.

Values: Ethics and Values

Value * A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior Values clarification * Ethical dilemmas almost always occur in the presence of conflicting values * To resolve ethical dilemmas, one needs to distinguish among values, facts, and opinion

Steps in Oxygenation

Ventilation - The process of moving gases into and out of the lungs Perfusion * The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs Diffusion * Exchange of respiratory gases in the alveoli and capillaries

A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 ½ NS infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? Select all that apply. IV site not tender Uses cane to walk Walked to end of hall No shortness of breath Slept better during night

Walked to end of hall No shortness of breath The goal for improving activity tolerance will require an outcome that is a measure of changes in activity tolerance such as no shortness of breath during exercise or walking a set distance.

A nurse is about to perform wound care on patient who has tested positive for a MRSA infection. What is the first thing they need to do? []Gather materials []Wash their hands []Clean the wound []Bandage the wound

Wash their hands

Gravity

Weight force exerted on the body

What About What We Eat?

What about sugars? * There is sugar in most foods/ Carbohydrates are broken down into simple sugars and are metabolized by bacteria the same way any sugar is. Frequency * How OFTEN we are eating * Takes 20 seconds to turn sugars into acid * Takes 30 minutes to get back to a neutral pH Consistency * The TEXTURE of our food * Differing textures mean different retention rates in our teeth * Good: crunchy, easily dissolvable * Bad: sticky * Natural sweeter that oral bacteria is unable to metabolize * As bacteria ingest this, they lose their abiliy to adgere to the tooth surface, decreasing plaque formation and decay rates * Many foods we already eat have xylitol: raspberry, strawberry, veggies, mushrooms * Found in many gums and mints - check the labels * Xylosweet is a sugar replacement available locally in the Co-op

Now

When a medication is needed right away, but not STAT

Endogenous

When the patient's flora becomes altered and an overgrowth results

Opioids

Work in the brain

Primacy of Caring

Written by Patricia Benner and Judith Wrubel - An ethic of care that deals with the patient as a whole, thus the nursing care is the type that deals with patient mental issues, stress, emotions, and clinical practice - Helping a patient cope with the stresses of illness, rather than just following clinical procedures - Mind and body are not two separate entities

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? Incorrect clustering Wrong diagnostic label Condition is a collaborative problem. Premature closure of clusters

Wrong diagnostic label The more appropriate nursing diagnosis for this patient would be Risk for Impaired Skin Integrity because the patient's skin is clean and intact. A risk nursing diagnosis is appropriate because the patient has two risk factors, radiation and secretions on the skin.

Do Nurses Really Do This In Practice?

YES!!! * They are not usually written in their entirety from a nurse memory. Each health care system has their own method. Method examples: * Pre-printed with checkboxes * Computerized * It is a JCAHO requirement in hospitals * Each institution will have a policy regarding when and how the care plan is initiated and how often the care plan is evaluated and revised

While caring for a child, you identify that additional safety teaching is need when a young and inexperienced mother states that: []teenagers need to practice safe sex []a 3-year-old can safely sit in the front sear of the car. []children need to wear safety equipment when bike riding []children need to learn to swim even if they do not have a pool.

a 3-year-old can safely sit in the front sear of the car.

straight catheter

a catheter that drains the bladder and then is removed

Stage 4 pressure ulcer

extended to the muscle and bone

Secondary health care

includes the diagnosis and treatment of emergency, acute illness, or injury. examples include care given in hospital settings (inpatient and EDs), diagnostic centers, or emergent care centers

anuria

absence of urine

If a nurse decides to withhold medication because it might further lower the patient's blood pressure, the nurse will be practicing the principle of: []responsibility []accountability []competency []moral behavior

accountability

p with a line over it

after

pc

after meals

prebycusis

age related hearing loss

Stroke volume

amount of blood ejected from the left ventricle with each contraction

near-death experience

an altered state of consciousness reported after a close brush with death (such as through cardiac arrest); often similar to drug-induced hallucinations

Spiritual well-being

an interconnectedness between God or a higher power and other people

Nursing theories provide nurses with perspectives from which to: []analyze patient data []predict phenomena formulate legislation []formulate legislation []link science to nursing

analyze patient data

ad lib

as desired

PRN (prn)

as needed

You notice a respiratory change in your immobilized postoperative patient. The change you note is more consistent with: []atelectasis []hypertension []orthostatic hypotension []coagulation of blood

atelectasis

ac

before meals

Bx

biopsy

Stage 2 pressure ulcer

blanchable means it's into stage 2, pressure ulcer has expanded into the dermis, but it still may just appear red on the outside

urinary obstruction

blockage of conducting system by a calculus or other factors

affective effects of sensory deprivation

boredom, restlessness, increased anxiety, emotional lability, panic, increased need for physical stimulation

O.U

both eyes

double barrel colostomy

bowel is surgically cut and both ends are brought through the abdomen

Granulation

buds, growth of new blood vessels and collagen matrix

Serous

clear, watery plasma

CDSS

clinical decision support system

cataract

clouding of the lens of the eye

Muslim

cannot eat pork, alcohol, animal fats, and meat that has not been slaughtered in islamic rights may fast during ramadan do not practice euthanasia do not want organ transplants or post mortem autopsy

CXR

chest x-ray

c/o

complains of

CPOE

computerized physician order entry

sensory overload

condition resulting from excessive sensory input to which the brain is unable to meaningfully respond

C & s

culture and sensitivity

diabetic retinopathy

damage to the retina as a complication of uncontrolled diabetes

Respiratory effects of immobility

decreased lung expansion, generalized respiratory muscle weakness, and stasis of secretions

4 Tenants of Nursing Theory

describe and define... - Human Being - Health - Nursing - Environment

advanced directive (living will)

details the conditions under which life support measures should be used

DC, D/C

discontinue

Population-based health care services

disease prevention, newborn screenings, education related

DNR

do not resuscitate

Passive Neglect: Elder Abuse

doing it without even knowing it

Stage 3 pressure ulcer

down into the adipose tissue

Gt or gtt

drops

ECG (EKG)

electrocardiogram

Lytes

electrolytes

Primary health care

emphasizes health promotion, and includes prenatal and well-baby care, nutrition counseling, and disease control. is based on a sustained partnership between client and provider. examples include office or clinic visits and scheduled school/work centered screenings (vision, hearing, obesity)

Unstageable

eschar (dead black tissue) slough (thick mucous filmy growth) - you do not see this though, it's beneath the skin * Our role is it identify it, tell instructor/wound care nurse

q

every

polyuria

excessive urination

Expert nurse

has an intuitive grasp of a clinical situation and zeroes in on the accurate solution

Advanced Beginner Nurse

has enough experience to recognize patterns in work but continues to need help in setting priorities; relies on rules and protocols

Novice Nurse

has no experience with specific patient populations and uses rules to guide performance.

HEENT

head, eyes, ears, nose, throat

HS

hour of sleep

Spiritual distress

impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself

presbyopia

impaired vision as a result of aging

aphasia

impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to Wernicke's area (impairing understanding).

urinary retention

inability to empty the bladder

intermittent catheter

inserted as needed several times a day to drain urine from the bladder

ID

intradermal

IM

intramuscular

IV

intravenous

enuresis

involuntary discharge of urine

Tertiary health care

involves the provision of specialized highly technical care. examples include oncology centers and burn centers

Altruism

is a concern for the welfare and well-being of others. In professional practice, altruism is reflected by the nurse's concern and advocacy for the welfare of patients, other nurses, and other healthcare providers

Integrity

is acting in accordance with an appropriate code of ethics and accepted standards of practice. Integrity is reflected in professional practice when the nurse is honest and provides care based on an ethical framework that is accepted within the profession.

Social Justice

is acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation.

lt

left

O.S

left eye

Information regarding a patient's health status may not be released to non-health care team members because: []legal and ethical obligations require health care providers to keep information strictly confidential []regulations require health care institutions to document evidence of physical and emotional well-being []reimbursement issues related to patient care and procedures may be of concern []fragmentation of nursing and medical care procedures may be identified

legal and ethical obligations require health care providers to keep information strictly confidential

sensory deficit

loss or impairment of sensation

single-barrel colostomy

opening to the colon that has a single stoma through which fecal matter is released.

po

oral

dysuria

painful urination

PMH

past medical history

Pt

patient

PE

physical examination

postop

postoperative

Nursing is defined as a profession because nurses: []perform specific skills []practice autonomy []utilize knowledge from the medical discipline []charge a fee for services rendered

practice autonomy

preop

preoperative

Skin mottling

prior to death

macular degeneration

progressive damage to the macula of the retina

Biofilm

protects bacteria on wound bed

Stage 1 pressure ulcer

redness, when you press it with your finger it does not 'blanch' or turn white

r/t or rt

related to

Ombudsman

resident advocate who investigates complaints and assists to achieve agreement between parties, often defending the rights of residents

A patient who needs nursing an a rehabilitation following a stroke would most benefit from receiving care at a: []primary care center []restorative care setting []assisted-living center []respite center

restorative care setting

Rt

right

O.D

right eye

unstageable pressure ulcer

slough and eschar

slough tissue

soft yellow or white tissue stringy substance attached to wound bed needs to be removed so wound can heal

granular tissue

soft, capillary-rich new tissue formed during tissue repair

urinary diversion

surgical creation of an alternate route for excretion of urine

Ostomy

surgical opening created to remove bodily waste

Sx

symptoms

loop colostomy

temporary in the transverse colon

sensory deprivation

the absence of normal levels of sensory stimulation

Religion

the belief in and worship of a superhuman controlling power, especially a personal God or gods.

The Self-Care Deficit Theory

theory based on the assumption that self-care needs and activities are the primary focus of nursing practice. Nursing is a response to a sick person's inability to administer self-care.

Purulent

thick, yellow, green, tan or brown

t.i.d

three times a day

x

times

b.i.d

twice a day

A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing interventions to prevent a fall for this patient would include: []raise all four side rails when darkness falls []use an electronic bed monitoring []place the patient in a room close to the nursing station []use a loose-fitting vest-type jacket restraint

use an electronic bed monitoring

Nursing informatics

uses information and technology to communicate, manage knowledge, mitigate error, and support decision making

Competent nurse

usually been in practice 2-3 years demonstrate increasing levels of skill and proficiency and clinical judgment

5 lead telemetry placement

white to the right, green over grass, smoke over fire, chocolate goes straight to the heart

c with a line over it

with

WNL

within normal limits

s with a line over it

without

dry eyes

xerophthalmia, result when tear glands produce too few tears, resulting in itching, burning, or even reduced vision.

Dementia: Oral Health

* Cultures of brains from dementia patients showed Porphyromonas gingivalis

Feeding Dementia Patients

* *remember how important NONVERBAL communication is with this type of patient * use more gestures and reduce verbal instructions * move slowly, keep your rate slow and voice calm * watch your body language. you want to look calm and relaxed - totally nonthreatening * ask yes/no or double choice questions, not open-ended ones

Injections: Safety, Needleless Devices

* 600,000 to 1 million accidental needlesticks and sharps injuries annually in health care * Common when workers recap needles, mishandle IV lines and needles, or leave needles at a patient's bedside * Exposure to bloodborne pathogens can be deadly * Most needlestick injuries are preventable * Needlestick Safety and Prevention Act

Code of Ethics

* A code of ethics is the philosophical ideals of right and wrong that define principles used to provide care. * It is important for you to incorporate your own values and ethics into your practice * Ask yourself: How do your ethics, values, and practice compare with established standards?

Malpractice Insurance

* A contract between the nurse and the insurance company * Provides a defense when a nurse is in a lawsuit involving negligence or malpractice * Nurses covered by institution's insurance while working

Nursing diagnosis

* A decision or judgement about the nature of a client's problems or needs * From the assessment

Biofeedback

* A mind-body technique that uses instruments to teach self-regulation and voluntary self-control over specific physiological responses * Instruments measure, process, and provide information about neuromuscular and autonomic nervous system activity * Immediate feedback is provided in physical, physiological, auditory, and/or visual signals

Natural Products and Herbal Therapies

* A natural product is a chemical compound or substance produced by a living organism * Herbal medicines are not approved for use as drugs and are not regulated by the FDA * Although many herbs are safe and effective, "natural" does not equal "safe" * Some interact with prescription and over-the-counter medications * Look for U.S Pharmacopeia (USP)-verified dietary supplement mark

Nursing Interventions Classification System (NIC)

* A standardized language to describe nursing activities * Can be used to develop a care plan by selecting nursing intervention levels and nursing activities pertinent to nursing diagnoses and expected outcomes.

Nursing Outcomes Classification System (NOC)

* A standardized terminology and measures to evaluate effects of nursing interventions

Risk Management and Quality Assurance: Legal Implications

* A system of ensuring appropriate nursing care that attempts to identify potential hazards and eliminate them before harm occurs Steps involved: * Identify possible risks * Analyze risks * Act to reduce risks * Evaluate steps taken * One tool used in risk management is the incident report or occurrence report Occurrence reporting * Serves as a database for further investigation * Alerts risk management to a potential claim situation * Documentation * TJC's Universal Protocols * Professional involvement

Evaluation

* A systemic and ongoing process of examining whether expected outcomes/goals have been met and whether nursing interventions have been effective * First you need to review the expected outcome for each diagnosis * Next you need to examine the client's responses to nursing interventions * After evaluating the client's responses to the interventions, you must judge the success of the interventions in achieve expected outcomes * Outcomes may be completely met, partially met, or not met

Nursing Research

* A way to identify new knowledge, improve professional education and practice, and use resources effectively * Many professional and specialty nursing organizations support the conduct of research for advancing nursing science

Routine Clinical Approach to Pain Assessment and Management: ABCDE ****

* A. ASK about pain regularly. Assess pain systematically. * B. BELIEVE patient and family in report of pain and what relieves it * C. CHOOSE pain control options appropriate for family, setting, and patient * D. DELIVER interventions in a timely, logical, and coordinated fashion * E. EMPOWER patients and their families. Enable them to control their course to the greatest extent possible.

Conditions

* According to studies, 63%-75% of the elderly in long term care have poor oral hygiene * 1/3 have untreated dental decay * 23% of 65-74y/o have severe gum disease

Retention

* Accumulation of urine resulting from an inability of the bladder to empty properly * Bladder is unable to respond to the micturition reflex (response to stretching as bladder fills) * Symptoms: pressure, discomfort, tenderness over symphysis pubis, restlessness, sweating, large bladder on palpation, small voids or leakage of small amounts or urine * Increases risk of urinary tract infection * May require catheterization

Professional Nursing Organizations

* Address member concerns * Present educational programs * Publish journals Student organizations * National Student Nurses Association (NSNA) * Canadian Student Nurses Association

Preoperative lap chole orders

* Admission Orders: * Admit to Dr. ___ * NPO * Sign consent form for Laprascopic cholecystectomy with possible intraoperative cholangiogram * Anesthesia to see * Start IV with large bore needle, LR at 100 cc/hr. * IV antibiotic on call to OR, per hospital policy SCD's intraoperative

Therapeutic Touch

* Affects energy fields with conscious intent to help or heal * Five phases: centering, assessing, unruffling, treating, and evaluating

Evaluate the Practice Decision or Change

* After applying evidence, evaluate the outcome When evaluating an EBP change determine: * Was the change effective? * Are modifications needed? * Should the change be discontinued? - Unexpected events or results may occur - Never implement a practice change without evaluating it's effects

Risk Factors: Surgery

* Age * Nutrition * Obesity * Sleep apnea * Immunocompetence * Fluid and electrolyte imbalance * Pregnancy

1st Priority Basic Physiological Needs

* Airway * Respiratory effort * Heart rhythm and strength of contraction * Nutrition * Elimination

Planning: Medication Administration

* Always organize your care activities to ensure the safe administration of medications * Setting goals and related outcomes contributes to patient safety and allows for wise use of time during medication administration * Provide the most important information about the medications first * On discharge, ensure that patients know where and how to obtain medications

Planning: Pain Management

* Analyze information from multiple sources * Apply critical thinking * Adhere to professional standards * Use a concept map * Goals and outcomes * Setting priorities * Teamwork and collaboration

Physiological Responses to Pain

* As pain impulses ascend the spinal cord toward the brainstem and thalamus, the stress response stimulates the autonomic nervous system (ANS) * Fight or flight * Continuous, severe, or deep pain typically involving the visceral (colon, stomach, gallbladder) organs activities the parasympathetic nervous system

Caring in Nursing Practice

* As you deal with health and illness in your practice, you grow in your ability to care and develop caring behaviors * Caring is one of those human behaviors that we can give and receive * Recognize the importance of self-care * Use caring behaviors to reach out to your colleagues and care for them as well

Definitions

* Aspiration: Taking into the lungs Dysphagia: difficulty when swallowing * See box 45-7 (pg 1068) in text for causes of dysphagia * See dysphagia handout available on Educat for signs/symptoms of dysphagia * What do we do if we see signs or symptoms of dysphagia in our patients?

Education: Ostomies

* Assessment * How to empty the bag * How to change the wafer and bag * Activity * Diet * Psychosocial needs

Role of the Registered Nurse

* Assessment - Take measurements * Wound assessment * Evaluation * Patient/family education * Coordination of care * Communication with physician/Nurse Practitioner * It is the responsibility of the RN to facilitate appropriate wound care and advocate for the patient

Medication Administration - Keys to accuracy

* Avoid distractions and follow the same routine *** * Administer only medications you prepare, and never leave prepared medications unattended *** * Document medication immediately after administration *** * Use clinical judgement in determining the best time to administer prn medications * When preparing medications, check the medication container label against the medication administration record (MAR) three times.

Alternative Food Patterns

* Based on religion, cultural background, ethics, health beliefs, and preference * Vegetarian diet (many variations) * Gluten Free diets * Low residue diets * Kosher diet

Nursing Priorities from Maslow's Hierarchy

* Basic physiological needs must be met first * Second level is safety and security * Third level is love and belonging * Fourth level is self-esteem * Fifth level is self-actualization * Example: If a person is having difficulty breathing (a basic physiological need) and with his self-esteem, you must make his breathing a priority over a self-esteem problem

Providing Presence

* Being with * Eye contact * Body language * Tone of voice * Listening * Positive and encouraging attitude

Training-Specific Therapies

* Biofeedback * Acupuncture * Therapeutic touch * Chiropractic therapy * Traditional Chinese medicine * Natural products and herbal therapies

Arterial Ulcers

* Blockage prevents nutrients, cellular migration, and oxygen from reaching LE Characteristics * Very painful * Dark red/dusky and cool skin - ischemia * High risk for Amputation * Treatments: Stenting, removal of blockages, Bypass grafting by vascular surgeon * *Do Not use compression of debride until blockage is resolved * *Palpable pulses do not always indicate good blood flow - use vascular testing!

Periodontitis 1000,000-10,000 Gram - and Gram

* Bone loss * Bleeding * Puffy * Irreversible

Act of Urination

* Brain structures influence bladder function - can either inhibit or allow voiding to occur: cerebral cortex, thalamus, hypothalamus, brain stem * Bladder can hold 600-1000 mL of urine * Voiding occurs every 4-6 hours * Desire to urinate at 150-250 mL * Normal output: 1500-1600 mL/day or greater than 30mL/hour Voiding is voluntary * The micturition center in the sacral spinal cord receives sensory impulses * A person can choose to respond or wait * Damage to the spinal cord above the sacral region can inhibit this response causing reflex incontinence

Best Practices

* Brush twice a day (2 minutes) * Floss at lest once daily, preferably at night * Use a fluoride mouth rinse * Use any additional oral hygiene aids to minimize bacteria * Choose a diet to keep your mouth and body healthy and watch sugars

Listening

* Creates trust * Opens lines of communication * Creates a mutual relationship

Critical Thinking Synthesis

* Critical thinking and the nursing process go hand-in-hand in making quality decisions about patient care

Complementary, Alternative, and Integrative Approaches to Health

* CAM - an array of health care approaches with a history of use or origins outside of maintain medicine * Complementary - therapies used in addition to conventional treatment (aka integrative therapies) * Alternative - therapies that replace allopathic medical care * Whole medical systems - based on different philosophies and life systems Holistic nursing regards and treats the mind-body-spirit of the patient * Uses holistic nursing interventions such as relaxation therapy, music therapy, touch therapies, and guided imagery * The American Holistic Nurses Association maintains Standards of Holistic Nursing Practice Integrative nursing * Advances health and well-being through caring-healing relationships * Uses evidence to inform traditional and emerging interventions that support whole-person/whole-systems healing Weight risks and benefits of each intervention when recommending complementary therapies

Discharge Teaching: Care of Surgical Patients

* Call your doctor immediately if you experience any of the following postoperative complications * shortness of breath or dizziness or weakness that does not go away; * increased redness, swelling, or drainage at your incision sites; * fever greater than 101 F (38.3 C); * nausea or vomiting that is not relieved with medication; abdominal swelling; * pain that is not controlled with medication; or * no bowel movement by two or three days after surgery

Causes: Ostomies

* Cancer (colon, rectal, or anal) * Traumatic injury (gunshot wound) Intestinal blockage * Tumor or mass * Crohn's disease (inflammatory bowel disease affecting any part of the GI tract) * Diverticulitis (infection or inflammation of the intestinal lining) * Ulcerative colitis (inflammatory bowel disease of the colon)

What is Cardiac Catheterization?

* Cardiac Catheterization is a procedure used to diagnose and treat cardiovascular problems. The procedure finds and tests the heart to see if it has: * Narrowing/blocked blood vessels * Measures pressure and oxygen levels in heart * Check atrial and ventricular function * Biopsy heart muscle * Look for problems in heart valves

Theoretical Views on Caring

* Caring: a universal phenomenon that influences the way we think, feel, and behave * Since Florence Nightingale, nurses have studied caring * Caring is at the heart of a nurse's ability to work with all patients in a respectful and therapeutic way Caring is primary * Caring determines what matters to a person * Caring helps you provide patient-centered care

Pneumonia: Oral Health

* Cause by inhalation of microorganisms resulting in inflammation in lungs. Bacterial biofilm can hold pathogens that can cause pneumonia

The Twenty-First Century

* Changes in curriculum * Advances in technology and informatics * New programs address current health concerns * Leadership role in developing standard and policies

Metabolic Changes Immobility

* Changes in mobility alter * Endocrine metabolism * Calcium resorption * Functioning of the GI system Endocrine system helps maintain homeostasis Immobility disrupts normal metabolic functioning * Decreases metabolic rate * Alters metabolism * Causes GI disturbances

The Future of Health Care

* Charge open up opportunities for improvement * Health care delivery systems need to address the needs of the uninsured and the underserved. * Health care organization are striving to become better prepared to deal with these and other challenges in health care * The solutions necessary to improve the quality of health care depend largely on the active participation of nurses

Groin Care-Male

* Circumsised- if patient can do this themselves, provide them with washcloth or cleaning wipe Noncircumcised - make sure foreskin is pulled back to clean * Prevent paraphimosis

Care of Perineal Area-Female

* Clean from front to back * Clean anal area last * Do not clean from back to front

Behavioral Responses to Pain

* Clenching the teeth, facial grimacing, holding or guarding the painful part, and bent posture are common indications of acute pain * Chronic pain affects a patient's activity * Lack of pain expression does not indicate that a patient is not experiencing pain

Learning Needs Older Adults

* Cognitive and sensory changes are challenges for teaching older adults * During assessment, the nurse needs to determine additional needs for teaching and limitations of the older adult in their capability to learn * Learn at a slower rate * Difficulties processing multiple bits of information at one moment

Assessment

* Collect data that can be used to identify client needs that can be managed or treated with nursing care Objective vs Subjective * Objective - What you assess, see, vitals * Subjective - What the patient tells you Vital signs * Temperature * Pulse * Respirations * Blood Pressure * Pain * Oxygen Saturation

Safety Guidelines for Nursing Skills

* Communicate clearly with members of the health care team * Assess and incorporate the patient's priorities of care and preferences * Use the best evidence when making decisions about your patients care

Purposes of the Medical Record

* Communication * Legal documentation * Reimbursement * Education * Research * Auditing/monitoring

Clinical Information Systems

* Computerized provider order entry (CPOE) Clinical decision support systems (CDSSs) * Used to support decision making

2015 American Heart Association CPR update...

* Continues to be C-A-B * It used to be follow your ABC's: airway, breathing and chest compressions. * Now, Compressions come first, only then do you focus on Airway and Breathing * Keep compression rate at least 100 minute for all persons * Keep compression depth of between 2-2.4 in chest for adults and children, and about 1.5 inches for infants * Allow complete chest recoil after each compression * Minimize interruptions in CPR, except to use an AED or to change rescuer positions * Do not over ventilate

Range of Motion

* Contractures: develop in joints not moved periodically through their full ROM * Neck, shoulder, elbow, forearm, wrist, finger and thumb, hip, knee, ankle and foot, and toes

4th Priority Self-Esteem

* Control * Competence * Positive regard * Acceptance/worthiness

Nursing Assessment Questions: Pain Management

* Current pain: (Modify for patients age, cognitive ability, culture, language, and other factors. * P - Palliative or Provocative factors * Q - Quality - Describe pain - What does it feel like? * R - Relief measures. What makes it better? * S - Severity - What is the worst pain in past 24 hours? * What is the average of pain you have had in past 24 hours? * T - Timing - Is pain constant, intermittent, or both? * U - Effect of pain - How does this affect you? Your family? Do you have the help you need?

Disease processes to consider:

* Cystitis (inflammation of bladder), pyelonephritis (inflammation of kidneys) * Diabetes Mellitus * Diabetes Insipidus * Renal calculus (kidney stones) * Muscular abnormalities * Benign prostatic hypertrophy (BPH) Renal disease: * Pre-renal, renal, or posy renal * EDRD (uremic syndrome) * Hemodialysis * Peritoneal dialysis * Organ transplantation

Reproductive system Older Adult

* Decreased estrogen causes vaginal dryness

Neurological system Older Adult

* Decreased number of neurons * Response rate slows

Gastrointestinal system and abdomen Older Adult

* Decreased output of acid in the stomach * May be an increased risk of constipation

Polypharmacy

* Definition: when a patient takes two or more medications to treat the same illness, takes two or more medications from the same chemical class, uses two or more medications with the same or similar actions to treat several disorders simultaneously, or mixes nutritional supplements or herbal products with medications * Taking over-the-counter (OTC) medications frequently, lack of knowledge about medications, incorrect beliefs about medications, and visiting several health care providers to treat different illnesses.

Healthcare Team

* Dentist * Dental Hygienist * Oral surgeon * Periodontist * Nurse * Doctor * Dietician * CNA * Endodontist * OBGYN * Radiologist * Pediatrician * Oncologist * Pharmacist

Postoperative Nursing Diagnosis and Planning

* Determine status of preoperative diagnosis * Revise or resolve preoperative diagnosis; identify relevant new diagnoses * Goals and outcomes: * Patient's incision remains closed and intact * Patient's incision remains free of infectious drainage * Patient remains afebrile * Setting priorities * Teamwork and collaboration

Knowing the Patient

* Develops over time * The core process of clinical decision making Aspects of knowing include * Responses to therapy, routines, and habits * Coping resources * Physical capacities and endurance

Alterations in urinary elimination

* Dysuria Altered amount * Oliguria: low output * Anuria: no output * Polyuria: increased output * Enuresis: night time incontinence * Urinary tract infection (females more susceptible) * Urinary obstruction (stones, tumor, scar tissue) * Urinary diversion

Administering Injections

* Each injection route differs based on the types of tissues the medication enters Before injecting, know: * The volume of medication to administer ** * The characteristics and viscosity of the medication ** * The location of anatomical structures underlying the injection site ** * If a nurse does not administer injections correctly, negative patient outcomes may result.

Privacy, Confidentiality, and Security Mechanisms

* Electronic documentation has legal risks * Most security mechanisms for computerized information systems use a combination of logical and physical restrictions to protect information * Physical security measures include placing computers or filer servers in restricted areas or using privacy filters for computer screens visible to visitors or others without access

Nightingale's Environmental Theory

* Environment as the focus of nursing care * Grand theory

Institutional Resources: Ethics and Values

* Ethics committees are usually multidisciplinary and serve several purposes: education, policy recommendation, and case consultation * Any person involved in an ethical dilemma, including nurses, physicians, health care providers, patients, and family members, can request access to an ethics committee

How to Assess a Wound

* Etiology - what caused this wound? * Time since onset * Treatment history * Wound location * Wound bed - slough, granulation, eschar * Changes in wound - bigger smaller? * Peri-wound-maceration, callus, dry, excoriation * Is there pain? * Dry or wet? * Picture - capture a ruler with date Measure - length head to toe - perpendicular - depth, tunnels and undermining * Temperature * Odor

Preoperative Evaluation

* Evaluate whether the patient's expectations were met with respect to surgical preparation * During evaluation, include a discussion of any misunderstandings, so patient concerns can be clarified * When patients have expectations about pain control, this is a good time to reinforce how pain will be managed after surgery

Trends in Nursing

* Evidence-based practice * Quality and Safety Education for Nurses (QSEN) * Impact of emerging technologies * Genomics * Public perception of nursing * Impact of nursing on politics and health policy

Trailing Zeros & Lack of Leading Zeros

* Example: 1.0 or _.1 Doctor prescribes 1.0mg of medication * The dot may not be seen and can result in patient receiving 10 times the dose of medication Trailing zeros may ONLY be used when * Demonstrating the level of precision of the value being reported * Laboratory results * Imaging studies reporting size of lesions * Catheter/tube sizes NEVER use in medication orders or other medication-related documentation

Shared Theories

* Explain a phenomenon specific to the discipline that developed the theory * Also known as a borrowed or interdisciplinary theory

Head and neck Older Adult

* Facial features * Visual acuity * Auditory changes Salivary secretion * Decreases * Dry mouth

Chain of Infection

* Infectious agent or pathogen * Reservoir or source for pathogen growth * Portal of exit * Mode of transmission * Portal of entry * Susceptible host

MRSA in a Hospital Setting

* MRSA can be spread by direct contact with infected wounds, usually by healthcare providers * Wash hands before and after care with each patient! * Some people may have MRSA but not show signs or symptoms - they can still spread the infection

Guidelines for Quality Documentation

* Factual * Accurate * Complete * Current * Organized Timely entries are essential in a patient's ongoing care. Delays in documentation lead to unsafe patient care. Most health care agencies use military time. Document the following activities or findings at the time of occurrence: * Vital signs * Pain assessment * Administration of medications and treatments * Preparation for diagnostic tests or surgery, including preoperative checklist * Change in patient status and who was notified (e.g., physician, manager, patient's family) * Admission, transfer, discharge, or death of a patient * Treatment for sudden change in patient status * Patient's response to treatment or intervention

Continuing Care: Hospice

* Family centered care that allows patients to live with comfort, independence, and dignity while easing the pains of terminal illness * Focuses on palliative (not curative) care * Many hospice programs provide respite care, which is important in maintaining the health of the primary caregiver and family

Injections: Intramuscular

* Faster absorption than subcutaneous route * Many risks, so verify the injection is justified Needles * Very obese: 3 inches; use different route * Thin: 1/2 to 1 inch * Amounts: * Adults: 2 to 5mL can be absorbed * Children, older adults, thin patients: up to 2mL * Small children and older infants: up to 1mL * Smaller infants: up to 0.5mL * Assess the muscle before giving the injection * Properly identify the site by palpating body landmarks * Be aware of potential complications with each site * The site needs to be free of tenderness * Minimize discomfort * Insertion angle is 90 degrees * Flu shot is only one you don't check for blood return on ***

Opioid Epidemic in America

* Federal Response to the Opioid Epidemic * In response to the opioid crisis, HHS is focusing it's efforts on five major priorities: * Better addiction prevention, treatment and recovery services * Better targeting of overdose reversing drugs * Better data * Better pain management * Better research

Infection Control After Discharge

* Finish the prescribed antibiotics * Wash your hands often * Wash clothes and linens * Keep the wound covered until it is fully healed.

Acute Care Safety

* Fires * Electrical hazards * Seizures * Radiation * Seizures * Disasters

Dental Hygiene - Nursing

* First line of preventative care * Deal with: health history, assessments, patient complaints, and reporting findings * We build relationships with our patients and are able to spend more time with them. Use this connection wisely!

Florence Nightingale

* First practicing epidemiologist (health professionals who investigate patterns and causes of disease and injury in humans) * Organized first school of nursing * Improved sanitation in battlefield hospitals * Practices remain a basic part of nursing today.

What about flossing?

* Flossing is the mechanical removal of plaque (containing bacteria, food, acid) from between the teeth

Peplau's Interpersonal Theory

* Focus on interpersonal relations between nurse, patient, and patient's family * Phases: preorientation, orientation, working, resolution * Middle-range theory

Secondary and Tertiary Care

* Focus: Diagnosis and treatment of disease * Disease management is the most common and expensive service of the health care delivery system * Postponement of care by uninsured contributes to high costs Hospitals * Work redesign * Discharge planning * Intensive care * Psychiatric facilities * Rural hospitals

Orem's Self-Care Deficit Nursing Theory

* Focuses on patient's self-care needs * Goal is for patient to manage his or her health problems * Grand theory

If Nothing Else Remember

* Focusing on etiology will guide wound care * Blood flow is required for healing * If it is dry make it wet and if its wet make it dry * Chronic wounds can heal with proper wound care * Chronic wounds must be debrided * Dressings alone do not heal wounds * There is no such think as a small wound, the smallest of wounds in compromised patients can becomes devastating if appropriate wound care is not provided

Surgical Wounds

* Follow the surgeons preference * Typically keep covered with sterile dry gauze until drainage daily gentle washing * Drainage should resolve ~ 3-5 days postop * Monitor for s/s of infection Dehiscence (wound opening up) prevention * Abdominal binders * Prevent fall * Immobilizers - surgical wounds should be assessed every shift

Continuing Care

* For people who are disables, functionally dependent, or suffering a terminal disease Available within institutional settings or in the home: * Nursing centers or facilities * Assisted living * Respite care * Adult day care centers * Hospice

Stages of the Adult Sleep Cycle

* Four stages of NREM * Sleep cycle lasts 90 to 100 minutes * Sleep goes through stages 1 to 4, then reversal from 4 to 3 to 2, followed by REM

MDHHS webpage-Opioids

* From 1999 to 2016, the total number of overdose deaths involving any types of opioid increased more than 17 times in Michigan, from 99 to 1,699. Data from the Michigan Automated Prescription System (MAPS) reported 11.4 million prescriptions for painkillers in 2015 were written, about 115 opioid prescriptions per 100 people. * In 2016, 2356 people died of drug overdose, that was more than care accidents

Functional Changes

* Functional status in older adults includes the day-to-day activities of daily living (ADLs) involving activities within physical, psychological, cognitive, and social domains * Changes are usually linked to illness or to disease and degree of chronicity * Performance of ADLs (activities of daily living) is a sensitive indicator of health or illness * Occupational and physical therapists are your best resources for a comprehensive assessment

Dealing with Challenging behavior

* Gain rapport before starting. Ask! Touch is great! * Talk at eye level * Massage TMJ area and cheek to get them to relax * Don't assume someone who says they brushed their own teeth actually did. Look to see. * "No" means try again later.

Physical Examination: Surgery

* General survey * Head and neck * Integument * Thorax and lungs * Heart and vascular system * Abdomen * Neurological status * Diagnostic screenings: CBC, CMP, PT/PTT, M

Nursing Process: Planning: Infection Prevention and Control

* Goals and outcomes Common goals of care applicable to patients with infection often include the following: * Preventing exposure to infectious organisms * Controlling or reducing the extent of infection * Maintaining resistance to infection * Verbalizing understanding of infection prevention and control techniques (e.g., hand hygiene) Setting priorities * Establish priorities for each diagnosis and for related goals of care Teamwork and collaboration * Remember to plan care and include other disciplines as necessary

Michigan Response

* Good Samaritan Law passed in 2016- to promote people who have overdosed to seek medical treatment without fear or prosecution * Behavioral health treatment locator The medications used to help with opioid use disorder treatment are: * methadone * buprenophome, and * naltrexone * Trained prescribers, familiar with these drugs guide the treatment plan

Documentation in the Long-Term Health Care Setting

* Governmental agencies are instrumental in determining standards and policies for documentation * Documentation in the long-term care setting supports as interprofessional approach to the assessment and planning process for all patients

Wear PPE when Treating MRSA Patients

* Gowns and Gloves will help to keep you from getting infected * Following these precautions will also help to minimize the risk that you will transfer the MRSA infection to other patients

Metric Specifics

* Gram = g or gm * Liter = 1 or L Use lowercase letters for abbreviations for other units: * Milligram = mg * Milliliter = mL Convert fractions to decimals * 500mg or 0.5g but NOT 1/2g * 10mL or 0.01L, but NOT 1/100L

Types of Theory

* Grand: Broad in scope, complex (most abstract) * Middle-range: Limited in scope and less abstract * Practice: Narrow in scope and focus * Descriptive: Describe phenomena and identify circumstances in which phenomena occur * Prescriptive: Address nursing interventions for a phenomenon, guide practice change, and predict the consequences (least abstract)

The Shift to Electronic Documentation

* HITCH established provisions to promote the meaningful use of health information technology (HIT) to improve the quality and volume of health care * Experts believe that implementing EHRs across the health care delivery system will decrease costs and improve the quality of patient care * Difference between EHR and EMR * EHR attributes, components, and advantages

Outcomes Research

* Helps patients, health care providers, and those in health care policy make informed decisions on the basis of current evidence * Typically focuses on the benefits, risks, costs, and holistic effects of a treatment on patients * Outcomes must be observable or measurable

Chest Tubes

* Hemothorax * Pneumothorax * Pleural Effusion

5th Priority Self-Actualization

* Hope

Drugs and Their Effects on Sleep

* Hypnotics-Interfere with reaching deeper sleep stages * Provide only temporary (one week) increase in quantity of sleep * Eventually cause "hangover", excessive drowsiness, confusion, decreased energy * Antidepressants and Stimulants * Suppress REM sleep, decrease total essleep time * Alcohol-sleeps onset of sleep, reduces REM sleep, awakens person during noc and causes difficulty returning to sleep. * Caffeine - prevents falling asleep, interfere with REM sleep, causes person to awaken during noc * Opiates and Anticonvulsants - interfere with REM sleep and cause daytime drowsiness * Diuretics - nighttime awakenings caused by nocturia * Nicotines - decreases total sleep time, decreases REM sleep time, causes awakening from sleep, causes difficulty staying asleep

Restorative and Continuing Care

* IADLs (Instrumental Activities of Daily Living) * ROM exercise * Walking

Medication Administration Parenteral (cont'd)

* If two medications are compatible, they can be mixed in one injection if the total dose is within accepted limits, so the patient receives only one injection at a time Mixing medications * Mixing medications from a vial and ampule * Prepare medication from the vial first * Use the same syringe and filter needle to withdraw medication from the ampule * Mixing medications from two vials

Nursing Diagnosis

* Impaired Tissue/skin integrity * Risk for infection * Risk for injury * Delayed surgical recovery * Deficient knowledge * Anxiety/depression * Acute & chronic pain * Disturbed body image * Imbalanced nutrition: less than body requirements * Ineffective peripheral tissue perfusion * Impaired physical mobility

Contemporary Influences

* Importance of nurses' self-care Changes in society lead to changes in nursing: * Affordable Care Act (ACA) * Rising health care costs * Demographic changes * Medically underserved

Ethic of Care

* In any patient encounter a nurse needs to know what behavior is ethically appropriate * An ethic of care is unique so professional nurses do not make professional decisions based solely on intellectual or analytical principles * Instead, an ethic of care places caring at the center of decision making

Critical Thinking: Sleep

* In the case of sleep, integrate knowledge from nursing and disciplines such as pharmacology and psychology * Use personal experience * Professional standards

Educating Older Adults

* Inadequate health literacy disproportionately affects older adults in the United States, causing misunderstanding of health information and subsequent nonadherence * Nurses must use more than words when teaching older adults * Assist in selecting, understanding, and using health-related information about medications

Restorative Care: Rehabilitation

* Includes physical, occupational, and speech therapy, and social services * Begins on admission * Focuses on preventing complications * Maximizes patient function and independence.

Addressing the Health Concerns of Older Adult

* Increase the proportion of older adults who receive diabetes self-management benefits * Increase the proportion of the health care workforce with geriatric certification

Diabetes and Your Mouth

* Increased inflammatory response * Sugar fuels bacteria * Rise in dental decay activity * Periodontitis and diabetes have a cyclic relationship

Implementation: Care of Surgical Patients

* Informed consent: legal issue Preoperative teaching: * Reasons for preoperative Instructions and exercises; time of surgery * Postoperative unit and location of family during surgery and recovery; anticipated postoperative monitoring and therapies * Surgical procedures and postoperative treatment; postoperative activity resumption * Patient verbalizes pain relief measures * Patient expresses feelings regarding surgery

Glomerulus

* Initial site of filtration of the blood * Beginning of urine formation Glomerulus capillaries filter the following into Bowman's capsule: * Water * Glucose * Amino acids * Urea * Creatinine * Major electrolytes * Large proteins do not filter through the glomerulus * Presence of large proteins (proteinuria) in the urine is a sign of glomerular injury * Filters approx. 125 mL of filtrate per minute * Only 1% of filtrate is excreted as urine, the remaining is reabsorbed by the plasma Key Points: * Kidneys play a major role in fluid and electrolyte balance * Large proteins present in urine are a sign of glomerular injury

Phases Healing

* Injury - hemorrhage/hemostasis Inflammatory phase (0-6 days) - * Clotting, Immune system response, healing triggered * Edema, erythema, inflammation, pain * *Chronic/non-healing wound cannot get past this stage **** KNOW THIS **** Proliferative Phase (4-24 days) * Granulation tissue fills in wound from the bottom up * Epithelial cells migrate inward to cover wound * The wound is actively healing in this stage Remodeling (21 days to 2 years) * Begins when wound has re-surfaced * Scar tissue forms * Considered healed but skin has poor strength

Research Process

* Institutional Review Board (IRB) Human Research Terminology - Informed consent means * Participants receive full and complete information * They can understand the information * They have free choice to participate * They understand how their confidentiality will be kept * Your signature only means that you saw them sign the form * Always document what you tell them/how Confidentiality

Describing Wound Depth *KNOW THESE*

* Intact skin - epithelial intact but shows signs of tissue damage * Superficial - only through epidermis * Partial thickness - extends into dermis * Full thickness - any tissue loss below dermis * Unknown - skin may be intact or covered with slough or eschar

Integrate the Evidence

* Integrating evidence: teaching, assessment or documentation tools, clinical practice guidelines, policies and procedures * Applying evidence: consider setting, staff support, scope of practice, resources * A pilot study may be conducted when evidence is not strong enough to apply in practice

Cath Lab Crew

* Interventional Cardiologists * Physician Assistants and Nurse Practitioners * Cath Lab Nurses * Radiologist Technicians * Surgical Technicians * Anesthesiologists

Incontinence

* Involuntary leakage of urine * Can be temporary, permanent, continuous or intermittent * Urge incontinence: urge to urinary but cannot keep from urinating long enough to reach toilet * Stress incontinence: muscles around the urethra become weak and small amounts of urine may leak spontaneously * Mixed

Relaxation Therapy

* Involves arousal reduction * Progressive relaxation * Passive relaxation * Limitations

Nature of Pain

* Involves physical, emotional, and cognitive components * Pain is subjective and individualized * Reduces quality of life * Not measurable objectively * May lead to serious physical, psychological, social and financial consequences

The Nursing Care Plan

* Is a tool for providing current information for client care and it helps to communicate the planned care to the health care team * Helps ensure continuity of care Consists of three components * Client problems (nursing diagnoses) * Expected outcomes/goals * Interventions (nursing care) Can use NANDA-I, NIC and NOC systems to develop a care plan

Treating MRSA Without Spreading the Infection

* Isolation Rooms * PPE for Hospital Personnel * Wear gloves when performing wound care on infected areas * Nurses and Doctors should wash their hands before and after working with an infected person * Treatments include antibiotics that can kill staph infections and sometimes surgery

How do you prevent a MRSA infection?

* Keep wounds and scrapes covered until they're healed * Don't pick at scabs, blisters, etc. * WASH YOUR HANDS! * Don't share personal items like towels and razors

Standards: Informatics and Documentation

* Know standards of your organization Documentation needs to conform to standards of the National Committee for Quality Assurance (NCQA) and TJC to maintain institutional accreditation and minimize liability * Assessment * Nursing process * Medical record components

Critical Thinking and Medication Administration

* Knowledge Experience * Psychomotor skills (how to) Attitudes * Be disciplined; take your time. * Be responsible and accountable Standards * Ensure safe nursing practice

Critical Thinking: Pain Management

* Knowledge of pain physiology and the many factors that influence pain help you manage a patient's pain * Critical thinking attitudes and intellectual standards ensure the aggressive assessment, creative planning, and thorough evaluation needed to obtain an acceptable level of patient pain relief, while balancing treatment benefits with treatment associated risks

To safely and accurately administer medications, you need knowledge related to:

* Legal aspects of health care * Pharmacology * Pharmacokinetics * Life sciences * Pathophysiology * Human anatomy * Mathematics

State Statutory Issues in Nursing Practice

* Licensure * Good Samaritan Laws * Public Health Laws * The Uniform Determination of Death Act * Autopsy * Death with Dignity or Physician-Assisted Suicide

Individual Risk Factors

* Lifestyle * Impaired mobility * Sensory of communication impairment * Lack of safety awareness

Continuing Care: Assisted Living

* Long-term care setting * Home environment * Greater resident autonomy * No fee caps

Urinary System Older Adult

* Loss of sphincter control

3rd Priority Love and Belonging

* Maintain support systems * Protect from isolation

A Few Key Points of Aspiration Precautions

* Make staff aware (ex: sign at HOB) * Keep HOB elevated when patient is eating * Assist patient with feeding * Serve appropriate diet * Assess for coughing, choking, gagging, pocketing of food * Provide verbal coaching * Provide rest periods

Dressing Types

* Many brands and products available - Get familiar with 1 or 2 of each types Primary dressing - placed into wound bed * Antimicrobial dressing - be sure that they are broad spectrum: silver (Ag), (KNOW THIS) PHMB * Occlusive - padded, some are medicated, prevents fluids from getting in and out * Transparent film - semi-permeable * Hydrogel * Collagen * Hydrocolloid Secondary dressing: Absorbent-Gauze and foam Secure * Wrap or tape to cover and secure Other * Enzymatic - honey, Santyl (debriders) (USE FOR DRY WOUNDS) * Compression wraps * Betadine to eschar and gangrene - drying * Also found in dressings as antimicrobial: 1-2 weeks Try to avoid * Wet to dry - * All dressings should be moist when removed * Pain and removal of healthy tissue * Dries wound bed * Debridement is better * Topical antibiotic ointments - not broad spectrum

Hyperbaric Oxygen Therapy

* Many treatments used throughout health care Primary use is for very specific wound healing * *Diabetic ulcers > Wagner grade 3 * Chronic Osteomyelitis * Wounds over a radiated field * Compromised skin grafts and flaps * Amputation dehiscence * Crush injury * Gas gangrene * Necrotizing fasciitis * High oxygen concentration in blood and tissues * Promotes angiogenesis

Risks in the Health Care Agency

* Medical errors TJC and CMS "Speak Up" campaign * Advocates patients to speak up for themselves * National Quality Forum mission * Environmental Risks Specific risks to a patient's safety within the health care environment * Falls * Patient-inherent accidents * Procedure-related accidents * Equipment-related accidents

Document in the Home Health Care Setting

* Medicare has specific guidelines for establishing eligibility for home care * Medicare guidelines for establishing a patient's home care cost reimbursement serve as the basis of documentation by home care nurses * Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance * Nurses need to document all their services for payment

Medication Administration Injections: Subcutaneous

* Medication is placed in loose connective tissue under the dermis * Absorption is slower than with IM injections * Administering low-molecular-weight heparin requires special considerations * A patient's body weight indicates the depth of the subcutaneous layer * Choose the needle length and angle of insertion based on the patient's weight and estimated amount of subcutaneous tissue. * Upper arm, upper back, hips, abdomen, and thighs *****

Additional Factors Regarding Oral Health

* Medications: Can cause dry mouth, bleeding, impaired wound healing (which can have implications on oral health), dry mouth (xerostomia), gingival hyperplasia * Stress: can cause grinding/clenching, recession, oral neglect, gum problems, more!

Physiologic Hazards of Mobility

* Metabolic * Respiratory * Cardiovascular * Musculoskeletal * Integumentary * Elimination * Psychosocial * Developmental

What is MRSA?

* Methicillin-Resistant Staphylococcus Aureus * Caused by a certain bacteria that is resistant to many antibiotics * populations at risk for MRSa include, student athletes, diabetics, and people with weakened immune systems * Symptoms include swollen and painful red bumps on the skin, warmness, pus and fever * If left untreated, the bacteria can lead to fatal bone and joint complications as it burrow further into the body

Nursing Knowledge Base: Factors Influencing Mobility-Immobility

* Mobility refers to a person's ability to move about freely, and immobility refers to the inability to do so * Bed rest Effects of muscular deconditioning * Disuse atrophy * Physiological * Psychological Hit to self-esteem to not be able to take care of yourself Be respectful * Social In nursing/assisted living, can't live on their own anymore

The Twentieth Century

* Movement toward scientific, research-based practice and defined body of knowledge Nurses assumed expanded and advanced practice roles * 1906: Mary Adelaide Nutting, first professor of nursing at Columbia University * Army and Navy Nurse Corps established * 1920s: Nursing specialization began

Expectations for surgery

* NPO after midnight the night before, but plain tap water is OK up to 2 hours before arrival to hospital * Hibiclens body wash-shower the night before and morning of surgery * No lotion, powder, or deodorant * Nothing metal in the OR - no rings, piercings, watches, or jewelry * No finger or toenail polish * Bring no medications or valuable to the hospital * Females between age of 10-55 will get a urine pregnancy test before surgery unless they have had a hysterectomy

The Integrative Nursing Role: Complementary Alternative Therapies

* Need to encourage dialogue about the use of CAM * Responsibility to understand the benefits of therapies that encourage active patient participation * Multiple practitioner approach: integrative * Holistic in nature * Follow Nurse Practice Act scope of practice * Work closely with patient

Normal Sleep Requirements and Patterns

* Neonates - 16 hours a day * Infants - 8 to 10 hours at night for a total of 15 hours per day * Toddlers - total 12 hours a day * Preschoolers - 12 hours a night * School Age - 9 to 10 hours * Adolescents - 7 1/2 hours * Young Adults - get 6 to 8 1/2 hours * Middle and Older Adults - total number of hours declines

Melatonin

* Neurohormone produced in the brain that helps control circadian rhythm and promote sleep * Recommended dose is 0.3 mg to 1 mg taken 2 hours before bedtime * Ramelton, a melatonin receptor agonist, is effective in improving sleep, is safe for short and long term use Ω

Nursing Assessment: Bowel Elimination

* Normal habits Color * Ex: Melana, black tarry, gray Consistency * Ex: Liquid, loose, formed, soft * Amount * General abdominal assessment

Confidentiality: Informatics and Documentation

* Nurses are legally and ethically obligated to keep all patient information confidential * Nurses are responsible for protecting records from all unauthorized readers * HIPAA requires that disclosure or requests regarding health information be limited to the minimum necessary

Gingivitis: Poor Plaque Control

* Red * Bleeding * Puffy * Reversible

Physiological Changes

* Older adult's concepts of health generally depend on personal perceptions of functional ability General survey * Begins during initial nurse-patient encounter * Quick, but careful, head-to-toe scan * Eye contact and facial expression * Presence of universal aging changes

Healing Impairment Factors

* Older age * Poor nutrition * Tobacco use - nicotine constricts blood vessels * Alcohol abuse * Pressure/friction/moisture - not just pressure ulcers * Medications - immunosuppressant, chemotherapy, corticosteroids Manifestation of other disease * Impaired blood flow * Impaired immunity * Diabetes, Cancer, etc. * Infection Biofilm - Bacterial burden on wound * Can't always be seen * Stalls healing * Required debridement - Debridement can be surgical (scraped out), whirlpool

Medication Administration

* Oral = by mouth Topical * Skin, nasal, eye, ear, vaginal, rectal * Inhalation Irrigation * Given within a cavity, such as a rectum/vaginal * Parenteral * Injection

Elderly and Oral Health

* Oral health can be a sign of cognitive decline

Conduction System

* Originates with the SA node or pacemaker, transmitted to the AV node, bundle of his and Purkinje fibers Sympathetic nervous system * Increases the rate of impulse generation and impulse transmission and innervates all parts of atria and ventricle Parasympathetic system * Decreases the rate and innervates atria, ventricles, sinoatrial and atrioventricular nodes

Cardiovascular Changes

* Orthostatic hypotension * Increased cardiac workload * Thrombus formation

Cardiovascular changes with immobility

* Orthostatic hypotension * Increased cardiac workload * Thrombus formation

Establishing Outcomes/Goals

* Outcomes/Goals are desired end results of nursing care for each client problem Outcomes/goals must be realistic, measurable, acceptable to the client, and include a time-frame * May be short term and reached in an hour, day, or week * May be long term in a few weeks or months * Example: Skin will be free of breakdown during hospitalization

Assessment of a Stoma

* Output (type and amount) * Surrounding skin * Stoma color * Intactness of pouch

Scientific Knowledge Base: Oxygenation

* Oxygen is needed to sustain life * Blood is oxygenated through ventilation, perfusion, and transport of respiratory gases * Neural and chemical regulators control the rate and depth of respiration

Why Do We Care About Oral Health as we age?

* Pain * Loss of oral function * Difficulty eating * Poor nutrition * Poor taste * Difficulty speaking and interacting with others * Systemic infection * Esthetic Concerns

Nursing Process and Pain

* Pain management needs to be systematic * Pain management needs to consider the patient's quality of life Clinical guidelines are available to manage pain: * American Pain Society * Sigma Theta Tau * National Guidelines Clearinghouse

Medication Administration Parenteral

* Parenteral = Injection into body tissues * Invasive procedure that requires aseptic technique * Risk of infection * Skills needed for each type of injection * Effects develop rapidly, depending on the rate of medication absorption Syringes * Luer-Lok * Non-Luer-Lok * Sizes from 0.5 to 60mL * Larger sizes to administer IV medications and to irrigate wounds or drainage tubes * May be prepackaged with a needle attached, or- * You may need to change a needle

What are the Nursing Roles in the Cath Lab?

* Patient assessment and preparation * Assist Physicians * Post-procedure care * Patient and Family Education

All medical records contain the following information

* Patient identification and demographic data * Existence of "Living Will" or "Durable Power of Attorney for Healthcare" documents * Informed consent for treatment and procedures * Admission data * Nursing diagnoses or problems and the nursing or interdisciplinary care plan * Record of nursing care treatment and evaluation * Medical history * Medical diagnoses * Therapeutic orders, including code status (provider order for "Do Not Resuscitate") * Medical and interdisciplinary progress notes * Physical assessment findings * Diagnostic study results * Patient education * Summary of operative procedures * Discharge summary and plan

Nursing as a Profession

* Patient-centered care Professionalism * Administer quality care * Be responsible and accountable Health care advocacy groups * Roberts Wood Johnson Foundation (RWJF) Future of Nursing: Campaign for Action * Institute of Medicine (IOM) publication on The Future of Nursing

Reliving Symptoms and Suffering

* Performing caring nursing actions that give a patient comfort, dignity, respect, and peace * Providing necessary comfort and support measures to the family or significant others * Creating a physical patient care environment that soothes and heals the mind, body, and spirit * Comforting through a listening, nonjudgemental, caring presence

Physical Hazards

* Physical hazards in the environment threaten a person's safety and often result in physical or psychological injury or death * Motor vehicle accidents Poison * Alcohol * Polypharmacy * Falls * Fire * Disasters

Variability Among Older Adults

* Physiological, cognitive, and psychosocial health * Levels of functional ability * Dependence vs. independence * Strengths and abilities

Healthy Gums Should Be

* Pink * Firm Tight * Stippled

Physiological Factors: Bowel Elimination

* Pregnancy: pressure, dietary supplements, fluid * Neurological Problems * Motor and sensory disturbances Intestinal pathology * Bowel obstruction: may have diarrhea or constipation * Ileus: absence of peristalsis * Crohn's disease: Inflammatory dx which may affect all GI tract * Ulcerative colitis: Inflammatory dx of colon * Hemorrhoids: dilated, engorged veins in the lining of the rectum * Cancer: blood in stool * Infectious diarrhea: fluid & electrolyte imbalances * C-diff * Medications * Laxatives, stool softness, narcotics, antibiotics * Surgical procedures * Anesthesia, immobility

Leininger's Culture Care Theory

* Theory of cultural care diversity and universality * Integrates patients' cultural traditions, values and beliefs into care plans * Middle-range theory

Patient Assessment and Preparation: Cath Lab

* Preparation nurses prepare the patient for the specific procedure that is getting performed * Educate patient on what the procedure entails Preparation includes: * Obtaining the vital signs * Need to be stable for them * Measure oxygen and heart rhythms * Fluid gives intravenously * Shake possible area of insertion * Hook patient up to EKG Telemonitor ASK ABOUT MEDICATIONS!! (and allergies, etc) * Especially diabetic medications such as metformin * Needs to be d/c 24-48 hours prior to catheterization * Metformin and dye used is very harsh on kidneys * Diabetic patients are already at an increased risk of kidney failure and when cathed under metformin * Main reason they use fluid NPO for 6-8 hours prior to procedure

Prescriber's Role: Medication Administration

* Prescriber can be physician, nurse practitioner, or physician's assistant * Orders can be written (hand or electronic), verbal, or given by telephone * The use of abbreviations can cause errors; use caution * Each mediation order needs to include the patient's name, order date, medication name, dosage, route, time of administration, drug indication, and prescriber's signature ****

Michigan: PDOAC

* Prescription Drug and Opiod Abuse Commission * Governor signed Executive Order establishing PDOAC in June 2016 * Statewide plan to "combat the severe and complex prescription drug and opioid abuse epidemic that faces our state"

Pressure Ulcers

* Pressure Wounds, Pressure sore, Decubitus ulcer, Bed sore * Found on boney prominences Pathogenesis * Tissue and skin between bone and external surface becomes compressed. * Pressure duration and intensity - Tissue ischemia - Blanching * Tissues die and wound forms

2019 National Hospital Safety patient goals

* Preventing surgical mistakes * Make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body * Mark the correct place on the patient's body where the surgery is to be done * Pause before the surgery to make sure that a mistake is not being made

Implementation: Health Promotion Immobility

* Prevention of work-related musculoskeletal injuries * Exercise * Bone health in patients with osteoporosis

Process of Wound Healing

* Primary intension - Edges are approximated * Minimal tissue loss * Suture/stapled * Clean surgical wounds and lacerations * Acute wounds * Fastest way to close wound Secondary intention * Wounds are left open to heal from the bottom * Wounds that are wider that they are deep * Dirty wounds * Chronic wounds * If a surgical wound opens it needs to heal from secondary intention

National Priorities Partnership

* Promote best practices * Promote prevention, treatment, and intervention practices for the leading causes of mortality * Ensure person - and family-centered care * Make care safer * Promote communication and care coordination * Make quality care affordable

Watson's Transpersonal Caring

* Promotes healing and wholeness * Rejects the disease orientation to health care * Places care before cure * Emphasizes the nurse-patient relationship

Interventions to Relieve/Prevent Retention

* Promoting urination * Fluid management: daily intake 1500 to 2000 mL * Enhancing stimulus to void * Privacy * Adequate time * Comfort * Using catheters * Catheterization * Folet Catheter * Straight Catheter * Suprapubic catheter * Three way catheter * Condom catheter * Managing urethral catheters * Maintaining comfort, patency * Relieving bladder spasms

2nd Priority Security

* Protection from injury * Promote feeling of security * Trust in nurse-client relationship

Continuing Care: Adult Day Care Centers

* Provide a variety of health and social services to specific patient populations who live alone or with family in the community * May be associated with a hospital or nursing home or may operate independently

Elimination System: Nursing Care Immobility

* Provide adequate hydration Serve a diet rich in fluids, vegetables, and fiber * If they can't get these naturally, they will in a supplement * Psychosocial changes * Developmental changes

Career Development (Cont.)

* Provider of care Advanced practice registered nurses * Clinical nurse specialist * Certified nurse practitioner * Certified nurse midwife * Certified registered nurse anesthetist * Nurse educator * Nurse administrator * Nurse researcher

Skeletal System

* Provides attachments for muscles and ligaments, protects vital organs, aids in calcium regulation * Provides leverage for mobility * Bones are long, short, flat, or irregular * Joints * Ligaments, tendons, and cartilage

Touch

* Provides comfort Creates a connection * Noncontact touch * Contact touch * Task-oriented touch * Caring touch * Protective touch

Nursing Process (ADPIE)

* Provides the structure for critical thinking, diagnostic reasoning, and clinical judgment * Composed of five interrelated phases - Assessment - Diagnosis - Planning - Intervention - Evaluation

Restorative Care: Home Health Care

* Provision of medically related services and equipment to patients and families in their homes for health maintenance, education, illness prevention, diagnosis and treatment of disease, palliation, and rehabilitation * Involves coordination of services * Focuses on patient and family independence * Usually reimbursed by government (such as Medicare and Medicaid in the United States), private insurance, and private pay.

Issues in Health Care Ethics

* Quality of life: Central to discussions about end-of-life care, cancer therapy, physician-assisted suicide, and Do Not Resuscitate (DNR) * Disabilities: Antidiscrimination laws enhance the economic security of people with physical, mental, or emotional challenges * Care at the end of life: Interventional unlikely to produce benefit of the patient * Health Care Reform: Facilitates access to care for millions of uninsured Americans

Cultivate a Spirit of Inquiry

* Question what does not make sense to you and what needs to be clarified * Gain evidence-based practice (EBP) knowledge and skills * Be committed to providing the best care possible * Use problem-and knowledge-focused triggers * Consider data gathered from a health care setting to examine clinical trends

Clinical Judgement in Nursing Practice

* Registered nurses (RNs) are responsible for making accurate and appropriate clinical decisions or judgements * Nurses must learn to question, wonder, and explore different perspectives and interpretations to find a solution that benefits the patient

Common Terms Used in Diet Orders:

* Regular, Diet as tolerated * Clear liquid * Full liquid * Cardiac * NAS: no added salt (4G sodium) * 2G sodium * Dysphagia (different levels see file in educat) * Low residue * Renal - dialysis * Renal - pre-dialysis * Neutropenic

Acupuncture

* Regulates or realigns vital energy (qi), which flows through channels in the form of a system of pathways called meridians * Effective for pain * Also used to treat other disorders with varying effectiveness

Sleep Regulation

* Regulation by a sequence of physiological states integrated by central nervous system (CNS) activity * Hypothalamus * Reticular activating system (RAS) * Homeostatic process (Process S)

Medication Errors

* Report all medication errors * Patient safety is top priority when an error occurs * Documentation is required * The nurse is responsible for preparing a written occurrence or incident report: an accurate, factual description of what occurred and what was done. * Nurses play an essential role in medication reconciliation

Integumentary System: Nursing Care Immobility

* Reposition every 1 to 2 hours Provide skin care * Always assess skin

Systems of Medication Measurement

* Require the ability to compute medication doses accurately and measure medications correctly Metric system (0 before the decimal only) ** * Teaspoon = 5mL ** * Tablespoon = 15mL ** * Ounce = 30mL ** * Most logically organized * Meter, liter, gram Household system * Most familiar to individuals * Disadvantage: inaccuracy Solution

Thorax and lungs Older Adult

* Respiratory muscle strength decreases * Increased risk of pneumonia * Anteroposterior diameter of thorax increases

Continuing Care: Respite Care

* Respite care provides short-term relief or "time off" for people providing home care to an individual who is ill, disables, or frail * Settings include home, day care, or health are institution with overnight care * Trained volunteers enable family caregivers to leave the home for errands or social time

Health Care-Associated Infections

* Results from delivery of health services in a health care facility Patients at greater risk for health care - associated infections (HAIs) * Multiple illnesses * Older adults * Poorly nourished * Compromised immune system * Remember make sure children with any communicable illnesses/disease are not in contact with immune compromised patients

Psychosocial Changes Older Adult

* Retirement * Social isolation * Sexuality * Housing and environment * Death

Nursing Knowledge Base: Medication Administration

* Safe administration is imperative * Nursing process provides a framework for medication administration Clinical calculations must be handled without error * Conversions within and between systems * Dose calculations * Pediatric calculations require special caution

Moving Patients

* Safety is first priority * Ask patient to help as much as possible * Determine if patient comprehends what is expected * Determine patient's comfort level * Determine if you need assistance in moving the patient

Calculus

* Saliva: rinses bacteria and acids out of the mouth and off the teeth, but the minerals contained in it also causes plaque to mineralize into calculus on the teeth * Dental calculus is hardened plaque * When plaque becomes calculus/tarter it can no longer be removed by floss

Nursing Process: Assessment Immobility

* See through the patient's eyes Mobility * Range of motion (ROM) Planes of the body * Sagittal * Cut in half left/right * Transverse * Cut in half top/bottom * Frontal * Cut in half front/back

Restorative Care

* Serves patients recovering from acute or chronic illness/disability * Helps individuals regain maximal function and enhance quality of life

Planning

* Set goals/outcomes and plan nursing care. Collaboration with the client is essential to successful planning

Cardiovascular disease: Oral Health

* Several possible pathways but inflammation due to bacteria a constant factor. Mouth bacteria is the leading factor to infections in artificial joints/valves

SBAR

* Situation * Background * Assessment * Recommendation (S) Situation: What is the situation you are calling about? * Identify self, agency, and patient name * What is going on with the patient that is a cause for concern. A concise statement of the problem (B) Background: What is the clinical background information that is pertinent to the situation? * Admitting diagnosis and date of admission * List of current medications, allergies, IV fluids, etc * Most recent vital signs * Lab results: provide the date and time test was done and results of previous tests for comparison * Medical history * Recent clinical findings * Advance Directive/code status (A) Assessment: Share the results of your clinical assessment * What are the clinician's findings? * What is the analysis and consideration of options? * Is this problem severe or life threatening? (R) Recommendation: What do you want to happen and by when? * What action/recommendation is needed to correct the problem? * What solution can you offer the physician? * What do you need from the physician to improve the patient's condition? * In what time frame do you expect this action to take place?

Theory-Based Nursing Practice

* Theory generates nursing knowledge for the use in practice, thus supporting evidence-based practice (EBP). Nursing knowledge * Is derived from basic and nursing sciences, experience aesthetics, nurses' attitudes, and standards of practice * Goal of nursing knowledge: To explain the practice of nursing as different and distinct from the practice of medicine, psychology, and other health care disciplines

Nursing Foundation

* Theory is the foundation for the art and science of nursing * Theory, research, and practice are bound together in a continuous interactive relationship

Why do we need SBAR?

* Situation: poor communication errors * Background: Training on communication styles varies among clinicians * Hierarchy -> lack of assertiveness * Distractions -> missing information * Assessment: we need a new communication style that all healthcare professionals can use * Recommendation: SBAR is a simple tool that has effectively improves communication in other settings and has been effectively applied to healthcare Physician engagement * SBAR provides answers to 3 important questions * What is the problem? * What do you need me to do? * When do I have to respond? * Similar to the SOAP model Provides answers to physicians' three main questions * What is the problem? * When do you need me to do? * When do I have to respond? * Standardized approach that promotes efficient transfer of key information * Helps create an environment that allows clinicians to express their concerns Clinician to Clinician * Provides direction * Provides opportunity for improved care planning

Postoperative Assessment

* Skin integrity and condition of the wound * Metabolism * Genitourinary function Gastrointestinal function * Paralytic ileus * Comfort

Spiritual Caring

* Spiritual health is achieved when a person can find a balance between his life values, goals, and belief symptoms and those of others * Spirituality offers a sense of intrapersonal, interpersonal, and transpersonal connectedness

Critical Thinking: Patient Safety and Quality

* Successful critical thinking requires a synthesis of knowledge, experience, critical thinking attitudes, and intellectual and professional standards * Ongoing process

Sources of evidence

* Textbooks * Articles from nursing and health care literature * Quality Improvement and risk management data * Standards of care * Infection control data * Benchmarking, retrospective, or concurrent chart reviews * Clinician's expertise

Informatics and Information Management in Health Care

* The Technology Informatics Guiding Education Reform (TIGER) is focused on better preparing the clinical workforce to use technology and informatics to improve the delivery of patient care * TIGER transformed to Healthcare Information and Management Systems Society (HIMSS) * Competence in informatics is not the same as computer competency

Reflection: Critical Thinking

* The ability to act on the basis of critical thinking comes with experience * Turning over a subject in the mind and thinking about it seriously is reflection * Reflection is not intuitive

Implementation

* The action phase of the nursing process The phase in which you implement nursing interventions * Interventions may be called nursing orders, nursing activities, or nursing approaches * Example: Turn client every two hours * Assess skin for breakdown

What's in a toothbrush?

* The best kind of toothbrush to choose is a soft toothbrush. Not only does it clean more effectively but it allows for less unnecessary wear on gum tissue and tooth enamel. Factors to consider when choosing a toothbrush are: * Size * Bristle texture and length Remember: brush morning and night for 2 minutes!

Evaluation

* The final phase in which the planned outcomes of nursing care are measured against the actual outcomes. Outcomes can be met, partially met, or unmet. * If needs not met, they need to be evaluated and a new care plan needs to be created

Scientific Method

* The foundation of research * The most reliable and objective means of acquiring and conducting research and gaining knowledge * A step-by-step process to ensure that findings from a study are valid, reliable, and generalizable to a similar group of subjects

Nephron

* The functional unit of the kidney * Forms urine Composed of: * Glomerulus * Bowman's capsule * Proximal convoluted tubule * Loop of Henle * Distal tubule * Collecting duct

Establishing Priorities

* The nurse must decide the priorities of nursing diagnosis (ranked in order of importance) * Maslow's hierarchy of needs is a helpful tool for thinking about priorities (refer to next slide) * Give top priority to basic survival needs when your client has a threat to physiological integrity

Intervention

* The phase in which you execute the care plan. Interventions include counseling, providing comfort measures, teaching, offering emotional support, managing the environment and assessing

Nursing Scope of Practice

* The practice of nursing includes the care/treatment and counsel/teaching of patients who (1) are experiencing changed in the normal health processes or (2) require assistance in the maintenance of health and the prevention or management of illness, injury, or disability. * A registered professional nurse (RN) is an individual (1) who is licensed to engage in the practice of nursing and (2) whose scope of practice includes the teaching, direction, and supervision of less skilled people who perform nursing activities.

Interprofessional Communication Within the Medical Record

* The quality of patient care depends on your ability to communicate with other members of the health care team * When a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or omissions in care often occur

The Six "Rights" ***

* The six rights of medication administration contribute to accurate preparation and administration of medication doses 1. Right medication 2. Right dose 3. Right patient 4. Right route 5. Right time 6. Right documentation

Respiratory Gas Exchange

* The thickness of the alveolar capillary membrane affects the rate of diffusion * Oxygen transport = Lungs + cardiovascular (CV) system * Hemoglobin carries O2 and CO2 * Carbon diaoxide transport

Nursing Informatics

* The use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research * Nursing informatics is also recognized as a specialty are of nursing practice

Managing Stress

* The work of professional nursing is difficult as you see patients endure suffering from disease and painful therapies and as you try to manage care responsibilities in busy, fast-paced work settings * Stress over prolonged periods or when extreme an lead to poor work productivity, impaired decision making and communication, and reduce ability to cope with clinical situations

Abbreviations for Drug Names

* These can get messy, as there are many abbreviations for drugs that are very similar * Hard to interpret the correct medication * Write out the full/complete drug name Examples * HCl: meant to represent hydrochloric acid or hydrochloride, can be mistaken as potassium chloride * H may look like K * DPT: meant to represent Demerol-Phermegan-Thorazine, can be mistaken as Diphtheria-Pertussis-Tetanus (TDAP) vaccine

Example of a Nonverbal way to Facilitate a Behavior:

* They may drink from their cup when you touch the cup lightly or move it an inch or two on the tray instead of you giving them a command to drink

How does MRSA Spread?

* Through contact with infected people or things * Contact with infected wounds * Sharing towels or razors * Lives up to 53 days on environmental surfaces

Assessment: Sleep

* Through the patient's eye Sleep assessment * Sources for sleep assessment = Patient, family * Tools for sleep assessment Sleep history * Description of sleeping problems, usual sleep pattern, current life events, physical and psychological illness, emotional and mental status, bedtime routines, bedtime environment, behaviors of sleep deprivation Description of sleeping problems * Conduct a more detailed history when a patient has a sleep problem. This ensures that you provide appropriate therapeutic care * Open-ended questions help a patient describe a problem more fully * Ask specific questions related to the sleep problem * Usual sleep pattern * Have patients describe their normal sleep patterns * Physical and psychological illness * Current life events * Emotion and mental status * Bedtime routines * Bedtime environment * Behaviors of sleep deprivation

Evaluation: Sleep

* Through the patient's eyes Patient outcomes * Determine whether expected outcomes have been met * Are you able to fall asleep within 20 minutes of getting into bed? * Describe how well you sleep when you exercise * Does the use of quiet music at bedtime help you to relax? * Do you feel rested when you wake up?

Assist Physicians: Cath lab

* Throughout the procedure the nurse monitors, reports and obtains vital signs. Making sure they are stable Cath Lab nurse administers medications according to physician's instructions * The can be before, during, or after the procedure * In the care of an emergency, be prepared to intervene provide life-saving techniques

Maintaining Patient's Rights: Medication Administration

* To be informed about a medication * Tor refuse a medication * To have a medication history * To be properly advised about experimental nature of medication * To receive labeled medications safely * To receive appropriate supportive therapy * To not receive unnecessary medications * To be informed if medications are part of a research study

Why Do I Have To Write A Care Plan?

* To begin to think like a nurse (here it is again..."critical thinking") * To gain an understanding od realistic goals/outcomes * To learn possible interventions for different diagnosis * To provide yourself with a framework for the care you provide in clinic

Health Promotion and Maintenance: Physiological Concerns

* To increase the desire for older adults to participate in health promotion, use an individualized approach, taking into account a person's beliefs about the importance of staying healthy and remaining independent * Limitations in ADLs limit the ability to live independently * Most older adults want to remain independent and prevent disability * Heart disease * Cancer * Chronic lung disease * Stroke * Smoking * Alcohol abuse * Dental problems * Exercise * Falls - Increased risk * Sensory impairments * Nutrition * Pain * Medication use

Civil and Common Law Issues in Nursing Practice

* Torts - civil law Intentional * Assault * Battery * False imprisonment Quasi-intentional torts * Invasion of privacy * Defamation of character * Slander * Libel * Unintentional torts * Negligence * Malpractice

Intraoperative Surgical Phase

* Transport to the operating room Preoperative (holding) area * IV placement * Anesthesia assessment * Admission to the operating room Nursing process * Assessment * Nursing diagnosis * Planning

Benzodiazepines

* Treatment of choice for insomnia because of improved efficacy and safety of use * Ambien - low dose for only 2-3 weeks * Cause relaxation, anti anxiety, and hypnotic effects by facilitating the action of CNS neurons to suppress responsiveness to stimulation, thereby decreasing levels of arousal * Warn patients not to take more than prescribed dose `* Do not use in elderly, causing respiratory depression, next day sedation, rebound insomnia, impaired motor functioning and coordination-increasing risk of falls

Challenges to Health Care

* Uninsured patients * Reducing health care costs while maintaining high-quality care for patients * Improving access and coverage for more people * Encouraging healthy behaviors * Earlier hospital discharges result in more patients needing nursing homes or home care

Minimizing Patient Discomfort

* Use a sharp-beveled needle in the smallest suitable length and gauge * Select the proper injection site, using anatomical landmarks * Apply a vapocoolant spray or topical anesthetic to the injection site before giving the medication, when possible * Divert the patient's attention from the injection through conversation using open-ended questioning * Insert the needle quickly and smoothly to minimize tissue pulling * Hold the syringe steady while the needle remains in tissues * Inject the medication slowly and steadily.

Injections: Intradermal

* Use for skin testing (TB, allergies) * Slow absorption from dermis * Skin testing requires the nurse to be able to clearly see the injection site for changes * Use a tuberculin or small hypodermic syringe for skin testing * Angle of insertion is 5 to 15 degrees with bevel up * A small bleb will form as you inject; if it does not form, it is likely the medication is in subcutaneous tissue, and the results will be invalid

2019 National Hospital Patient Safety goals - Prevent Infection

* Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning * Use proven guidelines to prevent infections that are difficult to treat * Use proven guidelines to prevent infection of the blood from central lines * Use proven guidelines to prevent infection after surgery * Use proven guidelines to prevent infections of the urinary tract that are catheter related

Dose Calculation Methods

* Verify medication calculations with another nurse to ensure accuracy The ration and proportion method * Example: 1:2 = 4:8 * Formula method * Dose ordered/Dose on hand x Amount on hand = Amount to administer Dimensional analysis * Factor-label or unit factor method

Dressing Changes

* WASH and GLOVE hands * PPE - Gown for contact precautions and drainahe splashing * Bandage removal - do not dmage health tissue Washing * Saline or soap & H2) with gauze, ATBX solutions * do not cause pain but clean and dry well * Irrigate - syringe and angiocath Dress - always! - prevents infection and drying * Primary, secondary, and secure * Clean technique * Sterile equipment * Place barrier beneath * Biohazard disposal

Major Goals of Wound Care

* WOUND PREVENTION! (Especially with pressure ulcers and DFU) * Heal wounds * Reducing complications * Improve quality of life: Pain, depression, self image, time * Be economical: Reduce labor and financial burdens of chronic wound care, may require upfront costs and time, but will pay off

Immediate action required if a needlestick occurs

* Wash area thoroughly with soap and water * Complete an unusual occurrence report and notify immediate supervisor * Follow facility protocol for treatment and follow up

Nursing Shortage

* With fewer available nurses, it is important for you to lean to use your patient contact efficiently and professionally. Essential skills include * Time management * Therapeutic communication * Patient education * Compassionate implementation of bedside skills

Nursing Students: Legal Implications

* You are liable if your actions cause harm to patients, as is your instructor, hospital, and college/university * You are expected to perform as a professional when rendering care * You must separate your student nurse role from your work as a certified nursing assistant (CNA)

Handling and Disposing of Information

* You must safeguard any information that is printed from the record or extracted for report purposes * De-identify all patient data * Special considerations for faxing

Nursing Diagnosis

* is making conclusions about the meaning of the assessment data (analysis and synthesis) is a decision or clinical judgment about the nature of an individual's response to actual or potential illness or health needs. It requires the nurse to critically think. * Potential is often listed a risk for something * Example: Chemotherapy is a risk for low blood cell count * is an ongoing part of the nursing process requiring changes as the client's condition changes * helps nurses select nursing interventions to achieve desired outcomes

perceptual effects of sensory deprivation

*Changes in visual/motor coordination *Reduced color perception *Less tactile accuracy *Changes in ability to perceive size & shape *Changes in spatial & time judgement

Delerium-Medical Emergency

- Acute change in mentation - Assess for causes-in elderly commonly UTI and pneumonia - Other physiological causes- electrolyte imbalances, untreated pain, infection, cerebral anoxia, hypoglycemia, side effects of medications, tumors, subdural hematoma (bleed in subdural space), CVA or stroke - Other causes: sensory deprivation or overstimulation, sleep deprivation, emotional distress - Dementia greatly increases the risk of delirium-you can have both at the same time

Diagnosis: Loss, grief, bereavement

- Anticipatory grieving - Compromised family coping - Death anxiety - Fear - Impaired comfort - Ineffective denial - Grieving - Complicated grieving - Risk for complicated grieving - Hopelessness - Pain (acute or chronic) - Risk for loneliness - Spiritual distress - Readiness for enhanced spiritual well-being

What are the steps in the nursing process?

- Assessment Collect data that can be used to identify client needs that can be managed or treated with nursing care - Nursing diagnosis A decision or judgement about the nature of a client's problems or needs - Planning Set goals/outcomes and plan nursing care. Collaboration with the client is essential to successful planning - Intervention The phase in which you execute the care plan. Interventions include counseling, providing comfort measures, teaching, offering emotional support, managing the environment and assessing - Evaluation The final phase in which the planned outcomes of nursing care are measured against the actual outcomes. Outcomes can be met, partially met, or unmet.

What are the components of a nursing diagnostic statement?

- Basic format for 'risk' nursing diagnosis consists of two parts: the problem and the etiology Three part: problem, etiology, symptoms - AEB (as evidence by) - Constipation -> r/t -> inadequate dietary fiber -> AEB -> Bloating no BM in 5 days

How do we prioritize nursing diagnosis?

- Basic physiological needs must be met first - Second level is safety and security - Third level is love and belonging - Fourth level is self-esteem - Fifth level is self-actualization Example: If a person is having difficulty breathing (a basic physiological need) and with his self-esteem, you must make his breathing a priority over a self-esteem problem

What to do if you Think Someone is Overdosing

- Call 911 immediately - Administer naloxone (Narcan), if available - Try to keep the person awake and breathing - Lay the person on their left side to prevent choking - Stay with him or her until emergency workers arrive

Principles of error-free hand offs: SBAR

- Communicate interactively - allow and promote questions - Communicate up-to-date information regarding care, treatment, services, condition - Limit interruptions to avoid losing or skewing information - Allow sufficient time to complete hand off - Require a verification process - repeat-backs or read-backs - Ensure the receiver of the information has the opportunity to review relevant data, including previous care treatment services.

Types of Loss

- Developing a personal understanding of your own feelings about grief and death will help you better serve your patients Actual losses - Necessary losses - Maturational losses (natural) - Situational losses (unpredictable) - Perceived losses

Keeping dying patient comfortable

- Dying patients do not need to ear and drink, often they are nauseated and food does not digest, this causes discomfort - Instruct the family that providing oral care is helpful, preventing drying out of oral mucosa. Pink toothettes moistened with water-do not need to brush teeth - Do not predict time of death, support family with knowledge from assessment- "Mottling is a sign that the body has started to shut down"

Financial Exploitation: Elder Abuse

- Encourage residents and employees in health care not to place cash in pocket, difficult whose money it was if accused Phone scams - May not tell others about being scammed because they are embarrassed - Adult protective services: call goes directly to grand rapids - they look at it on paper first to determine if it is something in need of being investigated --- UPCAP is working with APS to try to investigate all of these concerns

Nursing Knowledge Base: Loss, grief, bereavement

- End-ofLife Nursing Consortium (ELNEC) - American Nurses Association (ANA) - Hospice and Palliative Care Nurses Association - American Society of Pain Management Nurses -American Association of Critical Care Nurses

What can nurses do to prevent/help with typical problem behaviors in dementia patients?

- Engage residents in mealtime and stimulate appetite - Determine triggers, change the environment - Acknowledge and not ignore a residents report of an event or his or her feelings and thoughts

Autopsy

- Family members give consent for autopsy to determine the exact cause of death or discover pathway of disease - A coroner or medical examiner determines the need for autopsy - Required by law is death is a result of foul play, homicide, suicide, accidental death from MVA, falls, the ingestion of drugs, or deaths within 24 hours of hospital administration - Inform family that all organs are replaced, body is not deformed

Why was HIPPA created?

- First enacted in 1996 to improve continuity of health insurance coverage, combat health care waste and fraud, and simplify the administration of health insurance - In 2003 - "the Privacy Rule" - to assure that individual's health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care - Was passed to establish a national framework for security standards and protection of confidentiality regarding health care data and information - Limits use of protected health information to those with a "need to know" - To penalize those who do not comply with confidentiality regulations

What is HIPPA?

- HIPPA is the acronym for the Health Insurance Portability and Accountability Act HIPPA achieves the following: - Provides the ability to transfer and continue health insurance coverage for Americans and their families when they change or lose their jobs - Reduces health care fraud and abuse - Mandate industry-wide standards for health care information and electronic billing and other processes - Requires the protection and confidential handling of protected health information

Physical changes hours/days before death

- Increased periods of sleepiness/unresponsiveness - Coolness and color changes of extremities-mottling, cyanosis, pallor - Bowel or bladder incontinence - Decrease urine output, dark colored urine - Restless, confusion, or disorientation - Decreased intake of food/fluids - Congestion - Altered breathing (apnea, labored or irregular breathing, Cheyne-Strokes pattern) - Decrease muscle tone, relaxed jaw muscles, sagging mouth - Weakness and fatigue

Critical Thinking: Loss, grief, bereavement

- Listen carefully to the patient's perceptions - Use culture-specific understanding Use Professional Standards: - Nursing Code of Ethics - Dying Person's Bill of Rights - ANA Scope and Standards of Hospice and Palliative Nursing - Use Clinical Standards: American Society of Pain Management Nurses' Guidelines

Eyes, Ears, Nose

- Medical devices - Basic eye care - Eyeglasses - Contact lenses - Artificial eyes - Ear care - Hearing aid care - Nasal care When hygiene care is provided, the eyes, ears, and nose require careful attention. Clean the sensitive sensory tissues in a way that prevents injury and discomfort for a patient, such as by taking care not to get soap in his or her eyes. The sense of smell is an important air to appetite

Nursing Care After Epidural

- Monitor injection site for bleeding, swelling, redness, drainage - Protect patient from injury-instruct them not to try to get out of bed without help - Position leg without pressure areas - Note when sensation starts to return to lower extremities - Notify anesthetist immediately if patient develops a headache after this procedure

Depression

- Most common impairment in older adulthood - Loss of significant other and placement in nursing home are common causes - Treated with meds, psychotherapy or combination of both - Suicide attempts in older adults are usually successful - White men, 85 years of age and older have the highest rate of suicide in the US

Important things to know as a nurse: HIPPA

- Obligation of the nurse to protect confidential information about patients, unless required by law to disclose the information - Permission to disclose information should be obtained by asking the patient or when circumstances clearly give the individual the opportunity to agree or object - Providers may disclose protected health information when necessary to prevent or lessen a serious and imminent threat to a person or the public - Passwords should not be shared, and personal information shared via e-mail should be encrypted - Failure to protect patients' information can result in significant penalties

What can be done to aid in the management of pain for a dementia patient?

- Observation to uncover unusual behaviors - Make appropriate referrals - Prevention of pain is the first defense - Offering medications

Elder Abuse

- Often the victims believe it's their fault, difficult to convince otherwise If your gut is telling you it is wrong, you should report it - Would rather over-report than under-report Sexual concerns: are those involved cognizant and is it consensual?

What should be included in a properly written nursing outcome?

- Outcomes/Goals are desired end results of nursing care for each client problem Outcomes/goals must be realistic, measurable, acceptable to the client, and include a time-frame - May be short term and reached in an hour, day, or week - May be long term in a few weeks or months - Example: Skin will be free of breakdown during hospitalization

What modifications can be made to a home or nursing home environment to help the dementia patient?

- Physical environment can encourage and support independence while promoting safety - Environment feels comfortable and familiar

Anticipatory grief

- Provide emotional support - Assist with role change, education, and/or resources - Encourage life review - Educate the patient/family about dying process - Encourage patient/family to complete unfinished buisness - Provide presence, active listening, touch and reassurance

Implementation: Health Promotion: Loss, grief, bereavement

- Providing palliative care in acute and restorative setting - Providing hospice care - Using therapeutic communication - Providing psychosocial care - Managing symptoms - Promoting dignity and self-esteem - Ensuring a comfortable and peaceful environment - Promoting spiritual comfort and hope - Protecting against abandonment and isolation - Supporting the grieving family

What are some techniques you might use to communicate effectively with a dementia patient?

- Speaking in simple direct language. - Providing relaxing physical contact - Listening to concerns and providing reassurance

Theory

- Theory bases when you do research on - Evidence based practiced is based on nursing theory Helps explain an event by * Defining idea or concepts * Explaining relationships among the concepts * Predicting outcomes Nursing theory * Is a conceptualization of some aspect of nursing * Describes, explains, predicts, and/or prescribes nursing care

Grieving

- When caring for patients who have experienced a loss, facilitate the grief process by helping survivors feel the loss, express it, and move through their grief. - Loss comes in many forms based on the values and priorities learned within a person's sphere of influence. - The type and perception of the loss influence how a person experiences grief.

Self neglect: Elder abuse

- Will not buy own meds because may not be able to afford other things - Un-kept - Hoarders --- have a right to live that way unless it is found to be harmful to them

Importance of Nurses' Self-Care: Loss, grief, bereavement

- You cannot give fully engaged, compassionate care to others when you feel depleted or do not feel cared for yourself. - Frequent, intense, or prolonged exposure to grief and loss places nurses at risk for developing compassion fatigue. - Being a professional includes caring for yourself physically and emotionally. - To avoid the extremes of becoming overly involved in patients' suffering or detaching from them, nurses develop self-care strategies to maintain balance.

Health care providers can breach confidentiality without permission when a patient has a:

- gunshot wound - stab wounds - injuries sustained in a crime - child/elderly abuse and infectious - communicable or reportable disease

Cognitive Effects of Sensory Deprivation

- reduced capacity to learn, - inability to think or problem solve - poor task performance - disorientation/confusion - bizarre thinking - increased need for socialization, altered mechanisms of attention

Effects on psychosocial caused by immobility

In independence results in loss. Depression, sleep wake disturbances and impaired coping.

A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 ½ NS. Which intervention is a dependent intervention? Reporting hand-off at change of shift Ambulating patient down hallway Sleep hygiene IV fluid administration

A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 ½ NS. Which intervention is a dependent intervention? Reporting hand-off at change of shift Ambulating patient down hallway Sleep hygiene IV fluid administration

A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? Review of systems approach Use of a structured database format Back channeling

A problem-oriented approach This is an example of a problem-focused approach. The nurse focuses on assessing one body system (cardiovascular) to determine the nature of the patient's pain and other presenting symptoms.

stroke

A sudden attack of weakness or paralysis that occurs when blood flow to an area of the brain is interrupted

Most Common Never Events

Although most never events are rare, these safety incidents can have significant effects on patients and hospitals. Here are three statistics on the frequency of never events, compiled by the Agency for Healthcare Research and Quality: 1. More than 4,000 surgical never events occur each year in the U.S. according to a 2013 study * The average hospital may experience a wrong-site surgery case once evry 5 to 10 years, according to a 2006 study * The majority - 71 percent - of never events reported to The Joint Commission between 1995 and 2015 were fatal * Most common never events * In March 2018, The Joint Commission updated its sentinel event statistics for 2017. The organization reviewed 805 reports of sentinel events reported during the 2015-17 calendar year * Here are the 10 most frequently reported sentinel events according to The Joint Commission: * Unintended retention of a foreign body -116 reported * Fall - 114 * Wrong patient, wrong-site, wrong procedure - 95 * Suicide - 89 * Delay in treatment - 66 * Other anticipated event, such as asphyxiation, burn, choking on food, drowning or being found unresponsive - 6 * Criminal event - 37 * Medication error - 32 * Operative/postoperative complication - 19 * Self-inflicted injury - 18

To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery? Turn, cough, and deep breathe every 30 minutes while awake Ambulate patient to chair in the hall Passive range of motion 4 times a day Immobility is not a concern the first postoperative day

Ambulate patient to chair in the hall Prevention of complications of immobility begins when the patient becomes immobilized. Every 30 minutes is not necessary and disruptive to the healing process. Active patient participation in exercises is more beneficial to preventing venous stasis.

A faculty member is reviewing a nursing student's plan of care, including the interventions the student provided for a patient with dementia. The student reviewed clinical guidelines on a professional website to identify interventions successful in reducing wandering in patients with dementia. The faculty member should evaluate which of the following? Select all that apply. Number of interventions Appropriateness of the intervention for the patient The prior use of interventions by other nursing staff Correct application of the intervention for the patient care setting The time it takes to provide interventions

Appropriateness of the intervention for the patient, Correct application of the intervention for the patient care setting In this situation the faculty member reviews the plan for the appropriateness of the intervention and its correct application. Because the nursing student selected proven interventions from a professional website, it is likely the interventions represent an accepted standard of care and meet the criteria of appropriateness. The number of interventions is not important. Whether an intervention has been used by other nurses is not important in the context of evaluating this nurse's plan of care. However, if other interventions are known to be effective for this patient, the student might choose to revise the plan later and add such interventions.

A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son who accompanied her to the hospital. The nurse's next step is to: Call social services to begin nursing home placement. Ask the son to step out of the room so she can complete her assessment. Call adult protective services because you suspect elder mistreatment. Assess patient's cognitive status.

Ask the son to step out of the room so she can complete her assessment. The assessment leads you to suspect elder mistreatment, but the nurse needs more information directly from the patient before calling social services or the adult protective services. She will best get this information by asking the son to leave so she can ask the patient direct questions privately. If the son refuses to leave, this will be another indication that elder mistreatment may be occurring. Cognitive testing will be important but is not the priority.

A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? Select all that apply. Assess condition of skin before making the call Rely on the nurse specialist to know the type of surgery the patient likely had Explain the patient's response emotionally to the repeated leaking of stool Describe the type of bag being used and how long it lasts before leaking Order extra colostomy bags currently being used

Assess condition of skin before making the call, Explain the patient's response emotionally to the repeated leaking of stool, Describe the type of bag being used and how long it lasts before leaking The nurse should have as much information as possible available before making the call to the nurse specialist. It is also important for the nurse to interpret and explain the problem. In addition, it is important to explain the patient's perspective. Assuming that the nurse specialist knows the extent of the surgery is not appropriate. Ordering extra supplies is not a guaranteed solution that the existing bag is beneficial to the patient.

Nursing Assessment: Ostomies

Assess for color, edema, and injury (bleeding) * Should be pink to red. If it's pale, dusky, purple, brown or black it should be reported immediately * Swelling and edema will decrease for several months * Minimal bleeding may be present Assess skin around the stoma * Look for breakdown, irritation, and bleeding * Prolonged exposure to moisture causes erosion Measure and inspect the output * Colostomy * Will depend on which part of the colon is used * Ileostomy * Thickened liquid * Urostomy * Liquid, color may vary

Nursing Process: Assessment: Infection Prevention and Control

Assessment includes a thorough investigation: * Defense mechanisms, susceptibility, and knowledge of how infections are transmitted * Review of systems, travel history * Immunizations and vaccinations * Earl recognition of risk factors * See through the patient's eyes. * Status of defense mechanisms Patient susceptibility * Medical therapy Clinical appearance * Signs and symptoms of infection * Laboratory data

Developmental Tasks for Older Adults

Associated with varying degrees of change and loss * Health, significant others, a sense of being useful, socialization, income, and independent living Coping with * Retirement * Residence change * Death Adult children

History of Surgical Nursing

Association of perioOperative registered Nurses (AORN) * Established in 1956 * Focus on clinical practice professional practice, administrative practice, patient outcomes, and quality improvement Ambulatory surgery * Hospital-based or freestanding * Many laparoscopic surgeries, such as gallbladder removal (cholecystectomy)

HIPPA'S major goal

Assure that individuals' health information is properly protected while allowing the flow of health information needed to prove and promote high quality health care and to protect the public's health and well being

Patient and Family Education: Cath lab

Before the Procedure * Family and friends should be supportive * Patient should be aware not to eat or drink anything 6 to 8 hours before Cath Lab * A trusted human is needed to drive to and from the hospital * Make sure patient is not pregnant * Several tests will be done before hand (whether it be a day or two beforehand) * Tests like - EKG, blood tests, and urine tests * Empty bladder is recommended before entering the Cath Lab * Patients family and friends can not be in lab After the Procedure * Lie flat in bed for 4-6 hours * Reduction of patient activity during the first 24 hours after the cath lab * Do not lift heavy objects for a few days after * Food and water consumption is okay after Lab * If pain or a warm, sticky, wet sensation is felt do not hesitate on reporting to to a medical health provider immediately * If legs get stiff, movement of foot or wiggling of toes is permitted * With one hand apply pressure over insertion site when coughing, laughing, sneezing, straining, or lifting head off pillow * Pulse and blood pressure will be checked frequently

Diagnostic Tests

Blood tests * CBC (complete blood count, RBC, hemoglobin, hematocrit) * Cardiac enzymes (CK, Troponin * Serum electrolytes (electrolytes can affect the electrical conduction system) * Cholesterol * ABGs (arterial blood gases. who can draw ABGs? - Respiratory therapists, nurses) X-rays * Chest x-ray * Cardiac catheterization Noninvasive * TB skin test * Holter monitor (at home heart monitor) * ECG * Thallium stress test * EPS (look at electrical conduction system) * PFT (pulmonary function test)

Urinary Diversion

Continent Urinary Reservoir * Created from the distal pouch of the ileum and proximal portion of the colon * Ureters are attached * Narrow ileal segment use to create stoma * Ileocecal valve created a one-way valve and catheterization is require 4-6 times/day Orthotropic neobladder * Ileal pouch to replace the bladder (in the bladder's location), allows continent voiding Incontinent Diversion * Ureters connected to a portion of the ileum and a stoma is formed * Urine drains continuously into a collection pouch

Concepts of bowel elimination

Contraption * Improper diet, reduced fluid intake, lack of exercise, medication * Elderly at increased risk Fecal impaction * Hardened feces wedged in the rectumDigital examination and disimpaction Diarrhea * May cause fluid and electrolyte imbalances * May be caused by: antibiotic use, enteral nutrition, food allergies and intolerances

Assessment: Loss, grief, bereavement

Conversations about the meaning of loss to a patient of a lead to other important areas of assessment - Patients coping style - The nature of family relationships - Social support systems - The nature of the loss - Cultural and spiritual beliefs - Life goals - Family grief patterns - Self-care - Sources of hope

Body Mechanics

Coordinated efforts of musculoskeletal and nervous systems * Lift with your legs not your back * Keep patient close to you * Move your feet, don't twist your torso

lack of erythropoietin

Renal failure causes anemia because of?

Q.D., QD, qd, q.d., QOD, etc...

DO NOT USE These are tricky and are often mistaken for each other * The period is often mistaken for the letter O as well Critical medication errors can be made when these abbreviations are mistaken * Meds could be given everyday vs. every other day * QD vs QOD Instead, write out fully when things are supposed to be administered * Every day, every other day, etc.

@

DO NOT USE * Can be mistaken for a number 2 or 0, or the letter O * Instead, write the word "at"

U

DO NOT USE * Instead, write out the full word "unit" * Can be mistaken for numbers 0 or 4, or cc when being read/written quickly

The nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing: Delirium. Depression. New-onset dementia. Worsening dementia.

Delirium. Hallmark characteristics of delirium are acute confusion, hallucinations, and agitation. It is not a new onset of dementia since she already has a diagnosis of Alzheimer's disease and, as dementia worsens, we see a gradual rather than sudden changes in memory usually not accompanied with hallucinations. Depression does not present with acute confusion and agitation.

A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing: Dementia. Depression. Delirium. Hypoglycemic reaction.

Depression. Factors that often lead to depression include presence of a chronic disease or a recent change or life event (such as loss). Patients are alert but easily distracted in conversation.

Scientific Knowledge Base: Patient Safety and Quality

Environmental safety * A patient's environment includes physical and psychosocial factors that influence or affect the life and survival of that patient * A safe environment protects the staff to function optimally * Basic needs

Patients Who Cannot Eat By Mouth

Enteral feeding options * Nasogastric tube (NG tube) * Small bore feeding tube (post-pyloric) * Gastrostomy (G tube) * Jejunostomy (J tube) * See table 44-7 page 1124 (potential complications)

Enteral Tube Feeding

Enteral nutrition (EN) provides nutrients into the GI tract. It is physiological, safe, and economical nutritional support * Bedside, surgical or endoscopic placement * Risk of aspiration Parenteral nutrition * Intravenous * Different names: TPN, PPN, HAMMS

A nurse has been caring for a patient over 2 consecutive days. During that time the patient has had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks if the patient feels tenderness when the site is palpated. This is an example of which indicator reflecting the nurse's ability to perform evaluation: Examining results of clinical data Comparing achieved effects with outcomes Recognizing error Self-reflection

Examining results of clinical data Examination of the IV site is an example of examining results of clinical data. The nurse will next take the results of the examination and compare them to the norms for a normal IV site to decide if the outcome of maintaining a site free of infection is achieved. No errors were identified in this example, and the nurse is not self-reflecting.

Evaluation: Care of Surgical Patients

Examples of evaluation questions: * "Are you satisfied with the way we are managing your pain?" * Do you feel you have learned enough to be able to follow your diet at home?" * "Are you having any ongoing issues, questions, or concerns that we can address for you at this time?" Evaluate whether the patient and the family have learned self-care measures.

A nurse researcher studies the effectiveness of a new program designed to educate parents to promote the immunization of children. The nurse divides the parents randomly into two groups. One group receives the typical educational program and the other group receives the new program. This is an example of which type of study? Historical Qualitative Correlational Experimental

Experimental In experimental studies the subjects are randomly assigned into groups with one group receiving the standard treatment and the other group receiving the intervention.

Restorative Care: Extended Care

Extended care facility * Provides intermediate medical, nursing, or custodial care for patients recovering from acute illness or disabilities Intermediate care/skilled nursing facility * Provides care for patients until they can return to their community or residential care location

Topical Medications cont.

Eye instillation * Avoid the cornea. * Avoid the eyelids with droppers or tubes to decrease the risk of infection * Use only on the affected eye * Never allow a patient to use another patient's eye medication Intraocular instillation * Disk resembles a contact lens * Teach patients how to insert and remove the disk * Teach about adverse effects Ear instillation * Structures are very sensitive to temperature * Use sterile solutions * Drainage may indicate eardrum rupture * Never occlude the ear canal * Do not force medication into an occluded ear canal

Implementation: Sleep

Health promotion * Environmental controls * Promoting bedtime routines * Promoting safety * Promoting comfort * Establishing periods of rest and sleep * Stress reduction * Bedtime snacks * Pharmacological approaches * Environment controls * Promoting bedtime routines * Promoting safety * Promoting comfort * Establishing periods of rest and sleep * Stress reduction * Bedtime snacks * Pharmacological approaches Acute care * Environmental controls * Promoting comfort * Establishing periods of rest and sleep * Promoting safety * Stress reduction Restorative or continuing care * Promoting comfort * Controlling physiological disturbances * Pharmacological approaches

Implementation: Inection Prevention and Control

Health promotion * Preventing an infection from developing or spreading Acute care * Treating an infectious process includes eliminating the infectious organisms and supporting the patient's defenses Asepsis * Absence of pathogenic (disease-producing) microorganisms * Medical asepsis * Standard precautions * Hand hygiene * Alcohol-based hand rub Cleaning * The removal of all soil * Use protective eyewear and gloves * Steps * Rinse contaminated object or article with cold running water to remove organic material. * Wash the object with soap and warm water * Use a brush to remove dirt or material in grooves or seams * Rinse the object in warm water. * Dry the object and prepare it for disinfection or sterilization if indicated * Clean and dry cleaning equipment

Addressing the Health Concerns of Older Adults

Healthy People 2020 goals: * Increase the number of older adults with one or more chronic conditions who report confidence in maintaining their conditions * Reduce the proportion of older adults who have moderate-to-severe functional limitations. * Increase the proportion of older adults with reduced physical or cognitive function who engage in light, moderate, or vigorous leisure-term physical activities.

A 71-year-old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? Select all that apply. Impaired vision Residence design Blood pressure Leg weakness Exercise history

Impaired vision, Leg weakness, Exercise history Risk factors for falling include sensory changes such as visual loss, musculoskeletal conditions affecting mobility (in this case weakness), and deconditioning (from lack of exercise). The mere presence of a chronic disease is not a risk factor unless it is a condition such as a neurological disorder that alters mobility or cognitive function. The patient's blood pressure is stable, and there is no report of orthostatic hypotension. A one-floor residence should not pose risks.

A nurse is visiting a patient in the home and is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? Select all that apply. Reviewing the family caregiver's availability during medication administration times Making a judgment of the value of improved adherence for the patient Reviewing the number of medications and time each is to be taken Determining all consequences associated with the patient missing specific medicines Reviewing the therapeutic actions of the medications

Making a judgment of the value of improved adherence for the patient, Determining all consequences associated with the patient missing specific medicines Tips for making good clinical decisions during implementation include making a judgment of the value of the consequence to the patient, reviewing all possible consequences associated with each nursing action, determining the probability of all possible consequences, and reviewing the set of all possible nursing interventions for a patient's problems.

Bowlby's Attachment Theory

Numbing - Protects the person from the full impact of loss Yearning and seeking - Tearing, sobbing, and acute distress Disorganization and despair - Person examines loss and expresses anger Reorganization - Person begins to accept change, new role or skills

Nursing Practice

Nurse Practice Acts (NPAs) * Overseen by State Boards of Nursing * Regulate scope of nursing practice * Protect public health, safety, and welfare Licensure and certification * Licensure: NCLEX-RN examination * Certification requirements vary

The nurses on an acute care medical floor notice an increase in pressure ulcer formation in their patients. A nurse consultant decides to compare two types of treatment. The first is the procedure currently used to assess for pressure ulcer risk. The second uses a new assessment instrument to identify at-risk patients. Given this information, the nurse consultant exemplifies which career? Clinical nurse specialist Nurse administrator Nurse educator Nurse researcher

Nurse researcher The nurse researcher investigates problems by applying evidence-based practice or by conducting research to improve nursing care and further define and expand the scope of nursing practice. He or she often works in an academic setting, hospital, or independent professional or community service agency.

Institute of Medicine (IOM)

Nurses need to be transformed by: * Practicing to the full extent of their training * Achieving higher levels of education through an education system that provides seamless progression * Becoming full partners with physicians and other health care providers in redesigning the health care system * Improving data collection and the information infrastructure to effective workforce planning and the policy making

NIC

Nursing Interventions Classification System (NIC) is standardized language to describe nursing activities. Can be used to develop a care plan by selecting nursing intervention levels and nursing activities pertinent to nursing diagnoses and expected outcomes.

NOC

Nursing Outcomes Classification System (NOC) is a standardized terminology and measures to evaluate effects of nursing interventions

Assessing the Needs of Older Adults

Nursing assessment to ensure an age-specific approach * The interrelation between physical and psychosocial aspects of aging * Effects of disease and disability on functional status * Tailoring the nursing assessment to an older person

Nursing Diagnosis: Patient Safety and Quality

Nursing diagnosis for patients with safety risk: * Risk for falls * Impaired home maintenance * Risk for injury * Deficient knowledge * Risk for poisoning * Risk for suffocation * Risk for trauma

Implementation: Pain Management

Nursing implications * You maintain responsibility for providing emotional support to patients receiving local or regional anesthesia * After administration of a local anesthetic, protect the patient from injury until full sensory and motor function return * Nursing implications for managing epidural analgesia are numerous * Patient education Nursing implications for local and regional anesthesia * Provide emotional support * Protect patient from injury * Patient education * Invasive interventions for pain relief * Procedure pain management * Cancer pain and chronic noncancer pain management * Physical dependence: A state of adaptation that is manifested by a drug class-specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist * Addiction: A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing it's development and manifestations * Drug tolerance: A state of adaptation in which exposure to a drug induces changes that result in a diminution of one of more effects of the drug over time

Science and Art of Nursing Practice

Nursing requires * Current knowledge and practice standards * Insightful and compassionate approach * Critical thinking Benner's stages of nursing proficiency: * Novice * Advanced beginner * Competent * Proficient * Expect

Myths and Stereotypes

Older adults are: * Ill, disabled, and unattractive * Forgetful, confused, rigid, boring, unfriendly, and poor * Unable to learn and understand new information * Not interested in sex or sexual activities These ides demonstrate ageism, which is discrimination against people because of increasing age

For the nursing diagnosis of Deficient Knowledge a nurse selects an outcome from the Nursing Outcome Classification (NOC) of patient knowledge of arthritis treatment. Which of the following are examples of an outcome indicator for this outcome? Select all that apply. Nurse provides four teaching sessions before discharge. Patient denies joint pain following heat application. Patient describes correct schedule for taking antiarthritic medications. Patient explains situations for using heat application on inflamed joints. Patient explains role family caregiver plays in applying heat to inflamed joint.

Patient describes correct schedule for taking antiarthritic medications, Patient explains situations for using heat application on inflamed joints. The patient must exhibit behaviors that measure knowledge of arthritis treatment. This would include describing his medication schedule and explaining when to apply heat to inflamed joints. The nurse providing teaching sessions is not a patient outcome. The patient denying joint pain is not an evaluative indicator of knowledge. Explanation of the family caregiver's role is not a measure of the patient's knowledge of treatment.

When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? []Chronic pain is psychological in nature []Patients are the best judges of their pain []Regular use of narcotic analgesics leads to drug addiction []Amount of pain is reflective of actual tissue damage

Patients are the best judges of their pain

Patient's Perspective of Caring

Patients value the affective dimension of nursing care * Connecting with patients and their families * Being present * Respecting values, beliefs, and health care choices

Factors Influencing Pain

Physiological * Age, fatigue, genes, neurological function * Fatigue increases the perception of pain and can cause problems with sleep and rest Social * Attention, previous experiences, family and social support, spiritual * Spirituality includes active searching for meaning in situations, with questions such as "Why am I suffering? Physiological * Anxiety * Coping style Pain tolerance * The level of pain a person is willing to accept Cultural * Meaning of pain * Ethnicity

Factors Affecting Oxygenation

Physiological factors * Decreased oxygen-carrying capacity (CO2 poisoning, anemia - low hemoglobin count) * Decreased inspired oxygen (altitude, obstruction, < effort) * Hypovolemia * Increased metabolic rate (> demand) example; burn patients, fever/infections Conditions affecting chest wall movement * Pregnancy * Obesity * Musculoskeletal abnormalities * Trauma * Neuromuscular disease * CNS alterations

A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first? Reconnect the drainage tubing Inspect the condition of the IV dressing Obtain the next IV fluid bag from the medication room Explain when the health care provider is likely to visit

Reconnect the drainage tubing The nurse must reconnect the drainage tube for the priority of patient safety. There is no reason to suspect a problem with the IV dressing unless the fluid is not infusing on time. The nurse must prepare the next bottle of solution after reconnecting the drainage tube. At that time the nurse can check the condition of the IV dressing. As the nurse performs her care, she can inform the patient about when the physician will round, unless she is uncertain and needs to contact the physician.

Professional Registered Nurse Education

Registered nurse education * 2-year associate's degree * 4-year baccalaureate degree * Graduate education * Master's degree, advanced practice RN * Doctoral degrees Continuing and in-service education

Health Care Regulation and Reform

Regulatory and competitive approaches * Professional standards review organizations (PSROs) * Created to review the quality, quantity, and cost of hospital care provided through Medicare and Medicaid * Utilization review (UR) committees * Review admissions, diagnostic testing, and treatment ordered by physicians who care for patients receiving Medicare * Prospective payment system (PPS) * Diagnosis-related groups (DRGs) * Capitation * RUGs * Profitability * Managed care "Never Events" * Things that should have never happened Patient Protection and Affordable Care Act * Access to health care for all * Reducing costs * Improving quality * Provisions include * Insurance industry reforms * Increased funding for public programs * Improved coverage for children

A nurse is caring for a patient preparing for discharge from the hospital the next day. The patient does not read. His family caregiver will be visiting before discharge. What can the nurse do to facilitate the patient's understanding of his discharge instructions? Select all that apply. Yell so the patient can hear you. Sit facing the patient so he is able to watch your lip movements and facial expressions. Present one idea or concept at a time. Send a written copy of the instructions home with him and tell him to have the family review them. Include the family caregiver in the teaching session.

Sit facing the patient so he is able to watch your lip movements and facial expressions, Present one idea or concept at a time, Include the family caregiver in the teaching session. Teaching and communication are more effective with older adults when you sit and face the patient and present one idea or concept at a time. This requires planning. Speaking loudly can distort sound. Speak in a normal tone. Sending instructions is helpful but will not directly facilitate the patient's own understanding. Sharing information with a caregiver provides someone to clarify instructions.

Which of the following nursing diagnoses is stated correctly? Select all that apply. Fluid Volume Excess related to heart failure Sleep Deprivation related to sustained noisy environment Impaired Bed Mobility related to postcardiac catheterization Ineffective Protection related to inadequate nutrition Diarrhea related to frequent, small, watery stools.

Sleep Deprivation related to sustained noisy environment, Ineffective Protection related to inadequate nutrition The correct diagnoses of Sleep Deprivation and Ineffective Protection are worded with related factors that will respond to nursing interventions. Nursing interventions do not change a medical diagnosis or diagnostic test. Instead nurses direct nursing interventions at behaviors or conditions that they are able to treat or manage. The first two incorrect diagnoses use a medical diagnosis and diagnostic procedure respectively as related or etiological factors. These are not conditions that nursing interventions can treat. The last diagnosis is incorrect because it is related to an assessment finding of a symptom or a defining characteristic.

implementation: Health Promotion: Medication Administration

Teach the patient and family: * Medication benefit * How to take the medication correctly * Symptoms of side effects * Safe use and storage of medications * Help the patient and family establish a medication routine * Refer them to community resources for transportation as needed

During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings place him at risk for an adverse drug event? Select all that apply. Taking two medications for hypertension Taking a total of eight different medications during the day Having one physician who reviews all medications Patient's health history of renal disease Involvement of the caregiver in helping with medication administration

Taking a total of eight different medications during the day, Patient's health history of renal disease The patient is at risk for an adverse drug event (ADE) because of polypharmacy and his history of renal disease, which affects drug excretion. Taking two medications for hypertension is common. Having one physician review all medications and involving a family caregiver are desirable and are safety factors for preventing ADEs.

A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? Giving the enema on time Talking with the patient about her past experiences with illness Talking with the patient about her concerns and acknowledging her sense of unfairness Beginning instruction on postoperative procedures

Talking with the patient about her concerns and acknowledging her sense of unfairness The patient is obviously emotionally upset. Her concerns, whether they are about surgery or cancer or both, need to be addressed first for her to be able to be instructed and be comfortable for the enema. Talking with the patient about her past experiences may be appropriate in the long term but is less important than the other three priorities.

Skills of Implementing Interventions

Teaching * Increase client's knowledge * Cannot leave patient, family, staff outside of the implementations Collaborating * Working with other health care providers to identify and implement the most adequate care to the client Managing * Delegating care to other heath care providers Coordinating * Typically a nurse takes charge of coordinating various services provided by the health care team * Speaking to pharmacy, physical therapy, therapy Monitoring * A primary nursing intervention, monitoring the client's status and reporting changes to a physical is a major component of nursing Assisting * Providing direct physical care when the client is unable to perform self-care * Or delegating that Supporting * Can be psychological (helps the client to feel able to face adverse circumstances) or physiological (needed to maintain life functions) Protecting * Nurses play a major role in protecting clients from harm Sustaining * CPR

A nurse meets with the registered dietician and physical therapist to develop a plan of care that focuses on improving nutrition and mobility for a patient. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? Patient-centered care Safety Teamwork and collaboration Informatics

Teamwork and collaboration This is an example of the competency of teamwork and collaboration. This competency focuses on the nurse functioning effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.

Documenting Communication with Providers and Unique Events

Telephone calls made to a provider * Document every call Telephone and verbal orders * Telephone orders (Tos) * Verbal orders (Vos) Incident or occurrence reports * Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient * Follow agency policy

During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? So you've had headaches periodically in the last week and sometimes they cause you to feel nauseated—correct? Have you taken anything for your headaches? Tell me what makes your headaches begin. Uh huh, tell me more.

Tell me what makes your headaches begin. An open-ended question that probes such as "Tell me what makes your headaches begin" encourages a fuller description of a situation. The statement "So you've had headaches periodically in the last week, and sometimes they cause you to feel nauseated—correct?" is a summative statement. Asking whether the patient has taken anything for the headaches is a closed-ended question. Saying "Uh huh, tell me more" is an example of back channeling.

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? Select all that apply. The application of the skin barrier is a dependent care measure. The call to the ostomy and wound care specialist is an indirect care measure. The cleansing of the skin is a direct care measure. The application of the skin barrier is an instrumental activity of daily living. Inspecting the skin in a direct care activity.

The call to the ostomy and wound care specialist is an indirect care measure, The cleansing of the skin is a direct care measure. The call to the specialist is a referral and an indirect care measure on the patient's behalf. Cleansing of the skin is an example of direct care. Application of a skin barrier is an independent measure and it is not an instrumental activity of daily living. Inspecting the skin is assessment, not direct care.

Evaluation

The final phase in which the planned outcomes of nursing care are measured against the actual outcomes. Outcomes can be met, partially met, or unmet.

expressive aphasia

The inability to produce language ( despite being able to understand language)

Which of the following factors does a nurse consider for a patient with the nursing diagnosis of Disturbed Sleep Pattern related to noisy home environment in choosing an intervention for enhancing the patient's sleep? Select all that apply. The intervention should be directed at reducing noise. The intervention should be one shown to be effective in promoting sleep on the basis of research. The intervention should be one commonly used by the patient's sleep partner. The intervention should be one acceptable to the patient. The intervention should be one you used with other patients in the past.

The intervention should be directed at reducing noise, The intervention should be one shown to be effective in promoting sleep on the basis of research, The intervention should be one acceptable to the patient. Select interventions that alter the etiological factor, in this case noise. Choose interventions that have a research base and are acceptable to patients.

A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? Select all that apply. The loss of his work role The risk of social isolation A determination if the wife will need to start working How the wife expects household tasks to be divided in the home in retirement The age the patient chose to retire

The loss of his work role, How the wife expects household tasks to be divided in the home in retirement The psychosocial stresses of retirement are usually related to role changes with a spouse or within the family and to loss of the work role. Often there are new expectations of the retired person. This patient is not likely to become socially isolated because of the size of the family. Whether the wife will have to work is not a major concern at this time nor is the age of the patient.

A nurse working on a surgery floor is assigned five patients and has a patient care technician assisting her. Which of the following shows the nurse's understanding and ability to safely delegate to the patient care tech? Select all that apply. The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test. Determining what is the patient care technician's current workload. The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure. The nurse confers with another registered nurse about organizing priorities.

The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test, The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test, The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure. A nurse must consider priorities of all assigned patients in deciding which activities should be delegated to NAP. When the decision is between vital signs versus a patient arriving from a diagnostic test, delegation of routine vital signs is appropriate. Ensuring that a NAP is competent to perform an activity is also important. Conferring with another RN about organizing and checking the tech's personal workload are not factors that will assist the RN's own priority setting.

In which of the following examples are nurses making diagnostic errors? Select all that apply. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data The nurse who measures joint range of motion after the patient reports pain in the left elbow The nurse who considers conflicting cues in deciding which diagnostic label to choose The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.

The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data, The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping, The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia. When the nurse observes the patient wincing and holding his left side but does not gather additional assessment data, he or she makes a data collection error by omitting important data (i.e., pain severity). A nursing diagnosis cannot be made on basis of a single defining characteristic, as seen when the nurse identifies a diagnosis on the basis of a patient reporting difficulty sleeping. A nursing diagnosis needs to be related to a patient's response, not a medical diagnosis such as pneumonia. The nurse who measures joint range of motion after the patient reports pain is correctly validating findings. Considering conflicting clues ensures that the nurse does not make an interpretation error.

Faith

The theological virtue by which one believes in all that God has said and revealed to man and that the Church proposes for belief.

Stage 2 Pressure Ulcer

The skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid. At this stage, some skin may be damaged beyond repair or may die.

Skin Function

The skin is the body's largest organ, accounting for 15% of the total body weight. The skin provides: * A protective barrier * A sensory organ for pain, temperature, and touch * Vitamin D synthesis * Prevents dehydration * Retains heat and moisture * Excretes sweat and oils

Stage 3 Pressure Ulcer

The sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.

Three parts of the Self-Care Deficit Theory

Theory of Self Care Theory of Self-Deficit Theory of Nursing System

Interventions: Bowel Elimination

To promote healthful elimination * Developing plan for lifestyle management * Toilet habits * Diet * Fluids * Exercise * Use of laxatives/stool softness * Positioning * Promoting relaxation and privacy To manage constipation * Administering medications * Administering enemas * Removing an impaction * Maintenance of skin To alleviate diarrhea * Administering medications * Limiting food intake * Restoring fluids and electrolytes * Using a bedpan * Preventing skin breakdown * Ensuring privacy To reduce flatulence * Exercise To restore bowel continence * Maintaining skin integrity * Providing bowel training To manage fecal diversions * Emptying and changing ostomy pouch or bag * Irrigating the bowel * Teaching the client ostomy self-care

Urinary elimination Immobility

Urinary stasis * Sits in the bladder can cause UTIs Renal calculi * Calcium forms in stones in the kidneys

peripheral neuropathy

a painful condition of the nerves of the hands and feet due to damage to the peripheral nerves; also known as peripheral neuritis

A nurse floats to a busy surgical unit and administers a wrong medication to a patient. This error can be classified as: []a poisoning accident []an equipment-related accident []a procedure-related accident []an accident related to time management

a procedure-related accident

eschar

a thick layer of dead tissue and tissue fluid that develops over a deep burn area

complicated grief

a type of grief that impedes a person's future life, usually because the person clings to sorrow or is buffeted by contradictory emotions

male perineal care

cleanse urinary meatus (urethral opening) by moving in a circular motion from the tip to the base; use clean area of washcloth, repeat using a clean area of the washcloth each time; rinse and dry well

Native American

four sacred medicines tobacco, cedar, sage, sweet grass wellness is the preferred medical style

Human Dignity

is respect for the inherent worth and uniqueness of individuals and populations. In professional practice, concern for human dignity is reflected when the nurse values and respects all patients and colleagues.

Autonomy

is the right to self-determination. Professional practice reflects autonomy when the nurse respects patients' rights to make decisions about their health care.

Question 1 What should we use instead of the medical abbreviation "cc", which can be commonly misunderstanding in writing? []mg (milligram) []mcg (microgram) []L (liter) []mL (milliliter)

mL (milliliter)

Buddhism

male family member prepare the body dont touch body after death, dont leave body alone fast on holy days life support machines may not be used do not practice euthanasia

Self-transcendence

meaning, purpose, and communion beyond the self

Stoma

the end of the intestine or ureter that protrudes the abdomen