Fundt'l Exam 2
1. Which examples mentioned by the nursing student regarding quasi-intentional torts need correction? Select all that apply. One, some, or all responses may be correct.
Assault Battery Malpractice
Which of the following statements is correct regarding personal hygiene of the client? It is best when performed by nursing staff. Clients should be encouraged to perform their own perennial care. Gloves are not needed for bathing a client. Reddened areas on the skin should be massage during the bath.
Clients should be encouraged to perform their own perennial care.
What are the four acute changes in condition that Nurses must investigate?
Cognitive Changes: such as decreased level of consciousness, change in memory, change in mood, difficulty thinking and acute confusion. Physical Changes: Changes in vital signs, change in oxygen saturation, change in skin color, change in appearance of an incision, onset of diaphoresis, seizure activity, and an onset of pain Functional Changes: Respiratory distress, change in mobility, onset of slurred speech, weakness of an extremity, numbness of extremity and acute functional deficit. Behavioral Changes: Inappropriate movements, disorientation to time and place, hallucinating, depression and wandering.
Nonpharmacological pain-relief interventions:
Cognitive and behavioral approach, Relaxation and guided imagery, Distraction, Music, Cutaneous stimulation, Cold and heat application, Transcutaneous electrical nerve stimulator (TENS), Herbals, Reducing pain perception and reception.
Stereoscopic Vision
Combination of two retinal images to give a 3 Dimensional perception; depth, height, width
Red, scaly areas with surface loss of skin tissue: Axilla Excoriation Gingivae Alopecia
Excoriation
1. Stereognosis 2. Kinesthetic
1. is a sense that allows a person to recognize the size, shape, and texture of an object. 2. Enables a person to be aware of position and movement of body parts
Modulation:
Inhibits pain impulse; A protective reflex response occurs with pain reception
A 45-year-old patient who reports pain in the foot that moves up along the calf says my right foot feels like it is on fire. The patient reports that the pain started yesterday, and he or she has no prior history of injury or falls. What components of pain assessment has the patient reported? Intensity, temporal characteristics, functional impact. Location, quality, onset. Aggravating and alleviating factors. Exacerbation, with associated signs and symptoms.
Location, quality, onset.
1. Which action indicates that the nurse is actively listening to the client?
Interpreting what the client is saying and restating it for clarification
Antidote MS
Naloxone Narcan (trade name)
HYGIENE PRACTICE QUIZ What are the purposes / benefits of the nurse bathing or helping to pay the patient?
Promote circulation. Education on hygiene and personal care Inspection of the integument system Identify abnormal findings. Provide range of motion exercises.
Cranial Nerve I
Olfactory Nerve (CN I) Located in the nose, controls the sense of smell. To assess the nerve, use soap and coffee. Have the patient close both eyes, close one nostril, and gently inhale to smell the scent.
1. Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee?
Right communication
What is it called when a client is not able to perform one or more activities of daily living? Self-care deficit Precautionary feedback Risk for injury Personal preference
Self-care deficit
1. Which does the nurse understand by the term "regulatory law" as applied to nursing practice?
Reflects the decisions made by administrative bodies such as state boards of nursing
1. A 16-year-old single mother of a 1-year-old infant and the infant's grandmother bring the baby to the emergency department and report that the infant accidentally fell down the stairs. The nurse knows that a consent form for treatment would be signed. Who has the responsibility for signing the consent?
The mother, despite her age
The nurse is caring for a client in acute pain. When assessing the clients quality of pain, which statement will the nurse use? Is the pain better or worse at certain times of the day or night? have you noticed anytime day or night when the pain is better or worse? What words would you use to describe your pain? How long have you been having your pain?
What words would you use to describe your pain?
Nociception
an observable activity in the nervous system in response to an adequate stimulus (third-person perspective) Normal or nociceptive pain is the protective physiologic series of events that bring awareness of actual or potential tissue damage.
Regulatory law, or Administrative law
more clearly defines expectations of civil and criminal laws. For example, a Nurse Practice Act, as a civil statutory law, states that you have a duty to care for your patients. Regulations typically state that duty means you will observe, assess, diagnose, plan, intervene, and evaluate patient care. Providing current, evidence-based care is essential to meeting nursing statutory duty and regulations. Regulatory law also defines your duty to report incompetent or unethical nursing conduct to the State Board of Nursing or Nursing Commission.
PCA pump
patient controlled analgesic administered intravenously with a machine
Common Law
results from judicial decisions concerning individual cases. Most of these revolve around negligence and malpractice originates from decisions that were made in the absence of law. For example, the right to privacy is implied in the US Constitution. Thus, patient confidentiality originated as common law.
1. Presbyopia 2. Presbycusis 3. Xerostomia 4. Peripheral neuropathy 5. Stroke
1. Gradual decline in vision ability to focus on close objects. 2. Common progressive hearing disorder. 3. Decrease in salivary production. 4. Numbness and tingling of affected area and stumbling gait. 5. Caused by clot, hemorrhage, emboli disrupting blood flow to brain
Identify strategies to promote and maintain orientation to person, place, time, and situation for the client with acute confusion/delirium
-wear readable name tag -introduce self and use client's proper name -identify time and place, ask client "where are you" to orient -have a calendar and clock in the room -clear, concise instructions & explanations -schedule activities/maintain routines -tell client when you are leaving and when you will return -encourage familiar things -clothing, activities -reinforce reality--correct misperceptions **more details on pg 1015
1. Analyze the attributes of safety. 2. What is Campaign ZERO?
1. Attributes to safety are the qualities or properties of remaining safe. They are precautions individuals take in order to be safe and prevent adverse occurrences 2. is a safety initiative that advocates for patient safety by providing patients and their family members free checklists to use when admitted to a healthcare facility to help remain safe until discharge Quality and Safety Education for Nurses
QUICK QUIZ: 1. A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing interventions to prevent a fall for this patient would include: A. raise all four side rails when darkness falls. B. use an electronic bed monitoring device. C. place the patient in a room close to the nursing station. D. use a loose-fitting vest-type jacket restraint. 2. A nurse floats to a busy surgical unit and administers a wrong medication to a patient. This error can be classified as: A. a poisoning accident. B. an equipment-related accident. C. a procedure-related accident. D. an accident related to time management.
1. B 2. C
1. Autonomy 2. Beneficence 3. Nonmaleficence 4. Fidelity 5. Just Culture
1. Commitment to include patients in decisions 2. Taking positive actions to help others 3. Avoidance of harm or hurt 4. Being fair 5. Agreement to keep promises 6. The promotion of open discussion without fear whenever mistakes causing adverse events occur or nearly occur.
1. Sensory Deficit 2. Sensory Deprivation 3. Sensory Overload
1. Deficit in the normal function of sensory reception and perception 2. Inadequate quality or quantity of stimulation 3. Reception of multiple sensory stimuli (easy to confuse w/ mood swings or disorientation)
The pain management nurse assesses a patient with complex regional pain syndrome. The nurse is concerned about the patient's depressed mood because he or she has said I can't live with this pain. The nurse further assesses for suicide risk, because Suicidal thoughts are often expressed by patients with acute pain. Suicidal thoughts are common in patients with chronic pain. Verbalization of suicidal thoughts is a way for patients to get attention.
Suicidal thoughts are common in patients with chronic pain.
Summarize diagnostic tests and therapies used by interprofessional teams in collaborative care of an individual with acute and chronic pain.
-WBC count with differential -Radioallergosorbent test (RAST) -Blood type and crossmatch -Indirect Coombs test-Direct Coombs test -Immune complex assays-Complement assay •Skin testing
SAFETY LEARNING OUTCOMES Joint commission 2020 patient safety goals 2021 Hospital National Patient Safety Goals
1. Identify patients correctly 2.Improve staff communication 3. Use medicines safely 4. Use alarms safely 5. Prevent infection 6. Identify patient safety risks 7. Prevent mistakes in surgery
Aphasia 1. Expressive Aphasia 2. Receptive Aphasia 3. Global Aphasia
1. (motor) inability to name common objects or express simple ideas in words or writing; understands question but unable to express answer 2. (sensory) unable to understand written or spoken language able to express words but unable to understand comments/question from others 3. inability to understand language or communicate orally
1. PresbyOpia 2. PresbycUsis 3. Xerostomia 4. Peripheral Neuropathy 5. Tinnitus
1. Gradual decline in vision ability to focus on close objects. (O - Ocular) 2. Common progressive hearing disorder. (U - Med Abbr for EAR) 3. Decrease in salivary production. 4. Numbness and tingling of affected area and stumbling gait. 5. Ringing in one or both ears
"Know the names of the different assessment tools" Morse Fall Risk Tool
1. History of falling 2. Secondary diagnosis 3. Ambulatory aid 4. Intravenous therapy/heparin lock 5. Gait 6. Mental status
1. Transduction 2. Transmission 3. Perception 4. Modulation
1. is the process whereby an activated nociceptor converts energy produced by these stimuli (e.g., exposure to pressure or a hot surface) into an action potential. Once transduction is complete, transmission of the nociceptive impulse begins. 2. Sending of impulse across a sensory pain nerve fiber (nociceptor) 3. is the point at which a person is aware of nociceptive impulses and perceives pain. 4. Inhibits pain impulse; A protective reflex response occurs with pain reception
1. External stimuli 2. Internal stimuli 3. Which external stimuli can be internal as well?
1. visual auditory olfactory tactile gustatory 2. gustatory kinesthetic visceral 3. gustatory
1. The nurse would instruct a client with type I diabetes to dispose of a used syringe in which container?
A plastic liquid detergent bottle with a screw-top lid
A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to presbycusis. Which assessment of the patient would indicate an adaptation to the sensory deficit? a. The patient frequently cleans out his ears with a cotton swab. b. The patient turns one ear toward the nurse during conversation. c. The patient isolates himself from social situations. d. The patient asks the nurse to speak loudly during conversations.
ANS: B Adaptation for a sensory deficit indicates that the patient alters his behavior to accommodate for his sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the ear would not have an effect for a patient with presbycusis. Avoiding others because of a sensory deficit is maladaptive. Asking the nurse to speak loud alters the environment but does not adapt the patients behavior.
1. The nurse in a hospital skilled nursing unit witnesses a client's spouse vigorously shaking the elderly client who has dementia after the client has had an episode of incontinence. After discussing concerns with the nurse manager, to whom would the nurse report this observation.
Adult Protective Services
1. The nurse finds that an 80-year-old client's family is not caring for the client properly. Which action of the nurse indicates leadership quality?
Advocating on behalf of the client
FALL Prevention Skill page: Review record for injury from fall risk. ABCS
Age over 85; Bone disorders; Coagulation disorders; Surgery
Fall Prevention ABCS Tools to Assess Risk for Falls: "BMAT" and "TUG" Assess Previous Falls Using Mnemonic: SPLATT
Age over 85; Bone disorders; Coagulation disorders; Surgery ("BMAT") Banner Mobility Assessment Tool: assesses for functional tasks to identify level of mobility patient can achieve an amount of assistance needed. ("TUG") Timed get Up and Go: measures balance, sit to stand and walking ability. Symptoms prior to fall; Previous falls; Location during fall; Activity at time of fall; Time of fall; Trauma after fall.
1. Which color tag is used for a client who is expected to die after a disaster with mass casualties?
Black
Describe the etiology of acute and chronic pain.
Chronic pain is a disease rather than a symptom. Chronic recurrent (phantom pain, migraines) Chronic intractable benign pain (always present, intensity varies such as lower back pain) Chronic progressive pain (cancer, Rheumatoid arthritis) ACUTE: Physiological responses are usually from the SNS (fight or flight) tachycardia, anxiety, diaphoresis, muscle tension CHRONIC: Physiological responses do not usually alter vital signs, but clients may have depression, fatigue, and a decreased level of functioning.
1. The nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." Which does this nurse's comment reflect?
Demonstration of a personal bias
NSAIDS carry common potential side effects such as: Drowsiness. Constipation. Loss of appetite. GI bleeding.
GI bleeding.
The following are important actions when making a bed: select all that apply. Hold linens away from the body. provide comfort and reduce risk of skin integrity issues with smooth linens. bed positioned at working height to avoid back strain. Avoid shaking out linens. Keep the patient warm and covered. Obtain assistance if you need to move the patient.
Hold linens away from the body. provide comfort and reduce risk of skin integrity issues with smooth linens. bed positioned at working height to avoid back strain. Avoid shaking out linens. Keep the patient warm and covered. Obtain assistance if you need to move the patient.
"To Err is Human" it was created by
Institute of medicine
The nurse is caring for a client and acute pain and plans to use a pain scale for an assessment tool. What is the major advantage of using this tool? It works with the same efficacy among the entire populations. It allows organization in the assessment process. It allows for variations among various cultures. It can always be performed quickly.
It works with the same efficacy among the entire populations.
Describe the essential components in assessing a client's sensory-perception function
Nursing history: assess current perceptions and functioning; support people may provide data that client cannot Mental status exam: LOC, orientation, memory, attention span Physical examination: -Ask patient to read newspaper identify colors on color chart. Observe patients performing ADLs. -Assess patients hearing acuity using spoken word and tuning fork test. -Check patients ability to discriminate between sharp and dull stimuli -Have patient close eyes and identify several odors -Ask patient to sample and distinguish different tastes Client environment assess environment for quantity, quality, and type of stimuli
PQRSTU Approach to pain- ABCDE:
Palliative, Quality, Relief/Region, Severity, Timing, U-effect of pain on you/pt Ask, Believe, Choose, Deliver, Empower
SENSORY LEARNING OUTCOMES Analyze the physiology of sensory perception in the body.
Sensory reception the process of receiving stimuli or datacan be internal or external to the body
Americans With Disabilities Act (ADA)
The ADA prohibits discrimination and ensures equal opportunities for people with disabilities in employment, state and local government services, public accommodations, commercial facilities, and transportation. As defined by the statute and the US Supreme Court, a disability is a mental or physical condition that substantially limits a major life activity, including seeing, hearing, speaking, walking, breathing, performing manual tasks, learning, caring for oneself, and/or working. protects health care workers in the workplace with disabilities such as HIV infection. Likewise, health care workers cannot discriminate against patients who are HIV-positive
Pointers for the Fundamental Exam #2:
This exam will cover Sensory, Hygiene, Pain Management, Safety, Legal, and Ethics.
To Err Is Human Summary
To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda--with state and local implications--for reducing medical errors and improving patient safety through the design of a safer health system. To Err Is Human asserts that the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer.
A patient with decreased sensation will not be able to properly feel the temperature of the water and may be burned. True False
True
To prevent damage to a patient's dentures, the nurse should line the sink with a washcloth or gauze pad. True false
True
Case law
describes decisions made in legal cases that were resolved in courts. After a case is presented to a judge or jury, there is a report of the issue, facts, findings, and subsequent decision that was made to resolve the issue.
RAS reticular activating system
in the brain stem mediates all sensory stimuli
Perception:
is the point at which a person is aware of nociceptive impulses and perceives pain.
Transduction:
is the process whereby an activated nociceptor converts energy produced by these stimuli (e.g., exposure to pressure or a hot surface) into an action potential. Once transduction is complete, transmission of the nociceptive impulse begins.
Nursing interventions to promote and maintain sensory function
-Cognitive stimulation -Communication Enhancement: Hearing Deficit -Communication Enhancement: Visual Deficit -Nutrition Management -Environmental Management -Fall Prevention -Body Mechanics Promotion -Peripheral Sensation Management -Emotional Support -Surveillance: Safety
ISSUES IN HEALTH CARE ETHICS 1. Quality of life: 2. Disabilities: 3. Care at the end of life: 4. Health Care Reform:
1. Central to discussions about end-of-life care, cancer therapy, physician-assisted suicide, and Do Not Resuscitate (DNR) 2. Antidiscrimination laws enhance the economic security of people with physical, mental, or emotional challenges 3. Interventions unlikely to produce benefit for the patient 4. Facilitated access to care for millions of uninsured Americans
1. Uniform Anatomical Gift Act 2. Health Insurance Portability and Accountability Act (HIPAA) 3. Health Information Technology Act (HITECH) 4. Restraints
1. An individual who is 18+ has right to donate organs. Approached in order: spouse, adult child, parent, adult sibling, grandparent. 2. Protects employees from losing health insurance when changing jobs by providing portability. Protects Patients: establishes patient rights regarding privacy of their health care information and records. 3. Expands the principles extended under HIPAA, especially when a security breach of personal health information (PHI) occurs. Under the HITECH Act, nurses must ensure that patient PHI is not inadvertently conveyed on social media and that protected data are not disclosed other than as permitted by patients 4. Can be used only to ensure safety of patient or other patients. When less restrictive interventions were unsuccessful. Only on written order. Documentation of restraints used and follow up assessments required hourly or every 2 hours per national standards
There are four physiological processes of nociception:
transduction, transmission, perception, and modulation.
PROCESSING AN ETHICAL DILEMMA
Step 1: Ask if this is an ethical dilemma. Step 2: Gather all relevant information. Step 3: Clarify values. Step 4: Verbalize the problem. Step 5: Identify possible courses of action. Step 6: Negotiate the outcome. Step 7: Evaluate the action.
Four aspects of the sensory process that must be present for an individual to be aware of their surroundings
Stimulus Receptor Impulse conduction Perception
Mrs. Lewis rings the call light and asks for pain medication. Monty enters the room and, in an attempt to better understand Mrs. Lewis' pain, he asks about the characteristics of the pain. Which of the following factors should Monty assess regarding her pain? (Select all that apply.) A. Onset B. Duration C. Strength D. Location E. Intensity
Answer: A, B, D, E Rationale: The characteristics of pain that the nurse should assess are onset, duration, location, intensity, and quality.
Monty asks Mrs. Lewis where she feels pain, and she states, "Right where they cut me open. It's a dull, throbbing pain right in my gut." Monty knows that this type of pain is neuropathic pain. A. True B. False
Answer: false Rationale: Neuropathic pain is burning, shooting, or electric like. Pain from a surgical incision that is dull, throbbing, or aching is nociceptive pain.
The nurse is discussing foot care with client who was recently diagnosed with diabetes. Which statement by client indicates need for further teaching? I enjoy walking barefoot around the house. I am going to use a mirror to check my feet. I will increase the time that I wear new shoes each day. I will file my nails.
I enjoy walking barefoot around the house.
NPSG National Patient Safety Goals
Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery
1. Deontology 2. Utilitarianism 3. Feminist Ethics 4. Ethics of Care 5. Casuistry
1. Defines actions as right or based on their adherence to rules and principles such as fidelity to promises, truthfulness, and justice 2. Proposes that the value of something is determined by its usefulness sometimes called consequentialism because its main emphasis is on the outcome or consequence of action. The greatest good for the greatest number of people is the guiding principle for determining right action in a utilitarian system 3. Focuses on the inequality between people; it looks to the nature of relationships to guide participants in making difficult decisions, especially relationships in which power is unequal or in which a point of view has become ignored or invisible 4. Emphasizes the importance of understanding relationships, especially as they are revealed in personal narratives and the context in which ethical problems arise. Similar, but unlike feminism, ethics of care emphasizes the role of the decision maker in the situation. 5. Case-based reasoning, turns away from conventional principles of ethics as a way to determine best actions and focuses instead on the details of a situation. People who take this approach find similar precedent cases and determine a course of action on the basis of what was done to manage that prior situation
1. Ethical dilemma 2. Moral distress 3. Futile
1. Dilemma existing when the right thing to do is not clear. 2 opposing courses of action can both be justified by ethical principles. 2. The nurse feels the need to take a specific action while believing the action is wrong (often manifests as anger or frustration) 3. The interventions unlikely to produce a benefit for a patient.
Each side of your brain contains four lobes:
1. Frontal lobe cognitive functions & movement. 2. Parietal lobe processes information about temperature, taste, touch and movement 3. Occipital lobe is primarily responsible for vision. 4. Temporal lobe processes memories, integrating them with sensations of taste, sound, sight and touch.
1. Sensory deprivation: 2. Sensory overload: 3. Sensory deficits:
1. Inadequate quality or quantity of stimulation; RAS is unable to maintain normal stimulation to cerebral cortex 2. a person is unable to process amount or intensity of sensory stimuli; can prevent brain from ignoring or responding to stimuli (easy to confuse w/ mood swings or disorientation) 3. impaired reception, perception, or both, of one or more senses (blindness, deafness); those with sensory deficits are at risk for deprivation and overload
Pain Assessment 1. PQRST 2. ABCDE 3. OLDCART
1. Palliative, Quality, Relief/Region, Severity, Timing, U-effect of pain on you/pt 2. Approach to pain- ABCDE: Ask, Believe, Choose, Deliver, Empower 3. Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, and Treatment. It is assessing the physiological components of the pain.
Ototoxic Tinnitus Hyperesthesia Conductive hearing loss
1. Permanently damaged auditory nerve. 2. Ringing heard in one or both ears. 3. Overly sensitive to tactile stimuli. 4. Excessive cerumen occluding the ear canal causing hearing loss.
1. Which definition of photophobia is accurate? 2. The nurse is performing an assessment and notes that the client has exophthalmos and complains of double vision. These assessment findings are consistent with which condition? 3. Which medication worsens uncontrolled angle-closure glaucoma when used for the treatment of generalized anxiety disorder? 4. Which symptom would lead the nurse to suspect strabismus in a child? 5. A client complains of pain in the ear. While examining the client, the nurse finds swelling in front of the left ear. Which lymph node would the nurse expect to be involved? 6. The nurse is teaching the parents of an 18-month-old child the procedure for instilling eardrops. How would this procedure be done?
1. Persistent abnormal intolerance to light 2. Hyperthyroidism (Exophthalmos, or protruding eyes) 3. Duloxetine 4. One eye moves inward 5. Preauricular 6. By pulling the pinna down and back to straighten the auditory canal before instillation of the drops
1. Acute/transient pain: 2. Chronic/persistent noncancer: 3. Chronic episodic: 4. Cancer: 5. Idiopathic:
1. Protective, identifiable, short duration; limited emotional response 2. Is not protective, has no purpose, may or may not have an identifiable cause. 3. Occurs sporadically over an extended duration. 4. Can be acute or chronic 5. Chronic pain without identifiable physical or psychological cause
Types of Pain: 1. Acute/transient pain: 2. Chronic/persistent noncancer: 3. Chronic episodic: 4. Cancer: 5. Idiopathic:
1. Protective, identifiable, short duration; limited emotional response 2. Is not protective, has no purpose, may or may not have an identifiable cause. 3. Occurs sporadically over an extended duration. 4. Can be acute or chronic 5. Chronic pain without identifiable physical or psychological cause
1. Americans with Disabilities Act (ADA) 2. Emergency Medical Treatment and Active Labor Act 3. Mental Health Parity Act as Enacted Under PPACA Parity: The state or condition of being equal
1. Protects rights of people with physical or mental disabilities 2. When a patient presents to an emergency department, they must be treated. Prohibits the transfer of patients from private to public hospitals without appropriate screening and stabilization. It is intended to prevent what is referred to as patient dumping. 3. Strengthens mental health services. Requires health insurance companies to provide coverage for mental health and substance use disorder
3 types of sensory deprivation
1. Reduced sensory input (deficit from visual or hearing loss), 2. Elimination of patterns or meaning from input (exposure to strange environments). 3. Restrictive environments (bed rest) that produce monotony and boredom.
3 types of sensory deprivation:
1. Reduced sensory input (visual or hearing loss occurs); 2. Elimination of patterns or meaning from input (exposure to different environments) 3. Restrictive environment (bed rest, produces boredom/monotony )
1. Visual acuity 2. Visual acuity test use the _____ chart.
1. Sharpness of vision; 2. Snellen Smallest line red on chart = Visual acuity
1. Concomitant 2. Adjuvants 3. Multimodal Analgesia: 4. Regional anesthesia: 5. Perineural infusion:
1. Symptoms that occur w/ pain: nausea, headache, dizziness, urge to urinate, constipation, depression, and restlessness. 2. Co-analgesics; advance analgesic effects. 3. Combines drugs with at least 2 different mechanisms of action to optimize pain control. 4. injection/infusion of local anesthetics to block a group of sensory nerve fibers. 5. a surgeon places the tip of an unsutured catheter near a nerve or groups of nerves and the catheter exits from the surgical wound; infusions of local anesthetics maybe run on a pump or on demand.
1. Patient-inherent accidents 2. Procedure-related accidents: 3. Equipment-Related accidents:
1. are accidents other than falls where patient is the primary reason for the accident. example self-inflicted cuts, injuries, burns ingestion of foreign substance, setting fire. 2. are caused by health care providers & include medication, fluid administration errors, improper application of external devices, & accidents related to improper performance of procedures such as dressing changes or urinary catheter insertion. 3. result from an electrical hazard or malfunction, disrepair or misuse of equipment.
1. ("BMAT") Banner Mobility Assessment Tool: 2. ("TUG") Timed get Up and Go: 3. Assess Previous Falls Using Mnemonic: SPLATT
1. assesses for functional tasks to identify level of mobility patient can achieve an amount of assistance needed. 2. measures balance, sit to stand and walking ability. 3. Symptoms prior to fall; Previous falls; Location during fall; Activity at time of fall; Time of fall; Trauma after fall.
1. scope of nursing practice 2. Standards of nursing care
1. defines nursing and reflects the values of the nursing profession. 2. reflect the knowledge and skill ordinarily possessed and used by nurses; are derived from health care laws, best practice guidelines, professional organization white papers, evidence-based nursing knowledge, and citizen advocacy groups.
1. Seizures: 2. Aura: 3. Status Epilepticus: 4. Seizure Precautions:
1. hyperexcitation of neurons in brain leading to sudden violent involuntary muscle contractions causing loss of consciousness, falling, tonicity (rigidity of muscles) and clonicity (jerking of muscles). 2. Before seizure patient reports bright light, smell, or taste serving as a warning a seizure is coming. 3. prolonged or repeated seizures; medical emergency. 4. nursing interventions to protect patient from injury from seizures
Aphasia 1. Expressive (motor) 2. Receptive (sensory) 3. Global
1. inability to name common objects or express simple ideas in words or writing; understands question but unable to express answer 2. unable to understand written or spoken language able to express words but unable to understand comments/question from others; 3. inability to understand language or communicate orally
1. Nociception 2. There are four physiological processes of nociception:
1. is defined as an observable activity in the nervous system in response to an adequate stimulus (third-person perspective) Normal or nociceptive pain is the protective physiologic series of events that bring awareness of actual or potential tissue damage. 2. transduction, transmission, perception, and modulation.
Constitutional law
1. is derived from federal and state constitutions. For example, in the United States, a constitutional right afforded to every citizen is the right to refuse treatment. As a nurse, you must know the parameters of the right of your patients to refuse treatment even when you may not agree with their decisions.
1. Statutory law are either: 2. Civil laws 3. Criminal laws
1. is derived from statutes passed by the US Congress and state legislatures. These laws are either civil or criminal. 2. protect the rights of individuals and provide for fair and equitable treatment when civil wrongs or violations occur Civil law violations: Damages in forms of fine; Public service 3. protect society and provide punishment for crimes, which are defined by municipal, state, and federal legislation. Criminal mistreatment of vulnerable adults is an example of criminal statutory law. Criminal mistreatment is classified as either a misdemeanor or felony offense depending on the severity of harm done to a vulnerable patient. Misuse of controlled substance. Practicing without license.
The cerebellum
1. receives information from the sensory systems, the spinal cord, and other parts of the brain and then regulates motor movements. 2. coordinates voluntary movements such as posture, balance, coordination, and speech, resulting in smooth and balanced muscular activity. With cerebellar dysfunction often presenting with motor signs. In particular, it is active in the coordination, precision and timing of movements, as well as in motor learning.
1. Kinesthetic stimuli 2. Stereognosis 3. Visceral stimuli 4. Sensoristatis
1. refers to awareness of the position and movement of the body (i.e., a person walking is aware of one leg forward) 2. ability to perceive and understand an object through touch by its size, shape, and texture 3. any large organ within the body may produce stimuli that make a person aware of them (i.e., full stomach) 4. the state in which a person is in optimal arousal
1. Concomitant 2. Adjuvant and Co-Analgesics 3. Multimodal Analgesia
1. symptoms that occur w/ pain: nausea, headache, dizziness, urge to urinate, constipation, depression, and restlessness. 2. Adjuvants: Co-analgesics; advance analgesic effects. 3. Combines drugs with at least 2 different mechanisms of action to optimize pain control.
1. Morals 2. Value 3. Autonomy 4. Beneficence 5. Nonmaleficence Maleficence refers to harm or hurt. 6. Advocacy 7. Responsibility 8. Accountability
1. usually refer to judgment about behavior, based on specific beliefs, and ethics refers to the study of the ideals of right and wrong behavior. 2. is a deeply held personal belief about the worth a person holds for an idea, a custom, or an object. 3. refers to freedom from external control. In health care the concept applies to respect for the autonomy of patients. 4. refers to taking positive actions to help others 5. refers to the avoidance of harm or hurt. In health care, ethical practice involves not only the will to do good but the equal commitment to do no harm 6. refers to the application of one's skills and knowledge for the benefit of another person. 7. refers to a willingness to respect one's professional obligations and to follow through. As a nurse you are responsible for your actions, the care you provide, and the tasks that you delegate to others. 8. refers to answering for your own actions.
Federal Statutes Impacting Nursing Practice: Patient Protection and Affordable Care Act The Patient Protection and Affordable Care Act (PPACA) was passed in 2010. Its name was later changed to the Affordable Care Act (ACA).
A new Patient's Bill of Rights, created by the ACA, prohibits patients from being denied health care coverage because of prior existing conditions, limits on the amount of care for those conditions, and/or an accidental mistake in paperwork when a patient got sick The ACA intended to reduce overall medical costs by (1) providing tax credits, (2) increasing insurance company accountability for premiums and rate increases, and (3) increasing the number of choices available to patients to select insurers that best meet their needs. In addition, the ACA increased access to health care.
Outline the agencies that regulate workplace safety for nurses. Mission of the National Quality Form: Improving the quality of healthcare in America by - (1) Building consensus on National priorities & goals for performance & improvement & working in partnership to achieve them. (2) endorsing national consensus standards for measuring & publicly reporting on performance. (3) Promoting an attainment of national goals through education & outreach programs.
AHRQ, U.S Department of Health & Human Services: Has the initiative of producing evidence that supports healthcare safety, making it more available, have higher quality, be equitable and cost effective while reducing medical errors and improving patient safety CDC: Engages in health research, surveillance, promotion, and response to promote and increase security of the United States Institution of Medicare (IOM): Provides reliable evidence t the government and the private sector to support informed health decisions about assessment and improvement of health care systems and policies The Joint Commission: Promotes quality and safety through accreditation and certification of healthcare facilities representing high quality, safety and value for patients The National Institute for Occupational Safety and Health (NIOSH): A federal agency that provides evidence-supported recommendation on the prevention of worker injuries and illnesses to preserve human resources OSHA, U.S Department of Labor: A national public health regulatory agency that protects workers against safety and health hazards in the work environments by forcing compliance with health and safety standards Quality and Safety Education for Nurses (QSEN): Designed to prepare nursing students with knowledge skills, and attitudes (KSA) needs to improve quality of patient care and safety of providing healthcare using systems WHO: International authority to direct and coordinate health within the United Nation's system
A home health nurse is assembling a puzzle with an elderly patient and notices that the patient is having difficulty connecting two puzzle pieces. The nurse knows that this is most likely related to which aspect of sensory deprivation? a. Perceptual b. Cognitive c. Affective d. Social
ANS: A Alterations in spatial orientation and in visual/motor coordination are signs of perceptual dysfunction. Cognitive function is the ability to think and the capacity to learn; the patient is not disoriented or unable to learn. Affective problems include boredom and restlessness; the patient is participating in an activity. The patient is socializing with the home health nurse, so isolation is not a problem.
Which of the following sensory changes are normal with aging? a. Impaired night vision b. Difficulty hearing low pitch c. Increase in taste discrimination d. Heightened sense of smell
ANS: A Night vision becomes impaired as physiological changes in the eye occur. Older adults lose the ability to distinguish high-pitched noises and consonants. Senses of smell and taste are also decreased with aging.
The nurse would be most concerned about the risk of malnutrition for a patient with which sensory deficit? a. Xerostomia b. Disequilibrium c. Cataracts d. Peripheral neuropathy
ANS: A Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat and can lead to nutritional problems. The other options do not address taste- or nutrition-related concerns.
Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual sensory impairment? a. Self-care deficit b. Risk for falls c. Social isolation d. Impaired physical mobility
ANS: C In focusing on the psychological aspect of care, the nurse is most concerned about social isolation for a patient who may have difficulty communicating owing to visual and hearing impairment. Both self-care deficit and fall risk are physiological risks for the patient. Impaired physical mobility would not apply to this patient.
A nurse is caring for an elderly patient who was in a motor vehicle accident because he thought the stop light was green. The patient asks the nurse if he should no longer drive. Which response by the nurse is most therapeutic? a. Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk. b. Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you cant avoid an accident. c. No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is illuminated, it means stop, and if the bottom is illuminated, it means go. d. No, instead you should see your ophthalmologist and get some glasses to help you see better.
ANS: C Part of the normal aging process is an inability to see colors. Much as with a younger adult who is color blind, the nurse should teach the patient new ways to adapt to his deficit. This patients accident was not due to impaired cognitive function or reflexes. Glasses will not assist the patient in color discrimination.
A patient informs the nurse that she often becomes nauseated when riding in motor vehicles. The nurse knows that this is related to which sensory deficit? a. Neurological deficit b. Visual deficit c. Hearing deficit d. Balance deficit
ANS: D Vertigo is a result of vestibular dysfunction and often is precipitated by a change in head position. This disequilibrium can cause nausea and vomiting. The other options would not result in nausea based on movement.
Proprioception.
Ability of the body to sense its position and movement in space. Changes are common 60 plus ; Increased difficulty with balance, spatial orientation, coordination.
When assessing an infant for pain, the pain management nurse recognizes that Wong baker faces scale is an appropriate assessment tool. If something causes pain and an adult, it can cause pain in an infant. A lack of a physiologic or behavioral response means a lack of pain. The parent's observations should not be included in the patient's assessment of pain.
If something causes pain and an adult, it can cause pain in an infant.
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea
C,D, E Respiratory depression which can cause respiratory rates to drop to dangerously low levels, is a common adverse effect of opioid analgesia; dizziness or light-headeness when changing positions is a common adverse effect, nausea and vomiting are common, constipation, and urinary retention.(THINK PARASYMPATHETIC -- everything slows down)
Standard Precautions
CDC precautions used in the care of all patients regardless of their diagnosis or possible infection status; this category combines universal and body substance precautions
The nurse is observing an unlicensed assistive personnel perform perineal care for the client. Which action indicates that nurse needs to discuss additional teaching with UAP? Wipes from pubis to rectum. Uses a clean portion of washcloth for each stroke. Does not retract foreskin. Uses clean gloves.
Does not retract foreskin.
Which non-pharmacologic intervention is difficult to use with older adults who are cognitively impaired? Distraction. Aromatherapy. Guided imagery. Heat application.
Guided imagery.
PAIN PRACTICE QUIZ Which statement indicates the development of opioid tolerance? The patient becomes anxious about knowing the exact time of the next dose of opioids. Stimulants are needed to counteract the sedating effects of opioids. Larger doses of opioids are needed to control pain, as compared to several weeks earlier. The patient no longer experiences constipation from the usual dose of opioid.
Larger doses of opioids are needed to control pain, as compared to several weeks earlier.
Which of the following are expected findings during a patient's bath? Matted hair Reddened gums Moist mucus membranes Lower extremity edema Intact skin Rash on lower back
Moist mucus membranes Intact skin
Cranial Nerve III
Oculomotor nerve (CN III) In and behind the eyes also, controls pupillary constriction. Dim the lights, bring the light of the penlight from the outside periphery to the central of each eye and note the response. It's easy to check cranial nerves III, IV and VI together.
Cranial Nerve II
Optic nerve (CN II) Located in and behind the eyes, controls central and peripheral vision. Test one eye at a time. Ask patient to read IV bag. Then have him count how many fingers you are holding up 6 inches in front of him. Test peripheral vision one eye at a time. Cover one eye and instruct the patient to look at your nose.
PERRLA (CN II, CN III)
P - Pupils should be clear E - Equal in size and between 3 to 5 cm R - Round in shape R - Reactive to light both directly and consensually when a light is directed into one pupil and then the other L - Light A - Accommodation of the pupils when they dilate to look at an object far away and then CONVERGE and CONSTRICT to FOCUS on a near object.
A patient has just undergone an appendectomy. When discussing with the patient several pain-relief interventions, the most appropriate recommendation would be: A. adjunctive therapy. B. nonopioids. C. NSAIDs. D. PCA pain management (Patient-controlled analgesia)
PCA pain management
PAIN LEARNING OUTCOMES Describe the pathophysiology of acute and chronic pain.
Pathophysiology. Acute pain, which usually occurs in response to tissue injury, results from activation of peripheral pain receptors and their specific A delta and C sensory nerve fibers (nociceptors). Chronic pain related to ongoing tissue injury is presumably caused by persistent activation of these fibers.
Quick Quiz: 1. When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? A. Chronic pain is psychological in nature. B. Patients are the best judges of their pain. C. Regular use of narcotic analgesics leads to drug addiction. D. Amount of pain is reflective of actual tissue damage
Patients are the best judges of their pain.
What is QSEN? What are the competencies (and what do they do/definition)? Minimizes risk of harm to patient through system effectiveness and individual performance.
QSEN is the quality and safety education for nurses. It better prepares nursing students with practical experience in providing safer more effective care. 1. Patient-centered care: Patients are partners in their care, and thus their perspectives, beliefs and culture need to be taken into consideration during their care 2. Quality Improvement: Adverse events must be monitored and reported so they can be tools for learning in similar situations in the future and catalysts for improvements in quality and safety 3. Evidence-based practice: Medicine is evolving and changing everyday, and thus current medical findings must be monitored for the possibility of improved care. 4. Teamwork and Collaboration: Because treatment sometimes involves multiple departments and 24-hour care, teamwork across departments and shifts is necessary for optimal care 5. Informatics: As information technology becomes further integrated into medicine, nurses' input is an essential part of the design process 6. Safety: Activities such as knowledge sharing and error reporting must be taken seriously to help improve safety
Name at least two characteristics of pain that we assess?
Quality, onset, severity
Fire Safety: RACE Fire Safety: PASS
R-rescue: protect/evacuate clients in danger A-alarm: activate alarm/report the fire C-contain: close doors/windows E-Extinguish: use the correct extinguisher to eliminate the fire Pull, Aim, Squeeze, Sweep
Fire Intervention Guidelines RACE, PASS:
Rescue and remove all patients; Activate alarm; Confine fire by closing doors/windows; turn off oxygen and electrical equipment; Extinguish fire. Pull pin; Aim at base of fire; Squeeze handle; Sweep from side to side.
Nursing diagnoses for clients with impaired sensory function
Risk for injury Risk for fall Impaired verbal communication Impaired Socialization Impaired Mobility
Transmission:
Sending of impulse across a sensory pain nerve fiber (nociceptor)
To administer oral care to a semi-comatose patient, the nurse should place the patient in which of the following positions? Reverse Trendelenburg Side lying with the head turned toward the nurse. High Fowler with the head to the side. Supine with the neck slightly forward
Side lying with the head turned toward the nurse.
What are the concepts related to Safety and what is the relationship?
The Concepts Related to Safety are Accountability, Advocacy, Assessment, Clinical De cision Making, Evidence- Based Practice and Quality Improvement. Accountability: Unsafe nursing practice, behaviors, and thinking could cause harm to patients and others and if not addressed, will continue to occur Advocacy: Vulnerable populations may unintentionally make unsafe decisions about their healthcare. Sometimes, unethical, immoral, or illegal actions result in unsafe treatments and behaviors my professionals. Assessment: Data are used to monitor for changes in conditions or patients. Data can show numerical values indicating safe or unsafe parameters for patient's body systems. Clinical Decision Making: Nurses consider safety in all phases of the nursing process, and while prioritizing patient needs Evidence-based practice: Evidence supports that many errors occurring in the health care setting can be avoided with improved performance of health care workers. Evidence supports that everyone in the healthcare environment, including patients, can improve quality and safety. Quality Improvement: Improving quality of care for all patients involves ensuring and considering the safety of patients at all times when providing nursing care
Guidelines for perennial care of a female patient include select all that apply: The area be clean from back to front. The area be clean from front to back. Gloves should be worn. A different part of the washcloth should be used for each wipe.
The area be clean from front to back. Gloves should be worn. A different part of the washcloth should be used for each wipe.
A 61-year-old patient with diabetes mellitus has physicians orders for meticulous foot care. Which of the following is the best rationale for the order? The lower extremities are difficult to see and therefore hard to maintain with good hygiene. There is peripheral neuropathy with this pathology that places the patient at risk. The patient probably has a history of poor hygienic care. The aging process causes increased skin breakdown.
There is peripheral neuropathy with this pathology that places the patient at risk.
The pain management nurse follows the recommended protocol for preventing constipation when starting a patient on opioids by Increasing fluids and exercise. Giving the patient enemas as needed. Using a bowel stimulant and stool softener. Adding bulk fiber to the diet.
Using a bowel stimulant and stool softener.
What are Never events?
When a patient death or serious injury is associated with a fall while the patient is being cared for in a health care setting, it is called NEVER EVENT. The Centers for Medicare and Medicaid will not pay for additional costs associated with never events. When fall occurs within a healthcare setting, the Joint Commission mandates the organization perform a thorough root cause analysis after the event in an effort to find approaches to prevent similar events in the future.
When providing foot care for a client the nurse would perform which of the following? Wash the feet every other day, and dry them well, especially between the toes. Does not cover the feet and between the toes with creams or lotions to moisten the area. When washing, inspect the skin of the feet for brakes or red swollen areas. Does not check the water temperature before immersing the feet.
When washing, inspect the skin of the feet for brakes or red swollen areas.
The standard of proof
is typically what a reasonably prudent nurse would do under similar circumstances in the geographic area in which the alleged breach occurred.
Breakdown of skin caused by fluid: Deterioration evulsion maceration chafing
maceration
Patient Self-Determination Act (PSDA) durable power of attorney for health care (DPAHC) •Advance directives •Living wills •Health care proxies or durable power of attorney for health care
requires health care institutions to provide written information to patients concerning their rights to make decisions about their care, including the right to refuse treatment and to formulate an advance directive. A patient's record must indicate whether a patient has signed an advance directive and include a copy of the directive if it is available. Patients must also be offered information about advance directives.
RAS Two components of RAS
reticular activating system: in the brain stem mediates all sensory stimuli REA (reticular excitatory area--responsible for arousal and wakefulness) RIA (reticular inhibitory area)
Body Mechanics Principles
stand as close to object to be moved as possible, avoid stretching, reaching, and twisting, make use of bed elevation, lift using gluteal and leg muscles(not back), hold objects close to your center of gravity.
The nurse is preparing to assist a female patient with perennial care. The position of choice for this patient is: Prone supine side lying lithotomy
supine
A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when: A. you compare assessed pain w/baseline pain. B. body language is incongruent with reports of pain relief. C. family members report that pain has subsided. D. vital signs have returned to baseline.
you compare assessed pain w/baseline pain.
Senses:
• Sight/visual • Hearing/auditory • Touch/tactile • Smell/olfactory • Taste/gustatory • Position and motion/kinesthetic
ANA established DECADES ago Code of nursing ethics
•A set of guiding principles that all members of a profession accept •Helps professional groups settle questions about practice or behavior •Includes advocacy, responsibility, accountability, and confidentiality
Value Values clarification
•A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior. •Ethical dilemmas almost always occur in the presence of conflicting values. •To resolve ethical dilemmas, one needs to distinguish among values, facts, and opinion.
INSTITUTIONAL RESOURCES
•Ethics committees are usually multidisciplinary and serve several purposes: education, policy recommendation, and case consultation. •Any person involved in an ethical dilemma, including nurses, physicians, health care providers, patients, and family members, can request access to an ethics committee.