NSG 241: Fundamentals Final

SOAP notes

(S) Subjective data: what do the patients and others tell you? (O) Objective data: What are the results of the physical examination, relevant vital signs, or other test? (A) Assessment: What is the patients current status? (P) Plan: What interventions are necessary? (I) interventions: What treatments did the nurse provide? (E) evaluation: What are the patient outcomes after each intervention? (R) revision: does the plan stay the same? What changes are needed to the care plan?

health information must be

- accurate - accessible - actionable when implementing in the teaching plan it can guide the information, the approach, and the evaluation of progress

low health literacy

- associated with increased hospitalization, - greater emergency care use, - lower use of mammography, and - lower receipt of influenza vaccine.

definition of Health literacy

- defined in Healthy People 2020 as follows: "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions"

educator

- ensures the patient receives sufficient information on which to base consent for care and related treatment - assesses learning needs, uses specific teaching strategies to meet those needs - evaluates effectiveness of patient teaching - major focus of discharge planning - patient needs to be informed about their medications, procedures, diagnostics, and health promotion measures - the nurse must understand literacy standards and regulatory guidelines related to patient rights, informed consent, educating patients, improving quality care, and meeting patient needs

canes

- for additional support when walking due to balance problems or weakness may use a cane - the patient should hold the cane on his or her stronger side and move the cane forward first, followed by the weaker leg - a patient using a cane should be encouraged to stand up straight and look forward

patients position in a bed

- important to maintain proper respiratory status - body alignment - prevent skin breakdown - provide comfort for a patient who is unable to reposition himself or herself

change agent

- in a leadership role - requires knowledge of change theory - encourages change and provides strategies for effecting change - works with patient to address health concerns - works with staff member to address change in an organization or within a community - role can be extended to bringing about change in the legislation on health policy issues.

crutches

- increased patient mobility - used on a short-term or long-term basis for patients with lower extremity injury or paralysis - 2 inches under axilla and 6 inches to the side of the foot - Forearm or Lofstrand crutches are used with long-term or permanent impairment. - patient needs to possess adequate upper body strength and coordination when using all types of crutches

cognitive domain

- learning comprises knowledge and material that is remembered - literature written at the appropriate reading level, demonstration, and use of examples

steps when repositioning the bed

- lower the head of the bed to reduce resistance to gravity during repositioning - raise the bed to waist height of the nurse - use bed side rails or lift equipment to assist the patient during repositioning - align the patient's spine in the center of the bed

manager

- manages all activities/ treatments for patient - promotes, restores, and maintains patients health through coordinating all the health care providers services - also, manager of a unit in the hospital - managing a team of patients - oversees, staff on a patient care unit while managing the budget and resources required for necessary functions

Two-point crutch walking pattern

- patients who can bear partial weight on either or both lower extremities - patient move one crutch forward simultaneously with the opposite leg, providing a wide base of support

three point crutch walking

- patients who have injury to one leg - both crutches are placed forward and patient swings their legs to the center of the crutches , bearing weight on the uninjured leg - similar to: swing-to gait used by paraplegics

Urobilinogen

- produced by the breakdown of bilirubin and is responsible for the brown color of stool -increased levels of urobilinogen result in increased RBC destruction - decreased levels of urobilinogen result in biliary obstruction or in severe liver disease

leader

- provides direction and purpose to others, - builds a sense of commitment towards a common goal, - assists in addressing challenges that arise in HC setting characteristics include: - integrity - creativity - interpersonal skills - critical thinking - problem solving

Hand-off reports

- real-time process of passing patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety - hand-offs can be oral, as in face to face meeting or telephone communication, or they can be written or recorded. -hand-off reporting should provide accurate timely, important information about the care, treatment, and services rendered addressing the patients current condition and anticipated changes, and important information to the next caregiver to ensure patient safety

affective domain

- recognizes the emotional component of integrating new knowledge - takes into account the patient's feelings, values, motivations, and attitudes

Four point crutch gait

- requires partial weight bearing on both lower extremities - more stability than the 2-point pattern bc only 1 of 4 points of support is lifted off - one crutch moves forward, followed by the opposite leg, and repeats the pattern by moving the opposite crutch and then the leg forward

nursing process

- scientific process that nurses use to care for their patients is a multistep approach as a care provider the nurse follows this process to: - assess patient data, - prioritize nursing diagnoses, - plan the care of the patient, - implement the appropriate interventions, - evaluate care in an ongoing cycle

friction reducing sheets

- similar to transfer or slide boards - made of specialized material that reduces shear - when placed under a patient, the sheet minimizes the force required for repositioning or transfer

pain

- subjective symptom - an unpleasant sensory and emotional experience associated with actual or potential tissue damage

3 domains/types of learning

- to provide effective patient teaching - cognitive - psychomotor - affective effective patient teaching requires knowledge about how the patient learns

exercises should be performed

- two times per day - three to five times per joint - move the joints smoothly and slowly until resistance is met and stop before pain begins.

care provider

- use of knowledge and critical thinking to determine the necessary course of action - psychomotor skills to perform the necessary interventions - interpersonal skills to communicate effectively with the patient and family - ethical/legal skills to function within the scope of practice/code of ethics

transfer belts

- used for unsteady gait or generalized weakness - if patient has a weaker side, the nurse should stand on that side and hold the gait belt firmly at the back of the patients waist

Roles and Functions of the nurse

-care provider -educator -advocate -leader -change agent -manager -researcher -collaborator -delegator

physically restrained

-decreases in cognitive performance - requiring increased assistance with activities of daily living - increase in actual falls - pressure ulcers and incontinence - use of restraints can negatively influence physical and psychological well-being and should be used as a last resort

transfer to slide board

-made out of plastic-like material that reduces friction -linens easily slide over the board, facilitating bed linen changes - patients can be repositioned or transferred with a minimum of force

trapeze

-patients with upper body strength - to facilitate repositioning and transfers

Types of Nursing Diagnoses

1. Problem-Focused 3 part 2. Risk for 2 part 3. Health Promotion 2 part Problem-focused nursing diagnoses are clinical judgements about undesirable human responses to health conditions or life processes that occur in an individual, family, group, or community.

one cup of ice chips (240 mL)

120 ml of water

collaborator

2 or more people work together to a common goal - RN, UAP, LPN, PCP, Social workers, clergy, therapist work together - responsible for ensuring all patient care orders are carried out and for communicating with the entire team - the competency to work in teams is meant to provide safer, quality care.

Morse Fall Scale

6 item history of falling existence of a secondary diagnosis use of ambulatory aid use of intravenous line or a saline lock gait mental status

John Hopkins Hospital Fall Assessment Tool

7 item advanced age fall history specific medication classes patient care equipment that tethers mobility cognitive elimination functions

Hendrich II Fall Risk Model

8 item tool confusion/disorientation/impulsivity symptomatic depression altered elimination dizziness/vertigo gender use of antiepileptics use of benzodiazepines performance on the get up and go

UAP can

Do tasks that do not require nursing judgment (except vitals during codes). Should be routine in nature. Performed with exact standards. Stable patient care. Outcome of care should be reasonable and predictable.

· Safety assessment for falls

Johns Hopkins Hospital Fall Assessment Tool -Seven item tool Morse Fall Scale -Six item tool Hendrich II Fall Risk Model -Eight item tool

Nonopioid analgesics

NSAIDs and acetaminophen for mild to moderate pain mild pain = 1 to 3 moderate = 4 to 7

use to CONSTRUCT A GOOD RESEARCH QUESTION

PICO and PICOT P = patient, population, problem (describe the subject of the problem) I = intervention (define which intervention is being considered for the specific patient or population C = comparison intervention (ex: comparison of traditional x-rays with magnetic resonance imaging) O = outcome (define the type of outcome to assess) ex: outcome may be change in physical sign, the result of a diagnostic test) T = time (identify the time frame in which the research will take place

Pain Assessment

SOCRATES S = site (Where is it located?) O = Onset (When did the pain start? Was it gradual or sudden?) C = character (What is the quality of the pain? Is it stabbing , burning or aching in nature?) R = radiation (Does the pain radiate anywhere?) A = associations (what signs and symptoms are associated with the pain) T = time course (is there any pattern to when the pain occurs) E = exacerbating/relieving factors (Does anything make the pain worse or lessen it?) S = severity (on a scale of 0 to 10, what is the intensity of the pain?)

SBAR Communication Tool

a communication form specifically suggested for use in nurse-physician interactions (S) active situation: what is happening at the current time? (B) related background: what are the circumstances leading up to this situation? (A) assessment of the problem: what does the nurse think the problem is? (R) recommendation for a solution: what should we do to correct the problem?

defining characteristics

are cues or clusters of related assessment data that are signs, symptoms, or indications of a problem-focused,or health promotion nursing diagnosis

patient participation in Hand-off reports

are enhanced with patient participation nurses should: - teach patients to actively participate with staff during the bedside rounds - ask patients to validate the information shared during the rounding process - encourage the patients to ask questions during the rounding process

a nurse cannot delegate these

assessment planning evaluation accountability judgements

colorectal screening tests should be done starting at age

beginning at age 45 years

anaerobic exercise

builds power and body mass. -without oxygen to produce energy for activity -ex: heavy weight lifting

researcher

critique research studies and apply research to practice - determine care concerns and ask questions about the nursing practices - identify problems to be basis for research - evidence-based practice involvement

delegator

delegating aspects of patient care to other personnel

anuria

failure of the kidneys to produce or excrete urine failure of the kidney to produce or excrete 50 to 100 ml or urine in 24 hrs

short term goals

goals that are achievable in less than a week

Long term goals

goals that take weeks or months to achieve

Repositioning in bed

helps prevent the complications of immobility: - atelectasis - pneumonia - pulmonary embolism (PE) - deep vein thrombosis (DVT) - orthostatic hypotension - constipation - ileus - urinary stasis - hyperglycemia - insulin resistance - muscle atrophy - bone demineralization - contractures - pressure injuries - depression

stool analysis

identify disorders of the: - gastrointestinal (GI) tract - liver - pancreas commonly ordered to test for: - occult blood, fecal fat, urobilinogen - ova and parasites

positive occult blood

indicate disorders including: - peptic ulcer disease - inflammatory bowel disease - hemorrhoids - trauma to GI tract - gastric or colon cancer

steatorrhea

indicates a failure to digest and absorb dietary fat

incentive spirometry

inhale and exhame 5-12 times every 1-2 hours prevent atelactasis and pneumonia post-surgery

advocate

interprets info and provides the necessary education, then accepts and respects the patients decisions even if they are different from the nurses own beliefs - nurse supports the patients wishes and communicate those beliefs to other HC providers, and speak for patient

isotonic exercise

involves active movement with constant muscle contraction. ex: walking, turning in bed, and self-feeding

biopsy

involves removing a larger collection of cells, as in a tumor or mass, and may be used to detect cancer in the skin, breast or liver

Parecentesis

involves removing fluid from the peritoneal cavity

nursing diagnosis

is the nurses clinical judgement about a client's response to actual or potential health conditions or needs

lumbar puncture

lumbar vertebrae

fine needle aspiration

method of obtaining samples with minimal trauma to the underlying organ or structure

Opioid Analgesics

moderate to severe pain narcotic medications work by binding to the opioid receptors in the nervous system, which are sites of endorphin action. agonist analgesics = morphine, hydromorphone, oxycodone, fentanyl

diarrhea

parasites and their ova (eggs) in the stool can lead to this GI symptom

Sim's

patient in semiprone position lying on the left side

Fowler's position

patient in sitting position with pillow supporting thigh and legs

prone

patient lies face-down

supine

patient lies flat on back

knee-chest

patient lying in prone position with buttocks and knees drawn to the chest

side-lying

patient lying on side

lithotomy

patient lying supine with feet in stirrups

dorsal recumbent

patient lying supine with legs bent

trendelenburg's

patient lying supine with legs elevated higher than the head

semi-fowler

patient semisitting with head elevated

trochanter roll

prevents outward rolling of the hip when a patient is lying on his or her back

Needle aspirations

procedures that are used to remove fluid and tissue for testing

upper GI tract bleeding

produces stools that are black and tarry

lower GI tract bleeding

produces stools with bright red blood

thoracentesis

removes fluid from the pleural space

aerobic exercise

requires oxygen metabolism to produce energy. -patients may engage in rigorous walking or repeated stair climbing to achieve the positive effects of aerobic exercise.

isometric exercise

requires tension and relaxation of muscles without joint movement. ex: tension and relaxation of pelvic floor muscles (kegel exercise)

Institutional Review Board (IRB)

review committee established to help protect the rights and welfare of human research subjects.

five rights of safe delegation

right task right person right circumstances right communication right supervision

bone marrow aspiration

site: illiac crest, sternum

Maslow's Hierarchy of Needs

specifies the physiological and physiological factors that affect each persons physical and mental health top - self-actualization: morality, creativity, spontaneity, acceptance - self-esteem: confidence, achievement, respect of others - love and belonging: friendship, family, intimacy, connection - safety and security: health, employment, property, family, social stability - physiological needs: breathing, food, water, shelter, clothing, sleep bottom

risk factors

that are identified in a risk nursing diagnosis are environmental, physical, psychological, or situational concerns that increase a patients vulnerability to a potential problem or concern.

Cold therapy

therapy using ice or cold application to reduce or prevent swelling by decreasing circulatory flow to the injured body part Promotes vasoconstriction, increases blood viscosity, decreases metabolism of tissues, has local anesthetic effect - Decreases muscle tension - should not be applied for longer than 20 minutes or reflex vasodilation can occur

related factors

underlying cause or etiology of a patients problem

adjuvant medication

work synergistically laxative tricyclics for neuropathic pain