Concepts final

Pataasin ang iyong marka sa homework at exams ngayon gamit ang Quizwiz!

5 Preparatory Activities for the Implementation Process

1. Reassessing the client 2. Reviewing and revising the existing nursing care plan 3. Organizing resources: -Equipment -Personnel -Environment -Client 4. Anticipating and preventing complications -Areas of assistance 5. Implementation Skills -Cognitive Skills -Interpersonal Skills -Psychomotor Skills

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? 1. Reconnect the drainage tubing 2. Inspect the condition of the IV dressing 3. Obtain the next IV fluid bag from the medication room 4. Explain when the health care provider is likely to visit

1. 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.

Types of Multidisciplinary Communication

1. Record or chart- confidential, permanent legal documentation 2. Report- oral, written, or audio-taped exchanges of information 3. Consultations- a form of discussion where one professional caregiver offers formal advice about the care of a client to another caregiver

Priority Classifications `

1. high - if untreated could result in harm to the client -Physiological & Psychological Dimensions -Maslow -ABCs, LOC (level of consciousness 2. intermediate - involve non-emergent or non-life threatening needs of the client 3. low -nursing diagnoses for client needs that may not be directly related to specific illness or prognosis, but may affect the client's future well-being -May focus on the client's long-term health needs

Tonya sets out to formally plan Mr. Jacobs' care. For the nursing diagnosis of impaired physical mobility related to incisional pain, Tonya identifies the goal of "Patient will walk 100 yards three times a day"; and the outcome she lists is, "Patient will report pain below level of 4 and will not splint incision when moving within 48 hours." The interventions she selects for her plan include administering the ordered analgesic, progressive relaxation, and splinting the incision when the patient gets out of bed. The following three questions apply to the case study. 1. Critique the goal and outcomes that Tonya set and explain if they were written correctly. 2. Among the interventions that Tonya selected, which ones are independent, dependent, and collaborative? 3. What interventions will possibly increase the likelihood that the patient's goals of care and outcomes will be met?

1. The goal set by Tonya is not written correctly, instead it is written as an intervention. The outcome statement is not singular, instead it includes two outcomes. The correct wording would for the goal would be, "Patient will achieve pain relief". The two outcome statements would be stated as "Patient will report pain below level of 4 in 24 hours" and "Patient will not splint incision when moving within 48 hours." 2. The independent intervention is offering progressive relaxation and splinting the incision when the patient gets out of bed. The dependent intervention is administering the analgesic. There is no collaborative intervention. 3. The intervention should include a frequency and could also include more details about the method. For example, Use relaxation following each analgesic administration and play patient's preferred music.

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.) 1. The intervention should be directed at reducing noise. 2. The intervention should be one shown to be effective in promoting sleep on the basis of research. 3. The intervention should be one commonly used by the patient's sleep partner. 4. The intervention should be one acceptable to the patient. 5. The intervention should be one you used with other patients in the past.

1. The intervention should be directed at reducing noise. 2. The intervention should be one shown to be effective in promoting sleep on the basis of research. 4. 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.

Always begin your goals and outcomes with:

"The client will..."

Nursing interventions always begin with:

"The nurse will...."

Evaluation Statements always begin with:

"The outcome was (met, partially met, or not met) AEB...."

Nursing initiated intervention

(Independant) the response of the nurse to the client's needs and nursing diagnosis. -No supervision is required. - No order needed if it is within our scope of practice.

secondary health care

(screening) interventions aimed at increasing the probability that a person with a disease will have that condition diagnosed at a stage when treatment is likely to result in cure. Ex: BP screenings, mammograms, colonoscopy

normal grief

(uncomplicated) is common and universal reaction characterized by complex emotional, cognitive, social, physical, behavioral and spiritual responses to loss and death.

Internal Variables include what?

* Developmental stages * Intellectual Background *Perception of Functioning * Nature of Illness *Emotional Factor *Spiritual Factor

What are some external variables?

* Family Practice * Socioeconomic factors *Cultural background *Visibility of symptoms (to others) *Social group and support *Accessibility of the health care system

What sets nursing apart as a profession?

* Requires a basic liberal foundation and an extended education. * Theoretical body of knowledge *Provides a specific service * Autonomy in decision making * Has a code of ethics.

Why do we document?

*****To Establish Database * minimize errors * save time * reimbursement * comply with standards of care (behavioral expectation) * legal protection * avoid redundancy * show accountability

Moderate

*30-34C* (*86-93F*) is classified as _________ *HYPO*thermia

Mild

*34-36C* (93.2-96.8F) is classified as _______ *HYPO*thermia

Severe

*<30* ( 86 F) is classified as ________ *HYPO*thermia

HYPERpyrexia

*EXTREMELY High* temperature. -*40.0 or 41.5 °C* (104.0 or 106.7 °F)

CMS (Center for Medicare/Medicaid services )

*Emphasize error prevention

HYPO;TACHY; Dec

*Excessive* body temp can lead to ________tension , _______cardia and _______ Cardiac output - *Reduced* perfusion and *Coagulation* - *Cerebral edema* , CNS degeneration , renal *Necrosis*

Vector

*External* mechanical transfer ex: Flies

Dx, Tx and preventative errors

*Fall Risk* assessment Tool Heinrich *Get up and go* National Safety goals Alarms-bed/chair Restraints Pain management Quiet hour

Malignant Hyperthermia

*HYPER*metabolic disorder of skeletal muscle triggered by induction of *Anesthetics* ( succinylcholine)

Immobility

*Inability* to move

Brown adipose

*Infants* have a unique source of heat from ________ adipose which is associated with *Intensified* metabolism -*Inc* metabolism and *02* consumption

Stress

*Involuntary* leakage of small volumes of urine -Assoc with *Inc Intraabdominal pressure*, incompetent urinary sphincter - Laughing, coughing, exercise, walking, getting up from chair

Range of Motion

*Maximum* amount of movement available at a joint in one of the three planes Sagital , frontal , transverse

Shiver, Nonshivering

*Newborn infants* generally do not __________ A process called ____________ thermogenesis ( involves Inc metabolism and o2 consumption)

600

*Perspiration* provides a significant source of heat reduction accounts for _____mL of water loss per day

Thermoregulation (Pic depicts Posterior Hypothalamus innervation)

*Reverse* the process and stimulate sweat glands when body temp is *Elevated* (Anterior Hypothalamus) - *Negative-feedback*

Active measures

*Rewarming with blankets* - heat pads, warm water bath - Place pt. in *Heated Environment*

surgical aseptic

*Sterile* technique

SRE (Serious Reportable Events)

*Surgery*: performed on wrong body part *Patient* : Infant discharged to wrong person *Care* Management : Death or disability *Device* *Enviroment* *Criminal*

Fever

*Temporary* elevation in body Temp -Response to bacteria, parasite, fungi, virus, toxins, drugs -*Pyrogens* Inc hypothalamus thermostatic set point -Thought to *Inc* production of *WBC*

100 %

*Thyroid* hormones increase *BMR* by _______ %

Adverse Event

*Unintended harm* to the patient by an act of commission ( did not provide care correctly) or omission ( did not provide care)

HYPERthermia S/S

*vasoDILATION*: Skin *flushed* and *warm*, hot to touch -Diaphoretic or Dry(Heat stroke) (Depending on exposure & duration) -Dec Urinary Output -*Seizures!!!* -Confusion / coma

Sharp end

- *Active* Errors -Made by providers (Physician , Nurses, Techs) who are providing care , responding to pt. needs

Negative Nitrogen Balance

- *Deficiency* in calories and protein -*Dec* appetite secondary to *immobility* -Body *excretes* more Nitrogen than *Ingests*

Nosocomial , Catheterization

- *Hospital acquired* Most common cause is ______________ (CAUTI)

Blunt end

- *Latent* Error - Flaw in the system that does not immediately lead to an accident but establishes a situation in which a triggering event may lead to an error

Functional

- *Loss* of continence because of causes *Outside* the urinary tract -Related to *Immobility*, cognitive impairment , poor motivation , environmental barriers

Heat Exhaustion

- *Profuse diaphoresis* results in excess water and electrolyte *Loss* Tx: Remove pt. from *Hot environment*

Heat stroke Tx

- *Remove from environment* - *Ice packs* placed in the Axillary, groin, Neck -IV fluids, cool pt.

Who's at risk for UC?

- < 30 years old -race and ethnicity (caucasians, ashkenuzi jewish) -genetics (positive family history)

Planning

- A category of nursing behaviors in which client-centered goals and expected outcomes are established. - All about the patient - 3rd step of the nursing process - Requires deliberate decision-making and problem-solving skills (& critical thinking) - Dynamic (continuous) - Based on the full nursing diagnosis

Standing order

- A pre-printed document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures. -Tell us "WHAT TO DO" -Must be signed by the physician -Common in critical care settings -Ex. Adult Heparin Sliding Scale Cardiology, Adult Insulin Sliding Scale Nephrology, Pharmacy Management of MRSA

Protocols

- A written plan specifying the procedures to be followed during care. -Tell us "HOW TO" - Provides a standard of care (i.e. clinical guideline) - Ex. Eye medication application, Shaving, BP Assessment

Active Nursing Intervention

- Addresses a nursing action which truly attempts to achieve the outcome -Ex) The nurse will immediately 2 tabs of acetaminophen/hydrocodone as prescribed.

Common Documentation Forms

- Admission History (H&P- history & physical) - Flow Sheets and Graphs - Shift Report, Nurse Snapshot -Acuity Records- has to do with how sick patient is -Standardized Care Plans - Discharge Summary - Additional forms for nurses working in home health and LT care settings

Risk for falls

- Age - fall Hx -elimination habits - high-risk med -Mobility/ Cognition (Braden scale) Assessment for Risk for _________

some federal statutory issues:

- Americans with disabilities act - emergency medical treatment and active labor act - advanced directives (living will and power of attorney) - HIPAA - restraints

Quality Improvement

- An approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others. -Ex) Med administration, diet management, wound care, and discharge planning

What do we document?

- Any ADPIE that is done - Any change in status

What do we document?

- Any ADPIE that is done - Any change in status -Pertinent data

Nursing Interventions:

- Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes - designed to assist the client in moving from their present level of health to that which is described in the goals and outcomes - linked to outcomes

What is Documentation?

- Anything written or printed that is relied on as a record or proof for authorized persons - Provides a detailed account of the level of quality care delivered to clients - Ensures continuity of care, saves time, and minimizes errors - Enables health care institution to recover costs

Through Pt. eyes

- Assessment needs to be *Patient Centered* - Include the pt.s *Own perception* of his or her risk factors Assessment Through ____ _______

Physician-initiated Interventions

- Based on a physician's response to treat or manage a medical diagnosis - *Think invasive procedures* - Require specific nursing responsibilities and technical nursing knowledge - Ex. Administering a medication; changing a dressing; inserting a Foley catheter, applying restraints

What charting is used at OSF

- Charting by exceptions - Electronic Medical Record

Indirect Care Activities

- Communication Interventions -Especially for Interdisciplinary plans of care -Delegating -Supervising -Evaluating -Ex) Documentation, delegation, order transcription, environmental management, data entry, telephone consultation, shift report, specimen management, transport

Vehicle

- Contaminated items, water, drugs , solutions, blood, food (Improperly handled), stored, or cooked; fresh or thawed meat

Foot drop

- Debilitating contracture of the foot - Foot is permanently fixed in *Plantar flexion* -Pt. CANNOT dorsiflex the foot

National Safety Goals

- Establish National Safety goals -Help accredited programs address specific concern in regard to patient safety. Goals -Identify patient correctly -Improve staff communication -Use Medicines safely

Documentation Criteria

- Factual and Accurate - Complete (Pointed phrases, not wordy) - Specific - Organized - Current (use military time)

Evaluation

- Final step in the nursing process - Nurse determines whether or not the client's condition or well-being has improved -Ex. Pain management -Determines the usefulness and effectiveness of nursing practice - Informs the nurse of the need to change or revise the plan of care. - Links directly to the Plan - On-going process

Intervention for HYPERthermia

- Find *Etiology* - *Remove* excessive blankets/clothing -*Hydration*/nutrition support - *Cool Packs* to Axillary, groin -*Antipyretics* ( Naproxen, Ibuprofen, ASA, Tylenol) -*Dantrolene* ( MH)

Computerized Documentations

- Growing trend - Standardized language and format - Quick and Efficient - Variety of interfaces -Keyboard entry, Graphic, Automated Speech Recognition, Point of service, Notebook-sized computers - Legal risk - Correcting errors can be challenging - Transition from paper to electronic

Disuse Syndrome

- Immobilization causes *two* skeletal changes 1.) *Impaired* Ca metabolism & Joint abnormalities 2.) Bone tissue is *less* dense -High risk for *fractures* -*If you don't use it, you lose it*

Nursing Hx

- Includes data about a patients level of wellness to determine if underlying condition exist that pose threat to safety ex: Pt. taking diuretics is going to frequently get up and void ( Risk for fall ) Assessment ___________ Hx

"Secondary to"

- May be used to include the medical diagnosis in the nursing diagnosis - Not required - Ex. "Secondary to Mastitis"

Examples of opioids?

- Morphine - Hydromorphone - Oxymorphone - Butorphanol - Hydrocodone - Fentanyl - Etorphine - Buprenorphine - Pentazocine - Methadone - Codeine - Tramadol - Diphenoxlate, Loperamide, Apomorphone

What is unique about "risk for" diagnosis

- No defining characteristics - They have risk factors - Ex. "Risk for infection related to impaired skin integrity."

What is unique about "risk for" diagnosis

- No defining characteristics - They have risk factors - Ex. "Risk for infection related to impaired skin integrity." - Will have a goal but no outcome.

Do we ALWAYS establish priorities based on severity or physiological importance?

- Not always - Sometimes we have to focus on emotional side first

Do we ALWAYS establish priorities based on severity or physiological importance?

- Not always - Sometimes we have to focus on psychological side first

Health Insurance Portability & Accountability Act HIPPA

- Nurses may not discuss a client's examination, observation, conversation, or treatment with other clients or staff not involved in the client's care. - Only involved staff has legitimate access to client's medical records - Nurses are responsible for protecting records from unauthorized readers.

When do we document?

- Ongoing

Consequences of Hypothermia

- Prolonged vaso*CONSTRICTION* leads to peripheral tissue ischemia , intermittent reperfusion -Prolonged *HYPO*thermia leads to reduced perfusion ( *Inc Viscosity* of blood , reduced blood flow and coagulation)

Direct Care Activities

- Require competent and safe practice - ADLs - Physical Care Techniques - Counseling - Teaching - Controlling for Adverse Reactions and Preventative Measures

Mobility

- State or quality of being mobile or *movable* -Gross and fine motor

nursing legal guidelines are based upon:

- Statutory (Federal law) - Regulatory (Administrative) - Common law (Judicial)

Active Core rewarming

- Temp falls *below 30 C* (86.0 F) -*Warm IV fluids* -*Gastric Lavage* -*Cardiopulmonary Bypass* / Arteriovenous rewarming

Defining Characteristics

- The exceptional assessment data that led you to the problem - Defines the problem - Specific subjective and/or objective data - Essentially what you started with - Ex. "As evidenced by pain 8/10, diaphoresis, fever of 102.3"

Nurse-initiated Interventions

- The independent response of the nurse to the client's needs and nursing diagnoses. - No supervision or direction required - Within the legal scope of nursing (as delineated in nurse practice acts) - Ex. Turning client every 2 hours - Ex. Holding a BP medication if the BP is too low

Diagnostic Label

- The problem - Based on your data, think of the priority problems. - Refer to NANDA list for appropriate language - Ex. "Acute Pain"

Implementation

- The step of the nursing process where nurses provide care to patients - Begins after the nurse develops a plan of care - 4th step of nursing process -Occurs when the nurse initiates or completes INTERVENTIONS necessary for achieving the goals and expected outcomes of nursing care -Continuous process

Collaborative Interventions

- Therapies that require the knowledge, skill, and expertise of multiple health care professionals - Critical Pathways - Ex. Involvement of PT, RT, OT, D&N, and nursing following a CVA.

Related Factor/Etiology

- What is causing (or contributing to) the problem? - Can nursing impact this cause? (it must for etiology to work) - Should NOT be a piece of equipment -Should not be blameful -Often NOT the same as a medical diagnosis - Ex. "related to Inflammation"

Outcome

- a specific, measurable change in a clients status that is expected to occur in response to nursing care - the ultimate definition of effectiveness and efficiency for nursing interventions

Act of Urination

- brain structures influence bladder function (healthy NS) -voiding: bladder contraction + urethral sphincter and pelvic flood muscle relaxation STEPS: 1. stretching of bladder wall signals the micturition center in the sacral spinal cord 2. impulses from the micturition center in the brain respond to or ignore this urge, thus making urination under voluntary control 3. when a person is ready to void, the external sphincter relaxes, the micturition reflex stimulates the detrusor muscle to contract, and the bladder empties

four types of reports

- change of shift - telephone - transfer - incident

purposes of the clients chart

- communication - legal documentation - financial billing - education - research - auditing-monitoring

negligence

- conduct falls below standards of care - most common with nurses

common law

- court decisions - most common source of law for malpractice issues - ex. informed consent

administrative law

- created under the administrative boards - guidelines for reporting unethical or incompetence related to: -- child abuse -- elder abuse -- communicable diseases -- EMTALA violations - required to report unethical behavior by law

criminal law

- defines crimes and punishments - ex. diversion of narcotics - felony versus misdemeanor

statutory law

- formal written laws (federal, state, or local) - basis for standard of care - ex. nurse practice act

JCAHO standard of documentation (what must be documented?)

- initial assessment - client and family teaching - discharge planning - evaluation of outcomes - multidisciplinary care

malpractice

- injury occurs as a result of what a nurse does or fails to do - doctors and APNs more common

Direct care

- interventions are treatments performed through interactions with patients. (a patient receives a direct intervention in the form of medication administration, insertion of an IV, or counseling for grief)

state statutory issues

- licensure - good samaritan laws - public health laws - uniform determination of death act - physician assisted suicides

lawsuits nurses can positively impact:

- medication errors - negligent supervision - informed consent - accidental injury - nosocomial and wound infection - pain and suffering, emotional distress - lack of teamwork and communication - inadequate charting

methods of documentation

- narrative (coldspa) - progress notes (SOAPIE and DAR) - charting by exception (type we use) - critical pathways

what is Commitment?

- person anticipates when to make choices without assistance from others and accepts accountability for choices made (expert level of knowledge)

civil law

- protects a persons individual rights within our society - encourages fair treatment - ex. tort law

types of multidisciplinary communication

- record or chart - report - consultations - referrals

Consequences of incontinence

- skin breakdown (peri area constantly wed and moist) -changes in daily activities (withdrawal from social events; embarrassed) -changes in social relationships (isolation)

Client outcomes should be:

- specific and measurable - derived from the goal - address defining characteristics

Client outcomes should be:

- specific and measurable - derived from the goal - address defining characteristics - must be realistic

what is Basic critical thinking

- thinking is concrete and based on a set of rules or principles. Following step by step regardless of patients' needs

areas of negligence:

- treatment - communication - medications -monitoring

Indirect care interventions

- treatments performed away from the client but on the behalf of the client. (safety and infection control, looking up meds before you go into room, delegation, and setting up task beforehand)

Direct care interventions

- treatments performed through interactions with the client. (a client receives a direct intervention in the form of medication administration, insertion of an IV, or counseling for grief)

proving malpractice

- what your duty not fulfilled? - was there a breach of duty through omission? - casual connection between breach and harm? - was there actually harm or damage?

intentional tort

- willful or intentional act or wrongdoing that violates another persons rights or property - assault and battery, medical battery, false imprisonment, trespass, defamation

Western Biomedical Belief

-"white mans perspective" -imbalance in body-> causing illness -scientific culture

IOM: Take away points

-*User Center Design* : Build on human strength -*Avoid Reliance on memory*: Protocols & checklist -*Attend to Work safety*: Work hours, staffing ratios -*Avoid Reliance on Vigilance*: use checklist, alarms, signals These are several IOM _____ ______ ______

Never Event

-Adverse events that should *Never* occur in health care Examples -Foreign object *after* surgery -Pressure ulcer *Stages III / IV* -Catheter associated UTI ( *CAUTI*)

IOM

-Alerted Health care industry and the public to the problem of death from *preventable errors* -Ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors

Near Miss

-An error of commission or omission that could have harmed pt. BUT serious harm *did not* occur as a result of chance

Complicated fracture

-Comminuted: bone fragments -damage to other tissues or organs

Anterior Hypothalmus

-Controls temp if *High* at set point - Creates heat *Loss* by *sweating* & *Vasodilation*

Interrelated concepts

-Culture: different culture, different values and beliefs -Development: ability to express, too much pain can stunt development -Spirituality: being punished, method for pain relief -Sleep: sleep disturbances -Tissue integrity: pressure ulcers -Mobility: not going to move around

What are the components of the Nursing Practice Act

-Definition of Nursing -Licensure requirements -Revocation or suspension of license. -Reciprocity of license -Members of the Board of Nursing .

Health Care Environment

-Determine if any *hazards* exist in immediate care setting ex: *Drainage bags*, *IV pumps*, furniture Assessment of _______ _______ Environment

Types of interventions: (planning nursing care)

-Independent nursing interventions -Dependent nursing interventions -Collaborative nursing interventions

Dimensions of Cultural Attributes

-Individualism vs. Collectivism -Power Distance -Masculinity vs. Femininity -Long Term vs. Short Term orientation -Religiosity

You are preparing to ambulate a client who had abdominal surgery 24 hours ago. The client weighs 270 pounds and is 6 feet tall. He has a PCA (Patient Controlled Analgesia) system for pain control. He has IV fluids running and IV antibiotics scheduled to run every 6 hours. What questions do you need to answer before you attempt to ambulate this client?

-LOC -Need to urinate -Vitals -Pain level -Last push of PCA -Have push again to prevent pain -Personnel help we need -How are we ambulating with IV fluids -Personnel just for IV pole? -BP in case of orthostatic hypotension

Theoretical Links to Culture

-Leininger's Theory of Culture Care Diversity and Universality -Interprofessional Theory of Social Suffering

Non opioid

-NSAIDS -ibuprofen -ketovolae -celecoxib -naproxen

OPQRST

-Onset (duration) -Provocative/palliative (allieviating or relieving factors) -Quality -Region (location) -Severity (intensity) -Time -Understanding (effect of pain on quality of life and functional status, comfort and function goal)

Consequences of untreated pain

-Prolonged stress response: increased HR and BP, muscle tension -Reduced immune competence: compromised immune system -Cardiovascular instability: cardiovascular collapse or shot -Respiratory dysfunction: short breaths not moving secretions -Genitourinary disturbances: urinary retention, UTI -Decreased gastrointestinal motility: bas circulation to GI, reduced appetite -Metabolic imbalance: glucose levels up -Developmental issues: no energy to continue with development, regress to seek comfort -Increased chronic post surgical pain syndromes: mysterious, rewiring brain perpetuating pain syndromes

QSEN

-Quality and Safety Education for Nurses -Prepares future nurses who have the knowledge , skills, and attitudes necessary to continuously improve the quality and safety of health care system.

What are some examples of the standards of professional performance

-Quality of practice -Education -Professional Practice Evaluation -Collaboration -Communication -Ethics -Evidence-based practice and research -Resources -Leadership -Environmental health

Scope and categories

-Secular Humanism to varying degrees of devotion to religious practice -multiple faith traditions throughout the world

correct way to give an enema

-Wear gloves to prevent the transmission of fecal microorganisms -Explain the procedure, including the position to assume, precautions to take to avoid discomfort and length of time to retain the solution before defecation -Enema is given in the Sim's position -the IV pole is positioned so the enema bag is 12 inches above the anus and approximately 18 in above the mattress (depending on the patient's size) -insert the tip of the tube slowly by pointing tip in direction of patient's umbilicus. -Length of insertion varies: Adult and adolescent 7.5 to 10 cm (3 to 4 inches) Child: 5 to 7.5 cm (2 to 3 inches) Infant: 2.5 to 3.5 cm (1 to 1 ½ inch) -If patient is self-administering advise them to use the side lying position, do not do while sitting on the toilet

Fracture

-a break or disruption in the continuity of a bone -stress applied overcomes the resistance -can occur anywhere in body -cause neuropathic pain

Culture

-a pattern of shared attitudes, beliefs, and self-definitions, norms, roles, and values -critical in providing patient centered care

Flatulence

-accumulation of gas in the intestines causing the walls to stretch -lactose intolerant

Complications of fractures

-acute compartment syndrome -crush syndrome -hypovolemic shock (bleeding out) -fat embolism (blood clot of fat) -venous thromboembolism (blood clot in legs, break off into circulation) -infection -ischemic necrosis (lack of blood supply, death of tissue) -delayed union (bones don't heal back together)

Assessment of otitis media

-affected hearing -discolored/inflamed tympanic membrane -sleep affected -fever -decreased appetite -refusing to nurse -pain -loss of balance -headache

Renin (kidney functions)

-affects blood pressure -starts chain of events that cause water retention, thereby increasing blood volume

Prostaglandin E2 and Prostcyclin (kidney functions)

-affects blood pressure -aid vasodilation

Risk factors of otitis media

-age (shape of ear in children, poorly developed immune system in children) -group child care -infant feeding -seasonal factors (pollen counts) -poor air quality (second hand smoke)

Where is this concept encountered in nursing practice?

-all settings of care, particular roles include parish nursing -times of life transition -traumatic events -end of life (at any age)

Ethnocentrism

-an expression of the belief that one's culture of origin is the best approach to life -blocks effective communication by creating biases and misconceptions about human behavior

Culturally aware nurses...

-are conscious of culture as an influencing factor between themselves and others -understand the basis of their own behavior -recognize that health is expressed differently

Prevention of fractures for teens

-avoid alcohol and drugs -graphic videos -safety equipment -be aware of peer pressure

Communication

-biggest barrier -verbal and nonverbal

Race

-biologic variation within a population (genetic physical markers) -race differences: growth and development, skin color, enzymatic differences, susceptibility to disease, and laboratory test findings -same race may be of different cultures -race is explicit (can tell race when look at a person)

Things to Consider with Cultural Diversity

-biological variations -personal space -perception of time -environmental control -social organization -communication -nutrition -religion

Incontinence Management

-bladder or bowel retraining -biofeedback (sensor attached to muscle, see level of contraction) -timed and prompted voiding -use of protective pads -skin care (wash skin)

What are Collaborative nursing interventions?

-both independent and dependent

Ulcerative Colitis (UC)

-can happen anywhere within colon -affects mucosa of colon -narrow colon -affects flow of stool

Risk factors for pain

-cancer -arthritis -shingles -cluster headaches -fractures -kidney stones -child birth -acute pancreatitis -reposition and turning

Health Literacy

-capacity to obtain and use health information

Personal Space

-certain distance acceptable for certain cultures

Populations at greatest risk

-children (dont have mental capacity to control elimination) -pregnant women (more urgency, constipation, uterus putting pressure on bowels and bladder) -older female adults: urinary incontinence (lose tone in pelvic muscle) -older male adults: prostates enlarge (BPH: benign prostatic hypertrophy)

Social Determinants of Health

-circumstances of life and outside forces

Cultural Competence is guided by three principles:

-client centered -incorporate the cultural norms and values of the client -self empowerment

Three-Tier Cultural Competence

-clinical (provider at bedside) -organizational (healthcare institution) -structural (policies and procedures)

Culturally Sensitive

-cognition = awareness -affective = sympathetic -psychomotor = some skills Outcome = neutral

Culturally Competent

-cognition = knowledgeable -affective = committed to change -psychomotor = highly skilled Outcome = good, positive (constructive)

Culturally Incompetent

-cognition = oblivious -affective = apathetic -psychomotor = no skills Outcome = poor (destructive)

Three Dimensions of Developing Provider Cultural Competence

-cognitive (thinking) -affective (feeling) -psychomotor (doing)

Data Collection Phase

-collect self identifying data -ask questions that elicit client's perception of why he or she is here, his or her condition, and past and anticipated treatments -postnursing diagnosis, identify cultural factors that may influence effective nursing care actions

Characteristics or urine

-color: pale straw to amber color -clarity: transparent unless pathology is present -odor: ammonia in nature

caring for a deceased

-confirm that health care provider certified the death and documented time of death and actions taken -determine if autopsy is requested -validate organ donation status -identify patient

Culturally Competent Nursing Interventions

-cultural preservation -cultural accommodation -cultural repatterning -cultural brokering

Three Stages of developing Provider Cultural Competence

-culturally incompetent -culturally sensitive -culturally competent

Common Attributes of Culture

-culture is learned -culture is changing and adapting -values, beliefs, and behaviors are shared by members of the cultural group

Risk factors of spiritual distress

-death: actively dying, death of significant other, exposure to death, aging, illness, pain -loss: increasing dependence on others, loneliness, loss of body part, loss of function -life transitions: birth of a child, unexpected life event -social and self alienation

What to do with diarrhea:

-diet/fluid (oral rehydration therapy) -skin care -medications: antidiarrheal medications (Imodium, codeine phosphate, opium tincture), anticholinergic agents, others

Nutrition

-different dietary patterns -may predispose to certain things

Hemorrhoids

-dilated, engorged veins in the lining of the rectum -pregnant women, heart failure, liver dysfunction

Two Types of Cultural Encounter

-direct (face to face) -indirect (shared between one's own peers)

Factors influencing urination

-disease conditions -medications and medical procedures (diuretics, sleeping pill, antidepressants, lower GI procedure, brain procedure) -socioeconomic factors (need for privacy) -psychological factors (anxiety, stress, privacy) -fluid balance

Biculturalism

-duel pattern of identification

Cause of otitis media

-enlarged adenoids -congestion/mucus

Marginalization

-exclusion

Cultural Competence in Nursing

-expected component of professional nursing practice -requires underlying acceptance of patient's health beliefs -requires adapting care to meet unique needs and perspectives of individual

Behavioral signs of pain

-facial expressions -restlessness -change in activity (infant more restless) -crying (child) -assessment tool *apply to developmentally disabled, dementia, unconscious, in coma, children, infants

Lab tests

-fecal characteristics -fecal specimens (for diarrhea)

Immigration Health Care Challenges

-financial constraints -language barriers -differences in social, religious, and cultural backgrounds between immigrant and provider -use of traditional healing practices unfamiliar to their health care providers -providers' lack of knowledge of high risk diseases in the specific immigrant groups

Organization Phase

-gather data related to client's/family's views on optimal treatment choices, plus differences between cultural needs and goals of western medicine

Biological Variations

-gives us knowledge on the diseases more common with certain races -health promotion and prevention

Attribute of spiritual care

-healing presence -therapeutic use of self -intuitive sense -exploration of the spiritual perspective -patient centeredness -meaning centered therapeutic intervention -creation of spiritually nurturing evironment

What to do if constipated:

-hydrate -medicate (laxatives) -enema -suppository -increase fiber in diet

Causes of bowel retention

-ignoring the urge to go or decreased peristalsis -leads to: stool dies and hardens, constipation, impaction

Pain management for fractures

-immobilization -elevation -hot and cold -drugs -distractions -acupuncture -RICE (rest, ice, compression, elevation)

Consequences of untreated acute otitis media

-impaired hearing -speech or developmental delays -spread of infection -tearing of the eardrum

Adjuvant

-in addition to other drugs -cyclobexaprine -gabapentin -nortryptyline

Bowel Incontinence

-inability to control passage of feces and gas to the anus

Diarrhea

-increase in number of stools and passage of liquid, unformed feces -food poising, crohns disease, stress, lactose intolerance -complications: skin breakdown, dehydration, and electrolyte imbalance

Disparities in Health

-inequity in social structures based on characteristics -historically linked to discrimination

Cultural Nursing Assessment

-initial contact with a client -in depth cultural assessment -takes place over time Two Phases: -a data collection phase -an organization phase

The Nine Cultural Strategies

-interpreter services -increased minority representation -training in cultural competence and sensitivity -coordinate with community's traditional healers -use community health workers -incorporate cultural notions of health -include families and community members in care and decision making -provider immersion into another culture and administrative and organizational accommodation -linguistically appropriate information

Cultural Desire

-intrinsic motivation to engage in the four (previous) elements necessary to provide culturally competent care -based on the humanistic value of caring for the individual -cannot be taught in the classroom

Characteristics of Culture

-learned -integrate -shared -tacit -dynamic

Four categories of foreign-born

-legal immigrants -refugees -nonimmigrants -unauthorized immigrants

Descriptors of pain

-location: region/radiation -intensity: severity, scale 1-10, face diagram -frequency: timing, when did it start, how long did it last, every month, every few hours, standing, sitting, intermittent, constant

Traditional Health Belief

-magicoreligious -get sick because of something spiritual or sin -holistic view -balance of nature (ying and yang)

Consequences of spiritual well-being

-maintain or improve health status -dignified life closure -grief resolution -hope -psychosocial adjustment -quality of life -social involvement

Non pharmacological interventions

-massage -positioning and body alignment -splinting -thermal interventions (heat and cold) -mind body therapies

Attributes

-meaning making, finding purpose -unfolding mystery; experience of transcending the self -connectedness/experiencing relation -spiritual activities/practices

Special factors affecting bowel elimination

-more diarrhea for infants -constipation in elderly -constipation during pregnancy -constipation while in pain

Opioid

-narcotics -morphine -fentanyl -hydromorphone -oxycodone

Environmental control

-nature controls environment: individual has control over themselves -nature and environment equal harmony: cant control illness but can manage symptoms -environment has mastery over nature: my disease has master over me, there is nothing i can do

Hierarchy of pain measures

-obtain patient self report -consider patient condition or exposure to painful procedures -observe for behavioral signs of pain -evaluate physiological indicators -conduct an analgesic trial (giving a pain relieving med and seeing reaction)

risk of constipation

-opioid use/medications -impaired physical mobility/physical inactivity -irregular bowel habits and ignoring urge to defecate -chronic illnesses (Parkinson's, MS, RA, chronic bowel disease, depression, eating disorders) -low fiber diet high in animal fats (meats, and carbs), low fluid intake -stress (illness of family member, death of loved one, divorce) -changes in life or routine such as pregnancy, aging and travel -neuro conditions that block nerve impulses to the colon (stroke, spinal cord injury, trauma) -chronic bowel dysfunction (colonic inertia, irritable bowel)

Perception of Time

-past, present, future orientation -different for each culture

Chronic pairn

-persistent -lasted more than 3 months -lacks autonomic signs -no protective function -brain can create source of pain

Jean Watson's caring theory

-practice of loving, kindness and equanimity -authentic presence: enabling deep belief of other -cultivation of one's own spiritual practice toward wholeness of mind, body, spirit-- beyond ego -"being" the caring, healing environment -allowing miracles (openness to the unexpected and inexplicable life events)

Disease Conditions Affecting Urination

-prerenal, renal, postrenal classification -conditions of the lower urinary tract -diabetes mellitus and neuromuscular diseases such as multiple sclerosis -benign prostatic hyperplasia -cognitive impairments (ex. alzheimers) -diseases that slow or hinder physical activity -conditions that make it difficult to reach and use toilet facilities -end stage renal disease, uremic syndrome

Enculturation

-process by which a person learns norms, values, and behaviors of another culture

Assimilation

-process by which person gives up his or her original identity and develops a new cultural identity by becoming absorbed into the dominant cultural group

Acculturation

-process of acquiring new attitudes, role, customs, or behaviors

Cultural Knowledge

-process of searching for and obtaining a sound educated understanding about culturally diverse groups -emphasis is on learning about the clients' worldview from an emic (native) perspective

Erythropoietin (kidney functions)

-production of erythropoietin is essential to maintaining a normal RBC volume -erythropoietin stimulates bone marrow to produce RBCs and prolongs the life of mature RBCs

Surgical Interventions

-prostate surgery (enlarged, cause obstruction -bladder surgery (no muscle tone) -urinary diversion -surgery for renal calculi (kidney stones) -stents to relieve obstruction

Health Equity and Social Justice

-providing impartiality and objectivity at a systems or governmental level

Diagnostic exams

-radiologic imaging, with or without contrast -endoscopy (requires consent) -ultrasound -CT or MRI

Risk factors for fractures

-recklessness in adolescents -occupation -nutrition (anorexia) -driving/accidents -unsafe house -postural instability -osteoporosis -small maternal pelvis, large baby -impaired cognitive ability -athletes/sport -proprioception (not balanced) -age -tobacco and alcohol -poor vision with aging -multiple medications

Working with Immigrant Populations

-recognize the values, beliefs, and practices that comprise your own culture -identify the client's preferred language -learn clientele's health seeking behaviors -get to know immigrant community -get to know some traditional practices and remedies used by families and communities -learn how cultural subgroups explain common illnesses or events -consider and accommodate client viewpoint -conduce a cultural assessment

When t use non pharm interventions

-refusing drugs -going into surgery -end of dose period -while waiting for drugs to work *not for acute severe pain*

Ear anatomy and role of the eustachian tubes

-regulate air pressure in the middle ear -refresh air in the ear -drain normal secretions from the middle ear

Health Disparities and Socioeconomic Status

-relationship reflected in life expectancy, infant death rates, low birth rates, and many other health measures

Impaction

-results from unrelieved constipation -collection of hardened feces wedged in rectum that a person cannot expel

Prevention of fractures for older adults

-safe driving -keep hoe free of clutter -glasses -hearing aids -yearly physical -monitoring meds -canes, walkers, wheelchairs

Prevention of fractures for infants

-safe home environment -getting enough calcium and vitamin D -demonstrating car seat use -proper infant development -safe clothing -secure sleeping

Cultural Competence and Interrelated Constructs

-self awareness -cultural skill -cultural knowledge

Ethnicity

-shared feeling of peoplehood among a group of individuals -related to cultural factors (nationality, geographic region, culture, ancestry, language, beliefs, and traditions) Equally influenced by: -education -income -cross cultural experiences

Physical Assessment

-skin and mucosal membranes (assess hydration) -kidneys (flank pain may occur with infection or inflammation -bladder (distended bladder rises above symphysis pubis (retention) -urethral meatus (observe for discharge, inflammation, and lesions)

Religion

-some culture, religion permeates in everyday life -dress, talk, worship

Barriers to Developing Cultural Competence

-stereotyping -prejudice -racism -ethnocentrism -cultural imposition -cultural conflict -culture shock

Constipation

-symptom, not disease -frequent stool and/or hard, dry small stools that are difficult to eliminate -dehydration, opiates, depressed -common in elderly; not common in children

Bowel Diversion

-temporary or permanent artificial opening in the abdominal wall (stoma) -surgical opening in ileum or colon

Clinical manifestations of fractures

-tenderness/pain (tissue damage) -swelling (hematoma, inflammatory process) -decrease function of use/inability to bear weight (bone is broken) -may be bruised -severe muscular rigidity (tendons and muscle tightens, spasm) -crepitus crispy sounds (bone fragments scrapping) -in hip leg may appear shortened, externally rotated, foot turned out

Cultural Skill

-the ability of nurses to effectively integrate cultural awareness and cultural knowledge when conducting a cultural assessment and to use the data to meet the specific client's needs

Acute compartment sydrome

-the compartment is an area where muscles, vessels and nerves are surrounded by fascia, which is not elastic --fascia does not stretch --increases pressure --pressure on nerves and blood vessels --shut off circulation -increased pressure occurs within a compartment caused reduced circulation to the area -pressure can be internal (blood or fluid accumulation) or external (a tight bandage or cast) -Symptoms: severe pain, pain intensified with passive movement, pain unrelieved by analgesics, paresthesias, pale, weakening pulses --different pain, sensations --pain when moving passively -treatment: --go in surgically and cut fascia --relieve pressure --surgical emergency --can occur because of cast also

Cultural Encounter

-the process that permits nurses to seek opportunities to engage in cross cultural interactions

Cultural Awareness

-the self examination and in depth exploration of one's own beliefs and values as they influence behavior

Culture occurs among:

-those who speak a particular language -those who live in a defined geographic region

Causes of fracture

-trauma (common in kids) -motor vehicle accidents (common in kids and older adults) -falls (common in older adults) -abuse (common in kids)

Urine Tests and Diagnostic Examinations

-urinalysis (determines UTI from an increase in nitrates and WBCs) -specific gravity (ability to concentrate urine) -culture (pathogens) -noninvasive procedures (dyes) -invasive procedures (cystoscopy; risk of infection, informed consent)

Management of otitis media

-wait and see approach -managing pain -facilitating drainage, ear tubes (reoccuring) -family education (prevention) -emotional support (for child and family) -antibiotic therapy (education about side effects)

Things you may notice with elimination problems:

-weird color -lack of bowel sounds -presence of blood -consistency of stool

What does outcomes of nursing presence include?

1) Alleviating suffering 2) Decreasing a sense of isolation 3) Decreasing a sense of vulnerability 4) Personal growth

While working in a community health clinic, it is important to obtain nursing histories and get to know the patients. Part of history taking is to develop the nurse-patient relationship. Which of following apply to Peplau's theory when establishing the nurse-patient relationship? (select all that apply) 1) An interaction between the nurse and patient must develop. 2) The patient's needs must be clarified and described. 3)The nurse-patient relationship is influenced by patient and nurse preconception. 4) The nurse-patient relationship is influenced only by the nurses preconceptions.

1) An interaction between the nurse and patient must develop. 2) The patient's needs must be clarified and described. 3)The nurse-patient relationship is influenced by patient and nurse preconception.

When using ice massage for pain relief, which of the following are correct? (Select all that apply.) 1) Apply ice using firm pressure over skin. 2) Apply ice for 5 minutes or until numbness occurs 3) Apply ice no more than 3x a day 4) Limit application of ice to no longer than 10 minutes. 5) Use a slow circular steady massage. .

1) Apply ice using firm pressure over the skin 2) Apply ice for 5 minutes or until numbness occurs 5) Use a slow circular steady message.

Match the following caring behaviors with their definitions. 1. Knowing A) Sustaining faith in one's capacity 2. Being with to get through a situation 3. Doing for 4. Maintaining B) Striving to understand an event's belief meaning for another person. C) Being emotionally there for another person. D) Providing for another as he or she would do for themselves.

1) B 2)C 3)D 4)A

A nurse demonstrates caring by helping family members: 1) Become active participants in care. 2) Provide activities of daily living 3) Remove themselves from personal care 4) Make healthcare decisions for the patient.

1) Become active participants in care

Which of the following statements apply to theory generation? (Select all that apply) 1) Builds scientific knowledge base of nursing 2) Discovers relationships of phenomena to practice 3) Tests specific phenomena 4) Identifies observations about a phenomenon

1) Builds scientific knowledge base of nursing 2) Discovers relationships of phenomena to practice 4) Identifies observations about a phenomenon

Match the following components of systems theory with the definitions of that component. 1) Feedback A. Data entering the system 2)Input B. End product 3) Content C. Data related to system functioning 4) Output D. Product and information obtained from the system

1) C 2)A 3)D 4) B

A health care provider writes the following order for a patient who is opioid naive who returned from the operating room following a total hip replacement: "Fentanyl patch 100mcg, change every three days." On the basis of this order, the nurse takes the following action: 1) Calls the HCP and questions the order 2) Applies the patch the third post-operative day 3) Applies the patch as soon as the patient reports pain. 4) Places the patch as close to the hip dressing as possible.

1) Calls the HCP and question the order.

Which of the following closely aligned with Leininger's theory? 1) Caring for patients from unique cultures 2) Understanding the humanistic aspects of life 3) Variables affecting a patient's response to a stressors 4) Caring for patients who cannot adapt to internal and external environment demands.

1) Caring for patients from unique cultures

A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of this disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch? 1) Caring touch 2) Protective touch 3)Task-oriented touch 4)Interpersonal touch

1) Caring touch

Nursing diagnosis is based on what?

1) Characteristics 2) Expected Outcomes 3) Research Based 4) Feasibility 5) acceptability of Pt. 6) Capability of the nurse

What is the purpose of the clients chart

1) Communication 2) Legal documentation 3) Financial billing 4) Education 5) Research 6) Auditing-Monitoring

What are the multiple forces that affect nursing?

1) Demographic changes in population 2) Human rights 3) Increase number of medially undeserved 4) Threat of bio terrorism

What happens in shift change?

1) Discuss the patients plan of care and overall progress. 2) Current and relevant info 3) Nurses collaborate and share info prevents errors or delays.

As an art nursing relies on knowledge gained from practice and reflection on past experiences. As a science nursing relies on (Select all that apply) 1) Experimental research 2) Nonexperimental research 3)Research from other disciplines 4) Professional opinions

1) Experimental research 2) Nonexperimental research 3)Research from other disciplines

Four Types of errors in writing nursing interventions

1) Failure to precisely or completely indicate nursing actions. 2) Failure to indicate frequency 3) Failure to indicate quantity 4) Failure to indicate method.

What are the goals of the Theoretical Nursing Model

1) Identify the domain and goals of nursing 2) Provide knowledge to improve nursing administration, practice, education, and research. 3) Guide research and expand the knowledge base of nursing. 4) Identify research techniques and tools used to validate nursing interventions. 5) Formulate legislation governing nursing practice, research, and education. 6) Formulate regulations interpreting nurse practice acts. 7) Develop curriculum plans for nursing education 8) Establish criteria for measuring quality of nursing care, education, and research. 9) Guide development of a nursing care delivery system. 10) Provide systemic structure and rationale for nursing activities.

What are three problems that can arise if sleep disorders go untreated?

1) Insomnia 2) Abnormal movements 3) Sensation during sleep or when waking up at night 4) Excessive daytime sleepiness.

What is 4 things to keep in mind when dealing with aspects of care within different cultures?

1) Know the patient's cultural norms for caring practices. 2) Know the patients cultural practices regarding end-of-life care. In some cultures it is considered insensitive to tell the patients, 3) Determine if a member of the patient's family or cultural group is the best resource to use for caring practices such as providing presence or touching . 4) Know the patient's cultural practices regarding the removal of life support.

What are the nursing principles of administering analgesics?

1) Knowing the patients previous response to analgesics. 2) Select the proper medication when more than one is ordered. 3) Know the accurate dosages 4) Assess the right time and interval for administration.

What are the three areas for competency in critical thinking?

1) Knowing the scientific rational for the intervention 2) Possessing the necessary psychomotor and interpersonal skills. 3) Being able to function within a particular setting to use the available HC resources effectively.

A nurse is applying Henderson's Theory as a basis for theory based-nursing practice. What other elements are important for theory-based nursing practice? (Select all that apply) 1) Knowledge of nursing science 2) Knowledge of related sciences 3) Knowledge about current health care issues 4) Knowledge of standards of practice

1) Knowledge of nursing science 2) Knowledge of related sciences 4) Knowledge of standards of practice

Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about tobe sarted on a PCA of morphine? SATA 1) Only the patient should push the button 2) Do not use the PCA until the pain is severe 3) The PCA system can set limits to prevent overdoses from occuring. 4) Notify the nurse when the button is pushed. 5) Do not push the button to go to sleep.

1) Only the patient should push the button 3) The PCA system can set limits to prevent overdoses from occuring. 5) Do not push the button to go to sleep.

What are six competencies for a nurse?

1) Patient Centered Care 2) Teamwork and collaboration 3) Evidence based practice 4) Quality improvement 5) Safety 6) Informatics

A patient rates his pain as a 6 on a scale of 0-10. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? 1) Patients self-report 2) Behaviors 3) Surrogate report 4) Vital sign changes.

1) Patients self-report

What are the 7 Domains?

1) Physiological Basic 2) Physiological Complex 3) Behavioral 4) Safety 5) Family 6) Health Systems 7) Community

What are the CON's 3 main goals

1) Preparing the graduate to practice professional nursing in a variety of roles and healthcare settings. 2) Provide the essential foundation for undergraduate study in nursing 3) Foster a commitment to personal and professional growth and dignity

What is step 3 in the stages of sleep

1) Stage lasts 15-30 minutes 2) It involves initial stages of deep sleep. 3) Muscles are completely relaxed. 4) Vital signs decline but remain regular.

What is step 4 in the stages of sleep

1) Stage lasts approximately 15-30 minutes 2) It is the deepest stage of sleep 3) If sleep loss has occurred, sleeper spends considerable part of the night in this stage. 4) Vital signs are significantly lower than during hte waking hours.

What is involved in REM sleep

1) Stage usually begins about 90 mins after sleep has begun. 2) Duration increases with each sleep cycle and averages 20 minutes. 3) Vivid full color dreaming occurs; less vivid dreaming occurs in other stages. 4) Stage is typified by rapidly moving eyes, fluctuating heart and respiratory rates, increased or fluctuating BP, loss of skeletal muscle tone and increase in gastric secretions. 5) It is very difficult to arouse sleeper

What are the 3 categories of touch?

1) Task oriented 2) Caring touch 3) Protective Touch

A postoperative patient currently is asleep. Therefore the nurse knows that: 1) The sedative administered may have helped him sleep, but it is still necessary to assess pain. 2) The IV pain medication given in recovery is relieving his pain effectively. 3) Pain assessment is not necessary. 4) The patient can be switched to the same amount of medication by the oral route

1) The sedative administered may have helped him sleep but it is still necessary to assess pain.

Nurses follow HCP orders unless?

1) They believe the orders are in error or can harm the patient. 2) Violate agency policy 3) Harmful to the Pt.

A patient has returned form the operating room, recovering form repair of a fractured elbow, and states that her pain level is 6 on a 0/10 pain scale. She received a dose of hydromorphone just 15 minutes ago. Which interventions may be beneficial for this patient at this time? SATA 1) Trans-cutaneous electrical nerve stimulation (TENS) 2) Administer naloxone 2mg interveniously 3) Provide a back massage 4) Reposition the patient 5) Withhold any pain medication and tell the patient that she is at risk for addiction?

1) Trans-cutaneous electrical nerve stimulation (TENS) 3) Provide a back massage 4) Reposition the patient

While caring for a patient with cancer pain the nurse knows that a multimodal analgesia plan includes? SATA 1) Using analgesics such as nonsteroidal anti-infalmmatory drugs (NSAIDS) along with opioids. 2) Stopping acetaminophen which the pain becomes very severe. 3) Avoiding polypharmacy by limiting the use of medication to one agent at a time. 4) Avoiding total sedation, regardless of the severity of the pain 5) The use of adjuvants ( co-analgesics) such as gabapentin to manage neuropathic type pain.

1) Using analgesics such as nonsteroid anti-inflammatory drug (NSAIDS) along wiht opioids. 5) The use of adjuvants (co-analgesics) such as gabapentin to manage neuropathic type pain.

What are some nursing assessment questions regarding pain?

1) What is the worst pain you have had in the past 24 hours? 2) What medication/herbs are you taking now 3) Which nonpharmacololgical treatments have you tried to relieve the pain? 4) What level of daily exercise can you maintain with your pain? 5) What is the average pain you have had in the past 24 hours? 6) Is your pain constant, intermittent, or both? 7) Have you used any recreational drugs or alcohol to alleviate the pain?

What are some nursing assessment questions regarding sleep deprevation

1) When did you notice this problem 2) Are you taking any new prescriptions or OTC medications 3) How has the loss of sleep affected you? 4) How often during the week do you have trouble falling asleep 5) Do you have a physical illness that affects your sleep?

Match the following theories with their definitions. 1) Grand theory A) Addresses specific phenomena and reflect practice 2) Middle- Range B) First level in theory Theory development and describes phenomenon 3) Descriptive Theory C) Provides a structural framework for broad concepts about nursing 4) Prescriptive Theory D) Linked to outcomes (consequences of specific nursing interventions)

1)C 2)A 3)B 4)D

Nursing as a Profession -Professions possess the following characteristics:

1. A theoretical body of knowledge leading to defined skills, abilities, and norms 2. Has a code of ethics for practice 3. An extended education of its members, as well as a liberal arts foundation 4. Members have autonomy in decision-making and practice 5. Provides a specific service

Nursing as a profession possess what characteristics

1. A theoretical body of knowledge leading to skills, ability and norms. 2. Code of Ethics for Practice (ANA) 3. Extended education of its members, as well as a liberal arts foundation (BSN) 4. Members have autonomy in decision making process 5. Provide a specific service

Steps for collecting evidence for evidenced-based practice

1. ASK (Ask a clinical question) 2. COLLECT EVIDENCE (collect the most relevant and best evidence) 3. APPRAISE (critically appraise the evidence you gather) 4. INTEGRATE INFO (integrate all evidence with ones clinical expertise and patient preferences and values in making a practice decision or change) 5. EVALUATE (evaluate the practice decision or change) 6. SHARE (share the outcomes of EBP changes with others)

Nigel is a nursing student assigned to Mr. Hannigan, a 72-year- old Caucasian with a diagnosis of pneumonia who is admitted to the medical-surgical unit. Mr. Hannigan is a one-pack-per-day smoker who experiences chronic problems with bronchitis and pneumonia as a result of his smoking. Nigel's immediate tasks are to complete an admission history and physical examination and design a care plan for Mr. Hannigan. 1. Which of the following of Mr. Hannigan's assessment findings can Nigel group together to formulate a data cluster? (Select all that apply.) A. Respirations 32 breaths/min B. Crackles in right and left lung bases C. Pain at incision site D. Shortness of breath with ambulation E. Hematuria 2. Nigel develops nursing diagnoses for Mr. Hannigan's care plan. Impaired gas exchange is a ______ nursing diagnosis for pneumonia. 3. Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. The acronym PES stands for _________ ______________ ___________________.

1. Answer: A, B, D Rationale: A data cluster is a set of signs or symptoms gathered during assessment that are grouped together in a logical way. Respiratory rate, lung sounds, and shortness of breath are respiratory assessment findings that may be grouped together to manage a respiratory problem. Pain at the incision site and hematuria aren't directly related to respiratory issues. 2. Answer: Risk Rationale: A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. Impaired gas exchange is a risk nursing diagnosis for pneumonia. 3. Answer: Problem, etiology, symptoms Rationale: The acronym PES stands for problem, etiology or related factor, and symptoms or defining characteristics.

Lalani is a nursing student who provides nursing care to a Vietnamese neighborhood as part of her community health rotation. The residents of this community typically do not speak English, nor do they have health insurance or access to medical care. Many of the older residents do not have reliable transportation. Lalani visits Ms. Lam, a 68-year-old with a history of breast cancer. Ms. Lam underwent treatment for breast cancer 5 years ago, including radiation and chemotherapy. She has not had a mammogram since completion of the cancer therapy. Lalani works with her to schedule a mammogram at the county hospital free clinic. 1. Lalani needs to call the county hospital free clinic to arrange an interpreter for Ms. Lam for her mammogram. Rank in order the steps Lalani should take for ensuring a successful phone consultation. A. Summarize the problem. B. Have all of the necessary information available. C. Think through possible solutions to the problem. D. Assess the patient. 2. Lalani reviews Ms. Lam's care plan to ensure accuracy. The main purpose of clinical pathways is to present an overview of the patient's care goals. A. True B. False 3. Lalani updates Ms. Lam's care plan. Care plans for community-based settings require a thorough assessment of ___________, _______, and _______.

1. Answer: B, D, C, A Rationale: To ensure a successful phone consultation, perform the following: have all of the necessary information available before making the call; assess the patient yourself before making the call; think through some of the possible solutions to the problem; and summarize the problem. 2. Answer: B Rationale: The main purpose of clinical pathways is to deliver timely care at each phase of the care process for a specific type of patient. 3. Answer: Community, home, and family Rationale: Planning care for patients in community-based settings involves using the same principles of nursing practice. However, in these settings a more comprehensive assessment of the patient's community, home, and family is required.

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.) 1. Assess condition of skin before making the call 2. Rely on the nurse specialist to know the type of surgery the patient likely had 3. Explain the patient's response emotionally to the repeated leaking of stool 4. Describe the type of bag being used and how long it lasts before leaking 5. Order extra colostomy bags currently being used

1. Assess condition of skin before making the call 3. Explain the patient's response emotionally to the repeated leaking of stool 4. 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 Process

1. Assessment: 2. Diagnosis 3. Outcomes Identification 4. Planning 5. Implementation 6. Evaluation

Standards of Care

1. Assessment: 2. Diagnosis 3. Outcomes Identification 4. Planning 5. Implementation 6. Evaluation

4 Types of Reports

1. Change-of-shift 2. Telephone -Use SBAR format with MDs -Situation, Background, Assessment, Recommendation 3. Transfer 4. Incident

Goals of care

1. Client-centered -Reflects client's highest possible level of wellness and independence of function -Ex. The client will perform self care hygiene independently from this day forward. -Ex. The client will remain infection-free from this day forward. 2. Realistic and based on client needs and resources 3. Meet immediate needs and strive for prevention and rehabilitation 4. When possible, clients should be involved in goal setting

Purposes of Client's Chart

1. Communication 2. Legal Documentation 3. Financial Billing 4. Education 5. Research 6. Auditing- Monitoring

Planning requires:

1. Decision-making skills 2. Problem-solving skills 3. Critical thinking

What are the Kubbler-Ross stages of grief? (5)

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance (No particular order or time frame)

6 Factors for Choosing Interventions

1. Desired or expected client outcome 2. Characteristics of the nursing diagnosis 3. Evidence Base 4. Feasibility 5. Acceptability to the client 6. Capability of the nurse

Components of an Actual Nursing Diagnosis

1. Diagnostic label (the problem) 2. Related factor/Etiology 3. "Secondary to" (not required) 4. Defining Characteristics

Components of an Actual Nursing Diagnosis

1. Diagnostic label (the problem) 2. Related factor/Etiology 3. Defining characteristics

What are the 6 types of transmission of pathogens?

1. Direct: person to person 2. Indirect: Personal contact with inanimate object 3. Droplet: Large particle that travels up to 3 feet 4. Airborne: Droplet Nuclei, small particles that travel through air. specific mask needed. 5. Vehicle: Contaminated items 6. Vector: External transfer such as insect/bug

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? 1. Engage the patient in setting mutual outcomes for distance he is able to walk 2. Confirm with the patient's health care provider about ambulation goals 3. Have physical therapy assist with ambulation 4. Refer to medical record regarding nature of patient's physical problem

1. 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.

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. What does the nurse need to determine before setting the goal of "patient will self-administer insulin?" (Select all that apply) 1. Goal within reach of the patient 2. The nurse's own competency in teaching about insulin 3. The patient's cognitive function 4. Availability of family members to assist

1. Goal within reach of the patient 3. The patient's cognitive function 4. Availability of family members to assist

The Evaluation Process

1. Identifying Criteria and Standards- knowing what to look for -Refer back to the specific goals and outcomes from planning phase of NP -Nursing Outcomes Classification (NOC) 2. Collecting Data- to determine if the criteria or standards are met -Repeating your assessment again: Use evaluative interventions 3. Interpreting and Summarizing Findings -Comparing expected and actual findings in an objective manner 4. Documenting Findings -Clear, accurate, and precise 5. Terminating, Continuing, or Revising the Care Plan -Requires critical thinking

Examples of some NANDA's for Gas exchange problems.

1. Ineffective airway clearance 2. Ineffective breathing pattern 3. Risk for aspiration

JCAHO Standards for Documentation

1. Initial assessment of physical, psychosocial, environmental, self-care, client education, and discharge planning needs. 2. Client and family teaching 3. Discharge planning 4. Evaluation of Outcomes 5. Multidisciplinary care plans/Critical Pathways

Three areas of competency (before initiating interventions)

1. Knowing the scientific rationale for the intervention. 2. Possessing the necessary psychomotor and interpersonal skills. 3. Being able to function within a particular setting to use the available healthcare resources effectively.

What are the parts of a nursing diagnosis?

1. NANDA approved diagnosis 2. Related to factor 3. Secondary to factor (Medical Diagnosis) 4. AEB defining characteristics

Methods of Documenting

1. Narrative -COLDSPA and Cardinal Techniques 2. Progress notes -SOAPIE format -DAR format 3. Charting by exception (CBE) -"WDL except..." -Only document the exception 4. Critical Pathways

3 Types of interventions

1. Nurse-initiated interventions 2. Physician-initiated interventions 3. Collaborative interventions

Scenario: At the beginning of her shift, the nurse assesses her client and discovers the following: T= 101.4° F (Tylenol PO) Accu check= 300 (Glucophage PO) Reported nausea (Compazine IV) Pain 7/10 (Morphine IV) How will the nurse prioritize her care for this client?

1. Pain first- Pain can affect vital signs and glucose - Give Morphine/Compazine first 2. Wait 30 min- Pain eval 3. Glucophage 4. Tylenol

The six P's

1. Pain: PQRST 2. Pulse: check circulation 3. Pallor: pale/whiteness 4. Paresthesia: numbness or tingling 5. Paralysis: no feeling or movement 6. Pressure: ability to sense pressure *worried about nerve and blood supply loss, could lose limb*

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.) 1. Policy for conducting hourly rounds 2. Staffing level 3. Interruption by staff nurse colleague 4. RN's years of experience 5. Competency of patient care technician

1. Policy for conducting hourly rounds 2. Staffing level 3. 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.

What are the 5 stages of health behavior change?

1. Pre-contemplation 2.Contemplation 3. Preparation 4. Action 5. Maintenance

Nursing Interventions Classification (NIC) 7 Purposes:

1. To develop a standardized language for the actions used to deliver nursing care. 2. To expand nursing knowledge about connections between nursing diagnoses, treatments, and outcomes. 3. To develop nursing and health care information systems. 4. To teach decision-making to nursing students. 5. To determine cost of services provided by nurses. 6. To better plan for resources in all types of nursing practice settings. 7. To articulate with the classification systems of other health care providers.

Purposes of Nursing Diagnoses

1. To offer a standardized language to promote understanding between nurses about clients' health problems so as to facilitate communication and care planning 2. To distinguish the nurses role from that of the physician 3. To help nurses to focus on the role of nursing in client care

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.) 1. Using a standardized checklist for essential information 2. Asking the wife to briefly leave the room 3. Completing the hand-off without inviting questions 4. Doing prework such as checking laboratory results before giving a report 5. Including the wife in the hand-off discussion

1. Using a standardized checklist for essential information 4. Doing prework such as checking laboratory results before giving a report 5. 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.

Included in writing intervention:

1. WHAT is the intervention? 2. WHEN should the intervention be implemented? 3. HOW should the intervention be performed for a specific client? 4. WHO should be involved in each aspect of intervention? -Ex) The nurse will turn the client every 2 hours as follows: 0800- supine; 1000- left side-lying; 1200- right side-lying; 1400- left Sims.

Four common issues in malpractice cases:

1. Wrong time 2. Verbal orders (not recorded or signed by MD) 3. Charting in advance 4. Incorrect data

Pre-HTN

120-139/80-89

What did Henderson's theory focus on?

14 basic needs, assisting patients in gaining independence, helps gain strength.

Urine output should be

1500-1700 ml

Water intake should be

1500-1700 ml/ day

HTN crisis definition

180+/120+

Americans with Disabilities Act

1990; rights of disabled people; treatment of workers and patient's affected with HIV

Health Insurance Portability and Accountability Act (HIPPA)

1996; protects privacy and sensitivity of health info

Reassess pain every _______ hours if uncontrolled?

2 hours

Constipation

2 or fewer BMs a week, change in bowel patterns, tumor, obstruction, inflammation

A patient is admitted to an acute care area. The patient is an active business man who is worried about getting back to work. He has had severe diarrhea and vomitting for the last week. He is weak, and his breathing is labored. Using Maslow's hierarchy of needs, identify this patients immediate priority. 1) Self-actualization 2) Air, water, and nutrition 3) Safety 4) Esteem and self-esteem needs

2) Air, water, and nutrition

A patient is prescribed morphine patient-controlled analgesia (PCA). What is the correct order for administering PCA? 1. Program computerized PCA pump to deliver prescribed medication dose and lockout interval. 2. Check label of medication 3 times: when removed from storage, when brought to bedside, when preparing for assembly . 3. Administer loading dose of analgesia as prescribed. 4. Attach drug reservoir to infusion device, prime tubing, and attach needleless adapter to end of tubing. 5. Identify patient using two identifiers. 6. Insert and secure needleless adapter into injection port nearest patient.

2) Check the label of medication 3x, when removed from storage, when brought to bedside, when preparing for assembly. 5) Identify patient using two identifiers 1) Program computerized PCA pump to deliver prescribed medication dose and lockout interval 4) Attach drug reservoir to infusion device, prime tubing, and attach needlesless adapter to the end of tubing. 6) Insert and secure needleless adapter into injection port nearest patient. 3) Administer loading dose of analgesia as prescribed.

Which of the following theories describes the life processes of an older adult facing chronic illness? 1) Systems theory 2) Developmental Theory 3) Interdisciplinary theory 4) Health and wellness models

2) Developmental theory

A Muslim woman enters the clinic to have a woman's health examination for the first time. Which nursing behavior applies Swanson's caring process of "knowing the patient"? 1) Sharing feelings about the importance of having regular woman's health examinations. 2) Gaining an understanding of what a woman's health examination means to the patient. 3) Recognizing that the patient is modest; obtaining gender congruent caregiver. 4) Explaining the ristk factors for cervical cancer.

2) Gaining an understanding of what a woman's health examination means to the patient.

A patient with diabetes is controlling the disease with insulin and diet. The nursing health care provider is focusing efforts to teach the patient self-management. Which of the following nursing theories is useful in promoting self Management? 1) Neuman 2)Orem 3)Roy 4) Peplau

2) Orem

A patient with a 3 day hx. of a stroke that left her confused and unable to communicate returns from the international radiology following placement of a Gtube. The patient has been taking hydrocodone/APAP 5/325 1 tab, per gtube q4 PRN. Which action by the nurse is most appropriate? 1) No action is required by the nurse because the order is appropriate. 2) Request to have the order changed to around the clock for the first 48 hours. 3) Ask for a change of medication to meperidine 50mg IVP, Q3 PRN 4) Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain.

2) Request to have the order changed to around the clock for the first 48hrs.

A new medical resident writes an order for oxycodone CR 10mg PO q2 PRN. Which part of the order does the nurse question? 1) The drug 2) The time interval 3) The dose 4) The route

2) The time interval

Helping a new mother through the birthing experience demonstrates which of Swansons 5 caring processes? 1) Knowing 2)Enabling 3)Doing for 4) Being with

2)Enabling

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

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? 1. Achieving wound healing of the foot ulcer 2. Enhancing patient knowledge about the effects of diabetes 3. Providing a dietitian consultation for diet retraining 4. Improving patient adherence to diabetic diet

2. 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.

A theory is a set of concepts, definitions, relationships, and assumptions that; 1) Formulate legislation 2) Explain a phenomenon 3) Measure nursing functions 4) Reflect the domain of nursing practice

2. Explain a phenomenon

Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? (Select all that apply.) 1. Numbered order of diagnosis on the basis of severity 2. Notion of urgency for nursing action 3. Symptom pattern recognition suggesting a problem 4. Mutually agreed on priorities set with patient 5. Time when a specific diagnosis was identified

2. Notion of urgency for nursing action 3. Symptom pattern recognition suggesting a problem 4. 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.

A nurse assesses a 78-year-old patient who weighs 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 goals are appropriate for the patient? (Select all that apply) 1. Patient will be turned every 2 hours within 24 hours. 2. Patient will have normal bowel function within 72 hours. 3. Patient's skin will remain intact through discharge. 4. Patient's skin condition will improve by discharge.

2. Patient will have normal bowel function within 72 hours. 3. Patient's skin will remain intact through discharge

A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, IV infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0 to 10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply) 1. The family comes to visit the patient. 2. The patient expresses concern about pain control. 3. The patient's vital signs change, showing a drop in blood pressure. 4. The charge nurse approaches the nurse and requests a report at end of shift.

2. The patient expresses concern about pain control 3. The patient's vital signs change, showing a drop in blood pressure

How many CEU's is required every 2 years

20 CEU's

Malpractice Percentage of Nurses Involved

20% 10 years ago; 35% now

Presence involves a person-to-person encounter that: 1) Enables patients to care for self. 2) Provides personal care to a patient. 3) Conveys a closeness and a sense of caring. 4) Describes being in close to contact with a patient.

3) Conveys a closeness and a sense of caring.

Which of the following is a strategy for creating work environments that enable nurses to demonstrate more caring behaviors? 1) Increasing the working hours of the staff 2) Increasing salary benefits of the staff 3) Creating a setting that allows flexibility and autonomy for staff 4) Encouraging increased input concerning nursing functions from physicians.

3) Creating a setting that allows flexibility and autonomy for staff

Which of the following statements about theory-based nursing practice is incorrect? 1) Contributes to evidence-based practice 2) Provides a systematic process for designing nursing interventions 3) Is not linked to nursing outcomes 4) Guides the nurse's assessment

3) Is not linked to nursing outcomes

A patient is being discharged home on an around the clock opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medications? 1) Opioid antagonists 2) Antiemetics 3) Stool softeners 4) Muscle Relaxants

3) Stool softeners

A nurse enters a patients room, arranges the supplies for a Foley catheter insertion, and explains the procedure to the patient what to expect; just before the inserting the catheter, she tells the patient to relax and that, once the catheter is in place, she will not feel the bladder pressure. The nurse then proceeds to skillfully insert the catheter. This is an example of what type of touch? 1) Caring touch 2) Protective touch 3) Task-oriented touch 4) Interpersonal touch

3) Task-oriented touch

The nurse reviews a patients MAR and finds that the patient has received oxycodone/acetaminophen (Percocet)(5/325), two tabs PO Q3 for the past 3 days. What concerns the nurse the most? 1) The patients level of pain 2) The potential for addiction 3) The amount of daily acetaminophen 4) The risk for gastrointestinal bleeding?

3) The amount of daily acetaminophen

A nurse is caring for an older adult who needs to enter an assisted living facility following the discharge from the hospital. Which of the following is an example of listening that displays caring? 1) The nurse encourages the patient to talk about his concerns while reviewing the computer screen in the room. 2) The nurse sits at the patients bedside, listens as he relays his fear of never seeing his home again, and then asks if he wants anything to eat. 3) The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story. 4) The nurse listens to the patient talk about his fears o fnot returning home and then tells him to think positively.

3) The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story.

To practice in today's health care environment, nurses need a strong scientific knowledge base from nursing and other disciplines such as the physical, social, and behavioral sciences. This statement identifies the need for which of the following? 1) Systems theory 2) Developmental theories 3) Interdisciplinary theories 4) Health and wellness models

3) interdisciplinary Theories

Of the 5 caring processes described by Swanson, which describes "knowing the patient"? 1) Anticipating the patients cultural preferences. 2) Determining the patient's physician preference 3)Establishing an understanding of a specific point 4) Gathering task-oriented information during assessment.

3)Establishing an understanding of a specific point

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.

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.

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? 1. Giving the enema on time 2. Talking with the patient about her past experiences with illness 3. Talking with the patient about her concerns and acknowledging her sense of unfairness 4. Beginning instruction on postoperative procedures

3. 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.

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.) 1. IV site not tender 2. Uses cane to walk 3. Walked to end of hall 4. No shortness of breath 5. Slept better during night

3. Walked to end of hall 4. 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.

Normal urine output per hour

30 mL/hr

How long must you wait to reassess pain after PO meds?

30 minutes

How many calories are in one gram of carbs?

4 calories

How many calories in one gram of protein?

4 calories

Reassess pain every _______ hours if controlled?

4 hours

What are the nursing paradigm's 4 links?

4 links: Person Health Environment/situation Nursing

Having a BSN degree

4 years at a college, includes liberal arts, critical thinking component

A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the bible with his nurse, who recommends a favorite bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The patient's nurse replies: 1) "Spiritual care should be left to a professional." 2) "You are correct, religion is a person decision." 3) "Nurses should not force their religious beliefs on patients." 4) "Spiritual, mind, and body connections can affect health"

4) "Spiritual, mind, and body connections can affect health"

An example of a nurse caring behavior that families of acutely ill perceive as important to patients's well-being is: 1) Making health care decisions for patients 2) Having family members provide a patient's total personal hygiene. 3) Injecting the nurse's perceptions about the level of care provided. 4) Asking permission before performing a procedure on a patient.

4) Asking permission before performing a procedure on a patient.

Listening is not the only "taking in" what a patient says' it also includes: 1) Incorporating the views of the physicians 2) Correcting any errors in the patient's understanding 3) Injecting the nurse's personal views and statements. 4) Interpreting and understanding what the patient means.

4) Interpreting and understanding what the patient means.

A patient wiht chronic low back pain who took an opioid around the clock for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: 1) Opioid Toxicity 2) Opioid Tolerance 3) Opioid addiction 4) Opioid withdrawal

4) Opioid withdrawal

When teaching a patient about transcutaneous electrical nerve stimulation, which information do you include? 1) TENS works by causing distraction 2) TENS therapy does not require a health care provider's order. 3) TENS requires an electrical source for use. 4) TENS electrodes are applied near or directly on the site of pain medication.

4) TENS electrodes are applied near or directly on the site of pain medication.

Which of the following are components of the paradigm of nursing? 1) The person, health, environment, and theory 2) Health, theory, concepts, and environment 3) Nurses, physicians, health, and patient needs. 4) The person, health, environment/situation , and nursing.

4) The person, health, environment/situation , and nursing.

Theory-based nursing practice uses a theoretical approach for nursing forward as a science. Suggests that: 1) One theory will guide nursing practice. 2) Scientists will decide nursing decisions. 3) Nursing will only base patient care on the practice of other sciences. 4) Theories will be tested to describe or predict patients outcomes

4) Theories will be tested to describe or predict patients outcomes

A nurse hears a colleague tell a nursing student that she never touches a patient unless she is performing a procedure or doing an assessment. The nurse tells the student that from a caring perspective: 1) She does not touch the patient either 2) Touch is a type of verbal communication 3) There is never a problem with using touch 4) Touch forms a connection between nurse and patient.

4) Touch forms a connection between nurse and patient.

When a nurse helps a patient find the meaning of cancer by supporting beliefs about life, this is an example of: 1) Installing hope and faith 2) Forming a human-altruistic value system 3)ICultural caring 4) Being with

4)Installing hope and faith

A patient has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? 1. Provide frequent mouth care. 2. Maintain IV infusion at 100 mL/hr. 3. Administer prochlorperazine (Compazine) via rectal suppository. 4. Consult with dietician on initial foods to offer patient. 5. Control aversive odors or unpleasant visual stimulation that triggers nausea.

4. Consult with dietician on initial foods to offer patient.

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? 1. Patient will be turned every 2 hours within 24 hours. 2.Patient will have normal bowel function within 72 hours. 3. Patient's skin integrity will remain intact through discharge. 4. Erythema of skin will be mild to none within 48 hours.

4. 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.

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? 1. Reporting hand-off at change of shift 2. Ambulating patient down hallway 3. Sleep hygiene 4. IV fluid administration

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

Setting a time frame for outcomes of care serves which of the following purposes? 1. Indicates which outcome has priority. 2. Indicates the time it takes to complete an intervention. 3. Indicates how long a nurse is scheduled to care for a patient. 4. Indicates when the patient is expected to respond in the desired manner.

4. Indicates when the patient is expected to respond in the desired manner.

The nurse writes an expected-outcome statement in measurable terms. An example is: 1. Patient will be pain free. 2. Patient will have less pain. 3. Patient will take pain medication every 4 hours. 4. Patient will report pain acuity less than 4 on a scale of 0 to 10.

4. Patient will report pain acuity less than 4 on a scale of 0 to 10.

The nurse writes an expected outcome statement in measurable terms. An example is: 1. Patient will have normal stool evacuation. 2. Patient will have fewer bowel movements. 3. Patient will take stool softener every 4 hours. 4. Patient will report stool soft and formed with each defecation.

4. 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.

Risk factors for colon CA

50+, polyps of the colon or rectum, family hx, IBD, exposure to radiation, diet high in animal fat

S/s of ulcerative colitis

6-10 diarrhea stools with blood and mucus, fever, anorexia, weakness

What percentage of body weight is water?

60-70%

How many calories in one gram of fat?

9 calories

what is normal body temperature

96.8-100.4

What is a client centered goal?

A behavior or response that reflects a client's highest possible need.

Goal

A broad statement that describes change in a patients condition or behavior, what will be accomplished

Nursing Diagnosis Definition

A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes

What is a nursing diagnosis

A clinical judgment by a nurse. (Us identifying the problem.)

Affect

A feeling that you get about someone in a given moment.

What is the difference between Misdemeanor and felony?

A felony is a crime of serious nature that has an penalty of imprisonment for longer than 1 year or even death. A misdemeanor is a less serious crime with penalty or imprisonment or less than 1 year.

durable power of attorney for health care

A legal document designating a person to make healthcare decisions for a patient when he/she is unable to.

Expected outcome

A measurable criterion to evaluate goal achievement (SMART)

Consent

A patients agreement to have a medical procedure after full disclosure of risks, benefits, alternatives, and consequences.

Nursing Paradigm

A pattern of thought that is useful in describing the domain of discipline

Autonomy

A person's independence for making decisions

Informed consent

A persons agreement to allow something to happen such as a surgery

Addiction

A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations

What is a Theory

A set of concepts, definitions, assumptions, or propositions that explain a phenomenon.

Code of ethics

A set of guiding principles that all members of a profession accept, this helps when questions arise

Theory

A set of interrelated concepts that explain and predict phenomena in nursing. Tested and Validated through research.

Drug tolerance

A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time

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

What does "Health" mean to a nurse?

A state of complete physical, mental, and social well being, not merely the absence of disease or infirmity

Health

A state of complete physical, mental, and social well being. Not merely the absence of disease or infirmity.

Nursing

A way that we learn to provide care

Living Will

A written document expressing a patients wishes in the event of a terminal illness or condition.

Fat soluble vitamins

A, D, E, K

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

A. Checks scientific literature or policy and procedure B. Reassesses the patient's condition C. Collects all necessary equipment E. 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.

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? A. Cognitive B. Interpersonal C. Psychomotor D. Consultative

A. 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.

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: A. Comparing outcome criteria with actual response. B. Gathering outcome criteria. C. Evaluating the patient's actual response. D. Reprioritizing interventions.

A. 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.

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? A. Critical thinking B. Managing an adverse event C. Exercising self-discipline D. Time management

A. 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.

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.) A. Data collection. B. Data clustering. C. Data interpretation. D. Making a diagnostic statement. E. Goal setting.

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

A. Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs C. Helps nurses focus on the scope of nursing practice E. 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.

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.) A. How is your diabetic diet affecting you and your family? B. You seem to not want to follow health guidelines. Can you explain why? C. What worries you the most about having diabetes? D. What do you expect from us when you do not take your insulin as instructed? E. What do you believe will help you control your blood sugar?

A. How is your diabetic diet affecting you and your family? C. What worries you the most about having diabetes? E. 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.

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

A. Impaired Skin Integrity related to physical immobility C. 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.

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.) A. Makes it quicker and easier for nurses to intervene B. Sets a level of clinical excellence for practice C. Eliminates need to create an individualized care plan for the patient D. Delivers evidence-based interventions for stage II pressure ulcer E. Summarizes the various approaches used for the practice concern or problem

A. Makes it quicker and easier for nurses to intervene B. Sets a level of clinical excellence for practice D. 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.

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

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

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.) A. Quality of life B. Patient satisfaction C. Use of clinic services D. Adherence to use of inhaler E. Description of side effects of medications

A. Quality of life C. Use of clinic services D. 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.

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.) A. 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. B. Determining what is the patient care technician's current workload. C. 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. D. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure. E. The nurse confers with another registered nurse about organizing priorities.

A. 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. C. 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. D. 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.) A. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data B. The nurse who measures joint range of motion after the patient reports pain in the left elbow C. The nurse who considers conflicting cues in deciding which diagnostic label to choose D. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping E. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.

A. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data D. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping E. 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.

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

A. To identify and label nurse-sensitive patient outcomes B. To test the classification in clinical settings E. To define measurement procedures for outcomes

Direct cares include

ADLS, physical care techniques, lifesaving measures, counseling, teaching, controlling adverse reactions

Criteria for writing goals & expected outcomes: (________ must be met)

ALL criteria must be met. 1. Client-centered 2. Singular (one at a time) 3. Measurable 4. Time-limited 5. Mutual (agreed with client whenever possible) 6. Realistic

Physician Assisted Suicide

ANA has states that nurses should not participate in assisted suicide because it is an act that violates the code for nurses and the ethical traditions of the profession

What is the ANA

ANA: Fosters high standards of nursing and to promote development and general/ economic welfare of nurses. (ICN is the same but Internationally parallel)

A - pain

ASK about pain regularly

Each outcome statement addresses ________________ for a given nursing diagnosis.

AT LEAST one Defining Characteristic

Accountability

Ability to answer for ones actions

What is "exceptional data"?

Abnormal data

Define Exceptional Data

Abnormal data or data outside the normal range

Distributive/vasogenic shock

Abnormal distribution of blood flow in capillaries (septic, neurogenic, anaphylactic)

Cheyne Stokes breathing

Abnormal respiration pattern with periods of apnea followed by periods of deep breathing

Apnea

Absence of respirations for 15 seconds or longer

Defining characteristics of ineffective airway

Absent cough, inability to remove airway secretions, orthopnea, diminished breath sounds

What are examples of non-opioids

Acetaminophen Aspirin

Opioid MOA

Act on CNS, relieve pain by binding to receptor sites in nervous system

What stage of health behavior change? Actively changing behavior.

Action

Prescriptive theory

Action oriented, nursing interventions

Fluid loss 15-30%

Activates sympathetic response can restore CO and BP

Inspiration

Active process

Healthy Behaviors

Activities related to maintaining, attaining, or regaining good health illness.

What are the two types of pain that you observe in patients

Acute Chronic

types of pain

Acute/transient pain Protective, identifiable, short duration; limited emotional response Chronic episodic Occurs sporadically over an extended duration Inferred pathological Musculoskeletal, visceral, or neuropathic Cancer Can be acute or chronic Idiopathic Chronic pain without identifiable physical or psychological Chronic/persistent noncancer Is not protective, has no purpose, may or may not have an identifiable cause

The difference between acute and chronic pain

Acute: short duration, severe, may affect functioning in any dimensions Chronic: persists for 6+ months, may affect functioning in any dim

prescriptive

Address nursing interventions for a phenomenon, and predict the consequence of a specific nursing intervention

Regulatory

Administrative

Pain Management protocol

Admission, after pain producing events, new report of pain, every 8 hours, discharge

Some level of experience even if its only observation but can identify meaningful aspects of principles of nursing care.

Advanced Beginner

What domain of learning deals with expression of feelings and acceptance of attitudes, opinions or values

Affective

What is the largest minority group?

African Americans

S/S of pain

Age, fatigue, genes, neurological function Fatigue increases the perception of pain and can cause problems with sleep and rest.

Fidelty

Agreement to keep promises

Fidelity

Agreement to keep promises, pain control

For patients to be part of goal setting they need to be?

Alert, some degree of independence with daily activities

Federal statutory laws:

Americans with disabilities Advanced directives: Living wills, and Power of Attorney

Activity Tolerance

Amount of exercise or work that a person is able to perform WITHOUT *undue* exertion or possible injury

Impaired gas exchange

An actual or potential decrease in passage of gases between alveoli of lungs and capillary

What is the most frequent route of a registered nurse education

An associates degree or BN

What is spirituality?

An awareness of ones inner self and a sense of connection to a higher being, nature, or some purpose greater than oneself.

Interpersonal interaction

An exchange between 2 people

Assault

An intentional threat with no contact.

Which instructional method has to do with explaining something in a way the other person would understand

Analogy

Nursing diagnosis includes ________________ the data to discover if there is indeed a _______________ and the problem is related to a cause that the nurse can ______________.

Analyzing Problem Impact

Accountability

Answering for ones actions.

Meds for impaired tissue/local perfusion

Anticoagulants (heparin), thrombolytics (TPA), lipid-lowering agents (statins), vasodilators, anti-platelet agents and platelet inhibitors (aspirin)

Oxygenation meds

Antihistamines, glucocorticoids, mucolytics, expectorants, antiinflammatorys

Meds for impaired central perfusion

Antihypertensives, antiarrythmics, inotropic (rate and strength of contraction: digoxin), antianginal agents (nitroglycerin), vasopressors (epinephrine, dopamine), vasodilators (nitroglycerine)

What is an example of Protective touch

Any touch you use when you are preventing harm towards the patient.

Main functions of colon

Arteries and veins carry O2 and nutrients, eliminates indigestible food residue from the body, absorbs salts, water and vitamins

Tissue perfusion

Arteries; volume of blood that flows to target tissue; requires patent vessels, adequate hydrostatic pressure, capillary permeability

Silence is important to which cultural groups?

Asian and native americans

What are some UTI interventions?

Assess color, odor, amount and clarity of urine. Personal Hygiene Catheter Care Fluid intake by measuring I/O Empty Catheter bag frequently Culture Urine Bladder Schedule every 2-3 hours Anti-infectives, phenopyridine, and urinary analgesics

Documentation criteria can be applied to all of ADPIE but most important for ________________.

Assessment

What are the standards of care

Assessment Diagnosis Planning Implementation Evaluation

Steps of the nursing process

Assessment Diagnosis Planning Implementation Evaluation

Assessment

Assessment collection of subjective and objective data: includes 2 steps: The collection of information from a primary source (a patient) and secondary sources (e.g. family or friends, health, professionals, and the medical record) The interpretation and validation of data to ensure a complete database

What are the ANA standards of nursing practice? (ADPIE)

Assessment, Diagnosis, Outcome identification/Planning, Implementation, Evaluation.

What is the difference between an atheist and an agnostic?

Atheist- Does not believe in a god. Agnostic- believes there is no known ultimate reality

Specific causes of impaired tissue/local perfusion

Atherosclerosis, hyperlipidemia, HTN, PAD, pulmonary embolism, stroke, venous thrombosis

What are the 5 leadership styles?

Autocratic- "Boss" 2. Democratic- Leader involves followers in decision making process 3. Laissez Faire: No Boss interference, they stand at a distance giving freedom. 4. Transactional- Rewarding and correcting 5. Transformational- changes individuals, long term and involves people and organizations.

Roles of a Professional Nurse

Autonomy, caregiver, responsibilities, advocate, educator, communicator, manager

What are the professional responsibilities and roles of a nurse

Autonomy/accountability Caregiver Advocate Educator Communicator Manager Career development

Nonmaleficence

Avoidance of harm or hurt, no lasix to a pt with low potassium

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.) A. Number of interventions B. Appropriateness of the intervention for the patient C. The prior use of interventions by other nursing staff D. Correct application of the intervention for the patient care setting E. The time it takes to provide interventions

B. Appropriateness of the intervention for the patient D. 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 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.) A. Reviewing the family caregiver's availability during medication administration times B. Making a judgment of the value of improved adherence for the patient C. Reviewing the number of medications and time each is to be taken D. Determining all consequences associated with the patient missing specific medicines E. Reviewing the therapeutic actions of the medications

B. Making a judgment of the value of improved adherence for the patient D. 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.

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

B. 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.

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.) A. Is willing to challenge other members' ideas because the nurse disagrees with their rationale B. Shows competence in how to monitor patients' clinical status and inform the physician of critical changes C. Asks a more experienced nurse to attend the conference D. Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly E. During the meeting focus on similar problems the nurse has had in delivering care to other patients.

B. Shows competence in how to monitor patients' clinical status and inform the physician of critical changes D. 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.

Which of the following nursing diagnoses is stated correctly? (Select all that apply.) A. Fluid Volume Excess related to heart failure B. Sleep Deprivation related to sustained noisy environment C. Impaired Bed Mobility related to postcardiac catheterization D. Ineffective Protection related to inadequate nutrition E. Diarrhea related to frequent, small, watery stools.

B. Sleep Deprivation related to sustained noisy environment D. 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.

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.) A. The application of the skin barrier is a dependent care measure. B. The call to the ostomy and wound care specialist is an indirect care measure. C. The cleansing of the skin is a direct care measure. D. The application of the skin barrier is an instrumental activity of daily living. E. Inspecting the skin in a direct care activity.

B. The call to the ostomy and wound care specialist is an indirect care measure. C. 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.

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? A. Incorrect clustering B. Wrong diagnostic label C. Condition is a collaborative problem. D. Premature closure of clusters

B. 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.

BRATY diet - treat diarrhea

BANANA, RICE, APPLESAUCE, TEA, or YOGURT

B- pain

BELIEVE the patient and family in their report of pain

Infectious agent

Bacteria, viruses, fungi, protozoa

Signs and symptoms of emphysema

Barrel chest, pink sputum, pursed lip breathing

Levels of critical thinking

Basic critical thinking -Complex critical thinking- -Commitment-

What are some impacts that illness can have on the client and family members

Behavioral and emotional changes Impact on body image Impact on self-concept Impact on family roles Impact on family dynamics

Planning is a category of nursing __________ in which _______________ and ______________ are established. The plan is all about ________________. Planning is the _____ step of the nursing process.

Behaviors Client-centered goals Expected outcomes The patient 3rd

What theorist believed caring is an interpersonal interaction?

Benner

We need protein for

Blood clotting, fluid regulation, and acid-base balance

Signs and symptoms of bronchitis

Blue cyanotic/hypoxia, Recurrent cough/ increased sputum

Fluid loss <15% (500-700 ml)

Body can compensate

Human Trait

Born with the ability to care

Impaired tissue/local perfusion interventions

Bypass and/or graft surgery, stent or angioplasty, endarterectomy

Water soluble vitamins

C and B-Complex

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

C. 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.

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? A. Insufficient cluster of cues B. Disorganization C. Insufficient number of cues D. Evidence that another diagnosis is more likely

C. 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.

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

C. 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.

A 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? A. Infant crying at breast B. Infant unable to latch on to breast correctly C. Mother's deficient knowledge D. Lack of infant weight gain

C. 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.

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.) A. Nurse provides four teaching sessions before discharge. B. Patient denies joint pain following heat application. C. Patient describes correct schedule for taking antiarthritic medications. D. Patient explains situations for using heat application on inflamed joints. E. Patient explains role family caregiver plays in applying heat to inflamed joint.

C. Patient describes correct schedule for taking antiarthritic medications. D. 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.

tests for temperature

CBC with diff, cultures, urinalysis, CXR, sed rate, CRP

Tests for cardio-pulmonary functioning

CBC, PEFR , Bronchoscopy, sputum specimens, Thoracentesis

C- pain

CHOOSE pain control appropriate for patient

Diagnostic tests of perfusion

CK, ANP, Troponin, Sserum lipids, EKG, Stress test, CXR, ultrasound, arteriogram

What is the treatments for sleep apnea?

CPAP/BIPAP

What is a concept?

Can be simple or complex and relate to an object or event that comes from individual perceptual experiences.

"Risk for diagnosis"

Can have goal, but no outcomes; no defining characteristics

Specific causes of impaired central perfusion

Cardiac dysrhythmias, shock, heart failure, pulmonary HTN

Cause of impaired central perfusion

Cardiac output is inadequate

Consequences of uncontrolled HTN

Cardiac: CAD, LV hypertrophy Neurovascular: TIA, stroke, PAD Renal: chronic failure, increased creatinine levels Eyes: retinopathy

Opportunistic pneumonia

Caused by pathogens that take advantage of an opportunity not normally available such as a host with a weakened immune system

The types of sleep apnea

Central Obstructive Mixed apnea

Ineffective breathing pattern

Change in rate, depth or pattern of breathing that alters normal gas exchange; insp or expir not providing adequate ventilation

Four types of report

Change-of-shift, telephone, transfer, incident

Ineffective breathing characteristics

Changes in resp rate, change in chest excursion, SOB, use of accessory muscles

Where do we get our data?

Charts Their family Labs Previous institutions Other members of the Healthcare team Nurses experience

Nursing monitoring for colon diversions

Check I&O, low residue diet, skin protection, coping difficulties, decision making support, emotional support, monitor foods to decrease odor and gas, choose foods that thicken stool

types of diet

Clear liquid (No red dyes) Full liquid (Broth, yogurt, water, juice) Pureed (Blended food) Mechanical Soft (For people that have trouble swallowing; cut up in small pieces) Soft/Low Residue High Fiber Low Sodium Low Cholesterol Diabetic

The order of priorities changes as _______________ changes, sometimes within a matter of ___________.

Client's condition changes Minutes

Examples of advanced practice career roles in nursing

Clinical nurse specialist (CNS) Certified nurse practitioner (CNP) Certified nurse midwife (CNM) Certified RN anesthetist (CRNA)

Treatment of fractures

Closed reduction and immobilization -didn't cut open to do surgery -cast/splint -align bones Open/surgical reduction and fixation -goes to surgery -screws or hardware -keep in place Traction -use weights and pulleys outside of limb to keep bone in place

What domain of learning includes all intellectual behaviors

Cognitive

What are the domains of learning

Cognitive Affective Psychomotor

What are the 3 learning domains?

Cognitive (intellectual) Psychomotor (ex: performing an insulin check) Affective (implementation, ex: teaching diet and then using it at home)

3 Implementation Skills

Cognitive- application of critical thinking in the nursing process. Using good judgment and sound clinical decisions Interpersonal- developing a trusting relationship to express a level or caring, and to communicate clearly. (Important to keep patient informed, individualized patient teaching) perception of verbal and nonverbal Psychomotor- integration of cognitive and motor skills. Knowing a skill and being able to demonstrate it effectively

Implementation skills are based on? (3 terms)

Cognitive- application of critical thinking in the nursing process. Using good judgment and sound clinical decisions Interpersonal- developing a trusting relationship to express a level or caring, and to communicate clearly. (Important to keep patient informed, individualized patient teaching) perception of verbal and nonverbal Psychomotor- integration of cognitive and motor skills. Knowing a skill and being able to demonstrate it effectively

Accidental Hypothermia

Cold water submersion , inadequate clothing in cold weather are examples of ?

Narrative Documentation

Coldspa and cardinal techniques

Type of intervention: Administering a breathing treatment every 4 hours.

Collaborative

Function of micro minerals

Collagen formation and wound healing

Exogenous

Comes from microorganisms found *outside* the individual ex: Salmonella

Malpractice

Commonly referred to as professional negligence.

What are some things to take into consideration when assessing culture?

Communication, Time, and Space

2-3 clinical years of experience, specific type of care performed like oncology or surgical, able to anticipate care and establish long range goals.

Competent

types of incontinence

Complaint of any involuntary loss of urine" Functional- altered mobility and manual dexterity, poor motivation, environmental barriers Stress- weak pelvic floor muscles, trauma after childbirth, radical prostatectomy, small volume Urge- overactive bladder, leaks Reflex- May not completely empty bladder, when bladder reaches certain level.

what is nursing theory

Conceptualizes an aspect of nursing to describe, explain, predict, or prescribe nursing care.

Collaboration

Concerted work with individuals and groups to attain a shared goal

What are the psychological symptoms of sleep deprevation

Confused and disoriented Increased sensitivity to pain Hyperactive Agitated

Give three examples of a nursing diagnosis that are also a medical diagnosis

Constipation Anxiety Chronic Pain

What are some nursing diagnoses that are also medical diagnoses

Constipation Anxiety Chronic pain

What stage of health behavior change? Considering change in next 6 months

Contemplation

what is continuing in education mean

Continuing education- involves formal, organized educational programs offered by universities, hospitals, state nurses associations, professional nursing organizations, and educational health care institutions

Hospital acquired pneumonia

Contracted by the patient who has been in the hospitalization at least 48-72 hours

Posterior Hypothalmus

Controls temp if *Low* at set point -Conserves heat by *vasoconstriction* and *Shivering*

Mucolytics, expectorants

Cough up mucus

Nursing diagnosis requires __________ and good _________________.

Critical thinking Clinical judgment

Signs of impaired tissue/local perfusion

Cyanosis, numbness, pain, gangrene, pressure ulcer, unilateral slow refill, dizziness, local edema, weak unilateral pulse, decreased urine output (loss of perfusion to kidneys)

What is an appropriate action by a nurse when providing care for an 18 year old with respiratory problems caused by excessive smoking? A) Remind the client that excessive smoking could lead to cancer. B) Exhibiting a expression of disapproval by staying silent C) Asking the client why he started smoking at a young age D) Suggesting methods and provide resources to assist with smoking cessation.

D) Suggesting methods and provide resources to assist with smoking cessation.

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: A. Collaborative data set. B. Diagnostic label. C. Related factors. D. Data cluster.

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

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? A. Disturbed Sleep Pattern evidenced by frequent awakening B Disturbed Sleep Pattern related to family caregiving responsibilities C. Disturbed Sleep Pattern related to need to improve sleep habits D. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested

D. 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.

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? A. Identifying the clinical sign instead of an etiology B. Identifying a diagnosis on the basis of prejudicial judgment C. Identifying the diagnostic study rather than a problem caused by the diagnostic study D. Identifying the medical diagnosis instead of the patient's response to the diagnosis.

D. 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.

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? A. Environment B. Personnel C. Equipment D. Patient

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

D- pain

DELIVER interventions in a timely and logical manner

Revising a care plan

Date any new data, delete any irrelevant nursing diagnosis, revise specific interventions that correspond to new nursing diagnosis

HTN collaborative care

Decrease to 140-/90-

Reason for cheyne stokes

Decreased blood flow or injury to the brainstem

Ischemia

Decreased blood supply to a body part such as skin tissue or to an organ such as the heart

QSEN Definition on safety

Defines safety as "Minimizing risk of harm to patients and providers through both systems effectiveness and individual performance"

What 5 components does every states Nurse Practice Act have?

Definition of Nursing Licensure Requirements Revocation or suspension of license Reciprocity of license Members of the Board of Nursing

What are 5 signs of caregiver stress

Denial Anger Social withdrawal Depression Anxiety

What are 5 signs of caregiver stress

Denial Anger Social withdrawal Depression Anxiety Sleeplessness Short focused Health problems

Susceptible Host

Depends on an individuals degree of *resistance* to pathogens - An individual becomes susceptible to the *strength* and *Numbers* of microorganisms

What is magnet status?

Describes the best of the best, it draws people in and is expensive to apply, these hospitals provide excellent care.

What are the components of an actual nursing diagnosis

Diagnostic label (problem) Cause/Etiology "Secondary to" Defining characteristics

What are some examples of "Coping with impaired functions"

Diet Activity Medication home care physical therapy Speech therapy (the nurse must consider each patient on individual basis)

How to complete a nutritional assessment

Diet history 24 hours or 3 days diet history Medication history Lab finding Lipid panel, Albumin, Protein, Iron, Creatinine, CBC, and Hemoglobin Physical history Bowel movement→ in elimination listen in lower right quadrate Anthropometry Mid-arm circumference, BMI, pinch, body fat measurement

Primary prevention

Diet, exercise, non smoking

Which of the following signs or symptoms in a patient who is opioid-naive is of greatest concern to the nurse when assessing the patient one hour after administering an opioid? 1) Oxygen saturation of 95% 2)Difficulty arousing the patient 3) Respiratory rate of 10 breaths/minute 4) Pain intensity rating of 5 on a scale of 0-10.

Difficulty arousing the patient.

When revising a care plan what do you do?

Discontinue current care plan, modify, reassess, re-define diagnosis, change goal/ expected outcome as well as interventions, and re-evaluate.

What are some examples of "Restoration of Health"

Disease or condition Cause of disease Expected effects on other body systems medications tests Therapies

causes of sleep apnea

Disorder characterized by the lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep. Occurs when muscles or structures of the oral cavity or throat relax during sleep Deviated septum, nasal polyps, certain jaw configurations, larger neck circumference, enlarged tonsils

What are some non-pharmacological pain relief interventions?

Distraction Prayers Relaxations Guided imagery Music.

Name 5 nonpharmacologic interventions

Distraction, Relaxation, Hot/cold therapy, Deep breathing, Guided imagery.

Anti-HTN meds

Diuretics (furosemide/Lasix), ACE inhibitors (prils), Alpha-adrenergic blocking agents (sins), Beta-adrenergic blockers (lols), Ca channel blockers, Centrally acting sympatholytics, Vasodilators

Cardiac chest pain

Does not occur with respiratory variations

Beneficence

Doing good for others.

Self Care theory

Dorothea Orem developed the ______-_______ deficit theory - Focus on performance and practice of activities that *Individuals initiate* and perfom on *their own* behalf to maintain life - Used in *Rehabilitation centers*

Airborne

Droplet nuclei or residue or evaporated droplets suspended in air during coughing, sneezing or carried in dust particles

Patient-controlled analgesia (PCA)

Drug delivery system that allows patients to self-administer analgesic medications on demand. with minimal risk of overdose.

Dantrolene sodium

Drug that Can *Reverse* the effects of *Malignant*HYPERthermia -Intracellular *Calcium* levels are *elevated* in MH - _________ _________ Reduces *Muscle tone* and *metabolism*

Passive Measures of Hypothermia

Dry, Warm clothing, warm liquids PO, exercise

Spreading disease

During Prodromal *Specific symptoms* Patient may be capable of _________ ___________ to others

E- pain

EMPOWER patients and their families, ENABLE them to control course as much as possible

Emergency Medical treatment and Labor Act

EMTALA; 1996; proper treatment/evaluation prior to transfer

Modes of transmission

Each disease has a *specific* _______ of _____________ ex: Direct, Indirect, Droplet, Airborne, Vehicles , Vector

Secondary HTN

Elevated due to identifiable cause (Cirrhosis, meds, endocrine or neuro disorders, renal disease, pregnancy, sleep apnea)

Primary HTN

Elevated with no identifiable cause (genetics, sodium retention, altered renin-angiotensin-aldosterone mechanism, stress, insulin resistance, endothelial dysfunction)

EMTALA

Emergency Medical Treatment and Active Labor Act. This ensures public access to emergency services regardless of ability to pay. This is to prevent "patient dumping" which means the medical staff can't refuse to treat the pt. if they are unable to pay.

Nursing considerations for shock

Emergency measures, fluid resuscitation, patient legs elevated 20 degrees w/ trunk horizontal and HOB 10 degrees (circulation to brain and kidneys), oxygen, monitoring fluid status

Health Promotion

Emphasizes Maintenance and Enhancement.

Confidentiality

Ensuring that information is accessible only to those who are authorized to have access.

What are 2 modifiable risk factors

Environment Lifestyles

What is the 4 things learning depends on

Environment Motivation Learning preference/Learning styles Ability

Organizing Resources:

Equipment -decide beforehand supplies needed and determine availability along with knowledge to use safely. Personnel -how nursing is organized and how the personnel delivers care (Who is accountable for what) (delegation or performance of intervention) Environment -needs to be safe and conducive to implement therapy. Patient safety is first concern. (Using privacy in exposing situations, limiting distractions in room) Patient -awareness of patients physical and physiological needs before implementation to ensure comfort and opportunity (alleviating pain before implementation, making sure their endurance and pain level is acceptable beforehand)

Organizing resources and care delivery: ensures timely, efficient, and skilled care: (how do these relate...?) equipment, personnel, environment, patient....

Equipment- decide beforehand supplies needed and determine availability along with knowledge to use safely. Personnel-how nursing is organized and how the personnel delivers care (Who is accountable for what) (delegation or performance of intervention) Environment- needs to be safe and conducive to implement therapy. Patient safety is first concern. (Using privacy in exposing situations, limiting distractions in room) Patient- awareness of patients physical and physiological needs before implementation to ensure comfort and opportunity (alleviating pain before implementation, making sure their endurance and pain level is acceptable beforehand)

Professional ethics

Ethical standards and expectations of a particular profession

Bioethics

Ethical surroundings surrounding biological sciences

What are the ANA standards of professional performance

Ethics Education EBP Quality Communication Leadership Collaboration Professional practice evaluation Resources Environmental health

Standards of professional performance

Ethics, education, evidence based practice, quality of practice, communication, leadership, collaboration

Standards of Professional Performance

Ethics: Education Evidence-Based Practice and Research -Quality of Practice Communication Leadership Collaboration Professional Practice Evaluation Resources Environmental Health

Cognitive Skills

Ex) Recognizing the possible complications of blood transfusion.

Evaluative Nursing Intervention

Ex) The nurse will reassess the patient's pain status in 30 minutes.

Goals of care (types)

Examples include patient-centered, short term, and long term

Sodium ; Dehydration

Excessive & prolonged *sweating* coupled with sustained *High* body temp can result in _________ *loss* & ______________

Interventions to help perfusion

Exercise, weight control, decrease smoking and alcohol, nutrition, SCD hose, doppler studies

Diverse experience, skilled at identifying patient centered problems and problems related to healthcare system, considered a mentor.

Expert

Interdisciplinary Theory

Explains a systemic view of a phenomenon specific to the discipline of inquiry.

paradigm

Explains the linkages between nursing science, philosophy, and theory; Directs the activity of the profession.

Obstructive shock

External force stops heart from beating

Diagnostic tests for colon CA

FOBT, flexible sigmoidoscopy every 5 years, barium enema every 5 years, colonoscopy every 10 years, CEA, CBC, CT, MRI

What did Nightingale's theory focus on?

Facilitates wellness by manipulating patients environment to include appropriate noise, nutrition, hygiene, light, comfort, socialization, and holistic care.

Metacommunication

Factors that compose the context of the message

Guidelines for quality documentation and reporting (FACCO)

Factual-descriptive, objective, what hear see smell Accurate-exact accurate measurements Complete-complete with appropriate essential info Current-timely entries, delays lead to unsafe care Organized-logical order, clear and to the point

Justice

Fairness

Justice

Fairness, transplant criteria

The nurse removes the epidural catheter. T or F

False, the anesthesiologist should remove or modify epidural.

Statutory

Federal law; formal written law; basis for standard of care; e.g. nurse practice act

Definition

Flow of blood through arteries and capillaries delivering nutrients and oxygen to cells and removing cellular waste products

Medical treatment for shock

Fluids for volume replacement (normal saline 0.9% or lactated ringers, plasma expanders like albumin or synthetics to take place of blood/pull fluid into vasculature, blood)

What did Peplau's theory focus on?

Focuses on nurse/patient interaction, interpersonal relationships

What is the best way to prevent Malpractice?

Follow standards of care, give competent healthcare, and communicate with health care providers.

Glucocorticoid, antiinflammatory, bronchodilators

For lower airway

Shared governance

Fosters a decentralized style of management that creates an environment of empowerment

Safety

Freedom from psychological & physical injury , is a basic human need

Pleuritic pain

From inflammation of the pleural space of the lungs. the pain is peripheral and radiates to scapular regions

Parenteral Nutrition

GI tract is not functioning, provides proper nutrients and calories

What are examples of Adjuvants?

Gabapentin Tricyclic Antidepressants

Central perfusion

Generated by cardiac output to the peripheral vascular system

What are 2 non-modifiable risk factors

Genetic and physiological factors age

What is the correct order of removing PPE?

Gloves--> Goggles--> Gown--> Mask

Goal or Outcome: Client will increase ambulation progressively during postoperative period.

Goal

Goal or Outcome: Client will maintain adequate peripheral tissue perfusion by discharge.

Goal

What is the difference between a Goal and Expected outcome?

Goal: Long term (by discharge) Expected outcome: Within a short period of time (by end of shift)

What is the correct order of putting on PPE?

Gown--> Mask--> Goggles--> Gloves

Which theory is the hardest to test

Grand theory

What are 3 causes of peptic ulcer disease?

H. Pylori, NSAID use, and Stress

48-72

HAP (Hospital acquired pneumonia) refers to any pt. contracted pneumonia *at least* ____-____ hours AFTER being admitted

types of report

Hand off report-necessary information the next nurse needs to know Telephone order report-health care provider gives therapeutic orders over the phone to the RN Incidence-example- if a patient falls Transfer-example if a patient transfers from the hospital to the nursing home.

What are some teaching strategies for healthy sleep-hygiene habits?

Have patients keep a sleep log for a week Teach the patient sleep hygiene measures Encourage the patient to drink a cup of chamomile tea or warm milk at bedtime Help the patient to develop a pan for exercise log.

Influences on Nursing:Health Care Reform

Health Care Reform Demographic changes Medically underserved Bioterrorism Rising Health Care Costs Nursing Shortage

definition of confidentiality

Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates confidentiality and protection of patients' personal health information. In practice you cannot share information about a patient's medical condition or personal information to anyone not involved in the care of the patient.

Planning

Health care team planning, interpersonal collaboration, determining implementation methods

What are 3 purposes of client education

Health maintenance and promotion and Illness prevention Restoration of health Coping with impaired functions

Airborne precautions

Healthcare workers must follow standard precautions along with a *fitted Mask* -Mask will not allow microscopic particles to be inhaled by the nurse ex: TB, Chicken pox

What are some modifiable risk factors?

Healthy diet Weight control Regular exercise No smoking Limited alcohol consumption Routine health assessments Environment Lifestyle

Cardiogenic shock

Heart is not pumping enough

Primary prevention

Heart-healthy lifestyle

Heat stroke

Heat *depresses* hypothalamic function temp of *104 F* or *above* Characteristics -ALOC -hot, *Dry*, skin

Respiration

Heat is also lost during ____________ Elevated Resp rates are seen in pt.s who are *Hyperthermic* and *Dec* for pt.s who are *hypo*thermic

What are some anthropometry factors?

Height/weight, BMI, Wrist measurement, Mid arm circumference, Skin fold measurement

What did Orem's theory focus on?

Help patient attain total self care, nursing is necessary when patient is unable to do so.

Causes of hypovolemic shock

Hemorrhage, GI loss (vomiting, pooping blood), fistula drainage, diabetes insipidus, hyperglycemia, diuresis

Risk factors of perfusion

High BP, high cholesterol/triglycerides, smoking, diabetes, sedentary lifestyle, inflammation from diseases

symptoms of pneumonia

High fever up to 105 F Coughing out greenish, yellow, or bloody mucus Chills that make you shake Feeling like you can't catch your breath, especially when you move around a lot Feeling very tired Low appetite Sharp or stabby chest pain (you might feel it more when you cough or take a deep breath) Sweating a lot

Modifiable risk factors for HTN

High sodium, low K, Ca, Mg, obesity, excess alcohol, insulin resistance, stress

What is an example of caring touch

Holding a hand when given news.

Facilities that provide restorative care

Home health care- Rehabilitation- Extended care facility(SNF)-

What are the 5 perspectives on caring

Human Trait Moral Imperative Affect Interpersonal Interaction Therapeutic Intervention

Five perspectives on caring

Human trait, moral imperative, affect, interpersonal interaction, therapeutic intervention

five perspectives on caring

Human trait-born with it Interpersonal interaction Moral imperative-right vs. wrong Affect-feelings you have Therapeutic interventions

The major sleep study in the body is ?

Hypothalamus

Secondary prevention

Identifying diseases early so treatment can be initiated; screenings or diagnostic tests

When does patient abandonment occur?

If you leave the patient without properly transferring or handing them to a capable person, you are liable for patient abandonment and are responsible for any injury suffered after you leave them. "Failure to Act".

Consequences of impaired tissue/local perfusion

Impaired blood flow to affected body tissue (localized); ischemia and infarction

A 72-year-old patient has come to the health clinic with symptoms of a productive cough, fever, increased respiratory rate, and shortness of breath. His respiratory distress increases when he walks. He lives alone and did not come to the clinic until his neighbor insisted. He reports not getting his pneumonia vaccine this year. Blood tests show the patient's oxygen saturation to be lower than normal. The physician diagnoses the patient as having pneumonia. Match the priority level with the nursing diagnoses identified for this patient: 1. Impaired gas exchange_____ a. long term 2. Risk for activity intolerance______ b. short term 3. Ineffective self-health management_____ c. intermediate

Impaired gas exchange- short term Risk for activity intolerance- intermediate Ineffective self-health management- long term

Nurses ______________ interventions.

Implement

Implementation

Implementation: formally begins after you develop a plan of care. This step involves teaching and following through with plans

What is the difference between a nursing diagnosis and a medical diagnosis

In a nursing diagnosis we can't say "The diagnosis" we can provide evidence to the provider. Medical diagnosis is for the doctor.

Professional responsibilities

Include responsibility to the profession and to oneself, patients, employers, and community.

What does it mean to have a BSN degree?

Includes 4 years of study in a college or university Focuses on basic sciences, theoretical and clinical courses, and courses in social sciences, arts, and humanities to support nursing theory

Interdisciplinary care

Includes contributions from all disciplines involved in patient care, is designed to improve the coordination of all patients therapies and communication.

advanced directive (living will)

Includes living will, health care proxies, and durable powers of attorney for healthcare

Kussmauls breathing

Increase in respiration and expiration with breaths usually 35 breaths or greater. and increase in depth

Personal ethics

Individuals own ethical foundation

Systemic Infection

Infections require measures to control fever and usually require *IV antibiotics*

Localized infection

Infections require monitoring of fever, antibiotics and may require measures to *remove debris* or dead tissue to facilitate healing

Describe the steps of chain of infection.

Infectious organism --> Reservoir for pathogen---> Portal of exit from host--> Mode of transmission--> Portal of entry to host---> A susceptible host

A symptom that patients experience when they have chronic difficulty falling asleep, frequent awakenings from sleep, and/ or a short sleep or nonrestorative sleep

Insomnia

skin break down

Integument system complication of *immobility*

Battery

Intentional offensive touching without consent or lawful justification.

Collaborative nursing interventions

Interdependent interventions, require combined knowledge, skill, and expertise of multiple health care professionals

PAD definition

Interferes with arterial blood flow to the lower extremities, increasing risk for paresthesias, neuropathy, unsealing ulcers in legs, necrosis, gangrene, amputation

NANDA changed it's name to NANDA __________ to better reflect the international utility of nursing diagnosis for the global health community.

International

Incubation

Interval between *Entrance* of pathogen into body and appearance of *First symptom* ex: Chicken pox 14-16 days after exposure -Common cold 1-2 days -Influenza 1-4 days

incubation stage

Interval between entrance of pathogen into body and appearance of first symptoms (ex. Chickenpox, 14 to 16 days after exposure; common cold, 1 to 2 days; influenza, 1 to 4 days; measles, 10 to 12 days; mumps, 16 to 18 days; Ebola 2 to 21 day)

Prodromal

Interval from *Onset of non-specific signs* (Malaise, low-grade fever, fatigue) to *More specific symptoms* ex: HSV

prodromal stage

Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to more specific symptoms. (During this time microorganisms grow and multiply, and patient may be capable of spreading disease to others.) For example, herpes simplex begins with itching and tingling at the site before the lesion appears.

Convalescent

Interval when *Acute symptoms* of infection *Disappear* -Length of recovery depends on severity of infection and patients host resistance.

Convalescence

Interval when acute symptoms of infection disappear. (Length of recovery depends on severity of infection and patient's host resistance; recovery may take several days to months.)

Illness

Interval when patient manifest signs and *symptoms specific to type of infection* ex: Strep throat is manifested by sore throat, pain, swelling

illness stage

Interval when patient manifests signs and symptoms specific to type of infection. For example, strep throat is manifested by sore throat, pain, and swelling; mumps is manifested by high fever, parotid and salivary gland swelling.

Nurses implement ______________.

Interventions

Implementation occurs when the nurse initiates or completes _________________ necessary for achieving the __________ and ______________ of nursing care.

Interventions Goals Expected outcomes

Types of communication

Intrapersonal communication: "self talk" self-self Interpersonal communication: one-on-one communication Small-group communication: the interaction that occurs when a small number of people meet Public communication: interaction with an audience Electronic communication: the use of technology to create ongoing relationships with patients and their health care teams

Urge

Involuntary leakage of *Large amounts of urine* Assoc with *strong sense of urge*, OVERACTIVE bladder caused by *neurological problems* , bladder *inflammation* , obstruction

How is a BSN degree different from other types of nursing degree

Involves courses in social sciences, arts, and humanities to support nursing theory

examples of micro minerals

Iron, Zinc, Manganese, Iodine fluoride, Copper,

Asepsis

Is the Absence of pathogenic microorganisms _______ Technique refers to practices keeping a client as free from microorganisms as possible - 2 types

Societal ethics

Issues such as abortion, physician assisted suicide, embryonic stem cell; society provides a strong normative basis for ethical behavior

What is the primary purpose of the nurse practice act in each state?

It describes and defines the legal boundaries of nursing practice. ADA protects the rights of individuals who are disabled in the workplace, educational institutions and through out our society.

Why is nursing theory important

It is a three fold practice it guides research, establishes and improves practice

Describe the descriptive theory

It is more concrete Describe what is going on Erickson theory describes what we can expect from a stage. Does not tell you what to do.

What is the Nursing Practice Act

It legally states what a nurse can do in practice. Explains what is expected of their nurses per state.

Common Law

Judicial

Most common source of law for malpractice issues:

Judicial Branch (e.g. informed consent)

Pleuritic pain is described as

Knifelike, lasting for minutes to hours, always in association with inspiration

Stage 2: NREM

Lasts 10 to 20 minutes Period of sound sleep Relaxation progresses Arousal relatively easy

Stage 4: NREM

Lasts 15 to 30 minutes Deepest stage of sleep Very difficult to arouse

Stage 3: NREM

Lasts 15 to 30 minutes Initial stages of deep sleep Difficult to arouse

Stage 1:NREM

Lasts a few minutes Includes lightest level of sleep Easily arouse person

American Disabilities Act

Law that prohibits employers from discriminating against people with physical disabilities

Standards of care

Legal requirement for nursing practice that describe minimal acceptable nursing care

What theorist focused on a trans-cultural perspective

Leininger

What are some I/O abnormals?

Less than 30mL of urine out every 2 hours is a concern Polyuria- more than 2000-2500 mL a day is also a concern.

State statuatory issues in nursing practice

Licensure-minimum educational requirements (NCLEX) Good Samaritan laws- limit liability and offer immunity in hopes that nurses and medical professionals will act in times of emergency Uniform determination of death act-standards for determination of actual death. Cardiopulmonary standards and whole-brain standards (irreversible cessation of function) Autopsy- postmortem exam if requested by family, or suspicious death Physician-assisted suicide- Oregon death and dignity act- competent individual ANA- nurse participation is against ethics

Bristol stool type 3

Like a sausage but with cracks on the surface

Bristol stool type 4

Like a snake, smooth and soft

What are three caring behaviors in nursing

Listening Touch Knowing the client

what is a living will

Living wills represent written documents that direct treatment in accordance with a patient's wishes in the event of a terminal illness or condition. Living wills are often difficult to interpret and not clinically specific in unforeseen circumstances. Thus you are required to know how your state interprets living wills and under which circumstances a nurse implements them.

Infarction can cause?

Local death of the tissue

Arteriosclerosis

Loss of elasticity, thickening/calcification of arterial walls; manifestation of atherosclerosis

Cause of impaired tissue/local perfusion

Loss of vessel patency or permeability, inadequate central perfusion

Hypovolemic shock

Low blood volume

What theorist stated "Caring is the essence and central, unifying and dominant domain that distinguishes nursing from other health disciplines. It is also an essential human need, necessary for the health and survival of all individuals. This theorist had a transductional view.

Madeleine Leininger

Nursing considerations for PAD

Maintain perfusion and slow atherosclerotic process, stop smoking, foot care, peripheral pulses, color, pain, temperature, refill, regular and progressively strenuous activity

What stage of health behavior change? Sustained change over time

Maintenance

Functions of lipids

Make cell membrane, brain tissue, Carry fat soluble vitamins ADEK, Store fuel in adipose, Meal satiation Maintains temp, insulates and protects internal organs

Describe interdisciplinary theory

Maslows theory Derived from other theories but we use them in ours.

Cause of kussmauls

Metabolic acidosis, acidic rate causes an increase in respiration rate

Systemic changes which may occur with immobility

Metabolic- Negative Nitrogen Balance Respiratory- congestion, increase secretions in lungs,narrow bronchial tube Cardio-orthostatic hypotension,increase workload of heart, thrombus formation MS- foot drop, decreased muscle tone, sensory alterations, osteoporosis Elimination- calculi, urine stasis, constipation Integumentary- stage 1-4 wounds, ulcers, pressure areas, friction/shear

Portal of Exit

Microorganisms need to find a *portal of exit* sites include -Blood, skin, mucous membranes, resp tract, GU, GI

Tertiary prevention

Minimizing the effects of disease or disability; treatment, pt, ot, rehab

Lifestyle modifications: physical activity

Moderate-intensity aerobics at least 30 min most days Vigorous intensity aerobics at least 20 min 3x/week Muscle-strenghtening 2x/week Flexibility and balance 2x/week

In what group of risk factors can we provide patient education

Modifiable

three types of carbohydrates

Monosaccharides, Complex, disaccharide

MPOC

Multidisciplinary Plan of Care

Adverse effects of opioids

N/V, constipation, altered mental status, drowsiness, respiratory depression

Protocols for Nasal Cannula.

NC up to 4L then humidification is needed. 6L-15L must wear mask Non-rebreather: bag attached collects CO2 Venturi mask- % of O2 needed plus the liters needed COPD- No more than 2L because it cuts off resp. Drive

Enteral Tube Examples

NG, Nasointestinal, Gastrostomy, Jejunostomy, PEG, PEJ, G/J tube

What is NLN?

NLN: National League of Nurses, Advances nursing education and prepares RN to meet needs of diverse population.

Does a "Risk For" diagnosis need a goal and an outcome statement?

NO outcome ONLY goal

What is step one in the Stages of the sleep cycle?

NREM 1) Stage lasts a few minutes 2) Includes the lighted sleep 3) Decreased physiological activity begins with gradual fall in vital signs and metabolism. 4) Sensory stimuli such as noise easily arouse the person.

Different between implementations and interventions

NURSES IMPLEMENT INTERVENTIONS

Some methods of documenting

Narrative, Progress notes, charting by exception, critical pathways

Oxygen delivery systems

Nasal cannula, face mask, partial and nonbreather masks, oxygen conserving cannula

What is special about a J tube

Never aspirate a J tube!!

Antimicrobial

Nicotine replacement therapy

Can patient look at own chart?

No, they may not look at chart without supervision of primary physician or other appointed personell

Can a patient look through their own chart while in hospital or clinic?

No- can be misinterpreted. There is a format.

What are three types of analgesics?

Non-opioids Opioids Adjuvants

Manifestations of HTN

None unless severe: fatigue, dizziness, palpitations, angina, dyspnea

Normal sleep involves what 2 phases?

Nonrapid eye movement sleep Rapid eye movement

Lifestyle modifications: weight loss

Normal body weight (loss of 22 lbs. may lower systolic by 5-20)

Descriptive theory

Not directed towards nursing activity, cause and effect, first level

What are some Characteristics of Chronic pain

Not protective serves no purpose Has a dramatic effect on a person's quality of life

HIPAA

Not sharing your information without consent. It protects individuals from losing their health insurance when changing jobs, by providing probability. The creation of rules to protect patient rights to consent to the use and disclosure of their protected health information. This limits who has access to their records.

Nursing student with no previous level of experience

Novice

What are Benner's levels of nursing? (5

Novice Advanced Beginner Competent Proficient Expert

types of nursing interventions

Nurse initiated interventions: the independent response of a nurse to client needs Physician initiated interventions: Based on physician response (need an order) Collaborative interventions: Physical therapy or dietitian.

Contact Precautions

Nurses must wear gown and gloves and must not take materials into the patients room that will be taken into other peoples rooms or used on other pt.s example: C-diff

Type of intervention: Delegating a bed bath to a nursing student.

Nursing

Type of intervention: Lifting a patient from the bed to the commode with a ceiling lift.

Nursing

Type of intervention: Taking a BP after a patient complains of dizziness

Nursing

Type of intervention: Teaching a patient about the side effects of a medication

Nursing

Type of intervention: Turning a patient every 2 hours.

Nursing

what is the nursing paradigm

Nursing Environment Health Patient

Any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes

Nursing Intervention

Facilities that provide continuing care

Nursing centers/facilities- Assisted living- nurse on call Respite care- Adult day care centers-

Goals represent predicted resolution of a _______________, must be ___________, do not need to be ____________, and address ________ behaviors or responses.

Nursing diagnosis (problem) REALISTIC Measurable 1

Conducting a basic exam at least 1x per shift.

Nursing pro

What are the areas of agreement within the different nursing theories

Nursing, health.person.environment/situation

Type of intervention: Holding the digoxin medication when the patients apical pulse rate is 52 BPM

Nursing/Physicians

Collaborative interventions

Nutrition, activity, exercise, positioning, stop smoking, meds

What are some risk factors for sleep apnea

Obesity Hypertension Type II Diabetes Positive Family Hx of OSA Smoking Heart Failure Alcohol

What are the 2 types of classifications of data?

Objective Subjective

Infarction

Obstruction of the blood supply to an organ or region or tissue, typically by a thrombus or embolus

Iatrogenic

Obtained from a *Diagnostic test* ex: Bronchoscopy & Tx with broad-spectrum antibiotics

S/S of hyperthermia

Occurs when the body temperature rises above 37.6 C with an unchanged hypothalamic set point. The condition of having a body temperature greatly above normal. Undress the patient and start cooling them down with fluids or rags.

S/S of hypothermia and nursing interventions

Occurs when the core body temperature decline below 37.6 C The condition of having an abnormally low body temperature. Take the patient's clothes off and put dry/warm clothes on them.

What is statutory Law?

Of or related to laws enacted by as legislature branch of the government.

Each goal and outcome should address only?

One behavior or response

What are the types of instructional methods? (7

One on one Group Demonstration Analogy Role Play Simulation Teach back Nurse must be aware of patient's ability to learn, learning needs, motivation to learn, teaching environment, health literacy, and functional illiteracy. After teaching is done nurse must document to evaluate effectiveness.)

What are the 7 different kinds of instructional methods

Ono-on-one Group Preparatory instruction Demonstration Analogy Role Play Simulation

What is used for severe pain?

Opioid Analgesics

Priority setting

Ordering the nursing diagnosis or problems using urgency to determine

Vitamins

Organic substances present in foods that are essential to normal metabolism

Portal of entry

Organisms enter the body through the same routes they exit ex: Venipuncture , organisms enter the body if proper skin preparation is not performed first.

Risk management

Organizations system of ensuring appropriate nursing care by identifying potential hazards and eliminating them

What relationship phase? (ex: Observing pt. set tone by your manner, getting to know someone via first impression)

Orientation

Goal or Outcome: Client will achieve incentive spirometer goal of 90% every 2 hours for the next 24 hours.

Outcome

Goal or Outcome: Client will sit up in chair for 20 minutes 3x per day without abnormal HR by day 2 post-op.

Outcome

PICOT

P- population of interest I-Intervention of interest C-comparison of interest O-outcome T-time

Can be given by IV, Brown color, Comes from manufacturer

PPN (partial parenteral nutrition)

Central perfusion medical interventions

Pacemaker, electrical cardioversion, ablation therapy, itraaortic balloon pump, cardiac valve surgery, cardiac transplant

Radiating

Pain feels as though it travels down or along the body part, intermittent, or constant.

Deep or visceral

Pain is diffuse and radiates in several directions. Duration varies but usually lasts longer. Pain is sharp, dull or unique to involved organ.

Referred

Pain is in part of body separate from source of pain an assumes any characteristic.

Superficial or cutaneous

Pain is short in duration and localized, usually is a sharp sensation.

Symptoms of bad perfusion

Pain, dyspnea, edema, dizzy, faint, decreased pulses, cramping in legs

types of documentation

Paper electronic health records Narrative documentation Problem oriented medical record: is a method of documentation that emphasizes patient's problems. Data are organized by problem or diagnoses. Ideally each member of the health care team contributes to a single list of identified patient problems.

what is a paradigm?

Paradigm: pattern of thought that is useful in describing the domain of a discipline. A paradigm links the knowledge of science, philosophy, and theories accepted and applied by the discipline. 4 Links person, health, environment/situation, and nursing

Expiration

Passive process

What are some error reduction techniques? (7)

Patient ID SALAD Time Out Needleless system Barcode scanning with EPIC Med Reconciliation Tallman Lettering

Med error reduction

Patient identification SALAD drugs Time out Needleless system Bar code scanning/ EPIC Med Reconciliation ISM Tallman lettering Standard order sheets

Invasion of privacy

Patient protection from unwanted intrusion into his or her private affairs.

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. Which of the following patient care goals are long-term? 1. Patient will explain relationship of insulin to blood glucose control. 2. Patient will self-administer insulin. 3. Patient will achieve glucose control. 4. Patient will describe steps for preparing insulin in a syringe.

Patient will achieve glucose control

Patient centered goal

Patients highest possible level of wellness and independence in function, realistic

What theorist focused on understanding events, projects, and things matter to people and talked about interpersonal interaction.

Patricia Benner

To keep on top of changes, we must ____________________ all the time.

Perform assessment

Therapeutic intervention

Performed by nurses to achieve goals/outcomes

Chronic illness

Persists for 6 months or more, may affect functioning; copd, renal failure

What are some characteristics of a chronic illness

Persists for at least 6 months May affect any functioning in any dimension

Describe chronic?

Persists longer than 6 months May affect any functioning in any dimension.

What are the 6 overlying concepts for the nursing curriculum at the SFMC CON

Person Health Nursing Environment Society Student Centered Learning

Ineffective airway clearance definition

Person unable to clear secretions, or obstructions from the respiratory tract to maintain clear airways

Community acquired pneumonia

Person who contracts pneumonia with little contact with the health care system

Links of a Nursing Paradigm

Person, health, environment/situation, nursing

direct

Person-to-person (Fecal, oral ) physical contact between *source* and *susceptible host*

Indirect

Personal contact of susceptible host with *contaminated* inanimate object ex: Needles or sharp objects, dressings, environment

interventions for pain:pharmacological

Pharmacological pain relief Acute pain management Analgesics Nonopioids Opioids Adjuvants/co-analgesics Delivery systems Patient-controlled analgesia (PCA) Local/regional anesthesia Topical agents

Type of intervention: Administering a pain medication

Physician

Type of intervention: Conducting a wound dressing change every day

Physician

Type of intervention: Inserting an IV catheter

Physician

Type of intervention: Transfusing Blood

Physician

Dependent nursing interventions

Physician initiated interventions, require an order

What are Maslow's hierarchy of needs? (5)

Physiological 2. Safety 3. Belonging 4. Self Esteem 5. Self Actualization You must meet each level before trying to attain the next.

Reservoir

Place where *microorganisms survive* ex: Humans, animals, organic matter on inanimate surfaces (Fomites)

PAD meds

Platelet inhibitors (aspirin, Plavix), Cilostazol (mild vasodilator that improves claudication), Trental (reduces viscosity to move like water)

Community acquired pneumonia

Pneumonia acquired outside of hospitals of extended care facilities

Interventions for chest wall movement

Postural drainage, positioning, coughing, chest physiotherapy, acapella, suctions, nebulizers, vaccines, types of 02 delievery

Psychosocial factors of HTN

Poverty, isolation, lack of support, stress, negative emotions

What stage of health behavior change? Not intending on changing with in 6 months

Pre-contemplation

What relationship phase? (ex: reviewing data with previous RN)

Pre-interaction

Condtions that affect chest wall movement

Pregnancy, lack of exercise, smoking, substance abuse, physical anatomy, stress, poor nutrition, muscular skeletal abnormalities.

Patients at Risk for Nutrition Problems

Premature birth, Eatting disorders, Obese, Surgery, CA

What stage of health behavior change? Making changes for a change in the next 6 months

Preparation

Which instructional method would you explain verbally or put it out on a piece of paper before doing a procedure

Preparatory Instruction

Musculoskeletal pain

Present following exercise, rib trauma, and prolonged coughing episodes. Inspiration worsens the pain.

What are 5 challenges for todays nurses

Pressure to deliver high quality Time constraints Cost constraints Technological advances Limited autonomy

Immunizations, fluoride in water, preconception folic acid supplements are examples of what level of care?

Primary Prevention

This type of prevention has interventions aimed at preventing disease, injury, or disability. Includes wellness efforts and illness prevention.

Primary Prevention

Which level of preventative care? Aimed at health optimization and disease prevention. Health education for optimal nutrition, exercise, hygiene, sanitation, protection from environmental hazards like allergens, toxins and carcinogens.

Primary Prevention

What are the levels of preventive care

Primary Prevention Secondary Prevention Tertiary Prevention

A gray area exists between what 2 levels of care?

Primary and Secondary

What are the 3 levels of preventative care?

Primary, Secondary, and Tertiary

Goals address _______________; Outcomes address ______________.

Problems Defining Characteristics

3+ years experience, perceives a patient as a whole, managing care instead of managing and performing skills.

Proficient

What did Watson's theory focus on?

Promote health and restore patient to health and prevent illness, interventions to meet human needs

Confidentiality

Protection for private patient information in the healthcare setting.

Illness prevention

Protection from actual or potential threats to health.

How is nursing defined

Protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and population. ANA: diagnosis and treatment of human responses to actual or potential health problems

What are some characteristics of acute pain?

Protective Has an identifiable cause Short duration Limited tissue damage

Reverse Isolation

Protective , reducing microorganisms for compromised patients

Americans with disability acts

Protects the right of people with physical or mental disabilities

What did Leininger's theory focus on?

Provides care consistent with nursing science as a central focus, transcultural, caring is what unifies nursing knowledge and practice.

Good Samaritan Law

Provides limited protection to someone who voluntarily chooses to provide first aid. Protected as long as you act without gross negligence.

What are the 10 caring behaviors in nursing?

Providing presence 2. Touch 3. Task oriented 4. Caring 5. Protective 6. Listening 7. Knowing the client 8. Spiritual caring 9. Relieving pain 10. Family care

caring behaviors in nursing

Providing presence, touch, task oriented, caring, protective, listening, knowing the client, spiritual caring, relieving pain and suffering, and family care.

What domain of learning involves acquiring skills that require the integration of mental and muscular activity.

Psychomotor

What is the single most reliable indicator of pain?

Pt's self report of pain

200 ; Greater

Pt. usually has a *feeling to go* when there is approx __________*mL* of urine in bladder Urinary *Urge* is __________ than *200* mL of urine in bladder

Hospital ; Long

Pt.s who contract __________ acquired pneumonia (Nosocomial) usually live in ________ -term care facilities

What are the physiological symptoms of sleep apnea?

Ptosis Blurred vision Fine motor clumsiness Decreased reflexes Cardiac arrrhythmia

Signs of impaired central perfusion

Pulmonary edema, shortness of breath, slow capillary refill, dizziness, hypotension

What is data clustering?

Putting like data together, primarily done with exceptional data

When you think of the word JCAHO what do you think of

Quality

What is the SFMC CON devoted to

Quality Personal and professional development Service Agility

what does RACE stand for when there is a fire

R- Rescue A- Activate the alarm C- Confine the fire by closing doors and windows E- Extinguish the fire with appropriate extinguisher.

Stage where vivid dreams occur, averages 20 minutes, rapid moving of the eyes, increase in gastric secretions, and loss of skeletal muscle tone.

REM sleep

Positioning for immobile patients

ROM and transferring

What does it mean to prioritize?

Rank order based on importance

HTN crisis manifestations

Rapid onset, blurred visit, headache, confusion, motor/sensory deficits

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 in the IV line, and the patient asking to be turned. Which of the following does the nurse perform first. 1. Reconnect the drainage tubing 2. Inspect the condition of the IV dressing 3. Improve the patient's comfort and turn her on her side. 4. Obtain the next IV bag from the medication room.

Reconnect the drainage tubing

Consequences of impaired central perfusion

Reduced CO leads to reduction of oxygenated blood reaching body tissues (systemic); may lead to shock, ischemia (hurts), infarction (kills)

Professional behaviors

Refer to discipline-related knowledge and skills, appropriate relationships with patients and colleagues, and acceptable appearance and attitudes.

HYPERthermia

Refers to a body temperature *Above* normal range *>37.6C*

HYPOthermia

Refers to a body temperature *below* normal range *< 36.6 C* (97.8 F)

Professional Parameters

Refers to the legal and ethical issues.

Legislation purposes

Regulate, authorize, proscribe, provide, sanction, grant

Non-pharmacological pain relief intervention

Relaxation, guided imagery Biofeedback, Distraction, music Cutaneous stimulation, Massage, transcutaneous electrical nerve stimulation (TENS), heat, cold, acupressure Herbals and Reducing pain perception

NSAID MOA

Relieves pain by acting on peripheral nerve endings at injury site and decreased level of inflammatory mediators generated at site of injury

Exp of a portal of entry into the host

Respiratory system

Can responsibility or Accountability be delegated?

Responsibility

What is the difference between accountability and responsibility

Responsibility can be delegated where accountability cannot.

Manifestations of PAD

Rest pain, intermittent claudication, paresthesias, diminished/absent peripheral pulses, pallor when elevated, inflammation when dangling, thin and shiny and hairless skin, thickened toenails, skin breakdown and discolored areas

Leg with critical limb ischemia

Revascularization via bypass, protect from trauma, decrease ischemic pain, prevent/control infection, improve arterial perfusion

Making decisions during implementation you should?

Review all possible nursing interventions for patients problem, review all consequences, determine probability of consequences, make a judgement of value of consequence

Moral Imperative

Right vs. wrong or value (nurture)

What is SOAP?

S- Subjective Data O- Objective Data A- Assessment (diagnosis based on this data) P- Plan (interventions)

IOM STEEP

S: Safety T: Timely (Reduce wait) E: Effective (Evidence base) E: Equitable ( Fair) P: Patient Centered

What happens in hypovolemic shock

SV, CO, BP drop, and SVR does not compensate

Braden Scale

Scale used to assess Skin break down risk *No Risk*: 19-23 *Severe Risk* 6-9 *Perception* *Activity* *Moisture* *Nutrition* *Friction/shear*

Which nursing theory do we practice?

Science/Domain: The worldview or perspective of the discipline.

Secondary prevention

Screening, early diagnosis, prompt treatment

Secondary prevention

Screenings, BP, lipid tests

This type of prevention has interventions aimed at increasing the probability that a person with a disease will have that condition diagnosed with treatment will be cured.

Secondary Prevention

Which level of preventative care? Identify individuals in an early state of disease process so prompt treatment can be started such as skin cancer screenings mammograms, and colonoscopies

Secondary Prevention

BP screenings, mammograms, colonoscopy, and bone density scans are examples of what level of care?

Secondary Prevention (screening)

Consultation

Seeking the expertise of a specialist to handle problems

Altruism/Respect for person

Selfish Concern for the welfare of others

braden skin assessment

Sensory Nutrition Friction and shear Activity Moisture

Complications of PPN

Sepsis/infection, Pneumothorax, Air embolism Hyper/hypo glycemia

90

Septic *Heart rate* is a HR *greater* than ______ bpm

20 , 32

Septic Respiratory rate is *greater* than _______ breaths per minute or a *PaCo2* *less than* ________ *mmhg*

96.8 F ; 100.4 F (36-38C)

Septic Temperature is *Less* than _________ or *Greater* than ____________

4,500; 10,000 ul/mm3

Septic WBC count *Less than* ___________ or *Greater than* ____________ ul/mm3

Planning

Setting priorities, identifying patient centered goals,expected outcomes

Native American culture

Shaman combination of prayers, chanting, and herbs to treat illness

Fluid loss of 1000+ ml

Shock progresses, multiple organ failure, death

Describe Acute?

Short duration Severe May affect functioning in any dimension.

What are some characteristics of an acute illness

Short in duration Severe May affect functioning of any kind..

SBAR

Situation Background Assessment Recommendation

What is SBAR

Situation, Background, Assessment, Recommendation. Used when you call the doctor regarding the patient

A disorder characterized by the lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep.

Sleep apnea

Modifiable risk factors

Smoking (vasoconstriction), hyperlipidemia (atherosclerosis), sedentary lifestyle, obesity, diabetes (atherosclerosis), HTN (myocardium works harder), stress

Bristol stool type 5

Soft blobs with clear-cut edges

Prescriptive

Something that must be done

Proscriptive

Something that must not be done

Droplet precautions

Spread *within 3 feet* of the patient - gown, gloves, *Regular mask*

What is step 2 in the Stages of the sleep cycle?

Stage lasts 10-20 minutes 2) It is a period of sound sleep 3) Relaxation progresses. 4) Arousal remains relatively easy.

Complex

Starches and fiber

NORMOthermia

State in which body temperature is *WDL* - *36.2 C - 37.6 C* (97.0 F- 100.0 F)

What are some examples of "Health Maintenance and promotion and illness prevention".

Stress management Immunizations Screenings Prenatal care Safety checks

Components of a SOAP note

Subjective-verbalization: "im worried about what surgery will be like" Objective-measured and observed: wife present Assessment-based on data: deficient knowledge Plan-caregiver plan to do: explaining surgical routine to patient

Internal transmission

Such as *parasitic* conditions between *Vector* and *Host* ex: Mosquito, louse, flea , tick

Advocacy

Supporting the cause

UTI symptoms

Symptoms include *dysuria*, cystitis, *Hematuria*, and pyelonephritis

Research

Systemic controlled investigation of hypothetical questions about relationships.

Definition of HTN

Systolic 140+, diastolic 40+ based on average of 3 separate readings or current use of antihypertensive drugs

What is a telephone or verbal order? How do you document?

TO, VO Ex) Administer 10mg Morphine IVP now. -T.O. Dr. Smilth/G. Beckwith SFNS

White, mixed by pharmacy, must be wasted if unused, given through central line.

TPN (total parenteral nutrition)

Beneficence

Taking positive actions to help others, patient advocacy

What is the difference between teaching and learning

Teaching is an Interactve process that promotes learning and the patient knows what is expected of them. Learning is the purposeful acquisition of new knowledge, attitudes, behaviors, and skills. The learner identifies a need for knowledge or acquiring and ability to do something.

What relationship phase? (ex: termination is near , evaluate, reminisce, separate by relinquishing care from patient)

Termination

Medical Treatment, Rehab, and Hospice are examples of what level of care?

Tertiary Prevention

This type of treatment is aimed at disability limitation and rehabilitation from disease or disability.

Tertiary Prevention

Which level of preventative care? Minimizing effects of disease/ disability, Restorative care, managing condition and minimizing complications to achieve highest level of health possible.

Tertiary Prevention

why do nurses have a code of ethics

The Code of Ethics is the philosophical ideas of right and wrong that define the principles you will use to provide care to your patients All members of a profession accept a code of ethics (it is a collective statement about the group's expectations and standards of behavio

Who is responsible for directing medical treatment?

The Healthcare Provider

Purdue University

The Virginia Henderson international nursing library is located at _________________

Perfusion

The ability of the cardio system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs

Anoxia

The absence of oxygen

As nurses, we base our priorities on ___________.

The data/problems collected

As nurses, we base our priorities on ___________.

The data/problems collected Maslow's Hierarchy of needs and ABC's LOC

Central perfusion

The heart; force of blood movement generated by cardiac output; requires cardiac function, BP, blood volume (CO= SV x HR)

fall risk assessment

The higher the score the greater the fall risk Fall assessment tool Heinrich get up and go SBAR (Irene) National safety goal

Analgesics

The most common and effective method for pain relief.

circadian rhythm

The most familiar rythem is the 24 hour, day-night cycle known as diurnal or_____________________.

Planning

The nurse collaborates with a patient and family (as appropriate) and the rest of the healthcare team to determine urgency of the identified problems and prioritizes patient needs. Ex:choosing interventions

Code of Ethics Provision 1

The nurse in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by consideration of social or economic status, personal attributes, or the nature of health problems

Code of Ethics Provision 4

The nurse is responsible and accountable for individuals nursing practice and determines the appropriate delegation of tasks consistent with the nurses obligation to provide optimum patient care.

Code of Ethics Provision 5

The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth

Code of Ethics Provision 6

The nurse participates in establishing maintaining, and improving health care environments, and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession.

Code of Ethics Provision 7

The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.

Code of Ethics Provision 3

The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

Code of Ethics Provision 2

The nurse's primary commitment is to the patient, whether an individual, family, group, or community.

Standards of care is what

The nursing process

What is a care plan

The nursing process in written form

What is patient centered care

The patient is the center of therapy, be respectful of and responsive to individual preferences.

If there is a procedure to be done who should be the one to do the informed consent?

The person doing the procedure

Ventilation

The process of moving gasses into and out of the lungs.

Diffusion

The responsibility of moving the respiratory gases from one area to another by concentration gradients

Privacy

The right of patients to keep personal information from being disclosed.

What are the standards of professional Performance (ANA)

The standards describe a competent level of behavior in the professional role of nursing.

What is the nursing process?

The work that we do. ADPIE

Maslow's Hierarchy of Needs is what kind of model?

Theoretical model

Benner

Theorist who focused on patients need for caring as a means of coping with stressors of illness.

Watson

Theorist who said we should promote health, restore patients to health, and prevent illness.

Watson

Theorist who said we should promote health, restore patients to health, and prevent illness. (Caring is essential care to the essence of nursing)

Leininger

Theorist who stated we should provide care consistent with nursing's emerging science and knowledge with caring as a central focus

King

Theorist whose goal was to use communication to help patients reestablish positive adaptation to the environment.

Henderson

Theorist whose goal was to work interdependently with other health care workers, assisting patients in gaining independence as quickly as possible' help patients gain lacking strength.

Henderson

Theorist whose goal was to work interdependently with other health care workers, assisting patients in gaining independence as quickly as possible' help patients gain lacking strength. (Nurses help Perform Needs)

Roy

Theorists whose goal for nursing was to identify the types of demands placed on the patient, assess adaptation to demands and to help patients adapt.

Nighingale

Theorists whose goal was to facilitate the reparative processes of the body by manipulating the patients environment.

Nighingale

Theorists whose goal was to facilitate the reparative processes of the body by manipulating the patients environment. (Hygiene, light, comfort, and socialization)

Neuman

Theorists whose goal was to help individuals, families, and groups attain and maintain maximal level of total wellness by purposeful interventions.

Neuman

Theorists whose goal was to help individuals, families, and groups attain and maintain maximal level of total wellness by purposeful interventions. (Stress reduction)

Describe the prescriptive theory

Theory that tells us what to do It gives nursing interventions

Collaborative Interventions

Therapies that require the knowledge, skill, and expertise of multiple health care professionals.

treatment for pneumonia

Therapy for underlying cardiac respiratory complications and emotional problems that occur as a result of the symptoms of this disorder cPAP machine Sleep schedule

Why are there so many nursing theories

There is a lack of consensus about a single nursing theory or which theory is the most useful.

What is so different about health promotion and illness prevention?

There is an overlap between these two definitions but they are used interchangeably.

Where are water soluble vitamins stored?

They aren't stored in the body

What is an assessment and why is it important?

This is the first step in the nursing process it is objective and subjective so we have all the data we need an can look at it carefully. Assessment has to be correct or the whole thing is wrong.

Battery: Assault:

Threat Action

When or where does teaching occur in the nursing process

Throughout the nursing process, timing is important

Infarction

Tissue death

What is nursing

To care for a person as a whole. Mentally, spiritually, and physically to provide a positive outcome and well-being.

North American Nursing Diagnosis Association (NANDA) Purpose:

To develop, refine, and promote a "language for nursing problems" for use by professional nurses

What is the purpose of NANDA

To develop, refine, and promote a language for nursing problems.

What is the biggest purpose of the nursing diagnosis

To distinguish the nurses role from that of the physicians

What is the code of Ethics for nurses

To provide safe and compassionate care

In service education

To remain current in nursing skills, knowledge and theory

parts of a cultural assessment

Touch, personal space Language Time orientation

Radiation

Transfer of *Heat* between 2 objects with out touch body ex: Environment ; blankets on skin

Evaporation

Transfer of heat energy when *Liquid changes to a gas* ex: Sweating

Conduction

Transfer of heat from one object to another by *direct contact*

Convection

Transfer of heat through *air movement* ex: Fan

HTN crisis treatment

Treat within 1 hour; decrease BP by no more than 25% within minutes to 1 hour, then to 160/100 within 2-6 hours (too quickly can lead to rebound issues)

Indirect care

Treatments performed away from the client, but on behalf of the client.

Direct Care

Treatments performed through interaction with the client.

Shock definition

Triggered by sudden drop in MAP; BP is sustained by CO and PVR

T/F Ignorance of the law of standards of care is Not a defense against malpractice

True

T/F The presence of risk factors, does not mean that a disease will occur. Risk factors do increase the chances for experiencing a particular disease or dysfunction though.

True

T/F Theory enables you to answer all the important "why" questions

True

True or False: There is an overlap between Health profession and illness prevention

True

What is Primary Prevention

True prevention that lowers the chances that a disease will develop

What are some examples of task-oriented touch?

Turning a patient and giving immunizations

Mixed

Typically a combination of *stress* and *urgent* symptoms: Urine leakage when sneeze, cough, laugh, exercise or lift something heavy

what is a UTI

UTI's are one of the most common health acquired infection, with almost all caused by instrumentation of the urinary tract. The risk for UTI increases in the presence of an indwelling catheter, any instrumentation of the urinary tract, urinary retention, urinary and fecal incontinence, and poor perineal hygiene practices.

Use for enteral tube

Unable to ingest food but is still able to digest and absorb nutrients.

Sentinel event

Unexpected occurrence involving *Death* or serious physical or psychological injury -Need for *immediate* investigation

False imprisionment

Unjustified restraints of a person.

interventions for pneumonia

Use spirometer Breathing treatment High Fowlers position Collect sputum in morning

Deconditioned

Used to describe a *loss* of physical fitness -Pt.s who do not maintain optimal physical activity or *extended periods of immobility*

Psychomotor skills

Using good coordination and precision when giving an injection

How does a nurse address the need for evidence-based practice

Using your clinical expertise and considering patient's' values and preference ensures that you will apply the evidence in practice both safely and appropriately.

REM sleep

Usually begins about 90 minutes after sleep has begun Duration increases with each sleep cycle and averages 20 minutes Vivid, full-color dreaming occurs Rapid eye movement Very difficult to arouse sleeper

Diagnosis

Validation of health care needs and priorities, analysis of assessment findings

Medications for perfusion

Vasodilators, Vasopressors, Diuretics, Antidysrhthmics, Anticoagulants, Antiplatelets, Thrombolytics, Lip lowering agents

High flow oxygen delivering device

Venturi mask

Assessment

Verbal interviewing, medical records, data gathering

verbal communication

Verbal: use of spoken or written words Vocabulary: words and phrases Denotative and connotative meaning: some words may have several meanings Pacing: communication is more successful at an appropriate pace Intonation: tone of voice Clarity and brevity: effective communication is simple, brief, and direct Timing and relevance: timing is critical

Describe the Grand Theory

Very abstract and large Theories on nursing Cannot be tested because they are tested.

14 needs, games

Virginia Henderson created the *Need* theory and has _____ Needs which includes ________

ANA hall of fame

Virginia henderson was inducted to what *Hall of fame* ?

Exp of portal of exit from reservoir

Visitor removing flowers from a vase that included a pseudomonas

50%

Voluntary movements or *Shivering Inc BMR* by _____ %

Bristol stool type 7

Watery, no solid pieces, entirely liquid

MH ( Malignant Hyperthermia)

What *Hyper*metabolic disorder is related to an Autosomal dominant disorder* ?

Cardiac Capacity; Cardiac output ; stasis (DVT)

What are some *Cardiovascular* complications of *Immobility* ? - Reduced _________ __________ - Dec ________ _________ - Venous ___________ ( )

Peristaltic; constipation

What are some *GI* complications of *immobility* -Reduced ________________ motility - ______________

Contracture; Demineralization ; Atrophy

What are some *Musculoskeletal* complications of *Immobility* - Joint _______________ - Bone _________________ - Muscle __________________

expansion; Atelectasis ; Pooling

What are some *Respiratory* complications of *immobility* ? - Reduced lung _________ - ____________ ( collapse of Aveoli ) - ___________ Secretions

Stasis; Calculi ; tone

What are some *Urinary* complications of *Immobility* ? - Urinary ____________ - Renal ____________ due to *Inc* Circulating *Calcium* resulting from *bone* reabsorption

Biphosphates; SERMS

What two specific meds *inc* chance of skin breakdown ? ________________ (Meds for *Osteopenia* / *Osis* ________________ (*estrogen Modulator*)

Writing a Nursing Intervention

What, When, How, Who; "The nurse will.."

ROM; gait; Activity

When *Assessing* mobility , focus on ____________ _________ Exercise and ___________

Hypoventilation

When alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate CO2

Arteriosclerosis

When blood vessels become thick and stiff and restrict blood flow to the organs and tissues

30C (86F)

When does the body *stop shivering* ?

Slander

When one person speaks falsely about another.

Hyperventilation

When the lungs remove CO2 quicker that it is produced by cellular metabolism

Charting by exception

When things only outside of the norm are charted

Are priorities mutually-agreed upon by the nurse and client?

Whenever possible

Are priorities mutually-agreed upon by the nurse and client?

Whenever possible, makes it smoother.

Functional Incontinence

Which type of *Incontinence* is a DIRECT result of caregiver *NOT RESPONDING* in a timely manner ?

Avoid Dysrhythmias !!!

Why do we *slowly* Rewarm *Severely* hypothermic pt.s ?

Responsibility

Willingness to accept ones professional obligatons

What relationship phase? (ex: involving, collaborating, setting goals and putting plan into action)

Working

Living will

Written documents that direct treatment in accordance to a patients wishes during a terminal illness

Do you need all 5 characteristics to be considered a professional nurse

Yes

What is a nursing care plan

You must be able to identify appropriately written nursing diagnoses, goal statements, expected outcomes, and nursing interventions Assessment-subjective and objective data Nursing Diagnosis-NANDA label, related to, secondary, as evidence by Goal Outcomes (SMART) Specific, Measurable, Attainable, Realistic, and Timely. Nursing interventions- done by the RN Evaluation-if the outcomes were met or not.

What is a client centered goal?

a behavior or response that reflects a clients increased possible level of wellness and independence of function

definition of metacommunication

a broad term that refers to all factors that influence communication

case management

a care-management approach designed to coordinate and link health care services across all levels of care for patients and their families while streamlining costs and maintaining quality.

Nursing Diagnosis

a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes

Diagnosis

a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, or community that a nurse is licensed and competent to treat. Ex: impaired gas exchange, ineffective breathing pattern, acute pain, impaired mobility, etc.

What is a SOAP note?

a method of documentation for initial and ongoing treatment

patient and family centered care

a model of nursing care in which mutual partnerships among the patient, family, and health care team are formed to plan, implement, and evaluate the nursing and health care delivered Respect and dignity Information sharing Participation Collaboration

complicated

a person has a prolonged or significantly difficult time moving forward after a loss, person experiences chronic and disruptive yearning for the deceased, has trouble accepting the death and trusting others, feels bitter, numb and anxious about the future. Occurs more frequently in those who had a conflicted relationship with the deceased or multiple losses, mental health issues or lack of support.

Informed consent

a persons agreement to allow something happen such as a surgery or invasive procedure based on full disclosure of risks, benefits, alternative and consequences of refusal

Standing order

a pre-printed document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures; pre-printed physician orders (e.g. sliding scale)

Occurrence report

a risk management system to keep track of how often a hazard is happening to attempt to determine deviations from standard care (patient falls)

Pain perception

ability to perceive the location, severity, and character of pain, the ability to apply past coping mechanisms, and the ability to interpret the intensity and quality based on culture and past experiences

Continence

able to control voiding

Impaired gas exchange characteristics

abnormal ABGs, abnormal resp rate/rhythm, confusion, tachy, hypoxia

heat exhaustion

abnormal condition causes depletion of body fluid and electrolytes due to intense heat

hypothermia

abnormal lowering of the core body temperature below 95 F usually due to prolonged exposure to cold

Neuropathic pain

abnormal processing in nervous system -nerve damage -burning, sharp, shooting

Dependent nursing interventions

actions that require an order from a physician or another health care professional

Nursing interventions

actions that the nurse initiates that do not require another health care professional, based on scientific rationale

Independent nursing interventions

actions the nurses initiate and do not require an order from a provider

Chronic pain affects

activity, emotions and thinking

Quasi-intentional torts

acts in which intent is lacking but volitional action and direct causation occur such as in invasion of privacy and defamation of character

Quasi intentional acts

acts where intention is lacking, but direct causation is occurring such as invasion of privacy

Combination

acute and chronic pain

Behavioral response of pain

acute pain, clenching teeth, grimacing, guarding,

Acculturation

adapting to a new culture

unintended act of omission or comission

adverse event

When do we document?

after each intervention (when we do something)

Factors that affect bowel elimination

age, diet, fluid intake, bacteria, parasites, physical activity, psychological factors, personal habits, positioning, pain, pregnancy, anesthesia, medications

factors affecting temperature

age, exercise, hormone level, stress, diet, medications, environment

What are some non modifiable risk factors?

age, gender, genetics, ethnicity, and physiological factors.

fidelity means

agreement to keep promises

Complications of TPN

air embolism

Which of transmission of pathogens? Droplet Nuclei, small particles that travel through air. specific mask needed.

airborne

Pain management is defined as

alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient

Humanism

also called Secular Humanism, views human existence without reference to religion, the Transcendent, a higher power, or ultimate truth

Urinary Retention

an accumulation of urine due to the inability of the bladder to empty

Quality improvement

an approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others (e.g. med admin, diet management, wound care, D/C planning)

self limiting pain

an end of pain is in sight

Outcome

an expected outcome is specific measurable changes in a client's status that is expected to occur in response to nursing care; derived from goal; each outcome statement addresses a pertinent piece of assessment data (defining characteristics); "The client will..."

Otitis media

an inflammation of the middle ear

Acute otitis media

an inflammation of the middle ear with a rapid onset of the signs and symptoms of acute infection, such as fever and pain

Glycogenesis

anabolism of glucose to glycogen for storage in liver and muscle

medications to help with thermoregulation

analgesics, anti-inflammatory, anti-infectives, antibiotics, antivirals, antifungals

what is complex critical thinking

analyze and examine choices more independent to look beyond expert opinion and thinking abilities begin to change (may seek opinions still)

medications for UTI

antiinfectives, phenopyridine, urinary analgesics,

Albumin and insulin

are simple proteins

Complications of enteral tube

aspiration or respiratory distress

NSAIDs include

aspirin, ibuprofen, acetaminophen

based on subjective and objective data

assessment

Nursing diagnoses flow from the __________________.

assessment data

interventions for UTI

assessment of urine, personal hygiene, cath care, fluid intake, I&O, empty drainage back frequently, UA culture and sensitivity, bladder schedule every 2 hours

shared leadership

associated with work teams is shared leadership, an approach in which employees are empowered to distribute leadership responsibilities broadly within a group. Effective with professionals and with project-focused workgroups

what does nonmaleficence mean

avoidance of harm/hurt

Nonmaleficence

avoiding harm

For a given client, an outcome statement is "The client will state 5 symptoms that indicate a possible problem that should be reported. The client will do this within 24 hours." At evaluation time, if the client can only state 3 symptoms, the evaluation statement would be: a. The goal was met AEB the client being able to state 3 symptoms. b. The goal was partially met AEB the client being able to state 3 symptoms. c. The goal was not met AEB the client being able to state 3 symptoms.

b. The goal was partially met AEB the client being able to state 3 symptoms.

thermoregulation

balance between heat lost and heat produced

Physician-initiated interventions

based on a physician's response to treat or manage a medical diagnosis; based on order; more invasive (admin med, foley, change dressing); require specific nursing responsibilities and technical nursing knowledge

Evaluative measures

basically assessment skills, you perform this at a point of care when you make decisions about the patients status and progress

Anticipatory Grief

before the actual loss or death occurs, especially in situations of prolonged or predicted loss

Digestion

begins in mouth and finishes in the small and large intestine

Client-centered goal

behavior/response that reflects their highest level of function; should be realistic and based on clients needs and resources; clients should be involved; meet immediate needs and strive for prevention and rehab

Religion

beliefs and practices related to the Transcendent -often organized as a community but can be practiced alone and exist outside of an organization

Race

biological term for persons who share distinguished physical features and genetic traits

Medications for immobility

bisphosphonates, selective estrogen receptor modulators

Preventative care

blood pressure and cancer screening, immunizations, mental health counseling and crisis prevention

Open/Compound fracture

bone broken through skin

How can you become a part of an ethnic group?

born into or adapt

Complications assoc with colon CA

bowel obstruction, perforation, metastasis

Simple/Closed fracture

break, no open wound, internal bleeding, swelling, bruising, hematoma (internal blood)

Biots breathing

breathing in clusters

grand theory

broad in scope, complex, require specification

Grand theory

broad, large segments of the physical, social or behavioral world

Protein is essential for

building of body tissue in growth, maintenance and repair

testing for immobility

calcium labs, imaging, bone density, fall risk score, stress test, assess for DVT

Examples of macro minerals

calcium, phosphorus, sodium potassium, magnesium, chloride

elimination changes associated with immobility

calculi, urine stasis, constipation

Describe the mid-range theory

can be hard to test a little more narrow it is over 1 or 2 concepts

six categories of nutrition

carbs, proteins, fats, vitamins, minerals, water

Uniform determination of death act

cardiopulmonary standard, whole brain standard, definitions of the above facilitate organ recovery for transplant

Benner

caring means that persons, events, and things matter to people, an interpersonal interaction

Gluconeogenesis

catabolism of amino acids and fat into glucose for energy when body exceeds glycogen storage

Planning

category of nursing behaviors in which client-centered goals and expected outcomes are established; 3rd step; requires deliberate decision making and problem solving skills; dynamic; based on nursing diagnosis

what is a CAUTI

catheter associated UTI, are ongoing problem for hospitals because they are associated with increased hospitalizations, increased morbidity and mortality, longer hospital stays, and increased hospital costs

Warning s/s of colon CA

change in bowel habits, diarrhea and constipation, weight loss, anorexia, anemia, occult bleeding

causes of UTI

change in flora, short urethra, hygiene measures, CAUTI, frequent sex, instruments in the urethra

Fluids and Electrolytes (interrelated concept)

changes in electrolyte balance can interfere with smooth muscles, reducing or increasing intestinal peristalsis; hypokalemic

Metabolism

chemical and physical process going on in living organisms

Shallow, deep, shallow breaths followed by periods of apnea (30 seconds) Can be caused by stroke, TBI, Carbon Monoxide poisoning. Agonal Breath (Big yawn)

cheyne stokes

enema administration

child: 300-500ml adult: 500-1,000ml

Ulcerative colitis

chronic inflammatory bowel disorder lasts 1-3 months, intervals for years, occurs in distal colon

Crohn's disease

chronic inflammatory disorder affects ascending and terminal ileum

Tort

civil wrong made against a person or property

Torts

civil wrong made against a person or property

Medical aseptic

clean technique

medical asepsis

clean technique

Examples of therapeutic diets

clear liquid, full liquid, pureed, mech. soft, soft to chew, high fiber, low sodium, low cholesterol, diabetic

Prep for flexible sigmoidoscopy

clear liquids then NPO, laxative or fleets enema

Prep for fiberoptic colonoscopy

clear liquids, then NPO, Mag citrate or Citrate magnesium, check for bleeding, chills ,pain , fever and avoid high fiber diet for 2 days following polyp removal

Kock Pouch

colon is gone; make pouch out of ilium; catheter pouch and drain stool

Ileoanal Pouch Anastomosis

colon removed: connect ilium to rectum

Mixed Incontinence

combination of stress and urge

Surrogate

communicating to the practitioner about the pain of the patient (parent for child)

What does "SBAR" stand for?

communication is hospital situation, background, assessment, recommendation

Purpose of Client's chart

communication, legal documentation, financial billing, education, research, auditing-monitoring

Proteins

composed of amino acids, contains C, H, O2, N

Fever (affect on urine)

concentrated urine

Negligence

conduct falls below standard of care; nursing areas of negligence: treatment, communication, medications, monitoring

respiratory changes associated with immobility

congestion, increased secretions in the lungs, narrow bronchial tube

Give two examples of a nursing diagnosis that is also a medical diagnosis

constipation and anxiety

Standing order

contains orders for routine therapies, monitoring guidelines, or procedures for a specific patient

vehicle transmission

contaminated items such as water, drugs, solutions, blood, and improperly handled food

heat stroke

continued exposure to extreme heat that raises the core body temperature to 105 F or higher

Interdisciplinary care plan

contributions from all disciplines involved in patient care, made to improve the coordination of all therapies

anterior hypothalamus

control temp if high via sweating and vasodilation

posterior hypothalamus

control temp of low via vasoconstriction and shivering

Administrative law

created under the administrative board (e.g. state boards of nursing); guidlines for reporting unethical or incompetence related to: child abuse, elder abuse, communicable diseases, emergency medical treatment and active labor act violations

Water

critical component of the body

Cognitive implementation skills

critical thinking, using good judgment, know the rationale for interventions

Macrominerals

daily requirement = 100mg or more

micro minerals

daily requirements is 100mg or less

Nociceptive pain

damage to body tissue and usually described as sharp, aching, throbbing

affective learning

deals with expression of feelings and development of values, attitudes, and beliefs.

Antihistamines

decongestant for upper airway, suppress cough

Oliguria

decrease urine production

Causes of constipation

decreased activity, low fiber, low fluid, meds,

Patient lives in future?

defer things for now to meet future goal and do use preventative care

Criminal law

defines crimes and punishment; e.g. signing RN when you haven't completed NCLEX, diversion of narcotics; felony vs misdemeanor

Transient Incontinence

delirium, infection, atrophy, pharmaceuticals, excess urine output, restricted mobility, stool impaction (DIAPERS)

total patient care

delivery was the original care delivery model developed during Florence Nightingale's time. In this model the RN is responsible for all aspects of care for one or more patients during a shift of care, working directly with patients, families, and health team members.

Which instructional method has to do with "showing"

demonstration

physician-initiated intervention

dependent nursing actions, involving carrying out physician-prescribed orders. - Think invasive procedures.

Physiological changes associated with immobility

depression, behavior changes, sleep alteration, coping, social isolation

descriptive

describe phenomena, speculate on why phenomena occur, and describe the consequences of phenomena.

Durable Power of Attourney

designate person to healthcare decisions when the patient can no longer make them for himself

Six factors for choosing nursing intervention

desired or expected client outcome, characteristics of nursing diagnosis, evidence based, feasibility, acceptability of the client, capability of the nurse

primary nursing

developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. It is typically not practiced today because of the high cost of an all RN staffing.

Interpersonal implementation skills

developing a trusting relationship, express level of caring, communicate clearly with family

Nutritional assessment

diet hx, med hx, physical exam, anthropometry, lab findings,

Which of transmission of pathogens? Person to person

direct

Double barrel colostomy

distal colon bypassed, mucus fistula, proximal functioning

Urinary Diversion

diversion of urine to external source

Laissez-Faire Leaders:

do not interfere with employees and their work. They stand at a distance, giving followers freedom to make decision and accomplish their work.

What are -Independent nursing interventions?

don't need a doctors order (giving water, patient teaching for side effects of medication)

Pain reassessment

done after medicine is given

Which of transmission of pathogens? Large particle that travels up to 3 feet

droplet

airborne transmission

droplet nuclei or residue if evaporated droplets suspended in air during cough, sneeze, or carried on dust particles

Sources of law

elected officials and congress create statutory laws. (nurse practice act to define nurse legal boundaries) Common law comes from judicial decisions made in courts, Civil laws protect the rights of individuals of our society. Criminal laws protect society as a whole.

function of macrominerals

electrolyte balance

fever

elevation in the hypothalamic set point so body temperature is regulated at a higher level

Secondary/tertiary care (types of care, and institutions)

emergency care, acute medical-surgical care, radiological procedures for acute problems Hospitals- Intensive Care- Psychiatric Facilities- Rural hospitals-

Good Samaritan Laws

encourage HCP to assist in emergency situations; some states have duty to rescue laws that requires training professionals to stop and help

What do we need carbs for?

energy

S/S of diverticulitis

episodic pain, constipation, diarrhea, IBS, weakness, fatigue, bleeding in stools, abdominal distention and low grade fever

EGD

esophagogastroduodenoscopy

Cultural assessment

ethnic hx, bioculture hx, social organizations, religious or spiritual beliefs, communication patterns, touch, personal space, time orientation

examples of this include: pain score, how far ambulated, teach back?

evaluation

Elimination

excretion of waste from the body

Pain modalities of gait theory include

exercise, heat or cold, massage, TENS

What are some complications of pain?

exhaustion (physical and emotional), immobility, sleep deprivation

Situational factors affecting pain

expectation, control, relevance

Voiding

expel

Defecation

expel stool

Micturition

expel urine

interdisclipinary

explain systematic views of phenomena specific to the discipline of inquiry (basic human needs, developmental, psychosocial, systems)

Communication

expressing and exchanging ideas

Affective domain

expression of feelings, values, attitudes and beliefs

vector transmission

external mechanical transmission, and internal transmission such as parasites

What makes up nonverbal communication?

facial expression, eye contact, body posture

Metacommunication

factors that compose the context of the message

justice means

fairness

Name a few reasons why health care system is being transformed

family and patient engagement, providing patient centered care, population health, Safety- eliminating errors, Compassionate care (DNR) Reducing overuse and waste

chronic pain can cause what?

fatigue, insomnia, anorexia, depression, withdrawal and anger

Where are fat soluble vitamins stored?

fatty components of the body

emotional factors affecting pain

fear, anger, frustration

Evaluation

feedback, comparison of actual and expected outcomes, update of care plan,

Mambo

female

heat loss does not keep up with heat production

fever

Stereotyping behavior

fixed concept of how all members think or act, can be learned and unlearned

methods of elimination

flax seed, acupressure, massagem reflexology, aroma therapy, stress management

Bristol stool type 6

fluffy pieces with ragged edges, a mushy stool

transactional leaders

focus on the daily operations of an organization and develop an exchange relationship with their followers. They reward followers when they do well and correct them when needed

What does nursing focus on

focuses on care

Mid range theory

focuses on only a piece of human reality or experience

Anabolism

food is built up into protoplasm

Musculoskeletal changes associated with immobility

foot drop, decreased muscle tone, sensory alterations, osteoporosis

Pathologic fracture

fracture in bone that has been weakened by disease

definition of autonomy

freedom from external control

Overactive Bladder

frequent, sudden urges to urinate

Common law

from judicial decisions made in courts when individual legal cases are decided

Lifestyle modifications: DASH diet

fruits, veggies, fat-free or low-fat milk, whole grains, fish, poultry, beans, seeds, nuts

deconditioning

functional loss

Psychological factors affecting pain

gender, age, cognitive level, previous pains, family learning culture

What is a standing order for?

general symptom, procedure and order for "chest pain" by heart doctors. Need a doctor's order to perform this type of procedure. (dealing with medication)

African American culture

granny midwife, spiritualist, voodoo practitioners

Generalizations

group similarities applied to an individual

how does acute pain threaten recovery?

hampering the patient ability to become involved

What is a complete amino acid?

has all the 9 essential amino acids (fish, chicken, soybeans, turkey)

Evaluative nursing intervention:

have to back to assess pain in 30 min

HAI

health care associated infection

Profuse diaphoresis results in excess water and electrolyte loss.

heat exhaustion

heat production

heat is a byproduct of metabolism the chemical reaction in cells from breakdown of food

BMR

heat produced by the body at rest

heat depress hypothalmic function, temp of 104

heat stroke

selective estrogen receptor modulators

help prevent osteoporosis

Asian American culture

herbalist, acupuncture, fortune teller, shaman

HDL

high density lipoprotein (GOOD)

Treatment for diverticulitis

high fiber, high residue diet

Pain causes release of

histamine, bradykinin, potassium

Retention

holding waste

nosocomial infection

hospital acquired, catheterization most common cause

A nurses knowledge, experience, ethical perspective, and knowing the patient all contribute to:

how to make judgements

Many nursing scholars disagree on whether the concept of caring is a nature or nurture issue. The perspective of caring which describes the concept as part of human nature and essential to human existence is:

human trait

Retention Prevention

hydration, fiber, mobility

cardio changes associated with immobility

hypotension, increase workload of heart, clot formation

Nursing actions for cultural differences

identify potential conflicts, meet client on their terms, resist stereotyping, understand yourself and your attitudes, constrain prejudices and tendencies to judgement

Evaluation Process

identifying criteria and standards (knowing what to look for), collecting data (repeat assessment to see if better), interpreting and summarizing findings, documenting findings, terminating, continuing, or revising the care plan

Ileostomy

ileum small intestine, usually colon, rectum and anus completely removed

Identify the interval when a patient progresses to manifesting signs and symptoms specific to a type of infection:

illness stage

fats

important for wound healing but can be dangerous

Physiological response of pain

impulse travels up spinal cord to stem and thalamus > fight or flight response > deep pain > chronic pain

Cognition (interrelated concept)

inability to recognize cues for elimination, leading to incontinence

Advanced directives

include living wills, health care proxies, durable power attorneys

thyroid hormones

increase BMR 100%

voluntary movements or shivering

increase BMR 50%

Diuresis

increase urine production

Barborygami

increased peristalsis

stages of infection

incubation, prodromal, illness, convalescent

Fiber

indigestible polysaccharide which is a dietary factor in disease prevention and treatment, essential for peristalsis

Which of transmission of pathogens? Personal contact with inanimate object

indirect

indirect or direct care?... Communicating nursing interventions- written, electronic, oral

indirect

Assimilation

individual adapts and incorporates characteristics of the dominant cultureu

Which age group has greatest % of total body water?

infants

Biggest concern with foley catheter:

infection

systemic

infections require measures to control fever and usually require IV antibiotics

localized

infections require monitoring of fever, antibiotics, and may require measure to remove debris or dead tissue to have appropriate tissue healing

Enteroclysis

injection of liquids into the colon

acute pain follows

injury disease or surgery, rapid onset that varies with intensity and length

Malpractice

injury occurs as a result of what a nurse does or fails to do

what does an in-service education mean

instruction or training provided by a healthcare agency or institution; designed to increase the knowledge, skills, and competencies of nurses and other healthcare professionals employed by the institutions (on the job)

Cognitive domain

intellectual skills, thinking, and acquisitions of nursing

Clinical judgement

interpretations and inferences that influence actions in clinical practice

incubation

interval between entrance of pathogen into the body and appearance of first of first symptoms

prodromal

interval from onset of nonspecific signs and symptoms to more specific symptoms

convalescent

interval when acute symptoms of infection disappear

illness

interval when patient manifests signs and symptoms specific to type of infection

how to achieve a goal for patient

intervention

tertiary health care

interventions are aimed at disability limitation and rehabilitation from disease, injury, or disability. Attempts to reduce (or prevent) further disability or loss of function. Ex: PT/OT, Hospice

Indirect care

interventions are treatments performed away from the patient but on the behalf of the patient or group of patient. (safety and infection control, looking up meds before you go into room, delegation, and setting up task beforehand)

Direct care

interventions that are performed through interactions with the patient, med administration

What do we document?

interventions that we perform on behalf of the patient

infection

invasion of a susceptible host of pathogens of microorganisms resulting in disease

Urinary Incontinence

involuntary leakage of urine

Urge Incontinence

involuntary loss of urine tat usually occurs when a person has a strong, sudden need to urinate

democratic leaders

involve followers in the decision-making process by using a participatory leadership style. Effective when followers are experienced workers, particularly when they have professional education and socialization.

Intermediate Priority

involve the non-emergent, non-life threatening needs of the client (they do relate to why client is there)

psychomotor learning

involves acquire coordination and the integration of mental and physical movements (perception, response, adaptation, and origination)

Unintentional tort

involves negligence and malpractice

unintentional tort

involves negligence and malpractice

maturational loss

is a form of necessary loss and includes all normally expected life changes across the lifespan. Ex: toddler experiences separation anxiety from mom when starting preschool, grade school child does not want to lose favorite classroom or teacher.

Clinical practice guideline- (protocol)

is a set of statements that help guide nurses, physicians, and other health care providers to make decisions about appropriate health care for specific clinical situations (DVT, low back pain) how to do a dressing change, what if a patient experiences hypoglycemia. HOW TO

Pain assessment

is essential for pain management, must be initiated by nurse, BELIEVE the patient

Chronic pain

is prolonged, related to tumor, chemotherapy or fistulas

Three area of Competency (before initiating interventions)

knowing the scientific rationale for the intervention, possessing necessary psychomotor and interpersonal skills, being able to function within a particular setting to use the available health care resources effectively

Evidenced-based knowledge

knowledge based on research, clinical expertise, that makes one a critical thinker

Type of hyperventilation deep and rapid. Late stage of metabolic acidosis, DKA. Patient is air hungry, decreased pH and blowing off lots of CO2.

kussmauls

cause of diarrhea

lactose not broken down and absorbed, cholera or E. coli, increase water secretions in colon, unabsorbed dietary fat, mucosal inflammation

droplet transmission

lare particles that travel up to 3 feet via cough, sneeze, or talking

Good Samaritan

laws to protect health care workers when helping at scenes of accidents

Spanish American culture

lay midwife, herbalist bonesetters, spiritualists

urge incontinence

leakage of small amounts of urine at unexpected times including during sleep

stress incontinence

leakage of small amounts of urine during physical movement such as coughing, sneezing, exercising

Culture is

learned, shared and transmitted practices that guide in decision making and actions in patterned ways

Standards of care (law):

legal requirements for nursing practice that describe minimum acceptable nursing care. Standards reflect the knowledge and skill ordinarily possessed and used by nurses actively practicing in the profession

Acute diarrhea

less than once a week

Interpretivist approach

life experiences are culturally bound, experiences are on the basis of the encounters of their culture

unsaturated fat

liquid at room temperature

Patient lives in present?

live only for now and not use preventative behaviors

Epidural analgesia

local anesthesia, controls without sedative effects of opiates

LDL

low density lipoprotein (BAD), oxidized and deposit on vascular walls

VLDL

low density lipoprotein, high triglycerides

normal body temperature

lowest between 4a and 6a highest between 4p and 6p

autocratic leaders

make all the decisions and are generally most concerned with the tasks to be accomplished. They maintain distance from their follower, motivating them through the threat of punishment and offer of rewards as incentives.

Calcium and Phosphorus

make up 80% of all minerals in the body

Nonverbal communication

makes up 65% of message perceived

Hougan

male

sweating

may loose 1 L of body fluid with exercise for 1 hour in hot conditions

two types of aseptic technique

medical asepsis and surgical asepsis

Lawsuits nurses can positively effect:

medication errors, negligent supervision, informed consent, accidental injury, nosocomial and wound infections, pain and suffering, emotional distress, lack of teamwork and communication, inadequate charting

Control

mental control (level of consciousness), muscle control

exogenous

microorganism found outside the individuals

Advanced practice career roles

midwife, nurse anesthetist, researcher, practitioner, educator, administrator

NSAIDs work for which type of pain?

mild to moderate pain

Mobility (interrelated concept)

mobility helps with stimulation of peristalsis

Goal for pain

modify or minimize pain, enhance ability to control pain, demonstrate actions to control pain symptoms, setting priorities

Paralytic ileus

monitor first 24-48 hours post op

monitoring pt with opioid use

monitor vitals, monitor for breakthrough pain,

Patient has "scientific view"

more comfortable with western medicine

middle range

more limited in scope, less abstract

hispanic culture

more sedentary and believe house work and caring for family is exercise

Chronic diarrhea

more then 3-4 times a week

Psychomotor

motor skills, mental and physical movements such as walking

airborne precautions

must follow standard precautions and wear a specifically fitted mask

What are dependent nursing interventions?

must have a doctor order (walking patient, giving meds)

contact precautions

must wear gown and gloves, dedicated equipment

droplet precautions

must wear gowns, gloves, and a regular mask

Mutual factors

mutually set goals and expected outcomes

Patient has "holistic view"

natural approach, against western medicine

nonverbal communication

ncludes the 5 senses and everything that does not involve the spoken or written word Personal appearance: physical characteristics, facial expression, and manner of dress and grooming Posture and gait: manner or pattern of walking are forms of self-expression Facial expression: face is the most expressive part of the body. Facial expressions convey surprise, anger, fear, happiness, and sadness. Eye contact: people signal readiness to communicate through eye contact Gestures: emphasize, punctuate, and clarify the spoken word Sound: such as sighs, moans, groans, and sobs Territoriality and personal space: territoriality is the need to gain, maintain, and defend one's right to space. When personal space is invaded people become defensive.

error that could have harmed the patient

near miss

Psychological considerations

negative body image, risk for sexual dysfunction

metabolic changes associated with immobility

negative nitrogen balance

what age group does not shiver?

neonates

Macedo-Malone Antegrade Continence Enema (MACE)

neurogenic problems with bowels; someone who may have anatomical dysfunction; make artificial flap where enema is given

Placebos

no effect, highly unethical,

Anuria

no urine

Paralinguistic

nonverbal exchange of symbols such as eye contact, facial expressions

Paralinguistic

nonverbal exchange of symbols, eye contact or facial expressions

essential amino acids

not made in the body come from diet

4 goals of IOM/Robert Woods Foundation:

nurses should: -practice to the full extent of their education and training -achieve higher levels of education -become full partners with physicians and other health care providers -improve data collection for effective workplace planning and policy making

Acuity rating systems

nurses use this to determine hours of care and number of staff for a group of patients in 24 hours

Low Priority

nursing diagnoses for client needs that may not be directly related to a specific illness or prognosis, but may affect the client's future well-being (may focus on long term needs)

treatment of a symptom rather than the disease

nursing diagnosis

NANDA is the leader in _________________ and is endorsed by the ________ as having the responsibility to do so.

nursing diagnosis classification ANA

any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes

nursing intervention

Narrative documentation

nursing interventions recorded in timed order of completion

Caron's disease at risk for

obstruction, fistula, decreased nutrient absorption

Iatrogenic

obtained from a diagnostic test

Which instructional method has to do with being face to face

one-on-one

When does malpractice insurance cover a nurse?

only at work

Charting by exception

only writing down abnormal findings

Treat diarrhea

opium, anticholinergics, absorbants and demulcents, give supplements, fluid and vitamin replacements

Primary prevention

optimizing health and disease prevention;immunizations

Possible opioid routes

oral, transdermal, SubQ, IM, IV, intraspinal, PCA

Uniform anatomical gift act

organ donation that takes effects after death. Gift is made by writing their signature. (patient must be 18+)

End of dose failure

pain at end of dose

Breakthrough pain

pain event though fully medicated

Neuromatrix theory

pain is multidimensional experience produced by characteristic neurological patterns, brain generates pain

Pain transmission

painful stimuli produce nerve impulses that travel along afferent peripheral nerve fiber, perception, CNS extracts information (location, duration or quality), impulses are sent to cereal cortex, hypothalamus and limbic system

PPN

partial parenteral nutrition through IV

Bowel elimination

passage and dispelling of stool through the intestinal tract by means of intestinal smooth muscle contraction

Urinary elimination

passage of urine out of urinary tract through the urinary sphincter and urethra

Absorption

passing nutrients into blood or lymph system, occurs in intestines

Advanced directives

patient self discrimination act (1991); mandatory signed documentation (e.g. living wills and durable power of attorney)

Living will

patient wishes in the event of a terminal illness or condition

Patient adherence

patients and families invest time in carrying out required treatments

endogenous

patients flora becomes altered

Ulcerative colitis risks

perforation, hemorrhage, infection

direct transmission

person - person, physical contact

uniform anatomical gift

person 18 or older that can make an organ donation

indirect transmission

personal contact of susceptible host with contaminated inanimate object

Factors affecting respirations

physiological factors, developmental, lifestyle, and enviornment

Epidural use

post-op, traumatic, chronic, non-cancer, and cancer pain

pathophysiological changes associated with immobility

postural abnormalities, trauma, bed rest, growth and development

Primary care (health promotion)

prenatal, baby care, nutrition counseling, family planning, exercise classes

Instrumental ADL's

preparing meals, shopping, house cleaning, writing checks

Standing order

preprinted document with continuing order for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures. What to do for chest pain. WHAT TO DO

bisphosphonates

prevent loss of bone mass

Civil law

protect a person's individual rights within our society; encourages fair treatment; e.g. tort law

Criminal law

protect society as a whole and provide punishment

reverse percautions

protective, reducing microorganisms for immunocompromised patients

disuse syndrome

protein breaks down and muscle mass decreases

Clinical practice guideline

protocol, helps health care workers make decisions about appropriate health care for specific situations

What type of procedure is a dressing change/ cleaning a central line.... (need an order?)

protocol...don't need an order

Catabolism

protoplasm is broken down into energy

Occurrence report

provides a database for further investigation such as falls

defamation of character

publication of false statements that result in damage to a person's reputation

Language includes

quality, tone, rhythm, speed, and pronunciations

what also needs to be stated when choosing the intervention

rationale

Once you have selected the nursing intervention, implementation preparation:

reassessing the client, reviewing and revising the existing nursing care plan, organizing resources (have all supplies), anticipating and preventing complications, implementation skills (cognitive, interpersonal, psychomotor)

Implementation process (continually do these things)

reassessing the patient, reviewing/revising existing care plan

definition of responsibility

refers to a willingness to respect one's professional obligations and to follow through. As a nurse you are responsible for your actions and the actions of those to whom you delegate tasks.

aseptic technique

refers to practices keeping a client as free from microorganisms as possible

definition of accountability

refers to the ability to answer for one's actions. You ensure that your professional actions are explainable to your patients and your employer.

functional nursing

reflect a view of nursing as a broad set of tasks that can be carried out by a variety of workers, presumably in response to factors such as economic and labour-market constraints

Restraints

regulates use of physical and chemical restraints in nursing facilities; only to ensure the physical safety of the resident or to other residents; only on the written order of a physician with a specific duration

Calcium and Phosphate (kidney functions)

regulation affected by kidneys

Patient lives in past?

reistant to change

Transpersonally

relatedness to the unseen, God, or power greater than the self

Goal

relates to the NANDA problem; represent predicted resolution of the nursing diagnosis; must be realistic; do not need to be measurable; "The client will..."

What is telephone or verbal order? How to document?

repeat order back; e.g. Administer 10 mg Morphine IVP now T.O. Dr. Smith/R. Vaughn RN, MSN

Public Health Laws

reporting communicable diseases, school immunizations, abuse and neglect, domestic violence, etc.

JCAHO Standards for Documentation

required: initial assessment of physical, psychosocial, environmental, self-care, client education, and discharge planning needs, client and family teaching, discharge planning, evaluation of outcomes, multidisciplinary care plans/critical pathways

cognitive learning

requires thinking and encompasses that acquisition of knowledge and intellectual skills.

Purpose of lifesaving measures

restores physiological or psychological homeostasis when threatened

UTI

results from catheterization or procedure

possible NANDA labels for thermoregulation

risk for imbalanced body temp, ineffective thermoregulation, hyperthermia, hypothermia

Diverticulitis

sac like projection of mucosa through muscular layer of colon

Bristol stool type 2

sausage shaped but lumpy

Examples of adjuvants or conalgesics

sedatives, anticonvulsants, steroids, antidepressants, anti anxiety agents, muscle relaxants

What should the nurse do if there is more than one problem for the patient

select the priority diagnosis

Standards based approach

selection from options of mutually exclusive possibilities, implying that there is a right decision

Braden scale categories

sensory, nutrition, friction and shear, activity, moisture

occurence involving death or serious physical injury

sentinel event

Bristol stool type 1

separate hard lumps like nuts, hard to pass

Nursing theory `

set of concepts, definitions, and assumptions that explain a phenomenon

Obstipation

severe unretractable constipation

Ethnicity

shared identity related to social and cultural heritage

Acute illness

short duration, severe, may affect functioning; the flu

End colostomy

sigmoid (most common)

Monosaccharides

simple sugars

hyperthermia

situation in which body exceeds the set point

definition of social networking

social networking presents ethical challenges for nurses. On one hand social networking can be a supportive source of information about patient care or professional nursingactivities. Social media can provide emotional support when you encounter hardships at work with colleagues or patients. On the other hand the risk to patient privacy is great. Do NOT post pictures of patients. Also, becoming friends in online chat rooms, on facebook, or on other public sites interferes with your ability to maintain a therapeutic relationship.

Enculturation

socialization into one primary culture as a child

saturated fat

solid at room temperature

Trans dat

solid at room temperature, ex. shortening or lard (WORST KIND)

Cause of Urinary Retention

sphincter does not open for release of urine or blockage of urethra -leads to increased urine volume and bladder distention (back flow to the upper urinary tract, dilation of the ureters and renal pelvis, pyelonephritis and renal atrophy)

Modern Spirituality

spirituality is largely self defines, can mean nearly anything a person wants it to mean

skin changes associated with immobility

stage 1-4 wounds, ulcers, pressure areas, friction, shear

Health

state of complete physical, mental, social, well-being, not merely the absence of disease or infirmity

surgical asepsis

sterile technique

calculi

stones of calcium

Disaccharide

sucrose, milk sugar (lactose),maltose

disituational loss

sudden, unpredictable external events Ex: person in automobile accident sustains an injury with physical changes that make it impossible to return to work or school, leading to loss of function, income, life goal and self-esteem.

Gait control theory of pain

suggests that pain impulses can be regulated/blocked along spinal cord

Treat chron's with

surgery, antibiotics, steroids, antidiarrheal agents

Colectomy

surgical resection and removal of colon or toxic megacolon, perforation, hemorrhage, and cancer

Theoretical model

symbolic depictions of reality showing relationships among concepts

urinary tract infection

symptoms include dysuria, cystitis, hematuria and pyelonephritis

Lipogenesis

synthesis of fatty acids or glucose to fat

nonessential amino acids

synthesized in the body by the body

Root Cause Analysis

systematic process for identifying *"root causes"* of problems or events and an approach for responding to them.

Interdisciplinary theory

systematic view of a specific phenomenon, interacting with other people, Maslow's Hierarchy

Informatics

takes information science and computer science to study the process, management, and retrieval of info.

definition of beneficence

taking positive actions to help others

Implementation

teaching activities, delegation, documentation of patients progress

core temperature

temperatures of deep tissue

Loop colostomy

temporary allows tissue healing for several months

Acute pain

temporary, identifiable cause

Ethnocentrism

tendency to hold ones own way of life as superior to other cultures

team nursing

the RN is the leader who leads a team of other RN's, practical nurses, and nursing assistive personnel who provide direct patient care.

NANDA definition of Spirituality

the ability to experience meaning in life through connectedness with self, others, world, or a superior being

mobility

the ability to move physical using muscular function

asepsis

the absence of pathogenic microorganisms

Traditional Spirituality

the core of what it meant to be religious

Medical diagnosis

the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests and procedures

Nurse-initiated interventions

the independent response of the nurse to the client's needs and nursing diagnoses; within legal scope of nursing practice (e.g. holding B/P med)

Active nursing intervention:

the nurse will administer 2 tabs norco

High Priority

the nursing diagnosis that, if untreated, could result in harm to the client (must be addressed now)

perceived loss

the person experiencing the loss and is less obvious to other people. Ex: some people perceive rejection by a friend as loss, these losses are easily overlooked by others because they are experience so internally and individually, but can be just as painful as an actual loss and grieved in the same way.

Basal Metabolic rate

the rate at which the body uses energy while *at rest* to keep vital functions going, such as breathing and keeping warm.

what is deconditioning

the reform or reversal of previously conditioned behaviour, especially in the treatment of phobia and other anxiety disorders in which the fear response to certain stimuli is brought under control.

Nutrition

the study of food and how it affects the human body and influences health

definition of advocacy

the support of a particular cause. As a nurse you advocate for the health, safety, and rights of patient, including their right to privacy and their right to refuse treatment.

What is a phenomenon?

the term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations

use of restraints

the use of restraints must be clinically justified and a part of the patients prescribed medically treatment and plan of care. A physician's order is required Each original restraint order and renewal is limited to 8 hours for adults, 2 hours for ages 9 through 17, and 1 hour from children under 9. Restraints are not to be ordered PRN

Tissue perfusion

the volume of blood through arteries and capillaries by smooth muscle

Therapeutic communication

therapeutic nurse patient relationship and the nursing process

Collaborative nursing interventions

therapies that require combined knowledge of multiple professionals

Collaborative interventions

therapies that require knowledge, skill, and expertise of multiple health care professionals; deployed by multiple interventions; critical pathways

Transduction of pain

thermal, mechanical, chemical, electrical stimuli

Evaluation

this step is crucial to determine whether, after application of the first four steps of the nursing process, if the patient' condition or well being has improved.

How is an epidural administered?

thought a catheter into epidural space in spinal cord

Culture

thoughts, communication, actions, customs, beliefs,values, and institutions of racial, ethnic, religious or social groups

Nursing Interventions Classification

to develop a standardized language for the actions used to deliver nursing care, expand nursing knowledge about connections between nursing diagnoses, treatments, and outcomes, to develop nursing and health care info systems, to teach decision-making to nursing students, to determine the cost of services provided by nurses, better plan for resources in all types of nursing practice settings, articulate with the classification systems of other healthcare providers

North American Nursing Diagnosis Association (NANDA)

to develop, refine, and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses. - is the leader in nursing diagnosis classification

Goal of health informatics

to enhance to quality and efficiency of care provided by using electronic medical records

What is the purpose of SBAR?

to provide prompt and appropriate communication (AVOIDANCE OF LONG NARRATIVE DESCRIPTIONS)

TPN

total parenteral nutrition via PICC line or central line

Gate control theory

touch and electrical stimulation can close gate and not allow painful stimulations to get to nervous system

Leininger

transcultural perspective, a human trait, caring is the essence and central domain that distinguishes nursing from health care disciplines

radiation

transfer of heat between 2 objects without touching

evaporation

transfer of heat energy when liquid changes to a gas

conduction

transfer of heat from one object to another by direct contact

convection

transfer of heat through air movement such as a fan

authentic leaders

transparent and ethical in their dealings with followers. They are genuine, empathetic, reliable, and believable.

Nursing Interventions for constipation

treat with enema, diet, activity, increase fluid, laxatives

Indirect care

treatments performed away from the client, but on behalf of the client; e.g. talking with other members of the healthcare teams (critical pathway), delegating, evaluating

Indirect care

treatments performed away from the patient but on behalf of the patient, safety

Direct care

treatments performed through interactions with the client; e.g. physical care techniques, counseling, teaching

Types of fats

triglycerides, fatty acids, unsaturated, monounsaturated, saturated, polyunsaturated

primary health care

true prevention, interventions are aimed at preventing disease, injury, or disability Ex: immunizations

Nutrition (interrelated concept)

types of foods and fluids ingested impact stool formation and urinary elimination

What is unique about "risk for" diagnosis

typically do not have defining characteristics because they have no occurred

Incontinence

unable to control voiding

functional incontinence

untimely urination because of physical disability, external obstacles, or cognitive problems that stop a person from reaching the toilet

Intimate space

up to 1.5 feet, much of nursing done here, use of touch may make pt. uncomfortable

Social space

up to 12 feet, comfortable space

Personal space

up to 4 feet, teaching, pt. may back up if need more space

possible NANDA labels for UTI

urinary incontinence, impaired urinary elimination, urinary retention, toiling self care deficit

Polyuria

urinating a lot

Nocturia

urinating at night

transformational leaders

use approaches that change or transform individuals. They inspire and intellectually stimulate followers and recognize their contributions.

What is a NANDA?

used to develop, refine, and promote a taxonomy of nursing diagnostics terminology for use of professional nurses

Functional Incontinence

usually aware of need to urinate, but for one or more physical or mental reasons they are unable to get to bathroom

mixed incontinence

usually occurrence of stress and urge together

surface temperature

varies with blood flow to the skin and amount of heat loss to external environment

HYPOthermia S/S

vasoCONSTRICTION : Skin feels *Cool*, slow cap refill Skin is *Pale* & becomes cyanotic Muscle Rigidity and shivering *DYSRHYTHMIAS* ( A-FIB, V-FIB) due to myocardial irritability.

Which of transmission of pathogens? External transfer such as insect/bug

vector

Which of transmission of pathogens? Transmission through contaminated items

vehicle

Linguistic communication

verbal exchange of messages through spoken words and written symbols, face to face or texting

Linguistic

verbal exchange through spoken words, even cell phones

Flexible sigmoidoscopy

visual exam to diagnose polyps, infection, inflammation

Fiberoptic colonoscopy

visual exam, diagnose tumors, polyps

treatments for immobility

vitamin C and D, surgery, assistive devices

Pain

whatever the experiencing person says it is, existing whenever he says it does -patient report is the most reliable indicator of pain -unpleasant sensory or emotional sensation

Pain is

whatever the experiencing person says it is, existing whenever he/she says it does

actual loss

when a person can no longer feel, hear, see, or know a person or object. Ex: loss of a body part, death of a family member, or loss of a job.

Stress Incontinence

when physical movement or activity-- such as coughing, sneezing, running, or heavy lifting-- puts pressure on bladder

Disenfranchised grief-

when their relationship to the deceased person is not socially sanction, cannot be shared openly or seems of lesser significance. The person's loss or grief do not meet the norms of grief acknowledged by his or her culture, thereby cutting the person off from support system.

Quasi-intentional torts

where intent is lacking but violational action, privacy/defamation

Intentional tort

willful or intentional act or wrong doing that violates another person's right or property; assault and battery, medical battery, false imprisonment, trespass, defamation and intentional infliction of emotional distress

Interpersonally

with others and the natural environment

Intrapersonally

within oneself

What do we need protein for?

wound healing

4 common issues in malpractice

wrong time, verbal orders, charting in advance, incorrect data

population at risk for immobility

young, elderly, obesity


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