NUR 3056 Exam 1 FSU

Recall the most effective intervention to break the chain of infection ________________ is the most effective way to help prevent the spread of infectious agents" Handwashing, sterilization, antimicrobials Immunizations, disposable supplies, Most health care-associated pathogens are transmitted via the contaminated hands of _____________ ________ __________ _______________, ______________, and _____________ help break cycle of infection an prevent disease Disinfection used when preparing skin for procedure or cleaning equipment that does not enter ___________ body part Sterilization performed on equipment that is entering __________ portion of body

"Handwashing health care workers Cleansing, disinfection, and sterilization sterile sterile

Identify vital signs & the medical terminology which identifies changes.

T= temperature Afebrile (normal, no fever), pyrexia or febrile, hypothermia P= pulse N/A (normal), tachycardia, bradycardia R= respirations Eupnea, tachypnea, bradypnea BP= Blood pressure Normotensive, hypertensive, hypotensive O2 sat= oxygen saturation 95-100%; <90% Pain is "5th" vital sign

Integrative Therapy Define and demonstrate a mindfulness exercise

-Mindfulness exercises include: abdominal breathing, quick coherence technique, acupressure, inhaled scents, and guided imagery. See below. Demonstrate and teach a patient how to do abdominal breathing Abdominal breathing: -allows lungs to fully open, helps prevent atelectasis, promotes relaxation, and decreases stress hormones (adrenalin and cortisol) -requires focused attention, which creates distraction from pain or anxiety -good idea to recommend only a minute or two of this breathing technique at a time, but practicing on regular basis is good for overall health and healing -not appropriate for patients who have had upper ab or lower thoracic surgery, and also can be less painful method for patients with rib fracture because chest wall emainds more stationary

Differentiate the characteristics of pain

-OLDCART -PQRST

Recall the CDC recommendations for hand hygiene practices Moment 1 - Moment 2 - Moment 3 - Moment 4 - Moment 5 - No artificial nails- associated with higher bacterial counts; natural nails should be less than __/__ of an inch long

. Before touching a patient Before a clean or aseptic procedure After a body fluid exposure risk After touching a patient After touching patient surroundings ¼

Identify approved abbreviations and symbols used for documentation and distinguish these from error-prone abbreviations and symbols

...

Schedule 2 Drugs with high potential for abuse, use potentially leading to severe psychological or physical dependence Examples: combo products with < ___ mg of hydrocodone (vicodin), cocaine, methamphetamine, methadone, hydromorphone(dilaudid), meperidine, oxycodone, fentanyl, dexedrine, adderall and ritalin

15

Describe scopes of practice and roles of health care team members Diploma: ___ year hospital based nursing, strong emphasis on clinical experience ADN: ___ year program at junior college BSN: ___ year degree NP: _______________ degree, may have independent practice to assess and deliver primary care Chapter 24

3 2 4 advanced

Differentiate Chronic Pain from Acute Pain Acute; ___ months or less Rapid in onset, varies in intensity -disappears after underlying cause __________________ Ex: sore throat, pricked finger, surgery Chronic: persists for longer than ___ months Lasts beyond normal __________ period Experience periods of ______________ or __________________

3 resolved 3 healing remission or exacerbations

-Fowlers positions: (Low or Semi: ______ degrees, Fowlers ____-____degrees, High ____ degrees); Supine position; Dorsal recumbent position; Side lying or lateral position; Prone position -Support foot in correct anatomical position to prevent ___________________; use _____ ______ sneakers and ______ supports; _________________ _______ prevent external rotation of the hips; ________ ________ hold hands in functional position and prevent clawhand deformities

30 45-60 90 abnormalities high top heel Trochanter rolls Hand rolls

Identify subjective and objective data

Subjective: info perceived only by the affected person; cant be verified by another person; feelings, pain Objective: observable and measurable that can be analyzed by someone else; information perceptible to the senses; may be verified by another person

Identify the steps of the nursing process which identify actual and potential problems

Assessment, diagnosis, outcome identification and planning, implementation, evaluation, documentation All can be used to identify actual problems or predict potential problems

Standards of practice: nursing process: _____________, _____________, _____________ _______________, __________________, ________________, ___________________, ethics, education, evidence based practice and research, quality of practice, communication, leadership, collaboration, professional practice evaluation, resource utilization, environmental health, collegiality Nursing process are guidelines for nursing practice. It integrates the art and science of nursing and used by the nurse to identify patient's health care needs.

Assessment, diagnosis, outcome identification, planning, implementation, evaluation

Identify the importance of intact skin in the prevention of infection

Fewer entry points for possible infections Impaired skin serves as both a portal of exit and a portal of entry for microorganisms

Nontherapeutic comments and questions

Changing the subject Giving false assurance Gossip and rumor Disruptive interpersonal behavior Impaired verbal communication Describe strategies that counteract disruptive professional behaviors Using assertive language Be honest with the patient Listen to the patient and answer their questions

Medications Understand how drugs are named. _______________ name: drug's atomic & molecular structure ____________ name: identification in official publications ______________ name: name first given to drug __________ name: brand name copyrighted by a company

Chemical Official Generic Trade

Most HAIs caused by bacteria, such as:

E. coli, Staph A, Strep. Faecalis, Pseudomonas aeruginosa, klebsiella Many from an invasive device (catheter, ventilator)

Identify the causes of nosocomial infections An infection is referred to as ____________________ when the causative organism is acquired from other people. An _________________ infection occurs when the causative organism comes from microbial life harbored in the person (TB, E.Coli). An infection is referred to as _________________ when it results from a treatment or diagnostic procedure; not all nosocomial infections are iatrogenic

EXOGENOUS ENDOGENOUS IATROGENIC

Discharge summary cont. ________________ documentation Reports ___________ progress Sent to _______ and _______________ Helps continuity of care Also establish need for continuing home care with continued _______________ for necessary services, ex, Medicare Document nursing interventions completely, accurately, currently, concisely, and factually—avoiding _________ problems

Homecare patients PCP and insurance reimbursement legal

Demonstrate and teach a patient how to use P6 acupressure and inhaled scent of isopropyl alcohol for nausea and vomiting relief. P6: -P6 acupressure point: 3 fingers from wrist cease, between two tendons in middle of forearm -It is believed that pressure at this location stimulates nerve fibers that send a signal to the spinal cord, where endorphins are released -These can block chemoreceptor trigger zone (CTZ) signals that cause nausea and/or vomiting -Nerve impulses are also transmitted to the periaqueductal grey (PAG) area of the brain, causing release of serotoninand ACTH,and cause release of B-endorphins and ACTH from the pituitary gland, both of which help to calm the upper GI tract -said to be as effective as Phenergan or Zofran, is easy to use, and has no side effects

How to do it: -simply apply firm pressure to P6 point for 30-60 seconds -use either wrist, or one following the other -onset of effect usually within 1-2 minutes Isopropyl (rubbing) alcohol (IPA) -shown to decrease nausea severity by more than 50% in much faster time than Zofran, Phenergan, or placebo -thought that inhaled IPA influences neurotransmitters that activate chemoreceptor trigger zone (CTZ) -provides rapid relief for immediate postop nausea for adults and children, faster relief when compared to Zofran administered intravenously -no reported adverse reactions, inexpensive, easily available, rapid onset of action, and has potential to increase patient satisfaction with "immediate" treatment How to do it: Step 1: open alcohol swab Step 2: have patient hold alcohol swab just below nose and take in several deep breaths Step 3: repeat every few minutes until nausea relieved

Schedule 5 •drugs with lower potential for abuse than Schedule ____ •consist of preparations containing ____________ quantities of certain narcotics Examples: cough preparations with < ______ mg of codeine, lomotil, lyrica Typically used for ________________, _______________, and ________________ purposes Identify proper medication administration of controlled drugs. Understand proper waste of a controlled substance Double-locking cabinets: used in smaller facilities EX: long-term care facilities form of record (written, computerized) is kept each time a drug is ____________ Reason for ________________ and _____________ to medication must be documented Waste unused portion with another RN Document _________e with another RN Note: Special waste procedures: EX: ______________ patch

IV limited 200 antidiarrheals, antitussives, analgesic removed administration response waste Fentanyl

Recall appropriate patient teaching for use of a PCA pump ONLY THE ___________ to push the button—hence the name " ____________ ____________ _____________"—this is the primary safety mechanism of PCA }Assess patient's need for and understanding of PCA on a _______-by -_______ basis }Patients on PCA should be _________________ intact, ____________ able to press button, developmentally able to understand PCA }Only recommend "pushing the button" if needed for a _______-related purpose

Patient Controlled Analgesia shift-by-shift cognitively physically pain

How to do abdominal breathing:

Step 1: Imagine balloon just beneath belly button Step 2: Imagine that you are inflating the balloon while breathing in and deflating while breathing out -no specific number of breaths, patient should find pace that feels easy, not too fast or too slow

Demonstrate and teach a patient how to use the Quick Coherence Technique®

Quick Coherence Technique is fun and easy way to decrease stress hormones (adrenalin and cortisol) and boost levels of DHEA hormone. It helps to: -reduce stress -feel positive -become focused -create calm -feel energized Quick Coherence Technique: -allows heart to shift into coherent rhythm -interrupts draining emotions such as frustration, irritation, anxiety and anger -can be done anytime, anywhere -requires no particular musculature -easily done by variety of different patient types Step 1: Heart Focused Breathing -focus breathing on area around heart -imagine breath flowing in and out of your heart or chest area -breathe a little more slowly and deeply than usual Step 2: Activate a Positive Feeling -Think of someone that you love, or a fond memory -hold that thought for 45-60 seconds

Understand the importance of proper drug administration.

RIGHT patient, drug, dose, route, time, situation, documentation 3 checks before administration

Demonstrate knowledge of normal ranges for temperature, pulse, respirations and blood pressure in adults. Reference from health assessment sheet Identify age-related variances in vital signs in different patient populations.

Temperature Newborns lack developed temp mechanism; fever worrisome for less than 3 months Elderly lose thermoregulatory control; possible lower temps Immunocompromised: low threshold for fever concern >100.4 F Pulse Kids have higher pulse rate than adults Newborns have highest pulse rate Respirations Kids have higher rate than adults Newborns have highest respiratory rate BP Should be taken at rest Caffeine, tobacco, and activity will affect results Hypertension not diagnosed on only one BP reading Identify the role of the RN in monitoring vital signs. Unlicensed may take vitals but RN responsible for assessing and doing something about them Data collected may lead to a nursing diagnosis Nurses assess vital signs and compare findings with accepted normal values and the patient's usual patterns in wide variety of instances If patient has unexpected or change in vital signs, nurse should validate findings and further assess patient

List at least eight ways in which people communicate nonverbally

Touch Eye contact Facial expression Posture Gait Gestures dress/grooming Sounds Silence

Four categories that are responsible for a majority of HAIs in the acute care hospital setting:

Urinary tract infections Surgical site infections Bloodstream infections Pneumonia

Differentiate the various cleansing agents for hand hygiene and the most effective methods for high-risk environments handwashing with plain soap and water, use of antiseptic handrubs including waterless alcohol-based products, or surgical hand antisepsis.

What does the CDC recommend as the FIRST LINE OF DEFENSE? --> Alcohol based hand scrub

Recall independent nursing interventions to facilitate sleep -teach about rest and sleep -pharmacologic methods, employ relaxation, slow, deep, easy breathing from ________________ or _____________ with _________ closed, guided ______________, healing touch, therapeutic touch Identify expected outcomes following a plan of care to promote rest and sleep -Effectiveness of Pain Management Plan includes: - - -

abdomen or diaphragm eyelids imagery PIR's Comfort Goal Ability to eat, sleep, move so they can heal

Handwashing products that contain _____________ __________________ ingredients are recommended in high risk settings; these products can kill or suppress growth of microorganisms If the health care worker's hands are NOT visibly soiled, ___________-__________ handrubs are RECOMMENDED because they save time, are more accessible and easy to use, and reduce bacterial count on the hands. When used repeatedly, alcohol-based handrubs cause _________ dryness and skin irritation than soap products do. Those who have sensitive skin may benefit from use of an alcohol-based product that contains lotion

antimicrobial or antibacterial alcohol-based LESS

formats of documentation nursing ____________, nursing _______ plan, critical/collaborative pathways, ___________ notes, ________ sheets, ____________ summary, and _______ _______ documentation

assessment care progress flow discharge home care

Identify factors affecting personal hygiene -culture: cultures ________ differently, less/more often, etc. -socioeconomic class: financial resources define __________ options available to that person -spiritual practices: religious beliefs may dictate ceremonial washings and purifications -development level: children learn hygiene while growing up; adolescents take showers more often; bathing ____________ with age due to limitations in mobility and dryer skin -health state: ________, __________, or ______________may reduce person's ability to perform hygiene measures; illness may create demand for new or modified hygiene measures -personal ______________ shower or bath, bar or liquid soap, showering morning versus night, etc. Also influenced by self-concept and sexuality

bathe hygiene decreases disease, surgery, or injury preferences:

Identify the effects of exercise on the body systems. Improves _______________ circulation Improves ____ tract Cardiovascular system: -increased ______________ of heart - ______________ HR and BP -increased _________ ________ to all body parts -improved ___________ ____________ -increased circulating _______________ (breaks up small clots) Respiratory: -improved ______________ ventilation -decreased work of ______________ -improved ________________ excursion GI: -increased ____________ -increased _____________ tone Urinary: -increased blood flow to _________ -increased efficiency of _______-________ balance -efficiency in excreting _________ _________

blood GI efficiency decreased blood flow venous return fibrinolysin breathing diaphragmatic appetite intestinal kidneys acid-base body wastes

Demonstrate techniques for assisting patients with hygiene measures, including those used when administering various types of baths and those used in cleaning each part of the body -Hair care: daily _______________; best way to protect hair from matting is to ask patient for permission to ________ it; if patients hair needs to be cut you need ________ _____________; use comb with __________ ____________ teeth and work from _____________ upward toward forehead; Some African Americans have ___________ _______- not undone during shampooing and may need ____________ or ______ applied daily to prevent hair strands from breaking; brush hair before shampooing; other products available is shampooing inappropriate or contraindicated like _________, _____________, or _____ ___________; also shampoo caps; assist patients with shaving if needed -Fingernail care: file nails ________ across, then _________; remove hangnails by _______ them off; gently push cuticles back off nail when soft and pliable after washing in ______ _________ with blunt instrument or terry cloth; apply __________ to cuticle to prevent hangnails; clean under nails with ________ instrument -Foot care: cut toenails straight across; discourage patients with conditions like _______________ and ________ from doing nail care at home, encourage them to see podiatrist -Perineal care: _______ ________ may be used to clean and sooth area; ___________ procedure, perform _________ _____________, use disposable gloves; use small amount of mild, unscented soap and water; always proceed from _________ contaminated to _________ contaminated area and use _________ portion of washcloth for each stroke; dry and apply emollient as indicated, avoid __________ -Vaginal care: plain ________ and ________ best

brushing braid written consent wide-spaced neckline small braids lubricant or oil foams, concentrates, or dry powders straight round cutting warm water emollient blunt home diabetes and PVD sitz bath explain hand hygiene, least most clean powder soap and water

Soap and water more effective for removing ___. _______spores; alcohol does NOT kill __. _______ spores; However, in **addition* to soap and water, ___________ use is the best preventative measure to control this infection If hands visibly soiled or contaminated with blood or bodily fluids, wash hands with ________ and_________ (either antimicrobial or nonantimicrobial soap) Handwashing also required before eating and after using the restroom At least _____ seconds scrubbing with plain soap or disinfectant and warm water; if hands visibly soiled, need longer scrub! Differentiate between ___________ and ___________ asepsis and the necessary steps when surgical asepsis is contaminated Medical asepsis, or _______ _____________, involves procedures and practices that reduce the _______________ and ___________ of pathogens. Medical asepsis procedures include performing __________ and _____________ and wearing __________ Medical asepsis techniques are used continuously both within and outside health agencies, based on the assumption that pathogens are likely to be present.

c. diff C. dif glove soap and water 20 surgical and medical clean technique number and transfer hand hygiene gloves.

Explain the aims of nursing as they interrelate to facilitate maximal health and quality of life for patients. Nurses use ______________, ______________, _________________, and _______/__________ competencies to meet these aims In addition, the nurse integrates _________________ data with knowledge gained from an understanding of the patient's or group's ______________ experience, applies scientific knowledge in the nursing process, and provides a caring relationship that facilitates health and healing Defined as the _______________,_________________, and ______________ 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 populations

cognitive, technical, interpersonal, and ethical/legal objective subjective protection, promotion, and the optimization

Describe the priorities of scheduled hygiene care -Afternoon care: ensure _________ after lunch and offer assistance to __________________ patients with toileting, handwashing, and oralcare -Hour of sleep care: shortly before patient retires, offer assistance with toileting, washing face and hands, and oral care; **offer _________ ______________ rountinely**. Change _________ bed linens or clothing and position patient comfortably, Ensure call light and other objects the patient desires are within _______ _________ -As needed care (PRN): offer ___________ ____________ measures as needed; some need oral care every ___ hours, those ________________ may need clothing and bed linens changes more often, etc.

comfort nonambulatory soiled easy reach individual hygiene 2 diaphoretic

Plan, implement, and evaluate nursing care for common problems of the skin and mucous membranes -Planning: identify nursing measures to assist the patient to ____________ or ____________ hygiene practices that contribute to sense of well-being; example of appropriate expected outcomes: ______________ feeling comfortable and clean, participate fully in necessary hygiene measures according to ___________, ____________, _______________ an ________________ abilities; maintain intact ________ and ________________ membranes Implementing: respect patient's personal preferences and encourage as much ______-_______ as the patient can perform. Implement interventions that meet patient needs for privacy and promote _______________ and _________________ wellness; nurses who role model good health behaviors are effective teachers -Evaluating: ______________ that can be used to determine outcome achievement include: level of patient _______________ in hygiene program; elimination of or reduction in factors ________________ with hygiene measures; changes related to specific skin problems (ex: healing of skin lesions, elimination or reduction of causative factors)

develop or maintain verbalize cognitive, sensory, mobility, and endurance self care physiologic and psychological indicators participation interfering

Explain the aims of nursing as they interrelate to facilitate maximal health and quality of life for patients. Promotion of health, prevention of illness, care of ill, disabled and dying, advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education Knowledge base for practice includes _____________, ________________, and _________________ from an established plan of care Nursing aims: to promote __________ prevent illness, restore health, and facilitate coping with _____________ and __________

diagnosis, interventions, and evaluation of outcomes health disability or death

Differentiate a medical diagnosis vs a nursing diagnosis Medical diagnoses identify ___________; may be the same for as long as the disease is present Nursing diagnoses focus on _____________ responses to health and illness; may change _________ as patient's ___________ changes Medical diagnoses describe problems for which the ___________ directs the primary treatment, whereas nursing diagnoses describe problems treated by nurses within the scope of _____________ nursing practice Ex of _____________ diagnosis: myocardial infarction Ex of _________ diagnosis: fear, altered health maintenance, deficient knowledge

diseases unhealthy response physician independent medical nursing

Recall the substance which is precluded from the CDC guidelines of standard precautions CDCCDC ______ ______ mandate use of routine surveillance for colonization in patients with multidrug resistant organisms CDC prefers institutions make decisions based on available _______ and _______ assessments rather than mandate order them to do so

does not! data risk

Identify current trends in nursing. 1. Nurses should practice to the full extent of their _______________ and _____________ 2. Nurses should achieve _________ levels of education and training through an improved education system that promotes seamless ___________ progression. 3. Nurses should be full ____________ with physicians and other health professionals, in redesigning health care in the United States. 4. Effective workforce planning and policy making require better _______ collection and an improved information infrastructure Nursing ___________, _________ nurse workforce, rapid advances in __________ knowledge and ______

education and training higher academic partners, data shortage aging medical technology

Understand the importance of knowing a drug's pharmacological class. ________ on body systems (respiratory) ____________ composition (steroids) ______________ indc. / ______________ action (antibiotic) "Knowing the established pharmacologic class can provide healthcare professionals with important information about what to expect from a drugs and how it relates to other therapeutic options." (fda.gov) Helps reduce: _____________ therapy _________-_________ interactions important information in case of drug ____________

effect chemical clinical indication/therapeutic action duplicate drug-drug overdose

Identify the effects of exercise on the body systems. Musculoskeletal: -increased muscle ____________ and ____________ -increased efficiency of _________ _________transmission -reduced bone ________ -increased ______________ Integumentary -improved ________, _________, ___________ -improved skin ________________

efficiency and flexibility nerve impulse loss coordination tone, color, and turgor circulation

Describe the nurse's role in communicating with other health care professionals by reporting and conferring Methods : _______ to_______, ____________, ______________, ________________, computer ____________ method used Conferring is to consult with someone to exchange ideas or seek info, advice or instructions

face to face telephone, written audiotaped SBAR

-Eye care: wear _______, never use _______, use _________ or normal __________ and cotton balls/clean washcloth; position patient on ________ _____ to be cleaned so solution does not run and damage other eye, dampen washcloth/cotton ball and wipe once _______ __________, turn and use different section for each stroke; continue and use ______________ washcloth/cotton ball until clean; clean other eye in same manner; wipe lashes dry -Ear care: after ears washed, dry carefully with soft towel so water and ______________ removed by capillary action; other than cleaning outer ears, little _______________ needed for routine hygiene of the ear -Nose care: best way to clean is to ________; both nostrils should be _________; if external nares crusted, apply ________ ________ compress to soften and remove crusts; disposable paper tissues recommended

gloves soap water saline same eye inner to outer different cerumen intervention blow open warm moist

Describe the purpose and correct use of each of the following formats for nursing documentation: Nursing assessment From nursing _________ and __________ assessment Used for ____________ Care plan Goals, outcomes, interventions, progress and resolution of problems Incorporate standards of care Must be _______________________ to give high quality care critical/collaborative pathways Case management plan Specifies the plan of care linked to ___________ ____________ along a timeline Include expected ____________, list of ________________, ____________ and ______________ of those interventions Abbreviated summary of key info taken from detailed case management plan Progress notes Purpose to inform ___________ of progress patient is making to achieve goal Flow sheets Enable nurses to __________ document the ____________ aspects of care that promote patient goals, safety, and well being Discharge summary Summarizes reason for _______________, ______________ findings, _______________ performed and treatments given, patients condition on discharge and specific instructions given to patient or family

history physical baseline individualized expected outcomes outcomes interventions sequence and timing caregivers quickly routine treatment, significant findings, procedures

Understand the difference between standard precautions and transmission based precautions -Standard precautions: used in the care of all ______________ patients regardless of diagnosis or possible infection status -apply to _________, all body ________, ____________, and excretions except ________ (***whether or not blood is present**) ______________ skin, and ____________ membranes -additions are respiratory hygiene/cough etiquette, safe injection procedures, and directions to use a mask when performing high-risk prolonged procedures involving spinal canal punctures -Transmission based precautions: used in addition to standard precautions for patients in hospitals with suspected _____________ with pathogens that can be transmitted by __________, ____________, or ____________ __________ - ________ now required when entering room of patient on contact or droplet precautions -Three types of transmission based precautions include ___________, ____________, _________

hospitalized blood fluids, secretions sweat nonintact mucous infection airborne, droplet, or contact routes airborne, droplet, or contact routes PPE airborne, contact, and droplet

Describe the status of nursing as a profession and as a discipline. Nursing focuses on ___________ responses to actual or potential health problems and is increasingly focused on _____________, an area of caring that encompasses nursing's unique knowledge and abilities. It encompasses ___________________ and _____________________ care of individuals of all ages, families, groups, and communities, sick or well and in all settings. Based on ________ and not _______________

human wellness autonomous and collaborative EBP and not intuition.

Assess the condition of the patient's skin, oral cavity, hair, and nails using appropriate interview and physical assessment skills Develop nursing diagnoses that identify ___________ problems amenable to nursing _______________ -problems concerning deficient hygiene are categorized as ______-_______ deficits and address specific activities necessary to meet daily needs: ___________, ____________, _____________, ____________ -Important to identify cause of these problems ____________ -ex: Bathing self-care deficit related to _____________ _________________; impaired oral mucous membrane related to _____________ and ___________________; impaired social interaction related to ____________ body image: acne

hygiene intervention self-care feeding, bathing, dressing, toileting correctly postop weakness malnutrition and dehydration negative

Assess the adequacy of hygiene practices and self-care behaviors using appropriate interview and physical assessment skills -nurse assessing adequacy of a patient's ____________ practices determines whether the patient has the knowledge, attitude, skills, and resources to care for ______ and ____________ membranes -factors to assess: daily and weekly ____________ habits, factors interfering with hygiene practices, _______, _____________ history, history of _______ or _____________ membrane problems, special hygiene practices (mouth, eyes, ears, nose, hair, feet and nails, perineum, piercings/tattoos) -physical assessment of pertinent ________ systems can provide data about patient's _____________ status and patient's ability to maintain acceptable ____________ __________

hygiene skin and mucous bathing pain, exposure skin or mucous body hygiene personal hygiene

Describe the purposes of patient records *written or electronic legal record of all pertinent _____________________ with the patient—assessing, diagnosing, planning, implementing, and evaluating *contain data used to facilitate quality, ____________-________ patient care, serve as ___________ and __________ records, help in clinical research, and support ____________ analysis. *The patient record is the only _________________ _________ document that details the nurse's interactions with the patient and is the nurse's best __________ if a patient or patient surrogate alleges nursing negligence *The primary purpose of the patient record is to help health care professionals from different disciplines (who interact with the patient at ______________ times) _____________ with one another. * __________________ fosters continuity of care.

interactions evidence-based financial and legal decision permanent legal defense communicate different Communication

Recall physiologic responses to varying levels of pain Physiologic responses are _________________ body responses to the pain Typical sympathetic responses when pain moderate and superficial: -increased _____, increased _________ and ____, ________ dilation, muscle _________ and _________, ________ (peripheral vasoconstriction), increased ______________ output, increased blood __________ Typical Parasympathetic responses when pain severe and deep: - ______________ and _____________ , ____________ or unconsciousness, decreased __________ _______________, decreased _________ ________, prostration, and _________ and _______________ breathing

involuntary BP pulse and RR pupil tension and rigidity pallor adrenalin glucose nausea and vomiting fainting blood pressure, pulse rate rapid and irregular

MOST COMMON HAI

is catheter-associated urinary tract infections (CAUTIs)

Schedule 4 Drugs with a ______ potential for abuse and _____ risk of dependence Examples:

low low xanax, soma, darvon, darvocet, valium, ativan, phenobarbital, ambien, tramadol

Schedule 1 drugs with no currently accepted ____________ ______ a high potential for ________ potential to create severe ______________ and/or ___________ dependence Examples: - - - - -

medical use abuse psychological physical Heroin, LSD, marijuana, ecstasy, methaqualone, peyote

Recall independent nursing interventions to facilitate sleep -determine effects of patient's _________ on sleep pattern -adjust _______________ to promote sleep -encourage patient to establish ____________ routine -instruct patient to avoid bedtime ________ and ____________ that interfere with sleep -instruct patient how to perform ___________ muscle relaxation or other _________________ forms of sleep inducement -initiate/implement comfort measures of ______________, ____________, ______________ touch -discuss with patient and family sleep-enhancing techniques -promote __________ -schedule nursing care to avoid unnecessary disturbances -use ______________ to promote sleep if appropriate

meds environment bedtime foods and beverages autogenic nonpharmacologic massage, positioning, and affective comfort medications

Schedule 3 drugs with a _____________ to _____ potential for physical & psychological dependence abuse potential is less than Schedule __ and Schedule ___ drugs abuse potential is more than Schedule ___ drugs Examples: products containing < ____ mg of codeine per unit (tylenol with codeine), ketamine, anabolic steroids, testosterone

moderate to low I II IV 90

Differentiate between different etiologies of pain Nociceptive Pain: normal process that results in ___________ stimuli being percieved as painful Somatic: _________, __________, ___________ and ________________ tissue Visceral: visceral organs, GI tract, pancreas Neuropathic Pain: direct consequence of __________ or ___________ affecting abnormal functioning of ______ or ________; abnormal processing of sensory input by _____________ or _____________ nervous system; exact cause unknown Can be short in duration but frequently chronic Described as _________

noxious bones, joints, muscle, skin, connective tissue lesion or disease PNS or CNS peripheral or central

Describe nursing informatics and its contributions to nursing and health care *integrates __________ science, ____________ science, and ______________ science to manage and communicate data, information, and knowledge in nursing practice *Increases in the accuracy and completeness of nursing documentation *Improvement in the nurse's workflow and an elimination of _____________ documentation *Automation of the _______________ and ___________ of nursing data Facilitation of the analysis of clinical data

nursing computer science information redundant collection and reuse

Identify the implementation of the intervention component of the nursing process Any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient ______________ Where the nursing actions from the _____________step are carried out May take many forms: direct care, teaching, counseling, coordination, collaboration, health promotion, disease prevention, health maintenance, restoration, rehabilitation Must reassess before to ensure the patients _______________ did not change Purpose of this step is to help patient achieve valued health ____________ Nurse continues to collect _______ and ___________ plan of care if needed

outcomes planning status outcomes data modify

Nearly every nursing activity includes practices of medical asepsis. Nurse assumes a major responsibility for breaking the cycle of infection by providing safe patient care and protecting the patient, as well as the nurse, from microorganisms that may cause disease. When observing medical asepsis, areas are considered contaminated if they bear or are suspected of bearing ________________ Surgical asepsis, or ____________ technique, includes practices used to render and keep objects and areas free from _________________. Surgical asepsis procedures include inserting an indwelling ____________ _____________ or inserting an ____ ________________, sterile dressing changes, and preparing an ______________ ____________ -used regularly in ____________ room, labor and delivery areas, and certain diagnostic testing areas, but also by the nurse at patient bedside -when following surgical asepsis, areas are considered contaminated if they are touched by any object that is _______ also __________

pathogens sterile microorganisms urinary catheter IV catheter injectable medication operating NOT also sterile

Focus charting Bring focus of care on _______________ and _______________ concerns Has focus column for many aspects of patient care instead of list of problems and diagnoses Data, action, response format (DAR) Advantage: holistic emphasis on patient priority, ease of charging Disadvantage: nurses feel that DAR categories are artificial and not helpful to document care Charting by exception

patient and patients

Recall the general guidelines for a patient's pain rating §Because pain is "whatever a person says it is, existing whenever they say it does,*" the most reliable indicator of pain is the ____________ report §Subjective pain ratings such as the ____-____ score or ___________ scale are the most common—and most reliable--way to obtain a patient's input about their pain experience §However, the patient's report is only_______ component of a pain assessment!

patient's 0 - 10 FACES one

Identify how socratic questioning can improve critical thinking skills Socratic questioning leads to a deeper analysis of the problems It engages the _________, ____________ and other _________ to provide more information and think outside the box to answer your questions It gives you a more complete picture of the problems you need to address with the patient

patient, family, and other staff

List guidelines for effective documentation, including those of the American Nurses Association Note: Why is effective documentation important? → patient record is the ONLY ______________ ________ document that details the nurse's __________________ with the patient and is the nurse's best ____________ if a patient or patient surrogate alleges nursing negligence Complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document

permanent legal interactions defense

Violations of Confidentiality Violations: Giving info over the _________ without _____________, ___________ in the elevator, giving info to people who know the patient but arent on the _______ _______ Leaving info in a ________ area Leaving ___________________ unattended Sharing _____________ without verification,

phone verification talking care team public computer passwords

Maslows hierarchy: Level 1: _____________ needs (oxygen, water, food, elimination, rest, sexuality, physical activity, etc) Level 2: ________ and _____________ needs (proper hand hygiene, administering medications knowledgeably, skillfully moving patients, carefully explaining new and unfamiliar procedures and treatments, etc.) Level 3: ______ and __________________ needs (nurses should always consider love and belonging when developing plan of care; ex: include family and friends, establish nurse-patient relationship, refer patients to support groups) Level 4: _____ ___________needs (respect patient values and beliefs, encourage patients to set attainable goals, facilitate support from family or significant other) Level 5: ______ _________________ needs (nurse focuses on person's strengths and possibilities rather than on problems)

physiologic safety and security love and belonging self esteem self actualization

Orders, care planning, quality improvement, research, decision analysis, education, legal documentation, reimbursement Compare and contrast different methods of documentation : electronic health record, source-oriented record; problem-oriented record; PIE—problem, intervention, evaluation; focus charting; charting by exception; and case management model Electronic Health Record Fewer _______ outcomes and ______ errors Higher __________ and ________________ of patient care Increase ___________ participation Improve accuracy of ____________ and health _____________ Improve _______ coordination Increase cost _____________ and practice ________________ Source oriented records Paper records still used in rural and underserved areas

poor med quality and convenience patient diagnoses outcomes care savings efficiencies

Identify measures to protect confidential patient information All information about patients is considered ______________ and ____________________ Includes: *address,telephone and fax number, *Social Security number, and any other personal information. *It also includes the __________ the patient is sick or in the hospital, office, or clinic, *the assessments and treatments the patient receives, and information about ________ health conditions. *Protected health information might be found in the patient medical record, computer systems, telephone calls, voice mails, fax transmissions, e-mails that contain patient information, and conversations about patients among clinical staff.

private or confidential reason past

Identify the goal of interventions for "Risk For" nursing diagnosis Reduce or eliminate risk factors, prevent the __________, and monitor and evaluate ________ Prevent the outcome that the patient is at _____for Apply concepts of critical thinking throughout the nursing process _______________ of thought and _______________ are required for an unbiased general survey and assessment Integrity and perseverance are necessary for the planning and evaluation stages to ensure the highest quality of planning and interventions for their patient Problem solving is directly related to the planning stage of the nursing method Critical thinking is necessary in all areas of nursing to accurately assess the patient and create a care plan Patient conditions can change in minutes, so you must reassess patient for change in status that might dictate a different set of interventions Always question whether there are better ways to achieve desired patient outcomes Always monitor patient responses so you can modify plan of care as needed Assess, re-assess, revise, record

problem status risk Independence impartiality

The Socratic Method, where the ____________ and the ___________ are sought, is a technique in which one can investigate below the surface, recognize and examine the ___________, look for the _______________, investigate the multiple data views and distinguish between what one __________ and what he simply ___________ This method should be implemented by nurses at the _________ of their shifts, when reviewing patient ___________ and ___________, planning the nursing plan or discussing the treatment of a patient with colleagues

question and the answer condition consequences knows believes. end history and progress

Describe the interrelation between communication and the nursing process assessment often requires the nurse to ask the patient _____________ ____________ are communicated to other nurses and members of the care team Planning requires the team to _________ on what steps to take and what interventions to perform Implementing involves ______________ what is being done to the patient and their family about what is being done Evaluating includes __________ and ______________ info from the patient to determine if the _______________ is working or not Use effective communication techniques when interacting with patients from different cultures Learn what is considered respect in each culture Use interpreters if another language is their first language Use a standardized communication technique ____________ to communicate with physicians and transfer patient information to other nurses Describe how each type of ineffective communication hinders communication Failure to perceive the patient as a human being Failure to listen

questions Diagnoses agree explaining verbal and nonverbal intervention (SBAR)

Describe the priorities of scheduled hygiene care **When patients require assistance with hygiene, provide this care at __________ intervals (see below). These are individualized according to patient's ____________ and _______________ preferences -Early morning care: shortly after patient _____________. Assist with toileting if necessary and provide comfort measures to refresh patient and prepare him/her for breakfast -Morning care: offer assistance with toileting, oral care, bathing, back massage, special skin care measures, hair care, cosmetics, dressing, positioning

regular personal and cultural awakens

Identify the 5 classes of controlled drugs. what are they called?

schedule 1 schedule 2 schedule 3 schedule 4 schedule 5

Pain assessment should always consider such factors as: patient's __________ level ______________ status other _______ previously given response to previous _________________ type of ________ patient risk factors such as ________, high _______, respiratory disease or difficulty, ___________ tolerance or naivete Most pain scales either focus on _______________ domain (0-10 scale, FACES scale) or ______________ domain (FLACC, PIPP, etc.) _____________ report of pain most reliable, followed by ___________, report of pain from family/others, and physiologic measures ( ________ reliable)

sedation respiratory meds medications pain age BMI opioid SENSORY behavioral Subjective behavior least

Assist a patient with a brief guided imagery technique -use of imagination to benefit body and mind -different from visualization in that it involves ALL ___________ -allow person to see, hear, taste, smell, and/or feel -same ________ of __________ activated whether person is imagining or experiencing -the more _________ used, the more ________ it will seem to brain -promotes _____________ and facilitates relaxation A simple guidied imagery technique is to ask the patient: "If you could be anywhere other than here right now, where would you like to be?" -once patient has answered, nurse can "virtually" take them there by asking follow up questions to elicit how it ________, ________, __________, __________ in that place -Ask "what do you hear?" "What can you smell?" etc. -Important to keep calm tone of voice and slower pace of talking- help facilitate feeling of calm, comfort and ease

senses parts of brain senses healing looks, feels, sounds, smells, and/or tastes

source-oriented record; Doesnt develop ____________ plan of care; its incorporated into progress notes which identify problems by ______________ Patient assessment performed and documented at _________________ of each shift using fill-in-the-blank assessment forms; problems are _______________, worked up using ______, and then evaluated each _______ Resolved problems ______________ from daily documentation after nurses review Advantage: promotes ____________, saves time Disadvantage:nurses need to read all nursing notes to determine __________________ and _______________ Has nursing __________

separate number beginning numbered PIE shift dropped continuity problems and interventions origin

Each health care group keeps data on its own ______________ form Sections of record designated for nurses, physicians, lab and x ray Entered ______________________ with most recent on top Advantage: each discipline can easily find and ______ _________ Disadvantage: data is _________________ so its hard to track problems chronologically ____________ oriented records Paper record Organized around ____________ problems rather than on sources of info All healthcare professionals record info on _________form Advantage: team works together in identifying problems; contributes _________________ to plan of care Disadvantage: focuses too _______________ on problems PIE ( what is it?)

separate chronologically chart data fragmented Problem patients same collaboratively narrowly problem, intervention, evaluation

-Shower and tub baths: make sure bathroom available, clean and safe. Ensure necessary articles available. Provide place for weak or physically disabled patient to _______ in shower. Assist patient as indicated. Make sure water temp safe and comfortable. Ensure privacy. Call device _________ if they can shower alone safely. Keep bathroom door _____________ Help wash and dr areas patient cannot __________ Make necessary adaptations -Bed baths: provide patient with articles for ___________ and basin of water that is safe and comfortable temp; provide privacy; call light within reach; replace top linens with _________ blanket; assist patients who cannot bathe themselves completely -Bag bath or disposable bath -Oral hygiene: if patient is unable to perform oral hygiene, make sure the mouth recieves care as often as necessary to keep it clean and moist (every _-_ hours); moisten mouth with water, ____________ lips, following steps for cleaning mouth thoroughly more important than agent used; ________________ _____________ can be used

sit handy unlocked. reach. bathing bath 1-2 lubricate chlorhexidine gluconate

Discuss professional responsibilities when using electronic communication Protecting patient privacy No posting on _________ _________ about patients info All emails to patient are _____________ and become part of the patient's ____________ __________ ______ ______ of any computers and do not leave computers unattended

social media duplicated medical record Log off

Identify the role of the skeletal, muscle and neurologic system on the effects of movement. Skeletal: -supports ________ ___________of body -protects crucial components of body -furnishes surfaces for attachment of ____________, ______________, __________________ -provides storage areas for ________________ and _____ -produces blood cells -motion, maintenance of posture, support, heat production Nervous System -afferent system conveys info to ________; info processed by CNS; ___________ system conveys response from CNS to skeletal muscles via _____________ nervous system

soft tissues muscles, tendons, and ligaments minerals and fat CNS efferent somatic

Discuss the effects on nursing practice of nursing organizations, standards of nursing practice, nurse practice acts, and the nursing process. Nursing controls and guarantees its practice through ____________ of practice, nurse practice _______ and ______________, and the use of the nursing process. Nurses are accountable for their quality of practice and responsible for safe use of standards

standards acts and licensure

Nursing care often directed towards meeting _______ and ______________ needs; this hierarchy provides framework for nursing assessment and for understanding the needs of patients at all levels, so that _____________ to meet priority needs become a part of plan of care Planning must prioritize needs in this order in order for patient to improve in ________ areas

unmet or threatened interventions higher