Fundamentals 117 - Final Exam (Qtr 1)
otoscope
instrument used to visual ears
Data of collection methods
interview and nsg hx physical examination observation of pts behavior diagnostic and lab data
establishing presence
involves giving attention, answering questions, having an encouraging attitude, and expressing a sense of trust; "being with" rather than "doing for"
Assault
is an intentional threat toward another person that places the person in reasonable fear of harmful, imminent, or unwelcome content.
incident report
is filled out when anything potentially harmful occurs to a patient, visitor, or employee
Define Stress
nonspecific response of the body to any demand made on it.
Eye contact is a _________________ means of communication?
nonverbal
Physical examination ad data collection methods
nurse examine pt body system includes: v/s ht/wt, general appearance, behavior and heat to toe assessment
purposeful data
nurse identifies purpose of assessment type of assessment needed (initial, shift, etc)
Graduate education-masters
nurse practitioner, educator, management
Advocacy
nurse provides information to the patient needs to make decisions and supporting them in whatever they choose to do. Stand up for your patient
Journaling improves ___________ & ______________ skills
observation, descriptive
not kept in patient records
occurrence report
Who is the center of nursing process?
patient
illness behavior variables- internal
perception of illness and nature of illness
Mourning
period which the person learns to accept grief
What does the nursing history include?
physical status developmental status emotional health social practices resources goals/values lifestyle expectations of the health care system
Maslow's Hierarchy of Needs
physiological, safety, love/belonging, esteem, self-actualization
health promotion and illness prevention (3 levels)
primary (Dr visits, immunizations, vaccincations) secondary ( screenings, children with normal growth development) tertiary- after diagnosed and tx, reducing disability (teaching pt about diabetes)
Patient as source of data
primary source usually best source be alert for accuracy (may deny s/sx r/t fear) note any discrepancies (pain)
Dorothy Johnson (1968)
problems arise because of disturbances in system/subsystem
Aims of nursing
promoting health, preventing illness, restoring health, facilitating coping with disability or death
Cardiopulmonary Standard
requires failure of a patients circulatory and respiratory functions
Patient self determination act
requires health care facilities to provide information to all patients regarding advance directives and to document advance directivesin the medical record
How is nursing viewed now?
respected profession, holistic care must be careful of practicing outside of scope of practice
A microorganism is considered resistant if replication cannot be stopped by _______ ____ ______ antibiotics sequentially or simultaneously.
two or more
blended competencies
understand evidence supports action be skilled in handling required equipment promote pt sense of wellbeing practice ethically
Discrimination
unfair tx of a person or group based on race, ethnicity, age, gender, sexual orientation, religion
preparation
unsuccessful with changes, will take action within a month
social justice
upholding moral, legal and humanistic principals to promote access to healthcare
subjective data
what pt says. things that are not apparent to another person or can only be felt or perceived by the pt
nursing process (implement)
what the nurse does, carryout care, modify plan of care, move into action, DO IT
code of ethics
when a nurse provides care within a philosophy of ethnical decision making professional expectation
Endogenous (HAIs)
when the patient's flora becomes altered and overgrowth occurs
hypotension
decreased blood pressure
bradypnea
decreased respiratory rate
dyspnea
difficulty breathing
Pathogens
disease causing agents
When giving pain medicine you must
document in MAR and in nursing documentation
Emergency assessment
done when there is a life threatening problem. Identify conditions that could lead to worsening health problems, or death, BIGGEST emergency has to do with breathing, if not breathing, nothing else matters
hypertension
elevated blood pressure
The last phase in the processing of an ethical dilemma is to: 1. evaluate the action taken 2. consider treatment options 3. negotiate the options and outcomes 4. identify the problems
evaluate the action taken
cultural imposition
everyone should conform your own belief system
crackles
fine to course crackling sounds due to fluid in the air passages
percussion tones
flat-soft muscle dull-medium-liver(solid organs resonance-loud-lung (air) Hyperresonance-very loud-emphysema (more air pockets) tympany-loud-gastric (air bubble)
Implementation
focuses on initiation of appropriate interventions designed to meet the unique needs of each patient
Evaluate
focuses on the patient and the patient's response to nursing interventions and goal or outcome attainment.
Working Phase
gather subjective data for database good communication (client focus, listen, ask about problems) problems- opened ended questions- use back channeling, avoid clichés, giving advice, and avoid closed ended questions doing something phase
3 interdisciplinary bases for nursing theories
general adaptation developmental
deductive reasoning
general actions/ideas to specific
Federal nursing home reform act
gives nursing home residents the right to be free of unnecessary and inappropriate restraints
Examples of _______ communication are nurses discussing pt care; educating pts; emailing a doctor
Interpersonal
The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take v/s, the nurse thinks, " How is Mrs. Barclay today?" Are our nursing actions helping her to achieve her goals? How can we better help her? This demonstrates which characteristic of the nursing process?
Interpersonal
Critical Thinking SKILLS
Interpretation Analysis Inference Evaluation Explanation Self-Regulation
Types of spiritual connections
Intrapersonal Interpersonal Transpersonal
Health disparities are unequal burdens of disease morbidity and mortality rates experienced by racial and ethnic groups. These disparities are often exacerbated by: A: Bias B: Stereotyping C: Predujice D: All of the above
D: All of the above
Aseptic technique
Efforts to minimize the onset and spread of infection to patients are based on the principles of:
Mary Elizabeth Mahoney
Graduated from the New England Hospital for Women and Children in 1879 as America's first African American nurse
Most frequent reservoir for health care workers
Hands
Situational spiritual assessment cues
Has a life-threatening diagnosis or life-changing condition Is facing death Faces treatment decisions
Qualified
Having the competency and authority to perform the action
Nursing care delivery model goal ?
Help nurses achieve desirable outcomes for their patients
Flow sheets and graphic records
Help team members quickly see patient trends over time and decrease time spent on writing narrative notes
Watson's Transpersonal Theory of Caring
Holistic model
Watson's Transpersonal Theory of Caring
Holistic model that describes a conscious recognition that caring for a person involves sensitivity, respect, and a high moral and ethical commitment
Palliative care
Hospice care; taking care of the whole person, with the goal of giving patients with life threatening illness the best quality of life they can have through the aggressive management of symptoms
Lab results with high WBC & or positive blood culture often indicate
Infection
Iatrogenic (HAIs)
Infection stems from a procedure
The purpose of communication within the nurse-pt interaction is to
Influence a pts health & well being
Interpersonal variables
Influence communication because the sender & receiver continually influence one another
Two Standards used in the Critical Thinking Model.
Intellectual & Professional
You can teach and evaluate every time you
Interact with a patient
Assertive communication
Based on a philosophy of protecting individual rights and responsibilities
First impressions are largely
Based on appearance
Evidenced-based knowledge
Based on research or clinical expertise
Three levels of critical thinking
Basic, Complex, Commitment
Open-Mindedness
Be tolerant of different views; be sensitive to the possibility of your own prejudices; respect the right of others to have different opinions.
Nursing Interventions for Seizures
Before: ensure the environment is safe During: Positioning, no objects in mouth, do not restrain, time seizure, privacy After: Post ictal, Reorient , Assessment
Complex Level of Critical Thinking
Begin to separate yourself from authorities, analyze and examine choices more independently.
PTSD (Post Traumatic Stress Disorder)
Begins when a person experiences witnesses, or is confronted with a traumatic event and responds with intense fear or helplessness.
Problem-focused approach
Begins with problematic areas. (Gather detailed information about a specific condition)
Providing presence
Being with Eye contact Body language Tone of voice Listening Positive Encouraging attitude
Transcendence
Belief of outside/bigger force
folk healing
Beliefs in practitioners of specific alternative therapies by herbalists, spiritualists, and naturalists to promote health, NOT LISENSED ex. reflexologists
Agnostic
Believe that there is no known ultimate reality
Judaism healthcare beliefs
Believes in sanctity of life Balance between God and medicine Observance of Sabbath important Treatments sometimes refused on Sabbath
By administering medication to a patient on a unit in an extended care facility, a nurse is applying the ethical principal of: 1.justice 2. fidelity 3. autonomy 4. beneficence
Beneficence
Culture Domain 9 - Death Rituals
Bereavement, ceremonies
Navajos response to illness
Blessingway is practiced that attempts to remove ill health by means of stories, songs, rituals, prayers, symbols, and sand paintings
To prevent infection you must
Break the chain
A nurse follows accepted guidelines for a healthy lifestyle. How can this promote health in others?
By being a role model for healthy behaviors
SPIRIT
S: Spiritual belief system P: Personal spirituality I: Integration and involvement in a spiritual community R: Ritualized practices and restrictions I: Implications for medical care T: Terminal-events planning (advance directives)
SOAPIE documentation
S: subjective data O: objective data A: assessment P: plan I: intervention E: evaluation
SOAP documentation
S: subjective data O: objective data A: assessment (diagnosis) P: Plan
Examples of actual health problems?
SOA, pneumonia
Your documentation has to be specific to the
Patients needs
Patient center care requires you to know a
Patients preferences, values, &expressed needs
When to call for help (seizures)
Person has never had a seizure previously, Status Epilepticus, Lasing more than 5 minutes, 2 or more seizures within 5 minutes, Airway Difficulty, Injury, Underlying condition, Diabetes, heart disease, pregnancy
Phases of Interview
Preparatory phase induction/orientation phase working phase termination phase
Clinical nurse leader
Prepared at graduate level, oversees lateral integration of care for distinct group
what are the phases of a nursing- interview
Prepatory phase-read current and past records Introduction-introduce self, give title and purpose of interview Working Phase- data gathering Clarify and verify- ask additional questions about conditions, meds, anything that is unclear, if they have been seen for this condition, any tx or meds currently being used prescription or otc Termination- Is there anything else you would like us to know that will help us plan your care
Nurse Researcher
Advanced degree, conducts research
Nurse Practitioner
Advanced training that enables them to work independently of a physician
Linda Richards
America's first trained nurse, night superintendent Bellevue, keeping records and order writing
What is the ANA?
American Nurses Association nurses nurses are responsible for diagnosis and treatment of human responses to actual and potential health problems
Short-term goal
An objective behavior or response expected within hours to a week
Cultural Competence
An understanding of how a patient's cultural background shapes his/her beliefs, values, and expectations
1 grain
60 mg
The nurse recognizes that the patient would benefit from reflection. Which action promotes reflection? A Allow time and opportunity for self-disclosure by the patient B Integrate the family into spiritual practices, as appropriate C Arrange for regular visits from religious advisers as desired by the patient D Support avenues to spiritual growth that are meaningful to the patient
A
1 teaspoon (tsp)
5 milliliters (mL)
Watson's Carative Factors
5) Promoting/expressing positive/negative feelings -Support and accept your patients' feelings. In connecting with your patient's show a willingness to take risks in what you share with one another
LPN
1 year program, can do most nursing functions
Watson's Carative Factors
1) Forming a human-altruistic value system -Use loving kindness to extend yourself -Use self-disclosure appropriately to promote a therapeutic alliance with your patient
Eye contact
Is usually maintained during conversation, however some cultures (Asian & Native American) consider this to be intrusive or threatening
What can health care professionals use to check understanding during an assessment?
ice cream labels and ask 6 questions
inference
judgment-ask questions to validate
percussion
striking one object against another to produce sound to determine location, shape, size, and density of tissue
Older adult considerations
•Decreased immunity •Dry mucous membranes •Decreased secretions •Decreased elasticity in tissues
Personal Protective Equipment (PPE)
•Gowns •Mask or respirator •Gloves •Eyewear
Synthesis
•Knowledge •Experience •Attitudes •Standards
The PES format
Problem, etiology, & symptoms
PIE
Problem, intervention, evaluation
Surgical asepsis includes
Procedures to eliminate ALL microorganisms from an area
Medical asepsis includes
Procedures used to reduce the number and prevent the spread of microorganisms
Reflection
Process of thinking back or recalling an event or discovering the meaning and purpose of that event. Asking yourself how you can improve.
Culturally based physical assessment
Ask patients about their home remedy practices
a 55 year old patient is being discharged from the hospital after a heart attack. He is being referred to a cardiac program where he will receive education on healthy eating, exercise, and stress reduction. This is an example of: A) Primary prevention B) Secondary Prevention C) Tertiary Prevention D) Rehabilitation
C) Tertiary Prevention
Which statement complies with The Joint Commission's (JCAHO) requirements to incorporate spiritual health into the patient's care? Select all that apply. A "Does your spouse believe the same as you?" B "How often do you attend any religious gatherings?" C "Do you have family in the area?" D "Is there anyone that you would like to call?" E "Do you belong to a faith community?"
C, D, E
1 milliliter
0.001 L
1 millimeter (mm)
0.001 meter (m) = 0.1 cm
During a nursing assessment a patient displayed several behaviors./. Which behavior suggests the patient may have a health literacy problem? 1. Patient has difficulty completing a registration form at a medical office 2. Patient asks for written information about a health topic 3. Patient speaks Spanish as primary language 4. Patient states unfamiliarity with a newly ordered medication
1
4 phases of the nurse-patient relationship
1 preinteraction 2 orientation 3 working 4 termination
Watson's Carative Factors
10) Allowing for existential-phenomenological-spiritual forces -Allow spiritual forces to provide a better understanding of yourself and your patient
A nurse is caring for a patient with a seriously advanced infection who asks to have a spiritual care provider come who can offer Blessingway, a practice that attempts to remove ill health. This patient is likely a member of which religion or culture? 1. Hinduism 2. Navajo 3. Sikhism 4. Judaism
2
A patient has just learned she has been diagnosed with A malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. You have cared for her for only two hours but had a good relationship with her. What might be the most appropriate intervention for support of her spiritual well-being at this time? 1. make a referral to a professional spiritual care advisor 2. sit down and talk with the patient; have her discuss her feelings and listens attentively 3. Move the patient's bible from her bedside cabinet drawer to the top of the over-bed table 4. ask the patient if she would like to learn more about the implications of having this type of tumor
2
Purpose of patient education is to
Help individuals, families, or communities achieve optimal levels of health, safety, and independence
1 inch = ___ cm
2.54
1 ounce (oz)
2 tablespoons (tbsp)/30 ml
grand mal seizure (tonic-clonic seizure)
2-5 minutes, cry, loss of consciousness, tonic-clonic movement, incontinence, During: shallow breathing, cyanosis, incontinence, Postictal phase: disoriented, no recall of event, deep sleep
1 kg = ? lbs
2.2 lbs
A patient states that he does not believe in a higher power but instead believes that people bring meaning to what they do. This patient most likely is an: 1. Academic. 2. Atheist. 3. Agnostic. 4. Anarchist.
3
1 tablespoon (tbsp)
3 teaspoons (tsp) /15 mL
Promote Health, Prevent Illness Restore Health Facilitate coping with disability or death
4 broad aims of nursing practice
Teach-back
A method of teaching in which the patient verbalizes information that he or she has learned
Mindfulness
A moment-to-moment present awareness with an attitude on non-judgment, acceptance, and openness. Mindfullness meditative practices are effective in reduing psychological and physical symptoms or perceptions of stress
Environmental Safety
A patient's environment includes physical and psychosocial factors that influence or affect the life and survival of that patient. Think of Maslow's hierarchy of needs.
reservoir is
A place for pathogens to grow
Nurse anesthetist
A registered nurse who has received additional training and education in the administration of anesthetic medications.
Patient-centered goal
A specific and measurable behavior or response that reflects a patients highest possible level of wellness and independence in function
The nursing process is also..
A standard of practice, which, when followed correctly, protects nurses against legal problems related to Nursing care
Health is defined as
A state of optimal functioning or wellbeing. often subjective
Refusing to provide spiritual care for patients because of a nurse's fear of spiritual vulnerability represents
A violation of the nurse's commitment to nonmaleficence
Concept mapping, nursing Dx.
A visual representation of a patients nursing diagnosis and their relationships with one another
Asepsis
Absence of disease producing microorganisms
Adult legal consent
ANY COMPETENT 18 YEAR OLD any parent for an unemancipated minor any guardian for his or her ward any adult for a minor brother or sister any grandparent for grandchild if parents are not present
RN
AS or BSN degree, completes all nursing skills, specialized training, BSN level looking into evidence-based practice, papers focused on research
Listening does not inply
Agreement
When you suspect a pt to have health literacy problems,
Always say the most important things first
3. Give the patient a bath 4. Take the patient's vital signs 6. Take the patient for a walk down the hall
An RN is caring for a patient who has bronchitis. Which of the following tasks can the RN delegate to an NAP (select all that apply) 1. Teach the patient about ordered medications 2. Auscultate the patient's lungs 3. Give the patient a bath 4. Take the patient's vital signs 5. Evaluate the patient's temperature to help determine the effectiveness of the patient's antibiotics 6. Take the patient for a walk down the hall
aseptic technique
An effort to keep pts. as free from exposure to infection-causing pathogens as possible
Hope
An energizing source that has an orientation to future goals and outcomes
Cultural Awareness
An in-depth self-examination of one's own background, recognizing biases, prejudices, and assumptions about other people
Systemic infection
An infection that affects the whole body
Long-term goal
An objective behavior or response expected within days, weeks, or months
Mother
Ancient history nursing care provided by family members usually the _____________ and male priests or medicine man.
Accountability
Answerable for their actions
Commitment Level of Critical Thinking.
Anticipate the need to make choices without assistance from others, accountability
Culture (assessment)
Ask about the patient's faith and belief systems for understanding the relationship between culture and spirituality
Holistic Health Model
Attempts to create conditions that promote optimal health, active participation of patients
Perseverance:
Be cautious of an easy answer, look for a pattern and find a solution. Keep looking for additional resources until you find a successful approach.
Inquisitiveness
Be eager to acquire knowledge
Interpretation
Be orderly in data collection. Be systematic in approach to assess all characteristics of a patient's problem.
A 30 year old woman has just found out that her mother has been diagnosed with breast cancer. This is an example of which type of risk factor for the 30 year old? A) Age B) Lifestyle C) Genetic D) Environment
C) Genetic
Actual loss
Can be recognized by others as well as by the person sustaining the loss
Modes of transmission include
Contact, vehicles & vectors
Culture Domain 3 - Family roles and organization
Defines relationship of insiders and outsiders; includes concepts related to head of household, gender roles, family goals and priorities, and developmental goals of family members
Swanson's Theory of Caring - BEING WITH
Definition: Being emotionally present to the other Subdimensions: Being there Conveying ability Sharing feelings Not burdening
Sterilization
Destroys all microorganisms including spores
Nursing Notes
Detailed descriptions noting factual information regarding the patient. Required: date, time, detailed description, signature and credentials.
Atheist
Do not believe in the existence of God
Integrity
Do not compromise nursing standards or honesty in delivering nursing care. Willing to admit mistakes in own behavior, ideas, and beliefs.
The interview is a partnership
Do not control it
Telephone Report
Document every call, Read back, Repeat any prescribed orders back to the physician or health care provider, called "read back," for verification.
Grief
Emotional response to loss
LPN Programs
Established to teach bedside nursing care to patients
Hinduism healthcare beliefs
Except modern medical science
Nonverbal spiritual assessment cues
Exhibits neediness (e.g., doesn't want to be alone, or has frequent requests for care or company) Is angry or noncompliant Seems depressed or withdrawn Has emotional outbursts and cries quietly
Situational loss
Experienced as a result of an unpredictable event, including traumatic injury, disease, death, or national disatster
Cultural Influences (Health History cont)
Expressed both verbally and non-verbally: -Touch -Facial Expressions -Eye contact and movement -Body Posture
Appalachians healthcare beliefs
External focus of control Nature controls life and health Accept folk healers
Spiritual assessment frameworks
FICA SPIRIT HOPE
Guidelines for Quality Documentation and Reporting
Factual, Accurate, Complete, Organized, Current,
FICA assessment tool
Faith Importance and influence Community Address (Interventions to address)
True or False: A person who is experiencing a productive cough and fever takes a sick day to recuperate and decide whether to make an apt with the doctor. This person is said to be in stage 3 of illness behavior: assuming dependent role .
False: Stage 2
External Variables
Family Practices, Socioeconomic Factors, Cultural Background
RN works directly with the patients
Family, and health care team members
Secondary traumatic stress
Feeling of despair caused by transfer of emotion distress from a victim to caregiver.
Evaluation is the _______________ step of the nursing process
Final
Cultural Congruent
Fits a person's life patterns, values, and systems of meaning
Christianity response to illness
Followers use prayer, faith healing They appreciate visits from clergy Some use laying on of hands Holy communion is sometimes practiced Anointing of the sick is given when patient is ill or near-death (Catholic)
ICN
Founded in 1899 first international organization of professional women
General Adaptation Syndrome (GAS)
Generalized defense response of the body to stress; consists of three stages: alarm, resistance, and exhaustion
Implementation is the
Fourth step in the nursing process
exogenous infection
From microorganisms Outside the individual
Exogenous infection
From microorganisms outside the individual
Termination
Give pts. cue that the interview is coming to an end
Standard precautions
Good hand hygiene and use of barriers such as gloves, masks, and gowns minimize exposure to infection
Marginalized Groups
Groups that have been relegated to the fringes or margins of the moral community. More likely to have poor health outcomes and die earlier because of the complex interaction between their individual behaviors, the environment of the communities in which they live, the policies and practices of health care and government systems, and the clinical care they receive
When providing health promotion classes, a nurse uses concepts from models of health. What do both the health-illness continuum and the high-level wellness models demonstrate?
Health as a constantly changing state
4 models of health and illness
Health belief model health promotion model health illness continuum agent host environment
Cultural Assessment Guide
Health beliefs and practices Faith-Based Influences and Special Rituals Language and Communication Parenting Styles and Family Roles Sources of Support Beyond the Family Dietary Practices
Buddhism - implications for health nursing
Health is an important part of life Good health is maintained by caring for self and others Medications are not always excepted because of belief that chemical substances in body are harmful
Fall Interventions in the "in patient" setting
Hourly rounds, quick response time to call lights, Non-slip socks, Identification as fall risk , Bed/chair alarm, Remove non essential equipment, de-clutter
Appraisal
How a person interprets the impact of the stressor
The course of infection influences
How severe the infection is
Include family caregivers in the teaching when possible
If a pt is not ready to learn..
Removal of PPE
If you wear all four protective items, remove the gloves first to avoid contaminating your hair or uniform
High priority
Immediate threat to patient survival or safety
Care plan revision
Implement the new plan, and re-evaluate the patients response to the nursing actions
What is the Nurse Practice Act?
In each state, statutory law directs entry into nursing practice, defines the scope of practice, and establishes disciplinary procedures. State boards of nursing oversee this statutory law.
Culture
In its broadest sense, reflects the whole of human behavior including ideas, beliefs, and values; ways of relating to one another; language and manners of speaking; and work and lifestyle practices
Culture Domain 2 - Communication
Interrelationship of verbal language skills including dominant language, dialects, touch, contextual use of language, and willingness to share information
2. Perform hand hygiene 5. Put on gown 4. Put on mask 1. Put on eyewear 3. Put on gloves
In what order would you prepare to enter the room of a patient in contact and droplet isolation precautions for MRSA? 1. Put on eyewear 2. Perform hand hygiene 3. Put on gloves 4. Put on mask 5. Put on gown
Autonomy
Independent decision making about patient care
Infection
Invasive of a susceptible host by microorganisms (pathogens) resulting in disease
Self awareness
Is important for effective communication
no pork for what cultures?
Jewish Muslim Seventh day Adventists
JCAHO
Joint commission on accreditation of healthcare organizations (documentation be done according to NP)
Inferences
Judgement or interpretation of the cues.
The purposeful acquisition of knowledge, attitudes, behaviors or skills
Learning
Pacing (form of communication)
Long pauses & a rapid shift to another subject may give the impression that you are hiding the truth. Speak slowly, enunciate clearly, & use pauses to stress a particular point
Heindrich II Fall Risk Model
Looks at not only at physical factors but medications as well.
When performing hygiene...
Many factors influence personal hygiene.•Use communication skills to promote the therapeutic relationship.• Hygiene care is never routine.• During hygiene, assess: -Emotional status -Health promotion practices -Health care education needs
Culture Domain 7 - Nutrition
Meaning of foods, common foods, deficiencies, rituals, limitations
Mormonism dietary practices
Members abstain from alcohol and caffeine
Team nursing
Most common in acute care settings
Navajo's-implications for health and nursing
Navajos prefer holistic approach to healthcare They often are not on time for appointments Promote physical, mental, spiritual, and social health of people, families, and communities Allow family members to visit Provide teaching about wellness, not disease prevention, when possible
When performing professional duties..
Nurses will be required to use nonverbal, verbal & technological skills to communicate with pts, families, & other healthcare professionals
Objective data
Observations or measurements of a patients health status.
Cultural Knowledge
Obtaining sufficient comparative knowledge of diverse groups, including their indigenous values, health beliefs, care practices, worldview, and bicultural ecology
Termination phrase
Occurs at the end of a relationship
Preinteraction phrase
Occurs before meeting the patient
Lateral violence (horizontal violence)
Occurs in nurse-nurse interactions & includes behaviors such as withholding information, making snide remarks & demonstration of nonverbal cues
Anticipatory loss
Occurs when a person displays loss and grief behaviors for a loss that has yet to take place
Teaching methods
One-one-one discussion, group institution, preparatory instruction, demonstrations, analogies, role playing, simulation, use of technology
Disadvantage of primary nursing
Other nurses can't change care plan with out discussing it with the primary nurse
Epidermis
Outer layer of skin
PIE documentation
P: problem or nursing diagnosis applicable to patient I: Interventions or actions taken E: evaluation of the outcomes of nursing interventions
Major Seizure precautions
Padded side rails, Bed at lowest position, Clutter free environment, Call bell at all times, Suction equipment at bedside, Oxygen and Nasal cannula at bedside, Avoid use of restraints
Hinduism responds to illness
Past sins cause illness Prolonging life is discouraged
Microorganisms
Pathogens
What are the 6 human dimensions affecting health?
Physical (o2, food, water, shelter, sex, physical activity) intellectual (cog. abilities, edu backgrouds) environmental (housing, sanitation, climate, pollution) spiritual sociocultural (economic level, lifestyle, family, culture) emotional (how minds affects body function &respond)
Risk Taking
Positive Risk taking: Be willing to recommend alternative approaches to Nursing Care.
Can hurt or heal through the messages they send
Posture, facial expression, gestures,, every word you chose & every phrase you speak
Touch
Provides comfort and creates a connection
1/5 of American adults
Read at 5th grade level or below
Health-promotion diagnosis
Readiness for Enhanced Spiritual Well-Being Readiness for Enhanced Religiosity
Thinking independently
Reads the Nursing Literature, considering a wide range of ideas before making own conclusion
Self-Regulation
Reflect on your experiences. Identify ways to improve.
Immunity
Resistance to disease
accountable
Responsible and answerable for something
Responsibility & Accountability
Responsible for CORRECTLY performing activities based on STANDARDS OF PRACTICE. A willingness to accept an obligation and be accountable or an action or situation.
Five rights of delegation
Right task Right circumstance Right person Right direction/communication Right supervision/evaluation
How culture affects health care: 4 principals of beliefs
Scientifically based beliefs, biomedical naturalistically or holistically based belief Religiously based folk healing
Truth Seeking
Seek the true meaning of situation. Be courageous, honest, objective about asking questions
When educating a child
Sit in an chair to make them feel less threaten
Allostasis
The body will attempt to return to a state of balance
immune response
The body's specific recognition, response, and memory to a pathogen attack
Social Determinants of Health
The conditions in which people are born, grow, live, work, and age, shaped by the distribution of money, power, and resources at global, national, and local levels
Assessment
The deliberate and systematic collection of information about a patient
Spirituality example of a goal and associated outcomes
The patient will improve personal harmony and connections with members of his or her support system
Infection is
The invasion of a subceptable host by microorganism (pathogens) resulting in disease
Infection develops if
The links in the chain remain intact
American Nurses Association (ANA)
The national professional membership association of nurses that works for the improvement of health standards and the availability of healthcare services, fosters high professional standards for the nursing profession, and advances the economic and general welfare of nurses
Relational context refers to
The nature of the relationship between the participants. EXs include level of trust, degree of sharing, shared history, & balance of power and control
Ida Jean Orlando
The nurse reacts to the patient's verbal and nonverbal expression of needs both to understand the meaning of the distress and to know what is needed to alleviate it
Patient education objective for Meditation
The patient will verbalize feelings of relaxation and self transcendence after meditation
Nursing diagnosis focuses on
The patients physical, psychological, and social responses
If expected outcomes are not met
The plan of care needs to modified
Cultural Encounter
The process that permits nurses to seek opportunities to engage in cross-cultural interactions.
You send a message to
The receiver
Immunization increase
The resistance to an infectious disease
Organisms exit the body from
The same routes they entered
Bioethics/Clinical ethics
The study of health care
Narrative
The traditional method
Concepts for Critical Thinker
Truth Seeking Open-Mindedness Analyticity Systematicity Self-Confidence Inquisitiveness Maturity
Appalachians-implications for health and nursing
They become anxious in unfamiliar settings Encourage communication with family and friends when ill
Judaism-implications for health and nursing
They believe that it is important to stay healthy Jews expect a nurse to provide competent healthcare Allow patients to express their feelings Allow family to stay with dying patient
Socialization (Worldview)
Through family, friends, community, peers, schooling, media, work, religious institutions, government, legal system, health care system, etc.
TEEAMS approach
Time Empowers Enthusiastic Appreciates Manages Supports
4 broad aims of nursing practice
To promote health To prevent illness To restore health To facilitate coping with disability or death
Culture Domain 6 - High Risk Behaviors
Tobacco, alcohol, recreational drugs, physical activity, safety
Culture Domain 4 - Workforce Issues
Type of employment, location, autonomy, language barriers
Hospice
Type of end of life care for persons who are terminally ill
Conversion
Unconscious transformation of anxiety into a physical symptom with no organic cause
Relate factors that influence the condition of the nails and feet.- especially diabetic
Uncontrolled diabetes causes nerve damage in the extremities (a condition called peripheral neuropathy that limits pain sensation in up to 45 percent of all PWDs. Nerve damage also leads to poor circulation (which means wounds take longer to heal) and makes you prone to infection (it's difficult for the body to fight off bacteria in wounds). A small cut can lead to skin infections, open wounds called ulcers, and sometimes amputation
Situational crises
Unexpected crisis that arises suddenly in response to an external event or a conflict concerning a specific circumstance
Caring
Universal phenomenon influencing the ways in which people think, feel, and behave in relation to one another
Crisis intervention
Use of therapeutic techniques directed toward helping a patient to resolve a particular and immediate problem
Incident Reports
Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient. Follow agency policy. Examples of incidents include patient falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of ordered therapies, and circumstances that lead to injury or to risk for patient injury. Are not part of pt chart
Reinforcement
Using a stimulus that increases the probability of a response
2 categories of action-guiding theories
Utilitarian and Deontologic
Judaism response to illness
Visiting the sick is obligation There is an obligation to seek care, exercise, sleep, eat well, and avoid drug and alcohol abuse Euthanasia is forbidden Life support is discouraged
Curiosity
WHY? Explore and learn more about a client to make appropriate clinical judgments
Not appropriate to write
WNL (within normal limits)
Questions to ask yourself when caring for patients
What is the patient's status NOW? How might it CHANGE and WHY? How might their VALUES and EXPERIENCES affect the meaning of what I know? What do I know to IMPROVE the pt's condition? In what way will a therapy help? What should be my FIRST step?
Nursing interventions are evaluated to determine
Which strategies or interventions were effective
Islam-implications for health and nursing
Women prefer female healthcare providers During month of Ramadan Muslims do not eat until after the sun goes down Health and spirituality are connected Family and friends to visit during time of illness They usually do not consider organ transplantation or donations and postmortem examination
spiritual distress
a distruarnce in a persons belief system can occur at any time during life time of financial stress major life changes (divorce/death of loved one)
Morals
a judgment about behavior
Health
a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity
emancipated minors are:
emancipated by a court married active duty
integrity
acting according to the code of ethnics and standards of practice ex honest info and document care given
Nursing Process: Diagnosis
anxiety ineffective coping complicated grieving hopelessness powerless readiness for enhanced spiritual well-being spiritual distress risk for spiritula distress risk for impaired religiosity
Intentional Torts
are deliberate acts of wrongful conduct
standards of critical thinking
clear, precise, specific , accurate, significant, adequate
descriptive theories
describe a phenomenon
types of quantitative reserach
descriptive, correlation, quasi, experimental
power of attourney for health care
designated a health care proxy
prescriptive theories
designed to control, promote, and change clinical nursing practice
Malpractice
failure to use that degree of care that a reasonable nurse would.
Fidelity
faithfulness, keeping promises
criminal law
federal or state statutory that define as a crime certain actions that inflict or threaten substantial harm to individuals or public interest.
Sikhism response to illness
females are to be examined by females removing undergarments causes great distress
Exogenous (HAIs)
from microorganisms outside the individual
health assessment
gather information about pt's health status, identify strengths and actual and potential health problems, pt's response to the condition, TO ESTABLISH A BASE FOR THE NURSING PROCESS
stridor
harsh high pitched heard on inspiration
Contact (mode of transmission)
junction of body surfaces with other bodies or objects Direct: Contact with infected person Indirect: Contact with contaminated object
Puerto Rico
lactose intolerance parasitic disease hyperkinetic seizure activity- Ataques if stressed
apnea
no breathing
Common ethical problems in nursing are...
nursing shortage, manage care, end of life issues, cultural and religious sensitivity, delegation
What do lab and diagnostic test include?
past medical dx (look at previous charts)
Disease is defined as
pathological changes in structure of function of the body or mind
what is a nursing interview?
planned communication to obtain a history
Lydia Hall
rehab, autonomy, therapeutic use of self cure and care, self actualization
Utilitarianism
relies on the application of the "good" and "greatest"
ANA defines nursing as
the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations
Hildegard Peplau
therapeutic, interpersonal, goal orientated development patient personality for community living
febrile
with fever
afebrile
without fever
Defendant
would be the nurse
PLantiff
would be the patient
define inference
your judgement or interpretation of those cues
Cold Treatments
Chicken, Dairy, Veggies, Fruits, Honey, Barley, Bicarbonate of soda, Milk of magnesia, Sage
The nurse is educating the student nurse on the legal and ethical responsibilities of providing spiritual care. Which statement made by a student nurse signifies the need for additional training? A "I cannot contact the patient's faith community without the consent of the patient." B "I may violate my commitment to nonmaleficence if I don't provide spiritual care to my patients." C "Failing to recognize a patient's spiritual needs is unethical." D "Religious beliefs have no place in health care."
D
Health promotion nursing diagnosis
A clinical judgement of motivation, desire, and readiness to enhance well-being and actualize human health potential
A professional code of ethics includes: 1. legal standards 2. moral principals 3. guidelines for approaching common ethical dilemmas 4. a collective statement of group expectations of behavior.
A collective statement of a group expectations of behavior.
Electronic health record (EHR)
A digital version of a patient's medical record Integrates all of a patient's information in one record. Improves continuity of care
Celsius to Fahrenheit
(C x 1.8) + 32
Fahrenheit to Celsius
(F-32)/1.8
Explanatory Model
(Kleinman) A set of questions care providers can ask during an assessment which provides insight into what is most important for the client in terms of their health, illness, and care. Try blending these questions into your discussion in an informal manner.
Standards for patient education
*Patient education is considered a basic nursing competency. *Patient's Bill of Rights. *As a nurse you need to ensure that education takes place, evaluate if learning occurred, and document all steps of the process.
Inflammation
*The cellular response of the body to injury or infection *Signs include swelling, redness, heat, pain, or tenderness, and loss of function in the affected body part
Ability to learn
*developmental capability *age-group *physical capability
Learning styles
*linguistic *spatial *auditory *kinesthetic/tactile
Normal flora
*microorganisms that reside in the body *the number and variety of flora maintain a sensitive balance with other microorganisms to prevent infection
3. The nurse uses a doll to show the child how the injection works.
A 3-year-old child is diagnosed with type 1 diabetes. The provider starts the patient on injections of insulin at her endocrinology appointment. How does the nurse best explain the injection tot he child. 1. The nurse speaks only to the parents because a 3-year-old child cannot comprehend what is being said regarding medication. 2. The nurse verbally reviews information with both the patient and the parents. 3. The nurse uses a doll to show the child how the injection works. 4. The nurse demonstrates the injection on the child.
A 45 year old woman diagnosed with depression states, "I don't understand why everyone thinks I should seek counseling." This is an example of which state of behavior change? A) Precontemplation B) Contemplation C) Preparation D) Maintance
A) Precontemplation
2. Assess what the patient already knows about sleep apnea
A nurse is preparing to teach a patient about sleep apnea. Which action is most appropriate for the nurse to preform first? 1. Show the patient how the CPAP machine works 2. Assess what the patient already knows about sleep apnea 3. Evaluate the outcomes of the education session 4. Set mutual goals for the education session
3. Short sessions during which the nurse provides the most important information at the beginning and end of the education session
A nurse is teaching an older-adult patient about poststroke seizures. Which teaching technique is most appropriate to use? 1. A pamphlet with large font in green ink 2. Speaking in a high-pitched voice 3. Short sessions during which the nurse provides the most important information at the beginning and end of the education session 4. An hour-long lecture including symptoms of a seizure, safety during a seizure, types of seizures, and information regarding medications used to treat seizures
A patient with lung cancer states he has not prayed in years because he never thought it would do any good, but now wants to start going to church. Which goals are appropriate goals for this patient? Select all that apply. Patient will report the ability to pray after counsel by the hospital chaplain. A Patient will attend religious services within two weeks of discharge. B Patient will speak with a spiritual counselor within one week of admission. C Patient will consult with the family members about his desire to go to church. D Patient will start praying in one day.
A, B, C
Which intervention should the nurse determine once the cue for spiritual care is recognized? Select all that apply. A Reflection B Faith Rituals C Meditation D Connection with others E Change in environment
A, B, D
A nurses caring for a 78-year-old patient with chronic multiple sclerosis. The patient has severe fatigue, muscle weakness, severe muscle spasms, and difficulties with coordination and balance. Her disease will likely worsen. The nurse has gained the patients trust and wants to assess her life satisfaction. Which of the following questions should the nurse ask? (Select all that apply) 1. How often are you able to attend your synagogue? 2. what about your family makes you proudest? 3. What does your husband do for you at home? 4. looking back, what is your greatest accomplishment? 5. how has your illness and affected the way you live your life spiritually at home?
2, 4
Adaptation Theory
adjustment of living matter to other living things and environment
ABC
airway, breathing, circulation
Complete Data
all data needed to understand health problems and developing care plan ex. Weight loss: Intentional/unintentional
Define naturalistically or holistically belief systems
balance/harmony, yin/yang, hot and cold cold disease: menstrual cycle, rhintis, colic (babies) hot disease: hypertension, diabetes, pregnancy goal : restore balance
misunderstanding
barrier caused by a mistake of meaning or intention
Factual and accurate Data
based on fact no biased opinions allowed ex. client is depressed instead describe the behavior
common law
based on judical decision
Analysis
be open-minded as you look at information. DO NOT MAKE ASSUMPTIONS
values
beliefs about the worth of something learned from life experiences determine who you are influenced by environment, family, culture not born with it
Hot and Cold diseases
blood- hot and wet yellow-bile hot and dry black-bile cold and dry phlem-cold and wet
Nonverbal expressions of pain?
bp, clinching, avoiding activities
General Systems Theory
break whole things into parts to see how they work together in systems
White, Caucasian
breast cancer heart disease hypertension diabetes mellitus obesity matriarch eye contact
orthopnea
breathe easier in an upright position
The nurse questions a Jehovah's Witness patient about his faith belief system and whether or not members of his faith community need to be involved in his care. Which spiritual assessment framework is being used for this patient? A SPIRIT B FICA C Advocacy D Faith ritual
B
Which nursing action is most important in demonstrating concern for the various cultural differences surrounding illness and death? A Using the spiritual assessments framework upon hospital admission B Asking about patient preferences and accommodating those requests as much as possible C Paying attention to the patient's verbal and non-verbal cues D Observing the outward expression of the patient's religious preferences, such as items in their room
B
You are carry for a hospitalized patient who is Muslim and has diabetes. Which of the following items do you need to remove from the meal trade when it is delivered to the patient? 1. small container of vanilla ice cream 2. a dozen red grapes 3. Bacon and eggs 4. Garden salad with ranch dressing
3
1 quart
1000 mL
1 milligram
1000 micrograms
1 gram
1000 milligrams
two standards of determination of death
cardiopulmonary and whole brain
define person centered care
care is provided from the pts prospective
Death and Dying Legal Responsibilities
carefully document all events that occur treat deceased patients remains with dignity
roles of nurses
caregiver, communicator, teacher/educator, leader, advocate
Vector borne
carry the pathogens from one host to another. Vectors often are invertebrate animals such as ticks, but they can also be vertebrate animals such as raccoons, which can transmit rabies by biting.
Define Ethnicity
categorization of a group of people by a distinctive trait , such as the line of genealogy or ancestry, race, or nationality
experimental research
cause and effect under highly controlled conditions
dental caries
cavities
Reporting Obligations
child, spouse, elder abuse gunshot wounds rape attempted suicide certain communicable diseases
physical assessment
collect objective data about the patient, explain the exam to the pt and perform in warm, quiet, private environment
initial comprehensive assessment
completed after pt has been admitted to the floor, purpose is to obtain all possible information about the pt, complete database for problem identification and care planning, past hx, allergies, and all pertinent physical findings (skin breakdown)
statuatory law
confided by legislative bodies
contemplation
considering a change within 6 months, seriously
Dermis
contains bundles of collagen, nerve fibers, blood vessels, sweat glands, sebaceous glands, and hair follicles
More than problem solving, critical thinking is an attempt to _________________ _____________________ how you apply yourself when faced with patient care problems.
continually improve
hypothermia
core body temp too low
France descendants do not eat _______?
corn- animal food
adventitious breath sounds
crackles-fine to course crackling sounds due to fluid in the air passages wheezing- high pitched,musical-generally from narrowing of air passages stridor-harsh high pitched heard on inspiration
misdemeanor
crime that doesnt inflict serious harm
Nursing process is the foundation for what?
critical thinking and problem solving actions of nurse documentation
Other health care members a sources of data
critical when transferring to/from facility hospital to long term care facility recovery room back to med surgical floor
professional nursing requires:
cultivated personal attributes , mastery of science of nursing, reflective clinical experience
A nurse's neighbor tells the nurse, "I have a high temperature, feel awful, and I am not going to work." What stage of illness behavior is the neighbor exhibiting?
-Assuming the sick role When people assume the sick role, they define themselves as ill, seek validation of this experience from others, and give up normal activities. In stage 1: experiencing symptoms, the first indication of an illness usually is recognizing one or more symptoms that are incompatible with one's personal definition of health. The stage of assuming a dependent role is characterized by the patient's decision to accept the diagnosis and follow the prescribed treatment plan. In the achieving recovery and rehabilitation role, the person gives up the dependent role and resumes normal activities and responsibilities.
Analyticity
-Be alert to potentially problematic situations -Anticipate possible results -Value reason -Use EVIDENCE-BASED KNOWLEDGE
Knowing the patient
-Develops over time -Core process of clinical decision making Aspects of knowing include: -Responses to therapy, routines, and habits -Coping resources -Physical capacities and endurance -Experiences, behaviors, feelings, perceptions
Signs of Impending Death
-Difficulty talking or swallowing -Nausea, flatus, abdominal distention -Urinary and or bowel incontinence or constipation -Loss of movement, sensation, and reflexes -Decreasing body temperature with cold or clammy skin -Weak, slow or irregular pulse -Decreasing blood pressure'-Noisy, irregular or Cheyne-Stroke respirations -Restlessness and/or agitation -Cooling, mottling, and cyanosis of the extremities and dependent areas
Collecting a nursing history
-Don't make assumptions -Listen carefully -Rephrase statements for clarity -Be respectful and non-judgemental
A nurse assesses patients in a physician's office who are experiencing different levels of health and illness. Which statements best define the concepts of health and illness? Select all that apply.
-Health and illness are individually defined by each person. -Health is more than the absence of illness. -Illness is the response of a person to a disease.
Safety Assessment
-Patients Perception of Safety Needs and Risks, -Actual and Potential Threats, -Impact of Illness on Safety, -Risks Due to Developmental Stage and Environment, -Effect of Environmental Influence on Patients Safety
What are the principles of palliative care?
-Respects goals, likes, and choices of the dying person and his loved ones -Looks after the medical, emotional, social, and spiritual needs of the dying person -Supports the needs of family members -Helps to gain access to needed healthcare providers and care setting -Builds ways to provide excellent care at end of life
Spiritual well-being
-Supports the transcendent relationship between a person and God or a higher power -Describes positive relationships and connections that people have with others
AONE guiding principles for future care delivery
-The core of nursing is knowledge and caring -Care is user-based -Knowledge is access-based -Knowledge is synthesized -Relationships of care presence-virtual -Managing the journey -Patient safety and quality
Ladders of Oppression and Cultural Competence...part 2
-Understand the institutional forces that support or negate cultural competence -Develop appropriate interventions and techniques -Understand our world view as well as the world view of culturally diverse patients, co-workers -Develop self awareness of own assumptions, values, and biases about human behavior
Critical thinking involves
-recognizing an issue exists -analyzing information related to the issue -evaluating the information -drawing conclusions
Watson's Carative Factors
3) Cultivating sensitivity to one's self and to others -Learn to accept yourself and others for their full potential. A caring nurse matures into becoming a self-actualized nurse
Oppression
A formal and informal system of advantages and disadvantages tied to membership in social groups
Reservoir
A place where microorganisms survive, multiply, and await transfer to a susceptible host
Nursing Process
ADPIE Assessment Diagnosis Planning Implementation Evaluation
Professional nursing organizations In US
ANA, NLN, AACN,
Evaluate
Most important aspect of clinical care coordination
Linguistic Competence
Ability to communicate effectively and convey information in a manner that is easily understood by diverse audiences
Depends on physical and cognitive abilities, developmental level, physical wellness, thought processes
Ability to learn
Cultural Skill
Ability to perform a cultural assessment in a sensitive way
Virulence
Ability to produce disease
An internal impulse that guides behavior
Motivation
Nonverbal cues
Add meaning to verbal communication & help you judge the reliability of verbal messages. Involves all 5 senses
Analogies
Add to verbal instruction by providing familiar images that make complex information more real and understandable.
Deals with expression of feelings and acceptance of attitudes, opinions, or values. Requires active listening
Affective
Human suffering
Affects patients physically, emotionally, socially, and spiritually
What do current documentation standards require?
All patients admitted to a health care facility have an assessment of physical, psychosocial, environmental, self-care, knowledge level, and discharge planning needs
Joint Comission
All pt receive adequate healthcare
Evaluation is
Crucial to deciding weather after interventions have been delivered a pts. Condition or well-being improves
Campinha-Bacote's model of cultural competency
Cultural awareness Cultural knowledge Cultural skills Cultural encounters Cultural desire
Make sure your communication is
Culturally respectful
Special consideration to touch
Culture Painful conditions Past violence or abuse
Addresses the pts desire or willingness to learn
Motivation to learn
When formulating a diagnosis
Move from general to specific
Psychomotor learning
Occurs when patients acquire skills that require the integration of knowledge and physical skills
What are the goals of Healthy People 2020? (4)
Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages.
The mental state that allows the learner to focus on and understand a leaning activity
Attentional set
Communication is more successful in an
Appropriate environment
Stressors
Any event, situation, or other stimulus encountered a person's external or internal environment that necessitates change or adaptation by the person
Chemical Restraints
Any form of psychoactive medication used not to treat illness but to intentionally inhibit behavior or movement
Documentation
Anything written or printed within a patient record, which may be paper, electronic, or a combination of both formats
Spirituality assessment
Assess patient's faith and beliefs Review patient's view of life, self, responsibility, and life satisfaction Assess the extent of the patient's fellowship and community Review if the patient practices religion and rituals
Steps to effective delegation
Assess the knowledge and skills of the person to whom you are delegating
If pathogens cause no clinical signs and symptoms the infection is
Asymptomatic
Holistic
Of or pertaining to the whole; considering all factors
Denial
Avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain
Spirituality
Awareness of oneself (connectedness) and connection to higher being (transcendence)
Timing (form of communication)
Often the best time for interaction is when a pt expresses an interest in communicating. Don't try to do pt teaching when the pt is in pain or upset
Question 17 of 17 Which intervention promotes connectedness with others for a patient who seems more quiet than usual? Select all that apply. A Be physically present and actively listen when the patient speaks B Assess and promote supportive social contacts C Allow time and opportunity for self-disclosure by the patient D Integrate the family into spiritual practices, as appropriate E Refer the patient to a support group or for counseling
B, D, E
A female patient has just found a large lump in her breast. The physician needs to perform a breast biopsy. The nurse helps the patient into the proper position and offers support during the biopsy. The nurse is demonstrating: A. Enabling B. Comforting C. Sense of presence D. Maintaining belief
C. Sense of presence
Seven warning signs of cancer
CAUTION Change in bowel or bladder habits Any sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or indigestion Obvious change in wart or mole Nagging cough or hoarseness
Cold conditions
Cancer, Cold, aches, Malaria, Menses, Pneumonia, Stomach cramps, teething, TB
Leininger's Transcultural Caring
Caring is an essential human need. Caring helps an individual or group improve a human condition. Caring helps to protect, develop, nurture, and sustain people.
Family Care
Caring must include the family Family is an integral resource Identify the primary caregiver in the patient's family
Swanson's Theory of Caring
Caring science
Gestures (form of communication)
Carry specific meaning by themselves, or may create messages when used in conjunction with other communication cues, such as facial expression or tone of voice
Touch
Categories: Task orientated - Caring touch - influences a patient's comfort and security, enhances self-esteem, increases confidence of caregivers, and improves mental well-being. Protective - protects patient or nurse, positive or negative. Preventing an accident. Also protects nurse emotionally
Nursing diagnosis
Clinical judgement about the patient in response to an actual potential health problem
Includes all intellectual behaviors and requires thinking. What a pt knows and understands
Cognitive
Spirituality planning
Collaborate with the patient and family on choice of interventions Consult with pastoral care or other clergy for spiritual leaders as appropriate Incorporate spiritual rituals and observances
Case management
Collaborative process of assessing, planning, facilitating, and advocating for options and services to meet an individuals health needs
You are caring for a patient who was a victim of intimate partner violence. She tells you she is very concerned about where she will stay once she leaves the hospital. According to Maslow's Hierarchy of Needs, with which level of needs are you most concerned? A) Physiological B) Self-Actualization C) Love and Belongingness D) Safety and security
D) Safety and security
professional nursing organizations
to be considered a profession a professional organization needs to be in place to set standards for practice and education. This sets education minimums, and continuity of care
When a nurse enter's a patients room and says "Good morning" before starting care, the nurse combines nursing tasks and conversation. An important aspect of care for the nurse to remember is the need to: A. Establish a relationship B. Gather assessment data C. Treat discomforts quickly D. Assess the patient's emotional needs
D. Assess the patients emotional needs
in 1982 State board exams were revised why??
to test nurses ability to Assess pts, diagnose health prob, plan nursing care, implement care, evaluate
Assessing
Data collection
Nursing diagnosis is delivered from
Data gathered during assessment (subjective, objective)
DAR
Data, action, response
Necrotic
Dead tissue
Responsibility
Duties and activists to be performed
Actual nursing diagnosis
Describes human response to health conditions or life processes
Risk nursing diagnosis
Describes human responses to health conditions/life processes that may develop
Vocation (Assessment)
Determine if illness or hospitalization alters the ability to express some aspect of spirituality as it relates to the persons work or daily activities
World View
Determines how people perceive others, how they interact and relate to reality, and how they process information
Health Promotion Model
Directed at increasing a patient's level of well being
Three responsibilities of a nurse manger (UR)
Discipline actions Develop on going staff development plans Conduct staff meetings
Spiritual health questions
Do you have any family in the area (assess for family importance, relationships and meaningful experiences)? Is there anyone you would like to call? How are you handling this hospitalization or illness? What faith practices or beliefs will help you cope with this illness or hospitalization? Do you belong to a faith community? Do you want the community to be notified? Would you like a chaplain to visit?
Xerostomia
Dry Mouth
Disinfection
Eliminates almost all pathogenic organisms, with the exception of bacterial spores
Define informatics?
Emphasizes the use of technology to communicate, manage data, and prevent errors.
Interpreters (National CLAS Standards)
Ensures quality interpreters be provided to patients with limited english proficiency. Standards require you to notify patients both verbally in and writing of their rights to receive language assistance. -Don't use family -If necessary can use telephone -Speak in "I" statements -Interpreter sit beside or slightly behind patient -Look at patient, speak in short sentences
Paper record
Episode-oriented, Key information may be lost from one episode of care to the next.
Nora Gertrude Livingston
Established a training program for nurses at the Montreal General Hospital (the first 3-year program in North America)
Nurse Practice Act
Established in each state and territory that regulates the practice of nursing
Primary appraisal
Evaluating an event for its personal meaning related to stress
Secondary appraisal
Evaluating one's possible coping strategies when confronted with a stressor.
FICA
F: Faith and belief I: Importance of faith C: Faith community involvement A: Address spirituality or spiritual practices in care
Culture Domain 8 - Pregnancy and childbearing practices
Fertility practices, views towards pregnancy, birthing, post-partum
Buddhism response to illness
Followers sometimes refuse tx on Holy Days Nonhuman spirits invading body cause illness Followers may want a Buddhist priest Followers usually except death as a last stage of life and permit withdrawal of life-support Do not practice euthanasia Often do not take time off from work for family responsibilities when sick
Asian/Pacific Islanders
Hypertension Cancer of the liver Lactose intolerance Thalassemia mental health stigma discourage eye contact late is respect stoic if in pain hot cold disease
African Americans
Hypertension Stroke Sickle cell anemia Lactose intolerance Keloids matriarch stand close when talking to others
Alternatives to restraints
Identification of agitation/behavior, Pain, discomfort, basic needs, confusion, physiologic etiology. Bed/chair Alarms, Concave beds, Increase patient observations, Frequent reorientation, Family visits, Audio/video tapes, Consistent caregiver
Related factor
Identified from assessment
Diagnosis
Identifies the actual problem. Differentiates into 2 part and 3 part system.
Errors in nursing
Identify Patient Correctly, Improve Staff Communication, Use Medicines Safely, Use Alarms Safely, Prevent Infection, Identify patient safety risks. Prevent Mistakes in Surgery, "Speak Up" Campaign
Risk factor prevention
Identify and promote wellness and education to change factors
Cues
Information you obtain through the use of senses
Culture Domain 1 - Overview
Inhabited localities - country of origin and current residence
Maturity
Know that multiple solutions are acceptable. Reflect your on judgments
LEARN Model
L: listen E: explain A: acknowledge R: recommend N: negotiate
Coping
Making an effort to manage psychological stress
Compensation
Making up for weaknesses and mistakes through gift giving, hard work, or extreme efforts
Scientific Knowledge Base
Mind, body, and spirit are interrelated. Physical and psychological well-being results from beliefs and expectations. Beliefs and convictions are powerful resources for healing.
What does the TJC and CMS require for health care institutions?
Monitor and ovulate the quality and appropriateness of patient care
Total patient care
Most common in acute care settings
Islam response to illness
Muslims use faith healing Family members are comfort Group prayer is strengthening Often permit withdrawal of life-support Do not practice euthanasia They believe time of death is predetermined and cannot be changed They maintain a sense of hope and often avoid discussions of death
Islam healthcare beliefs
Must be able to practice five pillars of Islam Sometimes has fatalistic view of health
Diagnostic label
NANDA approved diagnosis
Advocate
Nursing Roles: The protection of human or legal rights and the securing care for all patients based on the belief that patients have the right to make informed decisions about their own health and lives.
Teacher- Educator
Nursing Roles: The use of communication skills to assess, implement, and evaluate individualized teaching plans.
Communicator
Nursing Roles: The use of effective interpersonal and therapeutic communication skills to establish and maintain helping relationships with patients of all ages and in all settings.
Confidentiality: Special Student Note
Paperwork can not have patient identifiers such as: birth date, social security number, room number, medical record number, Or any unique data that could identify the pt (i.e. NBA player, mayor, guy with ebola). Access to patient records is limited to individuals involved in the care of the patient.
PICOT
Patient population Intervention Comparison Outcome Time
Through assessment a ____________ begins to form
Pattern
Identification
Patterning behavior after that of another person and assuming that person's qualities, characteristics, and actions
Culture Domain 12 - Health Care Providers
Perceptions of providers, folk practitioners, gender, and health care status
comprehensive assessment approaches
Performed in initial contact, it is the baseline data. Begins when you walk in
Stages of Behavior change
Precontemplation, contemplation, preparation, action, maintenance
Example of Potential health problems?
Prediabetic
Contact Precautions
Private Room, Handwashing, gown, gloves
Airborne Precautions
Private room with negative airflow, handwashing, N95 respirator
Droplet Precautions
Private room, handwashing, gown, gloves, surgical masks, protective eye wear
What is spiraling immobility?
Process where an older person is perceived to be at risk for falling and is therefore restrained to prevent falling. The person then becomes unable to walk due to prolonged immobilization
Sikhism-implications for health nursing
Provide time for devotional prayer Allow use of religious symbols
What is the purpose of the nursing process?
Purpose is to diagnose and treat human responses to actual or potential health problems
Implemententation
Putting the care plan into action
Who sets the standards for documentation?
Set by many regulating bodies, including state and federal laws. Documentation must following the nursing process and show evidence of patient/family teaching and discharge planning.
Patient Abandonment
The joint commission requires institutions to have guidelines for the number of staff needed to care for patients
Maturational loss
The loss experienced as a result of natural developmental process
Why do we disinfect equipment
To eliminate all pathogen organisms
Always identify what the pt expects
To learn
The purpose of data validation is
To make sure data is factual and complete
Which clinic patient is most likely to have annual breast examinations and mammograms based on the physical human dimension?
Tricia, who has a family history of breast cancer -The physical dimension includes genetic inheritance, age, developmental level, race, and gender. These components strongly influence the person's health status and health practices. A family history of breast cancer is a major risk factor.
B. Notify the physician
You are caring for a patient who underwent surgery 48 hours ago. On physical assessment, you notice that the wound looks red and swollen. The patient's WBCs are elevated. You should A. Start antibiotics. B. Notify the physician. C. Document the findings and reassess in 2 hours. D. Place the patient on isolation precautions.
What does quality nursing care depend on?
Your ability to communicate effectively verbally and in writing, you are held accountable for the accuracy of documentation you enter into the patient's record
conceptual framework or model
a group of concepts that follows an understandable pattern
Americans With Disabilities Acr
a civil rights act protecting the disabled regarding access to public services, healthcare, and employment
Altrusim
a concern for others; generosity
Important aspects in assessing
think about pt and data needed dont repeat or ask questions about what you know setting age of pt/ peds vs adult/ Male vs. female
Parish nurses can be
health advisors health educators advocates liaisons to faith and community resources coordinators of volunteers developers of support groups
components of health assessment
health hx and physical assessment
What is the health- illness continuum moedel?
health is constantly changing high level wellness and death begin on opposite ends of scale.
Types of Health Promotion Activities
health promotion, wellness education, illness prevention
tachycardia
heart rate above 100
bradycadia
heart rate below 60
What is primary purpose of nursing process?
help manage clients care scientifically, holistically, individualize care plans
systematic data
helps you not miss anything important
Emergency medical treatment and active labor act
law that requires screening of patients in an emergency department and apropriate stabilization before transfer of patient to another facility
Unintentional injuries
result from incidents that occur at random and may be unavoidable. Patterns of unintentional injuries are often predictable and may be preventable.
Diagnostic and lab data as data collection methods
results of tests pt c/o cough with green sputum, increase in temp, with fever and chills (respiratory infection)
pt record as sources of data
review before 1st contact if able things in pt chart: demographics, p/p medical hx, labs, diagnostics , consultations, reports from therapies
Acute care
support systems diet therapies supporting rituals
maintanence
sustained change over time, avoid relapse
2nd phase of illness
symtopatic stage, assuming sick role may treat with OTC remedies, wait it out and see if sx resolve itself seek advise from friends/family
quality improvement
systematic and continuous actions that lead to measurable improvement in health care service and health status of targeted patient groups.
Isolation precautions
•Airborne •Droplet •Contact
Medical asepsis
•Control or elimination of infectious agents •Cleaning •Disinfection and sterilization •Control of elimination of reservoirs •Control of portals of exit •Control of transmission
Biohazardous waste
•Cultures •Pathological waste •Blood and blood products •Sharps •Selected isolation material
Hand hygiene
•Handwashing •Antiseptic hand wash •Antiseptic hand rub •Surgical hand antisepsis
Multidrug-resistant organisms (MDROs)
•Methicillin-resistant Staphylococcus aureus (MRSA) •Vancomycin-resistant enterococcus (VRE) •Clostridium difficile
Surgical asepsis
•Requires more precautions than medical asepsis •Commonly used in the operating room •Also used at the patient's bedside
Caring
◦A universal phenomenon influencing the ways we think, feel, and behave with one another
Providing presence
◦Being with ◦Eye contact ◦Body language ◦Expressions ◦Listening ◦Positive and encouraging attitude
Categories of touch
◦Task-oriented ◦Caring ◦Protective
Louise Schuyler
-A nurse during the Civil War; returned to New York and organized the New York Charities Aid Association to improve care of the sick in Bellevue Hospital -Recommended standards for nursing education
Healthy People 2020
-A set of disease prevention and health promotion objectives for Americans to meet during the second decade of the new millennium. -The fourth set of health goals and objectives for the U.S. that defines the nation's health agenda and guides its health policy
Florence Nightingale
-Founder of modern nursing -Developed first organized training program for nurses -Improved sanitation in battlefield hospitals -Used statistics to prove success
With Critial Thinking comes a willingness to look at each unique situation and determine which _________________ are true and relevant
assumptions
What is the STOP technique? and why is it useful?
(s) stop and take step back (t) take breaths (o) observe inside yourself (p) proceed after you pause
Listening
*Establishes trust *Opens lines of communication *Creates a mutual relationship
The Challenge of Caring
- Task-Oriented Care - Technology - Improved Nurse-to-Patient Ratios - Cost-cutting measures - Stressors that place nurses at risk for burn out and compassion fatigue
Health promotion activities may occur on a primary, secondary, or tertiary level. Which activities are considered tertiary health promotion? Select all that apply.
-A nurse teaches a patient with an amputation how to care for the residual limb. -A nurse provides range-of-motion exercises for a paralyzed patient. Tertiary health promotion and disease prevention begins after an illness is diagnosed and treated to reduce disability and to help rehabilitate patients to a maximum level of functioning. These activities include providing ROM exercises and patient teaching for residual limb care. Providing immunizations and teaching parents how to childproof their homes and use an appropriate car seat are primary health promotion activities. Providing screenings is a secondary health promotion activity.
What will you assess for and explain to family members of a dying patient?
-Adequacy of knowledge base -Realism of expectations -Adequacy of coping strategies -Adequacy of resources -Physical response
Despite a national focus on health promotion, nurses working with patients in inner-city clinics continue to see disparities in health care for vulnerable populations. Which patients would be considered vulnerable populations? Select all that apply.
-An African American teenager who is 6 months pregnant -A low-income family living in rural America -A Hispanic male who has type II diabetes -A White baby who was born with cerebral palsy National trends in the prevention of health disparities are focused on vulnerable populations, such as racial and ethnic minorities, those living in poverty, women, children, older adults, rural and inner-city residents, and people with disabilities and special health care needs.
Nurse Caring Behaviors as Perceived by Families
-Being honest -Advocating for patient's care preferences -Giving clear explanations -Keeping family members informed -Asking permission before doing something to a patient -Providing comfort: offering a warm blanket, finding food a patient can swallow, rubbing a patient's back -Reading to patient passages from religious texts, a favorite book, cards or mail -Providing for and maintaining patient privacy -Assuring the patient that nursing services will be available -Helping patient to do as much for self as possible -Teaching the family caregiver how to keep the patient physically comfortable
Swanson's Theory of Caring
-Defines caring as a nurturing way of relating to an individual -States that caring is a central nursing phenomenon but is not necessarily unique to nursing practice
Caring is primary (Benner)
-Dynamic - respect for person, love of humanity and freedom of choice -Experiential -Individual Caring means being connected; that is; "caring creates possibility"; describes a range of involvement, from parental love to friendship, from caring about one's work to caring for one's pet to caring for and about one's patients
Patient Satisfaction - Caring Assessment Tool (CAT) Pg 556 Box 20.3
-Mutual Problem Solving -Attentive Reassurance -Human Respect -Encouraging Manner -Appreciation of Unique Meanings -Health Environment -Affiliation Needs -Basic Human Needs
Relieving symptoms and suffering
-Performing caring nursing actions that give a patient comfort, dignity, respect, and peace -Providing necessary comfort and support measures to the family or significant others -Creating a physical patient care environment that soothes and heals the mind, body, and spirit -Comforting through a listening, nonjudgmental, caring presence
The student nurse learns that illnesses are classified as either acute or chronic. Which are examples of chronic illnesses? Select all that apply.
-Rheumatoid arthritis -Cystic fibrosis -Diabetes mellitus are chronic diseases because they are permanent changes caused by irreversible alterations in normal anatomy and physiology, and they require patient education along with a long period of care or support. Pneumonia, fractures, and otitis media are acute illnesses because they have a rapid onset of symptoms that last a relatively short time.
Clara Barton
-Volunteered to care for wounds and feed Union soldiers during the Civil War -Served as the supervisor of nurses for the Army of the James, organizing hospitals and nurses -Established the Red Cross in the United States in 1882
SBAR communication
-situation:include the admitting and secondary diagnoses and problem your patient is having as the current issues -background: pertinent medical history -assessment: head to toe assessment -recommendation: plan of care and request orders
Factors that influence Hygiene
-social practices -body image -health beliefs and motivation -developmental stage -personal preferences -socioeconomic status -cultural variables -physical condition
Informatics
-the science and art of turning data into information -it focuses on information and knowledge acquisition rather than the computer
Environmental Hazards
-transmission of pathogens -pollution
Ethics in nursing practice includes an embrace of accountability or the ability to justify your own actions. Even though your practice is defined in part by orders written by health care providers and polices enforced by administrators, you remain ethically accountable for your which of the following of actions illustrates accountability? Select all that apply. 1. Your patient receives a surgical procedure that is new to your facility. You ask your manager to provide an in service about the procedure. 2. A health care provider writes orders for pain medication even though the patient has been pain free for 3 days and out of respect you administer the meds. 3. During annual budget preparation at your facility, you advocate for annual pay increases for you and your peers. 4. Your patient confides in you that she has recently lost her job and is anxious about her medical bills, including her ability to pay for medications after discharge. Health care providers coverage is not your area of expertise but you know that the social worker might be able to help. You initiate a consultation request.
1 and 4
Opening Sterile Packages
1)Open flap farthest away from you first. 2)Don't let side flaps close once you've opened the sterile package. 3)Keep arms from crossing over sterile field. 4)Use outer 1" border to move field
7 Principles of Surgical Asepsis
1)Sterile can only touch sterile 2)Only sterile objects in sterile field 3)Object falling below waist, unattended objects or turning back on field causes all objects & field to be contaminated. 4)Do NOT cross arm over sterile field! 5)Prolonged exposure to air contaminates field 6)Moisture onto a sterile field causes field to become contaminated. 7)Fluid flow in the direction of gravity 1" border around field contaminated
Which of the following is an example of a health disparity? (Select all that apply) 1. A pt. who has a homosexual sexual preference 2. A pt. unable to access primary care services 3. Patients living with a chronic disease 4. A family who relies on public transportation 5. A patient who has had a history of smoking for 10 years
1, 2, 3, 5
Health care organizations must provide which of the following based on Federal civil rights laws? (select all that apply) 1. Provide language assistance services at all points of contact free of charge 2. Provide auxiliary aids and services, such as interpreters, note takers, and computer-aided transcription services 3. Use patient's family members to interpret difficult topics 4. Ensure interpreters are competent in medical terminology 5. Provide language assistance to all patients who speak limited English or are deaf
1, 2, 4, 5
The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with their chronic illness, which of the following principles should the nurse apply in practice? (Select all that apply.) 1. Pay attention to the patient's spiritual identity throughout the course of her illness 2. Select interventions that you know scientifically support spiritual well-being 3. Listen to the patient's story each visit to the clinic and offer a compassionate presence 4. When the patient questions the reason for her long-time suffering, try to provide answers 5. Consult with a spiritual care advisor and have the advisor recommend useful interventions
1, 3
Which of the following is required of a nurse practicing advocacy? 1. Speak up for the patient care issues even when others disagree 2. Contribute money toward the patients health care costs if the patient is indigent 3. Assess the patients point of view and prepare to articulate it. 4. Document all clinical changes in the medical record in a timely and legible way. 5. Become an active member of professional nursing organizations.
1, 3, 4
Select the three factors that are evident when a healing relationship develops between nurse and patient. 1. The nurse being able to realistically mobilize hope for the patient 2. The patient being able to share fears of loss with significant others 3. Finding an interpretation or understanding of the patient's illness that is acceptable to the patient 4. Understanding your own beliefs about spirituality 5. Helping the patient use spiritual resources that he or she chooses
1, 3, 5
A 35 year-old woman has Medicaid coverage for herself and her 2 young children. She missed an appointment at the local health clinic to get an annual mammogram because she has no transportation. She gets the annual screening because her mother had breast cancer. Which of the following are social determinants of this women's health? (Select all that apply) 1. Medicaid insurance 2. Annual Screening 3. Mother's history of breast cancer 4. Lack of transportation 5. Woman's age
1, 4, 5
Principles of surgical asepsis
1.A sterile object remains sterile only when touched by another sterile object. 2.Only place sterile objects on a sterile field. 3.A sterile object or field out of the range of vision or an object held below a person's waist is contaminated. 4.A sterile object or field becomes contaminated by prolonged exposure to air. 5.A sterile object or field becomes contaminated by capillary action when a sterile surface comes in contact with a wet contaminated surface. 6.A sterile object becomes contaminated if gravity causes a contaminated liquid to flow over the surface of an object. 7.The edges of a sterile field or container are considered to be contaminated.
1 meter
100 cm, 1000 mm
1 liter = ____ milliliters
1000
1 kg =
1000 g
1 pint (pt)
16 oz (500 mL)
Watson's Carative Factors
2) Instilling faith-hope -Provide a connection with the patient that offers purpose and direction when trying to find the meaning of an illness
A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are defining characteristics that supporting nursing diagnosis of spiritual distress related to loss of family members? (Select all that apply) 1. I need to call my sister for support 2. I have nothing to live for now 3. Why would my god do this to me? 4. I need to pray for miracle 5. I want to be more involved in my church
2, 3
.A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate? (Select all that apply.) 1. Encourage family members to participate in the exercise. 2. Have patient identify a quiet room in the home that has minimal interruptions. 3. Suggest use of a quiet fan running in the room. 4. Explain that it is best to meditate about 5 minutes 4 times a day. 5. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.
2, 3, 5
A nurse begins a night shift, assuming care for a critically ill patient who was resuscitated earlier in the day from cardiac arrest. He survived and is physically stable, alert, oriented, and responding appropriately to the nurse's questions. Knowing that the patient experienced a period when his heart stopped beating, what would be the best approach for the nurse to use with him? 1. Have family come to visit and focus discussion about their gratitude that the patient survived 2. Change the subject when the patient begins talking about entering a dark tunnel when the doctors were resuscitating him 3. Sit and encourage the patient to share what he experienced during resuscitation 4. Provide the patient the opportunity to have passages from the bible read to him
3
A patient who is recovering from a bilateral amputation of the legs below the knee shows transcendence when she states: 1. "My pain medicine helps me feel better." 2. "I know I'll get better if I just keep trying." 3. "I see God's grace and become relaxed when I watch the sun set at night." 4. "I have had a great life and a good marriage. My husband has been so helpful in my healing."
3
Evaluation of spiritual care is necessary to determine if a patient's level of spiritual health has changed following intervention. If the use of rituals was part of a nurse's care plan, which of the following questions is most appropriate to evaluate its efficacy? 1. Do you feel the need to forgive your wife over your loss? 2. What can I do to help you feel more at peace? 3. Are prayer or meditation helpful to you? 4. Should we plan on having your family try to visit you more often in the hospital?
3
A student nurse is developing a plan of care for a 74-year-old-female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered? (Select all that apply.) 1. Older adults do not routinely use complementary medicine to cope with illness. 2. Older adults dislike discussing the afterlife and what might have happened to people who have passed on. 3. Older adults achieve spiritual resilience through frequent expressions of gratitude. 4. Have the patient determine if her husband left a legacy behind. 5. Offer the patient her choice of rituals or participation in exercise.
3, 4, 5
Planning is the
3rd step in the nursing process
A student nurse is telling a faculty member that her patient talked about gaining spiritual comfort from being focused on her inner self, including her values and principles. The instructor explains that this is an example of: 1. Faith. 2. Community. 3. Interpersonal connection. 4. Self-transcendence.
4
Watson's Carative Factors
4) Developing a helping, trusting, human caring relationship -Learn to develop and and sustain helping-trusting, authentic caring relationships through effective communication with your patients
Watson's Carative Factors
6) Using creative problem-solving, caring processes -Apply the nursing process in a systematic way to provide patient-centered care
Watson's Carative Factors
7) Promoting transpersonal teaching-learning -Learn together while educating the patient to acquire self-care skills. The patient assumes responsibility for learning
1 cup
8 oz, 240 mL
Watson's Carative Factors
8) Providing for a supportive, protective, and/or corrective mental, physical, societal and spiritual environment -Create a healing environment at all levels, physical and nonphysical. This promotes wholeness, beauty, comfort, dignity and peace
Watson's Carative Factors
9) Meeting human needs -Assist patients with basic needs with an intentional care and caring consciousness
The nurse is planning care to meet the spirituality needs of a patient. How should the nurse involve the chaplain with this patient's care? A Nurses should make chaplaincy referrals when a patient demonstrates or verbalizes a need for spiritual care. B Once a chaplain referral has been made, the chaplain takes over the patient's spiritual care. C Ask the chaplain to meet with the patient's family to convince the patient to receive spiritual care. D Ask the chaplain to speak to the patient's family about the patient's spiritual beliefs.
A
What does the "I" stand for in the FICA Spiritual Assessment Framework? A Importance of faith B Integration in a community C Implications for medical care D Inclusion of family in decision making
A
Which action must the nurse take for the patient to accept spiritual care? A Create an environment of compassion and care. B Display strong faith in God. C Use spiritual assessments. D Use a five-point Likert system.
A
Spiritual distress
A belief or value disruption that threatens their sense of purpose in life
Goal
A broad statement that describes the desired change in a patients condition or behavior
Metacommunication
A broad term that refers to all factors that influence communication
C. A sense of presence
A female patient has just found a large lump in her breast. The physician needs to perform a breast biopsy. The nurse helps the patient into the proper position and offers support during the biopsy. The nurse is demonstrating A. Enabling. B. Comforting. C. A sense of presence. D. Maintaining belief.
Advantage of primary nursing
A flexible model uses a variety of staffing levels and mixes
describes what the patient will be able to do after instruction
A learning objective
B. Assess the knowledge of the CNA
A newly graduated nurse is assigned to a team consisting of herself and a CNA. When delegating skills, she needs to: A. Assign only bed-making and feeding skills B. Assess the knowledge of the CNA C. Remind the staff member that she is working under the license of the RN. D. Allow the staff member to perform only skills that the RN is able to teach CNA's to perform
3. "Why did you give that patient his tray? You should have known I needed to talk with him before you let him eat." 5. "Can you please give that patient this medication for me? I have to take phone call."
A nurse finished assessing all assigned patients and is discussing with an NAP what needs to be done in the next hour. Which statements require follow-up by the nurse manager (select all that apply) 1. "Can you please go answer the patient's call light in room 5117 and see what the patient needs?" 2. "I need to assess this patient's skin. About 5 minutes after you start the bath, I'll come into the room to help you turn her, wash her back, and look at her skin." 3. "Why did you give that patient his tray? You should have known I needed to talk with him before you let him eat." 4. "Thank you for helping me get that patient up in the chair. I could not have done it without you." 5. "Can you please give that patient this medication for me? I have to take phone call."
4. Asking the patient to explain the side effects of a newly ordered medication.
A nurse is caring for patient with type 2 diabetes. Which action shows the nurse is evaluating the effectiveness of the patient's care. 1. Asking the patient how often he exercises every week 2. Working with the patient to determine a target range for blood sugar first thing in the morning. 3. Measuring the patient's capillary glucose level before lunch. 4. Asking the patient to explain the side effects of a newly ordered medication.
1. "Help me understand what is preventing this patient from being able to walk independently." 4. "It seems like we need to get another opinion about why the patient isn't gaining weight. Who do you think we should ask to evaluate the patient?"
A nurse is participating in interdisciplinary team rounds. Which statements made by the nurse reflects appropriate team communication? (select all that apply) 1. "Help me understand what is preventing this patient from being able to walk independently." 2. "I have a lot of patients to see. Let's get through this as fast as possible." 3. "You are late. Where have you been?" 4. "It seems like we need to get another opinion about why the patient isn't gaining weight. Who do you think we should ask to evaluate the patient?" 5. "Did you hear about what happened between the nurses and doctors last night?"
2. A patient who is slightly more confused now compared with 4 hours ago
A nurse just received hand-off report at the change of shift. Which patient does the nurse need to see first? 1. A patient who needs to be taught how to change a dressing at home 2. A patient who is slightly more confused now compared with 4 hours ago 3. A patient who is ranking incisional pain as a 4 on a 0-10 scale 4. A patient who needs a soapsuds enema
Complementary role (assuming the role as the leader or professional)
A nurse may assume a ____________________________ when functioning as a clinical expert during health teaching
Health Disparity
A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage
4. The patient must remain in the room most of the time to control for transmission of the infection but with proper precautions can leave the room for procedures.
A patient diagnosed with a multidrug-resistant organism in a surgical wound asks the nurse what it means to be placed on isolation. What is the nurse's best response? 1. The patient must remain in the room at all times so that contact with other patients is avoided 2. The organism is easily spread, so family and visitors must be limited to one at a time. 3. The patient needs to remain in the room at all times and wear gloves when using the restroom 4. The patient must remain in the room most of the time to control for transmission of the infection but with proper precautions can leave the room for procedures.
C. Foley catheter bag
A patient is admitted to a medical unit for a home-acquired pressure ulcer. The patient has Alzheimer's disease and has been incontinent of urine. The nurse inserts a Foley catheter. You will identify a link in the infection chain as A. Restraints. B. Poor hygiene. C. Foley catheter bag. D. Improper positioning.
Spiritual care often is the most important nursing intervention when
A patient is terminally ill
d. psychomotor learning
A patient newly diagnosed with diabetes needs to learn how to use a glucometer. Use of glucometer constitutes as: a. affective learning b. cognitive learning c. motivational learning d. psychomotor learning
Patient care summary or Kardex
A portable "flip-over" file or notebook with patient information
Intrapersonal communication (self-talk)
A powerful form of communication that occurs within an individual. Is a mental rehearsal for difficult tasks or situations that enables individuals to deal with them more effectively
Prognosis
A prediction of the probable outcome of a disease or condition of a client and the usual course of the disease as observed in similar situations
Self-transcendence
A sense of authentically connecting to one's inner self
Burnout
A state of physical, emotional, and mental exhaustion created by long-term involvement in an emotionally demanding situation and accompanied by lowered performance and motivation
B. Primary nursing
A travel nurse has taken an assignment at a health care facility where nurses assume responsibility for a caseload of patients over a period of time. This type of nursing exemplifies: A. Team nursing B. Primary nursing C. Functional nursing D. Decentralized management
Storytelling
A way to begin to understand a patient's cultural perspective. Conveys culture, combining personal experience with the commonalities of all human experiences
Which of the following variables influence a patient's health and beliefs and practices? (Select all that Apply) A) Developmental stage B) Emotional Factors C) Family Practices D) Genetic Background
A) Developmental stage B) Emotional factors C) family practices
Which of the following are examples of external variables influencing illness and behavior? Select all that apply A) social group B) cultural background C) patient perception of the illness D) accessibility of heath care
A) social group B) cultural background D) accessibility of health care
Nurses are likely to refer chaplains to which care areas? Select all that apply. A Oncology units B Intensive care C Emergency department D Hospice E Critical care unit
A, B, D, E
Which are elements of the SPIRIT framework of spiritual assessment Select all that apply. A Spiritual belief system B Personal spirituality C Importance of faith D Regular practice of faith E Terminal-events planning
A, B, E
In order to incorporate spirituality into the plan of care, which questions, based on the HOPE framework; will the nurse ask an end-of-life patient? Select all that apply. A "How do you personally practice spirituality?" B "Can you tell me how important your faith is to you?" C "I see you're crying. Would you like me to call the chaplain?" D "Do you want me to call your family?" E "Why do you believe in God?"
A, C
Health care agencies often have assessment tools to use in clarifying patient values and assess spirituality. Using the FICA assessment tool, match the criteria on the left with the appropriate assessment question. 1. F - Faith 2. I - Importance of spirituality 3. C - Community 4. A - Interventions to address spiritual needs A. tell me if you have a higher power or authority that helps you act on your beliefs B. describe which activities give you comfort spiritually C. to whom do you go for support in times of difficulty? D. your illness has kept you from attending church. Is that a problem for you?
A, D, C, B
Situation-background-assessment-recommendation (SBAR)
About 60% of the worst type of medical errors, called sentinel events, relate to communication problems that often arise during telephone reports. Use SBAR to standardize telephone communication.
Buddhism healthcare beliefs
Accepts modern medical science
Sikhism healthcare beliefs
Accepts modern medical science
Christianity healthcare beliefs
Accepts modern medical science Complementary or alternative medicine often followed
Non-maleficence
Actively doing no harm
Common diagnoses associated with hygiene
Activity intolerance, Bathing self-care deficit, Dressing self-care deficit , Impaired physical mobility, Impaired oral mucous membrane, Ineffective health maintenance, Risk for infection,
Types of lossess
Actual Perceived Physical Psychological Maturational Situational Anticipatory
collaborative problem
Actual or potential physiological complication that nurses monitor to detect a change in patient status
Low priority
Actual or potential problems may or may not be directly related to patients illness or disease
Humor is a coping strategy that
Adds perspective and helps you and a patient adjust to stress
What are the two types of advanced directive?
Advanced Directives(Living will): allowing people to state in advance what their choice would be for health care should certain circumstances develop Durable Power of Attorney: appoints an agent the person trust to make decisions in the event of subsequent incapacity
Hinduism- Implications for health and nursing
Allow time for prayer and purity rituals allow use of amulets, rituals, and symbols
Faith
Allows people to have firm beliefs despite lack of physical evidence. It enables them to believe in and establish transpersonal connections. Although many people associate faith with religious beliefs, it exists without them
Why is a handoff report so important?
Also called "shift report". Report given from nurse to nurse. May be verbal, recorded or written. Occurs with transfer of patient care. Provides continuity and individualized care. Reports are quick and efficient.
Potential nursing diagnoses for spiritual health
Anxiety Ineffective coping Complicated grieving Hopelessness Powerlessness Readiness for an enhanced spiritual well-being Spiritual distress Risk for spiritual distress Risk for a impaired religiosity
Physical Restraint
Any manual method, physical or mechanical device, material or equipment attached or adjacent to the person's body that cannot be easily removed by the person. Inappropriate use of restraints violates both state and federal regulations. Use constitutes abuse.
What is documentation?
Anything written, verbal or printed that is relied on as a record of proof for authorized persons. Reflects the quality of care. Provides evidence of each health care team member's accountability in giving care. "If it wasn't documented, it wasn't done".
Cognitive skills
Application of critical thinking in the nursing process
Verbal spiritual assessment cues
Asks for prayer or chaplain Asks if the nurse has time to talk Talks about topics related to life, death, or purpose Talks about faith Uses religious words in conversation Asks frequent questions about diagnosis; needs to talk Expresses concerns about family
5 step nursing process
Assess Diagnose Plan Implement (perform) Evaluate
Life Satisfaction (assessment)
Assess a patients satisfaction with life
Life and Self Responsibility (assessment)
Assess the extent to which a patient understands the limitations or threats posed by an illness and the manner in which he or she chooses to adjust to them
Ritual and Practice (assessment)
Assessing the use of rituals and practices helps you understand a patient's spirituality
ACCESS model
Assessment Communication Cultural Negotiation, Compromise Establishing Respect & Rapport Sensitivity Safety
Nursing processes (5)
Assessment Nursing Diagnosis Planning Implementation Evaluation
What are the steps of the nursing process?
Assessment, Diagnose, Plan, Implement, Evaluate
Nursing Process
Assessment, Diagnosis, Outcome Identification, Planning, Implementation, Evaluation
sterotyping
Assuming that everyone in a particular group is the same.
Worldview
Assumptions that develop during childhood and guide how one sees, thinks about, experiences, and interprets the world
Healthy People 2020 guidlines
Attain high quality care achieve health equity create socal and physical environments that promote health promote quality of life
A patient states that he would like to go to church every week, but due to immobility limitations, is unable. Which diagnosis is correct for this patient? A Decisional Conflict B Impaired Religiosity C Spiritual Distress. D Moral Distress
B
Which spirituality-related goal written by a student suggests the student needs additional teaching? A After consulting with the dietician, the patient will identify acceptable ways to blend dietary restrictions with religious customs. B Patient will start going to church daily after discharge and will report back to the nurse. C Patient will discuss treatment choices with a trusted confidant to explore acceptable options before beginning treatment. D Patient will contact a spiritual counselor within two weeks of discharge.
B
A 50 year old woman decides to have an annual mammogram. Which level of prevention is this patient practicing? A) Primary prevention B) Secondary prevention C) Tertiary prevention D) Rehabilitation
B) Secondary Prevention
Which statement is true regarding parish nursing? A Parish nursing was designated as a specialty area of practice by the ANA in 2007 B The Reverend Dr. Granger-Westberg's work in the mid-1980s was the stimulus for Parish nursing. C Parish nurses act in roles such as health advisers, advocates, and liaison to faith and community resources D Holistic care focusing on the mind, body, and spirit is provided by parish nurses E Many faith traditions exclude parish nursing as part of their recognized spiritual communities.
B, C, D
The primary agents that cause infection are
Bacteria, viruses,fungi & Protozoa
Mary Adelaide Nutting
Became the first professor of nursing in the world as a faculty member of Teachers' College, Columbia University; with Lavinia Dock, published the four-volume History of Nursing
Hot Treatments
Beef, Cereal, Chili peppers, Chocolate, Eggs, Liquor, Onions, Anise, Aspirin, Castor Oil, Cinnamon, Garlic, Ginger Root, Iron, Penicillin
Communication can result in
Both harm and good
Goals of Nursing Research
Build the scientific foundation for clinical practice, Prevent disease and disability, Manage and eliminate symptoms caused by illness, Enhance end-of-life and palliative care.
How do you use and strengthen and spiritual resources?
By encouraging a patient to discuss the affect that illness has had on personal beliefs and faith (thus giving the chance to clarify any misconceptions or inaccuracies information)
A patient is a Jehovah's Witness and does not want a blood transfusion, but her health care provider told her she would risk her life without it. Which diagnosis is appropriate for this patient? A Spiritual Distress B Impaired Religiosity C Moral Distress D Decisional Conflict
C
Which goal is appropriate for a patient with a nursing diagnosis of Readiness for Enhanced Religiosity? A Patient will contact a spiritual counselor within one month. B Patient will sign a contract to no longer engage in harmful customs within three months after discharge. C Patient will contact estranged family members to arrange for a combined meeting with a spiritual counselor within two weeks. D Patient will attend meetings with a spiritual counselor daily.
C
Which nursing action demonstrates appropriate spiritual care for a school-age child whose parent is terminally ill? A Discussing with the child how the illness will affect the child's life and belief systems B Praying with the child and family members C Discussing with the child the permanence of the child-parent relationship and that the illness is not caused by anything the child did. D Discussing with the child the spiritual aspects of the parent's likelihood of passing
C
Which nursing action(s) are most effective to assist a typical adult male patient to make health care decisions related to spirituality? A Monitoring and promoting social contact B Providing extra communication and time for reflection C Researching and providing factual information D Asking the patient to lead a prayer session
C
You are caring for a patient who has just suffered a mild heart attack. You are developing his discharge education plan. Which statement by the patient indicates his readiness to change his behavior? A) "I don't think I really has a heart attack." B) "I already exercise 3 times a week." C) "I know my dad died early from heart disease." D) "I travel too much to eat healthy."
C) "I know my dad died early from heart disease."
Alarm stage
CNS aroused fight-or-flight rising hormone levels increased blood volume increased blood glucose increased epinephrine increased norepinephrine increased HRspiritual well-being Increase blood to muscles increased O2 intake increased alertness pupils dilate
Clinical decision making
Careful reasoning so that the best options are chosen for the best outcomes
Christianity - implications for health and nursing
Christians usually in favor of the organ donation Health is important to maintain Allow time for patients to pray by themselves or with family or friends
Allostatic load
Chronic arousal with the presence of powerful hormones causes excessive wear and tear on bodily organs
When admitting a pt. durning the initial interview, a family member tells you, "my mom really mean that's she does not understand her medical diagnosis." The communication form used by the family member is
Clarifying
Leadership skills for nursing
Clinical care coordination Team communication Delegation Knowledge building
Starts when you walk in for your shift
Communication
What's the purpose of a Health Record?
Communication, Legal documentation, Diagnostic-related groups (DRGs), Education, Research, Auditing.
Validation of assessment data consists of
Comparison of data with another source to determine accuracy of the data
Examples of ego-defense mechanisms
Compensation Conversion Denial Displacement Identification Dissociation Regression
Transcultural
Concept of care extending across cultures that distinguishes nursing from other health disciplines
Navajos healthcare beliefs
Concepts of health have fundamental place in their concept of humans and their place in the universe
Negligence
Conduct that falls below the generally accepted standard of care of reasonably prudent person
What are the 11 Critical thinking ATTITUDES?
Confidence, Thinking Independently, Fairness, Responsibility & Accountability, Risk Taking, Discipline, Perseverance, Creativity, Curiosity, Integrity, Humility
Discuss critical thinking skills used in nursing practice.
Connect knowledge and theory with day to day practice and reflect on and analyze thoughts, action and knowledge
Transpersonal
Connect with unseen, God, or a higher power
Intrapersonal
Connected with oneself
Interpersonal
Connected with others and the environment
Hot Conditions
Constipation, Diarrhea, Fever, Infection, Kidney Problems, Rash, Sore Throat
Islam dietary practices
Consumption of pork and alcohol is prohibited. Followers fast during the month of Ramadan.
An infectious disease transmitted directly from one person to another is
Contagious or communicable disease
Awareness of ________factors help you to make sound decisions during the communication process
Contextual
Dynamic process
Continually changing
Interdisciplinary care plan
Contributions from ALL disciplines involved in patient care
Reasons to not use restraints
Convenience, Family Pressure/Insistence, Request of the family, Family should be involved in care decisions but education as to 'cons' is required, Under Staffed, Decrease legal liability, Legal risk of using restraints is greater than not using restraints. Evidence shows using restraints does not reduce the incidence of falls and injuries.
Regression
Coping with a stressor through actions and behaviors associated with an earlier developmental period
Developmental crises
Crisis associated with normal and expected phases of growth and development (eg; the response to menopause); same as maturational crises
Nursing process
Critical thinking process that professional nurses use to apply the best avaiable evidence to caregiving (the fundamental blueprint for how to car for pts.)
Leininger's Transcultural Caring
Cultural focus
The nurse says to the patient when her family arrives, "Let me give you privacy." What is being promoted by the nurse? A Reflection B Connectedness to a higher power C Faith rituals D Connectedness to others
D
Which statement made by a Native American patient recovering from chemotherapy treatment indicates the diagnosis of Readiness for Enhanced Religiosity? A "It is very hard to stick to my diet while I am in the hospital." B "I have been off of alcohol for a month now and feel great." C "I feel like God will not forgive me each time I give in and smoke a cigarette." D "It is important for me to make dietary choices according to the tribal beliefs of my community."
D
Swanson's Theory of Caring - DOING FOR
Definition: Doing for the other as he or she would do for self if it were at all possible Subdimensions: Comforting Anticipating Performing skillfully Protecting Preserving dignity
Swanson's Theory of Caring - ENABLING
Definition: Facilitating the other's passage through life transitions (birth, death) and unfamiliar events Subdimensions: Informing/Explaining Focusing Supporting/Allowing Generating alternatives Validating/giving feedback
Swanson's Theory of Caring - KNOWING
Definition: Strive to understand an event as it has meaning in the life of the other Subdimensions: Avoiding assumptions Centering on the one cared for Assessing thoroughly Seeking cues Engaging the self or both
Swanson's Theory of Caring - MAINTAINING BELIEF
Definition: Sustaining faith in the other's capacity to get through an event or transition and face a future with meaning Subdimensions: Believing in/holding in esteem Maintaining a hope-filled attitude Offering realistic optimism Going the distance
Standards of care
Demonstrate the ethic of care Be thorough and ensure that assessmen is relevantt to the patient's situation Follow ANA code of ethics
Kubler-Ross Stages of Grief
Denial and isolation Anger Bargaining Depression Acceptance
Identification of a nursing diagnosis allows the nurse to
Develop an individualize plan of care
Factors that influence safety
Developmental Level, Mobility/Impaired mobility, Sensory, Lifestyle Choices, Knowledge and adherence to common safety precautions, Abuse.
What are the factors affecting grief and dying?
Developmental considerations Family Socioeconomic factors Cultural, Gender & Religious Influences Cause of Death
Internal Variables
Developmental stage, intellectual background, emotional factors, spiritual factors
hispanics
Diabetes mellitus Lactose intolerance inappropriate to tell problems to stranger no eye contact hot/cold disease
Safe use of restraints
Document the physical assessment , Must be done at least every 2 hours; remove the restraints and give them range of motion for circulation, As an RN you can delegate the task of applying restraints to the tech/aide/CAN but the assessment must be preformed by the RN
Living Wills
Documents instructing health care provides to withdrawl or withhold life sustatining procedure
Inference is a process of
Drawing conclusions from related pieces of evidence
a. analogy
During a teaching session, the nurse tells a patient with a recent neck injury that damage to the nerves is comparable to a water hose that has been pinched off. During this teaching session, the nurse is using the process of: a. analogy b. discovery c. role playing d. demonstration
Barriers to healthcare (8)
Economics, education, geography, language, stereotyping, prejudice and discrimination, misunderstanding
Presence
Establishes the nurse-patient relationship and is linked to positive patient outcomes. Conveys a closeness and sense of caring
Listening
Establishes trust Opens lines of communication Creates a mutual relationship
A holistic view enables you to
Establishing a helping role and a healing relationship
Problem Solving
Evaluating the solution over time to make sure it is effective
The last step in the nursing process is
Evaluation
Dissociation
Experiencing a subjective sense of numbing and a reduced awareness of one's surroundings
Spirituality and culture implications for patient centered care
Explore the spirituality of patience from different cultural backgrounds; assess the meaning of health and how patients achieve balance, stability, peace, or comfort in their lives Offer a universal and holistic approach when assessing the patient needs;; demonstrate caring and use therapeutic communication techniques Journey assessments respect patience human rights, values, customs, and spiritual beliefs Spiritual assessment should be interdisciplinary. If you feel uncomfortable with religion or spirituality, respectfully identify if a patient wishes referral to an appropriate professional chaplain or clergy Avoid use of language that alienates or discriminates among different cultures
Culture Domain 11 - Health Care practices
Focus of health care, traditional practices, responsibility for health, self-medication, pain, sick role, barriers
Transformational leadership
Focus on creating work environments that allow individuals to work to their highest potential and bring positive change to the work environment through their use of reflection, intellectual stimulation, and using the best evidence to guide their decisions.
Russian orthodox church dietary practices
Followers observed fast days and day "No meat" rule on Wednesdays and Fridays During lent all animal products, including dairy products and butter, or forbidden
Working phase
Gather information, use various communication techniques: active listening; paraphrasing; summarizing
RISK Factors for Disease/Illness
Genetics, physiological factors, Age, Physical Environment, Lifestyle
Patient education teaching strategies for Meditation
Give patient a brief description of information and they printed teaching guide that describes how to meditate Help patients identify a quiet room in the home that has minimal interruptions Explain that peaceful music for the quiet whirring other fan blocks out distractions Teach steps of meditation Encourage patient to meditate for 10 to 20 minutes twice a day Answer questions and reinforce information as needed
What to note about hair
Growth, distribution, and pattern indicate general health status
Admission nursing history form
Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems
HOPE
H: Sources of hope, meaning, comfort, strength, peace, love, and connection O: Organized religion P: Personal spirituality and practice E: Effects on medical care and end-of-life issues
Health care providers cannot contact a faith community without the consent of the patient because of
HIPPA
Hand Hygiene
Hands visibly soiled--- soap and water Rub vigoursly with soap for at least 15-30 seconds Hands not visibly soiled --- alcohol based rub Rub until alcohol is dry
Environmental spiritual assessment cues
Has religious books, jewelry, or symbols and/or has prayer objects Displays family pictures
When caring for a patient with impaired verbal communication related to a language barrier, your first priority is to
Have a professional interpreter made available
Competency
Having the knowledge and skill to perform an action safely and efficiently
American Indians and Alaska natives
Heart disease Cirrhosis of the liver Diabetes mellitus Fetal alcohol syndrome eye contact impolite 2 meals daily
How are palliative care and hospice care similar? How are they different?
Hospice: -Focuses on needs of the dying -Palliative care provided -Provided in home or treatment facility Palliative Care: -Care that relieves symptoms; doesn't alter the course of the disease. -Goal: to give pts the best quality of life by aggressive management of their symptoms. -Appropriate across spectrum of dz and illness
define self concept
How a person thinks/ perceives of himself/herself. past experiences, perceptions of strengths/ weaknesses
Commonalities of Caring Theories
Human interaction or communication, mutuality, appreciating the uniqueness of individuals, and improving the welfare of patients and families
Betty Newman (1972)
Humans are in constant relationship with stressors in the environment. The major concern for nursing is keeping the patient's system stable through accurately assessing the effects of environmental stressors and in assisting the patient with adjustments required for optimal wellness.
Determine conditions that place clients at risk for impaired skin integrity.
Immobilization-when unable to move freely dependent body parts are exposed to pressure=decreased circulation Reduced Sensation-pts w/ paralysis= circulatory insuff, nerve damage Nutrition and Hydration Alterations-less protein and colories devolope thinner, less elastic skin with less subcutaneous fat=imparied or delayed wound healing Secretions & excretions on the skin-moisture on skin serve as a resevoir for bacteria=irritation, softened cells=skin breakdown= infection Vascular insufficiency-decreased circulation to the extremities=ischemia and breakdown; also risk for infection because delivery of nutrients, o2, & WBCs to injured tissue is inadequate External Devices-exert pressure of friction on the skin Altered Cognition-unaware
Disparity is linked to
Inadequate resources Poor patient-provider communication Lack of culturally competent care Inadequate access to language services
Social determinants of health
Include resources such as access to health care, job opportunities nutritious food, clean air, and transportation
Affective learning
Includes a patient's personal attitudes, beliefs, behaviors, and emotions
Observation of a patients behavior
Includes a patients level of function
Cognitive learning
Includes what a patient needs to know and understand
Evidence shows us that higher levels of spiritual health are associated with:
Increased compliance with treatment regimens Less symptom distress Decreased pain levels Lowered anxiety Enhanced quality of life Lower mortality rates
In the oncology population, higher levels of spiritual well-being are associated with:
Increased levels of general health, hope, coping, social functioning, self-rated health quality of life. Less depression, financial strain, and suicidal ideation.
Native American dietary practices
Individual tribal beliefs influence food practices
Health literacy
Individual's ability to obtain, process, and understand basic health information and services to make appropriate and informed health decisions
Meaning (form of communication)
Individuals who use a common language share the denotative meaning of a word
Chain of Infection
Infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host
Interpersonal communication
Interaction that occurs between 2 people or within a small group. Refers to nonverbal & verbal behavior within a social context & includes the use of symbols & cues to give & receive meaning
Each step of the nursing process is ____________ with one another
Interrelated
Studying is an example of
Intrapersonal communication
Types of spiritual caring
Intrapersonal, interpersonal, transpersonal
Orientation
Introduce yourself, explain the purpose of interview, establish trust
Time Management
Involves learning how, and when to use your time
WHOLE BRAIN STANDARD
Irreversible failure of all functions of the ENTIRE brain
"Intellectual" as used in the Critical Thinking Model.
Is a guideline or principle for rational thought
Communication
Is a powerful therapeutic tool and an essential nursing skill that influences others & achieves positive health outcomes
Concept Mapping
Is a visual representation of client problems and interventions that shows their relationships to one another
Spiritual Caring
Is about developing caring relationships with patients by fostering connections to promote spiritual comfort and well-being
Spiritual caring
Is about developing caring relationships with patients by fostering connections to promote spiritual comfort and well-being.
Motivation
Is an internal state that helps arouse, direct, and sustain human behavior.
The message
Is the content of the conversation. It includes verbal & nonverbal that the sender expresses
The channel
Is the means of conveying & receiving messages through visual, auditory, & tactile senses
Attentional set
Is the mental state that allows the learner to focus on and comprehend a learning activity.
Feedback
Is the message that the receiver returns to the sender
The sender
Is the person who delivers the message
The environment
Is the physical & emotional climate in which an interaction takes place
Reflective Journaling
Is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning.
Connotative meaning (form of communication)
Is the shade or interpretation of the meaning of a word influenced by the thoughts, feelings, or ideas that people have about the word
Vocabulary communication
Is unsuccessful if a receiver cannot translate a sender's words & phrases
Core Measures
Key quality indicators that help health care institutions improve performance, increase accountability, and reduce costs
cultural awareness
Knowledge of various cultural beliefs and values
Allows a person to attend to instruction
Learning environment
Affects a persons preferences for learning
Learning styles
Licensure is defined as
Legal permit that a government agency grants to individuals to engage in the practice of a profession and to use a particular title
Authority
Legitimate power to commands and make final decisions specific to a given position
subcutaneous layer
Lies just beneath the skin; contains blood vessels, nerves, lymph, and loose connective tissue filled with fat cells
medical assessment
Looking for pathological conditions to make a sx i.e. HTN, appendicitis, CHF, determines the medical tx that will be ordered, surgery, meds, tx
Psychological loss
Loss caused by an altered self image
Physical loss
Loss of a limb, child, valued object such as money, and a job
Early recognition of infection helps
Make the correct nursing diagnosis and establish a treatment plan
Expected outcome
Measurable criteria to evaluate goal achievement
Nursing sensitive patient outcome
Measurable patient, family, or community state behavior, or perception largely influenced by and sensitive to nursing interventions
Contact precautions
Measures taken to prevent the spread of diseases transmitted by the physical transfer of pathogens to a susceptible host's body surface
Difference between nursing diagnosis and medical diagnosis
Medical Diagnosis: Identify and label medical illnesses. Can be Physical or Psychological. Nursing Diagnosis: Broader in focus-Consider patient's response to medical diagnoses to life situations-Make clinical judgments based on medical diagnoses and conditions.
Medical Asepsis
Medical asepsis are used for "clean" procedures. Medical asepsis reduces the number of pathogens and prevents spread of organisms. We should be using medical asepsis for all of our contact with patients and patient equipment. Practices promoting medical asepsis include hand hygiene, use of standard precautions, and cleaning equipment such as over bed tables, patient room, equipment and even our own stethoscope or pen/pencil/computer station!
Medical assessment vs. nursing assessment
Medical- dr. Dx, pathology, condition/dx, CVA/Stroke Nursing Assessment- based on p/t needs, whole person, response to health problems (BHN ADl), self care deficit (feeding, bathing, grooming, toileting)
What guidelines establish a patient's home care reimbursement by home care nurses
Medicare
Jehovah's Witnesses dietary practices
Members of avoid food prepared with or containing blood
Restraint Order Requirements
Method specified. Physician/licensed provider direct patient assessment and indications documented, In an emergency RN may initiate restraint but client must receive face to face evaluation within one hour.
Airborne precautions
Methods of infection control that must be used for patients known or suspected to be infected with pathogens transmitted by airborne droplet nuclei.
Droplet precautions
Methods of infection control that must be used for patients known or suspected to be infected with pathogens transmitted by large particle droplets expelled during coughing, sneezing, talking, or laughing.
Colonization
Microorganisms growth within a host, without tissue invasion or damage
Primary nursing
Most common in acute care settings & the home care setting
case management
Most common in the home care setting
What does the N.C.Q.A stand for? What do they do?
National Committee for Quality Assurance work with TJC to maintain accreditation and minimize liability
You are caring for a patient who will undergo a bone marrow aspiration, a difficult and painful procedure necessary to monitor the progress after a bone marrow transplant. You are eager to minimize pain for this patient. You review the medical record for the previous successful pain management plans. You discuss the procedure with the patient. You advocate for the patient when the health care arrives to prepare the procedure. Which ethical principle best describes the reasons for your actions? 1. Beneficence 2. Accountability 3. Non maleficence 4. Respect for autonomy
Non maleficence
Intermediate priority
Non-emergent, non-life threatening
Inflammatory response
Nonspecific defense reaction to tissue damage caused by injury or infection
Oral Cavity
Normal oral mucosa is light pink, soft, moist, smooth, and without lesions. Medications, exposure to radiation, and mouth breathing can impair salivary secretion.
What are providers required to do for patients regarding HIPAA?
Notify patients of their privacy policy and make a reasonable effort to get written acknowledgement of this notification
Examples of statutes that are enacted by state legislature to regulate nursing practice.
Nurse Practice Act
Nurse are required to protect patient information from who?
Nurses are responsible for protecting records from all unauthorized readers. HIPAA requires that disclosure or requests regarding health information are limited to the minimum necessary. Nurses may not discuss a patient's examination, observation, conversation, diagnosis, or treatment with other patients or staff not involved in the patient's care.
What does the assessment data base include?
Nursing History physical examination lab dx tests knowledge
Leader
Nursing Roles: The assertive, self confident, proactive of nursing when providing care, effecting change, and functioning with groups.
Ernestine Wiedenbach
Nursing as an art; nursing is providing nurturing care to patients care is directed to specific purpose meeting pts perceived needs
Nursing care plan
Nursing diagnoses, goals, and expected outcomes, and nursing interventions, and a section for evaluation findings
Faye Abdullah
Nursing is a problem-solving art and science used to identify the nursing problems of patients as they move toward health and cope with illness-related health needs. 21 nursing care problems
Loss
Occurs when a valued person, object or situation is changes or becomes inaccessible such that its value is diminished or removed
Facial expressions
Often become the basis for judgements by the receiver. Seek verbal feedback about the sender's intent when these are unclear
Ladders of Oppression and Cultural Competence
Oppression - institutional/cultural/societal level Discrimination - group level/interpersonal Bias/Prejudice - individual level/intra-personal Stereotype - individual/intra-personal
Systematicity
Organized and focused on priorities of care
Assessment
Organized and ongoing appraisal of a patient's well-being. Comprehensive assessment leads to accurate nursing diagnosis
Patient centered interview
Organized conversation with the patient
Concept maps promote problem solving and critical thinking skills by
Organizing complex patient data, analyzing concept relationships and identifying interventions
Body system defenses
Organs have specialized defense mechanisms
The three phases of an interview
Orientation Working phase Termination
Return demonstration
Participatory teaching method in which the technique is first described to the patient and then demonstrated to the patient; the patient is then asked to repeat the demonstration
Symptomatic
Pathogens cause clinical signs and symptoms
Asymptomatic
Pathogens do not cause clinical signs and symptoms
Disease or infection only result if
Pathogens grow & multiply
Critical pathways
Patient care management plans that provide the interdisciplinary health care team with activities and task to be put into practice sequentially (Main purpose: deliver timely care at each phase of the care process for a specific type of patient)
Considered a basic nursing competency
Patient education
One of the most important roles that a nurse will do is
Patient education
Healthcare-acquired infections (HAI)
Patient gets an infection from the hospital
If outcomes are met
Patient goals are met
sources for obtaining information on an assessment
Patient is number one source, family and significant others, patient record, other health care professionals, nursing and healthcare literature
Health Care Associated Infections
Patients at greater risk for health care- associated infections (HAIs) Multiple illnesses •Older adults •Poorly nourished •Compromised immune system
Transmission-based precautions
Patients with communicable disease and infections that are easily transmissible to others require special isolation precautions is called:
Value
Personal idea about value of something including religion/spirituality
Exhaustion stage
Phase that occurs when the body can no longer resist the stress (i.e. when the energy necessary to maintain adaptation is depleted)
Stress
Physiological or psychological tension that threatens homeostasis or a person's psychological equilibrium
Teach Back & Plain Language
Plan your approach Use handouts, pictures and models Chunk and Check - small segments throughout Clarify and Check again - Ask patient to teach back Start slowly and use teach back consistently, practice Use the show me method Clarify - repeat, and have patient teach back
Touch is one of the nurses most
Potent forms of communication (Conveys: affection, emotional support, encouragement, and personal attention
Dependence on others for routine self-care needs often creates
Powerlessness and the loss of a sense of purpose in life impair the ability to cope with alterations in functioning
Nursing Diagnoses for Restraints
Powerlessness, Chronic confusion, Hopelessness, Risk for falls, Risk for Loneliness, Chronic/situational low self esteem, Social isolation,
Restorative and Continuing Care
Prayer Meditation Supportive grief work
To block communication is
Prejudgment on part of the nurse
Fowler's Theory of Faith Development
Prestage: undifferentiated faith Stage 1: intuitive-projective faith Stage 2: mythical-literal faith Stage 3: synthetic-conventional faith Stage 4: individuative-reflective faith Stage 5: conjunctive faith Stage 6: universalizing faith
Organs have specialized defense mechanisms to
Prevent exposure to infection
A nurse has volunteered to give influenza immunizations at a local clinic. What level of care is the nurse demonstrating?
Primary
Three Levels of Prevention
Primary-true prevention lowers chances of getting a disease Secondary- Focuses on those who have disease, or at risk Tertiary- Defect or disability is permanent or irreversible
Ethical care is part of
Priority setting
ANA
Professional organization for RN's in the US. Publicizes standards of Practice to ensure knowledgeable, safe, comprehensive, nursing care by those who will receive a license
Mental health Parity Act
Prohibits health plans from placing lifetime or annual limits on mental health benefits
Functions of the skin
Protection, secretion, excretion, temperature regulation, and sensation
Reasons to use restraints
Protects the patient from exacerbating underlying illness or injury. Prevent interference with medical treatments
NANDA
Provides a precise definition that gives all members of the health care team a common language for understanding patient needs
What does HIPAA do?
Provides legislation to protect patient privacy for health information, governs all area of health information management, including reimbursement, medical records, coding, security, and patient record management
Which of the following situations represents an ethical rather than legal consideration? 1. Administering medications 2. Providing care to someone without health insurance 3. Sharing patient information with another health care provider 4. Reporting a communicable disease to the public health officer.
Providing care to someone without health insurance.
Involves acquiring skills that require integration of mental and muscular activity
Psychomotor
Good communication with all healthcare providers ensure
Pt safety & promote optimal pt outcomes
Sources of validation include
Pt. Medical record. Other health care team members. Family members.
Physicals assessments include
Pts. Height, weight, vital signs, general appearance and behavior, head to toe examination of all body systems
Three factors in a healing relationship between nurse and patient
Realistically mobilizing hope for the nurse and patient Finding an interpretation or understanding of the illness, pain, anxiety, or other stressful emotion that is acceptable to the patient Helping the patient to use social, emotional, and spiritual resources
Humility
Recognize when you need more information to make a decision. Admit when you do not know something.
Data Analysis and interpretation involves
Recognizing patterns in clustered data, comparing them with standards, and coming to a conclusion
legal guidelines for documentation
Record all facts; do not enter personal opinions. Do not leave blank spaces in nurses' notes. Write legibly in permanent blank ink. If an order was questioned, record that clarification was sought. Chart only for yourself, not for others. Avoid generalizations. Begin each entry with the date/time and end with your signature and title. A nurse's signature on an entry in a record designates accountability for the contents of that entry.
Fall interventions at the home
Reduce obstacles: scatter rugs, electrical cords, de-clutter, Improved lighting: non glare, Remove bathroom hazards, Small pets
"Professional" as used in the Critical Thinking Model.
Refers to 3 criteria: -ethical (pt advocate, pt autonomy, beneficence) -evidence-based (used to assess and determine efficacy of tx) -professional responsibility (Standards in Nurse Practice Act)
Health Literacy
Refers to the ability of the individuals to understand basic health info and to use that info to make good decisions.
Posture & gait (form of communication)
Reflect emotions, self concept, & health status
Two useful tools that can improve critical thinking skills
Reflective Journaling Concept Mapping
Team member ps provide care under direction of
Registered nurse (RN)
Ego-defense mechanisms
Regulate emotional distress and thus give a person protection from anxiety and stress
Culture Domain 10 - Spirituality
Religious practices, use of prayer, meaning of life
Intersectionality
Research and policy model used to study the complexities of people's lives and experiences. The model looks at how being marginalized affects people's health and access to care
Spirituality evaluation
Review the patient's self perceptions regarding spiritual health Review the patient's view of his or her purpose in life Discuss with family and close associates the patient's connectedness Ask if the patient's expectations are being met
The five rights of delegation
Right task Right circumstances Right person Right direction Right supervision
The agent-host-environment model of health and illness is based on what concept?
Risk factors
Risk nursing diagnosis
Risk for Spiritual Distress Risk for Impaired Religiosity
Risk associated with using restraints
Risk for Strangulation/Death from Strangulation. Demoralization, humiliation, feelings of low self worth, depression, impaired social functioning, social isolation
Infection prevention practices reduce the
Risk for cross-contamination & transmission to other patients when caring for a pt. with a known suspected infection
What are some nursing diagnoses for safety risks?
Risk for falls, Impaired home maintenance, Risk for injury, Deficient knowledge, Risk for poisoning, Risk for suffocation, Risk for trauma,
Nursing Process: Assessment (hygiene)
Self-care ability,Skin, Feet and nails, Oral cavity, Hair and hair care, Eyes, ears, and nose, Use of sensory aids, Hygiene care practices, Cultural influences
Culture (Worldview)
Shared experiences and commonalities that have developed and continue to evolve in relation to changing social and political contexts based on multiple social group memberships
Stages of grief
Shock and disbelief Developing awareness Restitution (rituals surrounding the death) Resolving the loss (dealing with the void left) Idealization (exaggeration of the good qualities in the person) Outcome (dealing with the loss)
S bar
Situation Background Assessment Recommendation
Morse Fall Scale
Six-item fall risk assessment tool, widely used nationally and internationally since the late 1980s in acute care and long-term care settings. Simple/Quick
Culture Domain 5 - Biocultural Ecology
Skin color, heredity, genetics, drug metabolism
normal flora, located...
Skin, saliva, oral mucosa, intentional walls
Christianity dietary practices
Some Baptists, evangelicals, and Pentecostals discourage use of alcohol and caffeine. Some Roman Catholics fast on Ash Wednesday and Good Friday. Some do not eat meat on Fridays during Lent
Buddhism dietary practices
Some are vegetarians and do not use alcohol. Many fast on Holy Days.
Judaism dietary practices
Some observe the kosher dietary restrictions (e.g., avoid pork and shellfish, do not prepare and eat milk and meat at same time).
Hinduism dietary practices
Some sects are vegetarians. The belief is not to kill any living creature.
Active Euthansia
Someone other than the patients commits an action with the intent to end the patients life, for example injecting the patient with a lethal dose of a drug
Confidence
Speak with conviction and always be prepared to perform care safely
Critical Thinking
Specific Knowledge + Expertise and Experience
Actual nursing diagnosis
Spiritual Distress Impaired Religiosity Decisional Conflict Moral Distress
factors influencing spirituality
Spiritual distress Acute illness Chronic illness Terminal illness Near-death experience
Recorded Data
Standardized manner
Surgical Asepsis
Sterile asepsis is a state where all microorganisms are eliminated from an area or an object. This is used when the client's skin is broken or sterile body area is entered (such as dressing change, surgical procedure or inserting a needle into skin). Sometimes the entire area and equipment need to be sterile by setting up a sterile field such as when inserting a urinary catheter or during a surgical procedure. In these sterile skills, the nurse's hands must be sterile by properly donning sterile gloves, setting up a sterile field (which is the area any equipment that may enter the area.
SOAP
Subjective, objective, assessment, plan
SOAPIE
Subjective, objective, assessment, plan, intervention, evaluation
Perceived loss
Such as loss of youth, financial independence, and a valued environment, is experienced by the person but s intangible to others
Seizures
Sudden, disorderly discharge of cerebral neurons
Explanation
Support your finding and conclusions. Use scientific knowledge and experience to choose stategies
Generalized seizures
Sustained Involuntary muscle contractions Tonic: rigid muscles Clonic: muscular jerking
If pathogens cause clinical signs and symptoms the infection is
Symptomatic
Trauma
Symptoms of stress persist beyond the duration of the stressor
Cultural Assessment
Systematic and comprehensive examination of the cultural care values, beliefs, and practices of individuals, families, and communities
Scientific method
Systematic, ordered approach to gathering data and problem solving
Most effective when it responds to the learners needs
Teaching
Examples of promoting health?
Teaching health lifestyles referrals and info health literacy healthy people 2020
Effective communication among nurses is essential for
Teamwork; which affects nurse recruitment & retention
Termination Phase
Tell pt when coming to an end highlight key points ask if theres anything else to know before pt knows name of nurse, plan of care whats expected and what is expected of them Always thank them
Teaching approaches
Telling, participating, entrusting, reinforcing
Medical Immobilization (restraint)
Temporary immobilization for the performance of or recovery from a medical procedure or surgical treatment
Examples of recognized parish nursing groups
The Jewish Congregational Nurses Muslim Crescent Nurses
assessment of individual spiritual needs is initiated early in the patient encounter by the admissions officer or the admitting care provider is required by
The Joint Commission
Health Literacy Assessment Tools
The Short Assessment of Health Literacy (Eng, Spanish) The Rapid Estimate of Adult Literacy in Medicine - short form
cultural compentence
The ability of an individual to understand and respect values, attitudes, beliefs and morals that differ across cultures, and to consider and respond appropriately to these differences
Linquistic competence
The ability to communicate effectively and convey information in a manner that is easily understood by diverse audiences. Audiences include: -Those with limited proficiency -Those with low literacy skills or are not literate -Those who have disabilities -Those who are deaf or hard of hearing
Inflammation
The cellular response of the body to injury or infection (Delivers fluid, blood products, & nutrients to interstitial tissues in an area if injury)
A female pt who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process?
The nurse reassesses the pt and decides how to best intervene in her care
Cultural Desire
The nurse's intrinsic motivation to provide culturally competent care
Appalachians response to illness
They dislike hospitals Tend to not follow medical regimens but expect to be helped directly when seeking episodic treatment
Resistance stage
Third stage of the stress response, when the person attempts to adapt to the stressor. The body stabilizes; hormone levels stabilize; and heart rate, blood pressure, and cardiac output return to normal
Pouring liquids ("lip" the solution)
This is pouring some of the sterile solution out of the container into the waste to remove contaminates that may be present in the bottleneck. When pouring liquids onto a field, use caution not to allow liquids to splash on a permeable surface. Germs can "wick" through the splashed liquid and contaminate your sterile field. Hold the container outside of the sterile field minimizing reaching over the field. Follow agency guidelines for how long the remainder of the solution can be used, often 24 hours when used with the same patient. Ensure you place your date, time and initials on any remaining solution.
1. Encourage fluids the insertion of the catheter is in place. 2. Make sure the catheter and insertion supplies remain sterile throughout the insertion procedure. 4. Secure the catheter tubing to the patient's thigh
To decrease the risk of a urinary tract infection while a patient has an indwelling urinary catheter, what should the nurse do? (select all that apply) 1. Encourage fluids the insertion of the catheter is in place. 2. Make sure the catheter and insertion supplies remain sterile throughout the insertion procedure. 3. Place the urine collection bag higher than the bladder to maintain patency of drainage tubing. 4. Secure the catheter tubing to the patient's thigh 5. Assess the patient's history of latex allergy
Clarity & brevity (form of communication)
To minimize confusion, effective communication is simple, short, & to the point
Intonation & volume (form of communication)
Tone of voice & volume dramatically affect the meaning of a message & emotions directly influence tone of voice
Fight-or-Flight response
Total physiological response to stress that occurs during the alarm reaction stage of the general adaptation syndrome. Massive changes in all body systems prepare a human being to choose to flee or remain and fight the stressor.
Displacement
Transferring emotions from the original source to another
Crisis
Transition for better or worse in the course of a disease, usually indicated by a marked change in the intensity of signs and symptoms
Communicable disease
Transmitted directly from one person to another
Indirect care
Treatments performed away from the patient but on behalf of the patient
Direct care
Treatments performed through interaction with patients
Basic Level of Critical Thinking
Trust that experts have the right answers for every problem; thinking is concrete and based on a set of rules or principles. You follow STEP-BY-STEP instructions.
Colonization occurs
When a microorganism invades the host but does not cause infection
D. Assess the patient's emotional needs.
When a nurse enters a patient's room and says "Good morning" before starting care, the nurse combines nursing tasks and conversation. An important aspect of care for the nurse to remember is the need to A. Establish a relationship. B. Gather assessment data. C. Treat discomforts quickly. D. Assess the patient's emotional needs.
Eyes, ears and nose
When hygiene care is provided, the eyes, ears, and nose require careful attention. •Clean the sensitive sensory tissues in a way that prevents injury and discomfort for a patient, such as by taking care to not get soap in his or her eyes.
Working phrase
When the nurse & pt work together to solve problems and accomplish goals
Orientation phrase
When the nurse & the pt meet & get to know each other
Endogenous infection
When the patient's flora becomes altered and an overgrowth results
endogenous infection
When the patients flora becomes altered and an overgrowth results (Usually from over use of antibiotics)
Feedback indicates
Whether the receiver understood the meaning of the sender's message
1. Place the patient in contact isolation precautions 2. Clean hands before and after each patient encounter with soap and water. 3. Clean hands before and after wearing personal protective equipment such as gloves, gowns, masks, and goggles.
Which are the most effective ways to prevent transmission of C. Difficile between patients? (select all that apply) 1. Place the patient in contact isolation precautions 2. Clean hands before and after each patient encounter with soap and water. 3. Clean hands before and after wearing personal protective equipment such as gloves, gowns, masks, and goggles. 4. Keep the patient's room door shut at all times 5. Use alcohol disinfectant wipes to clean work surfaces
1. Scrub the hub of an IV tubing port before inserting a safety needle 3. Frequent oral hygiene 4. Daily bathing with chlorhexidine gluconate 5. Keep point of connection between urinary catheter and drainage tube closed
Which of the steps are designed to control; the portal of entry of a microorganism? (select all that apply) 1. Scrub the hub of an IV tubing port before inserting a safety needle 2. Wearing PPE 3. Frequent oral hygiene 4. Daily bathing with chlorhexidine gluconate 5. Keep point of connection between urinary catheter and drainage tube closed
2. A patient describes how to set up her pill organizer for the week. 5. A patient demonstrates how to take his blood pressure at home using his home machine.
Which scenario best demonstrates that learning has taken place (select all that apply) 1. A nurse reviews the warning symptoms of a stroke 2. A patient describes how to set up her pill organizer for the week. 3. A patient attends a spinal cord injury support group 4. A nurse gives a patient written information regarding a new medication 5. A patient demonstrates how to take his blood pressure at home using his home machine.
1. A nurse asks a new mother what she understanding about her home care of her cesarean-section incision including activity restrictions and incision care. 4. A nurse gathers information regarding the home and school life of a 10-year-old patient who recently had an appendectomy.
Which scenario best describes the first step in the teaching process (select all that apply) 1. A nurse asks a new mother what she understanding about her home care of her cesarean-section incision including activity restrictions and incision care. 2. A nurse gives a patient who had a stroke a magnet that lists the warning signs of a stroke. 3. A nurse provides education regarding a new blood pressure medication to a patient before discharge 4. A nurse gathers information regarding the home and school life of a 10-year-old patient who recently had an appendectomy. 5. After a patient reads an informational pamphlet, the nurse has the patient explain the correct way to take a newly ordered diabetes medication.
Advance directive
Written directive that allows people to state in advance what their choices for health care would be if certain circumstances should develop
To develop a therapeutic relationship with a pt,
You must establish trust, empathy & caring
A plan of care will change as
Your patients needs change
Subjective data
Your patients verbal descriptions of their health problems .... cannot be measured
Health
____________a state of optimal functioning or well-being
Nursing informatics System
a nursing speciality that manages and communicates data, information, knowledge, and wisdom by integrating nursing computer and information science
Define health disparity
a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage
Values
a personal belief about the worth held for an idea, custom, or object
values verification
a process by which people come to understand their own values an value system
health
a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity
illness
a state which a person's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired
Health literacy refers to what? (3)
ability to understand basic health info make good decisions 12% of pop has a proficient health literacy score.
Indicators of Healthy people 2020 (every 10 years)
access to health care reproductive sexual health preventive services substance use oral health nutrition
Collection of client vital step in the nursing process because remaining steps depend on:
accurate complete factual relevant
data validation
act of confirming or validating keeps data free from errors or bias very important nurse must decide which data needs validating can perform at any time
deontologic
action is right or wrong independent of its consequences
Action
actively engaged in strategies to change behavior, requires commitment time and energy
nursing diagnosis
actual and potential health problems that nursing intervention can prevent or resolve. the goal of the nursing diagnosis is to focus on the patient's responses to health problems (NANDA)
two types of illnesses
acute- fast , strikes suddenly , limited time chronic- slow onset, 6 months or longer, periods of remission
Health Belief Model
addresses the patients relationship between a person's beliefs and behaviors
data communications
all data must be communicated STAT verbal communication needed when assessment indicates change (Failure = poor outcome) all data must be documented on same day subjective quotes, objective summarized write legible good grammar/spelling use med terms be specific avoid average, good, bad, large
How to deliver culturally sensitive care?
all pt to collect thoughts use interpreter if needed aware of nonverbal body language aware of hand gestures English may be broken
wellness is defined as
an active state of being healthy by living a lifestyle promoting good physical, mental, and emotional health.
How was nursing viewed in the past?
as a punishment, for women to care of sick instead of serving time in prison, tasked based
When does assessment begin?
as soon as you walk into the pts room, general observation, interview pt, head to toe assessment/focused,
Life and Self Responsibility Assessment
ask about a patient's understanding of illness limitations or threats and how the patient will adjust
Faith/belief (assessment)
ask about a religious source of guidance
Fellowship and community (assessment)
ask about patients supportive community
Connectedness
ask about the patient's ability to express a sense of relatedness to something greater than self
What are the ANA's 6 standard of practice?
assess diagnosis outcome identification planning implementation coordination of care health teaching and promotion evaluation
In every encounter with patients, a nurse must:
assess pt note alterations in health status, systems, BHN determine whether nursing action is helping pt achieve goals modify care plan PRN
nursing process
assess, nursing diagnosis, identify expected outcomes, implement care, evaluate results
it is important to document:
assessments, interventions, and evaluations to avoid liability
roles of the nurse in dx procedures
assist, be responsible for equipment needed, witness pt's consent, schedule tests, prepare pt physically and emotionally, provide care after test, dispose of used equipment, transport specimens
Basic Human Needs Model
attempts to meet the patients needs, prioritization of care, Maslow's Hierarchy of Needs
Do NOT impose your own
attitudes and beliefs
beauchamp and childress principal based approach to bioethcis
autonomy- respect pt right to choose non-maleficence avoid causing harm beneficence- benefit justice- act fairly fidelity- keep promises accountability- being responsible for own actions
cultural conflict
becoming aware of cultural differences and feel threatened. ridiculing beliefs and traditional to make themselves feel more secure
Prodromal (1st phase of illness)
before a person develops sx "doesnt feel good"
Impact of illness on Patient and family
behavioral and emotional changes, body image, self-concept, family roles and family dynamics
elements of nursing
body and application of knowledge
normal breath sounds
bronchial-heard over the trachea-high pitched, harsh sounds bronchiovesicular- heard over the mainstream bronchus-moderate"blowing" sounds, vesicular-heard over the base of the lungs-soft and low pitched
3 main activities of the valuing process
choosing, prizing, acting
Torts
civil wrongful acts or omissions against a person property that are compensated by awarding monetary damages to the individuals rights who were violated
14 Intellectual Standards
clear --plain, understandable precise--exact specific--metion, define, describe in detail accurate--true, free from error relevant--essential plausible--reasonable consistent--consistent beliefs, values logical--correct reasoning deep--contains complexities and multiple relationships broad--covering multiple viewpoints complete--thorough thinking and evaluation significant--focus on what is important, not trivial adequate--satisfactory in quality or amount fair--open-minded and impartial
Blended skills of nursing
cognitive skills (knowledge) technical skills (hands on) interpersonal Skills (communication, people skills) ethical and legal skills (personal accountability) critical thinking and clinical reasoning (whole person)
four essential competencies
cognitive, technical, interpersonal, ethical/legal
What is the nurses role in the assessment step of the nursing prcess?
collect and validate data from pt and other sources (family, neighbor, friends, coworker, chart, physicians) assess data
assess
collect, validate and communicate patient data, vital step-all remaining steps depend on complete, accurate, factual data, made at the beginning of care and throughout the course of care, goal is to come up with dx and interventions.
authoritative knowledge
comes from an expert and is accepted as truth based on the person's perceived expertise. senior staff teaches new graduate.
nursing theory
conceptualizes an aspect of nursing to describe, explain, predict, or prescribe nursing care 4 Concepts person, environment, health, nursing (person most important)
Discuss different approaches used in maintaining a patient's comfort and safety during hygiene care.
consider a pts normal grooming routine including hygiene products to use and routine (wash hair first or last), timing, frequency, extent, method (bath or shower, partial bath at sink or bedside). perform cleaniest to less dirty, use clean gloves, check water temp, use priniple body mechanics and safe pt handling, be sensitive to invasion of privacy and poss loss of self-esteem
preparing for the physical exam
consider the needs of the patient, explain the process, ask pt to change into a gown and empty bladder, answer questions directly and honestly, gather necessary supplies, provide privacy, and a warm quiet room with adequate lighting
A thoughtful nurse is:
considerate and compassionate, keeping person @center of all deliberations in order to promote humanity, dignity, and wellbeing
define Thoughtful practice
considerate and compassionate, person is center of care
What are LPNS responsible for?
continuous data collection and ongoing assessment and contributions to plan of care
Why is the nursing process important?
decision making framework, used to determine needs of pt and decide care
Deontology
defines actions as right or wrong based on "right making characteristics"
Nurse practice act
defines legal scope of practice, excludes untrained or unlicensed people from practicing, establishes education and licensing criteria, creates a state board of nursing, makes and enforces rules and regulations
focused assessment
detailed assessment of a specific problem. pt has abdominal pain- Ask questions about urinary problems, bowel problems, allergies, menstrual hx, assess vital signs and abdominal structures
Nursing Process (Diagnose)
determine nursing dx for actual and potential health probs, use maslows to prioritize nursing diagnosis , identify strengths, decide if normal/abnormal
Justice
determining the order in which the patient should be treated.
Ethics Committees
develop policies and procedures for handling issues focus on pt and his her her rights
nurses who practice pt centered care are committed to?
developing caring professional relationships, mutual respect and trust, holistic approach
4 functions of ethics committees
education policy making case review consultation research
comprehensive drug abuse prevention and control act
enacted to control and regulate hospital drug distribution of narcotics, antidepressants, hypnotics, sedatives, stimulants, and hallucinogens.
good samaritan law
encourages nurses and other healthcare providers to help in emergency situations within their scope of practice
documentation
enter data asap, if it isn't recorded, it didn't happen, summarize, use pt's own words, avoid non-specific terms
The International Council of Nurses Code of Ethics for Nurses (2012) urges all nurses to promote
environments in which the human rights, customs, spiritual beliefs, and values of individual patients, families, and communities are respected.
Nursing Process: Implementation
establishing presence supportive healing relationship acute care restorative and continuing care
purpose of code of ethics
ethical obligations and duty of every nurse nonnegotiable ethical standard expression of nursing own understanding
quasi-experimental research
examine effects of nursing interventions on patient outcomes
Nursing Process: Assessment
expresses a level of caring and support taking a faith history reveals patient's beliefs about life, health and a supreme being through the patients' eyes Assessment tools faith belief life and self-responsibiltiy fellowship and community: ask about support networks ritual and practice: ask about life practices used to assist in structure ans support during difficult times vocation: ask whethr illness or hospitaliztion has altered spiritual expression
Symptoms of stress (9)
feelings of anger/helplessness headaches / back pain/ insomnia hiding real feelings from loves ones hurting loved ones with words or physical harm constant worry, memory loss, trouble thinking clearly panic attacks isolation inability to make decisions drug use
anti-pyretic
fever reducing agent
Nursing process is a
five-step clinical decision-making approach that involves diagnostic reasoning and clinical decsion making
descriptive research
generate new knowledge about topics with little/no prior reserach
traditional knowledge
generation to generation ,we have always done it this way
prioritized data
get most important info first ex water pitcher vs cyanosis
health care proxy
give consent on behalf of anothe rpatient
Why learn the nursing process?
gives ability to assess, dx, plan, implement, and evaluate nursing care.
Nursing history
gives picture of the pt focus (getting to know pt) used to begin planning to meet pt needs begin thinking of actual/potential problems obtain ASAP Should clearly identify: Strengths/weakness, health risks/potential, actual/ existing problems
Members of the clergy or church, temple, mosque, or synagogue often assist in
giving physical care, providing emotional comfort, and sharing spiritual support
Nursing process (evaluate)
goals met/not-met/partially met ,
Implement the care
have patient exercise, eat more fiber, increase fluids, give meds for constipation, etc.
Physical Hazards
hazards in the environment threaten a person's safety and often result in physical or psychological injury or death
What does physical Examination include?
head to toe assessment
religious care
helping patients maintain faithfulness to their belief system and worship practices
spiritual care
helping people identify meaning and purpose in life, look beyond the present, and maintain personal relations as well as a relationship with a higher being or life force
wheezing
high pitched,musical-generally from narrowing of air passages
doctorate
higher level of practice
facilitating coping with disability or death
hospice, refer to support groups
Variables influencing health
how a person thinks and acts, influenced by internal and external variables-consider when planning care
Feminist ethics
how ethical decisions will affect women
what is the health promotion model?
how people react to their environment as the peruse health commitment to plan of action behavior may induce either a pos or neg subjective response or affect
define caring
human mode of being spiritual and human consciousness culturally diverse and universal
Medical diagnosis
identification of a disease condition based on specific evaluation of signs and symptoms
Nursing process (plan)
identify expected outcomes and plan care, develop pt outcomes and determine interventions, realistic/specific/can be evaluated
risk management
identifying possible risk, analyzing them, acting to reduce them, and evaluating the measures used to reduce them
purpose of documentation
if it isn't recorded, it didn't happen, to identify actual and potential health problems, plan appropriate care, evaluate the pt's responses to tx,
scientific knowledge
implying through research, scientific method.
tachypnea
increased respiratory rate
Autonomy
independence, can make decisions independently
Autonomy
independence, self determination, self reliance. supporting the patients right to informed consent.
Discuss conditions that place patients at risk for impaired oral mucous membranes.
ineffective oral hygiene, radiation to head or kneck, dehydration, trauma (braces, acidic food or drinks, drugs, alcohol) mouth breather, malnutrition, lack or decreased salivation, medication
gingivitis
inflammation of the gums
Define Cue
info you obtain through use of senses
Documenting nursing process
initial interview of pt forms assessment forms care plans paper/pen vs. informatics
When assessing the abdomen what order should the techniques be performed
inspection, auscultation, percussion, palpation
techniques used during a physical exam
inspection,palpation, percussion, auscultation
concept mapping
instructional strategy that requires learners to identify, graphically display, and link key concepts
opthalmoscope
instrument used to visual eyes
Battery
intentional offensive touching without consent or lawful justification
what is the agent hose environment model?
interaction between an internal agent, susceptible host and environment as causes of disease in person traditional model that explains how certain factors place some people at risk for disease limited when dealing with noninfectious disease
illness behaviors
involves how people monitor their bodies and define and interpret their symptoms
Standars of Care
legal guidelines for minimally safe and adequate nursing practice
Assessment tools
listening ask direct questions FICA (faith, importance, community, address), spiritual well-being (SWB) scale
auscultation
listening with the stethescope to lungs, heart and abdomen, listen for pitch, loudness,quality and rate
Nursing process (Assessment phase)
look at objective and subjective data begins when you walk into the room review med records, interview , ask questions, nurse senses, head to toe assessment
Nursing assessment
looking for patient's response to health problems. Response to medications ordered for HTN, Is BP at a normal reading, Information relayed to physician if patient is not responding to tx
inspection
looking to observe-using eyes look for symmetry in body parts, color
Religiously based beliefs
magico religious, disease is caused by supernatural forces, health care be restored by voodo. Belief that god may be punishing for sinful bahviors evil eye- looks can cast spells amulets may chase away bad spirits , herbs for healing
When obvious deficits exist
maximize existing motor and sensory function to help patients communicate more effectively
4th phase of illness- achieving recovery and rehab
may start in hospital- end at home, may complete phase at home, normal activivites and responsibilities, chronically ill may remain in dependent stage
common sources of negligence
medication errors iv errors burns to patients falls failure to use aseptic errors in sponge needle, or instrument counts failure to give complete reports failure to monitor patient failure to notify doctor of patient change in health
Florence Nightingale
meeting the personal needs of the patient within the environment cleanliness, ventilation, temperature, light, diet, noise
john Hopkins ebp model
meets needs of practicing nurse and uses PET. practice question, evidence, translation ensure latest findings
Airborne (mode of transmission)
microorganisms dispersed by air, then inhaled or deposited. Examples of illnesses transmitted through the air include tuberculosis, measles, and chickenpox
Supportive healing relationship
mobilize hope provide interpretation of suffering that is acceptable to patient help patient use resources
Common modes of value transmission
modeling- observe from parents moralizing- taught by school, church, parents laissez-faire- leave children to explore (confusion/conflict) rewarding and punishing responsible choice - encourage children to explore competing values and weigh consequences
Risk factors may be (2)
modifiable (Change) Nonmodifiable (cant change)
Minor Legal Consent
most the time minors are not able to consent without a parent, emancipated minors may consent
Droplet (mode of transmission)
mucous membranes of resp tract are exposed to secretions of infected person. Droplets cannot remain suspended in the air for long periods and seldom travel more than 3 feet from the source. Examples of illnesses transmitted by droplets are influenza and respiratory syncytial virus infection
Relevant Data
must determine what type of data and how much to collect for each pt get better with experience
introduction/orientation phase
name and purpose discuss confidenditality interview alone, unless requests family member eye level body language pt should trust you and feel like you care give names an credentials
NLN
national league of nursing educational programs use the NP as main intellectual process
Precontemplation
no changes within next 6 months, underestimates problem
To prevent falls
nurses should perform risk assessment. Those in the home and in the "in patient setting" are at highest risk for falls.
Pettigrew (1990) maintains that
nursing care that fails to recognize a patient's spiritual needs as a part of holistic care is unethical and defies the ethical concept of fidelity.
Nightingale contributions in nursing
nursing is distinct and separate from medical practice
Examples of modifiable risk factors:
obesity- diabetes, heart disease, breast cancer, colon ca) diet - diabetes, stroke, Heart disease hypertension- stroke, heart dis, kidney disease smoking- heart disease, lung cancer, COPD etc.
objective data
observable and measurable data that can be seen heard or felt by someone other than the pt. vital signs- a number or a lab
Observation of pts behavior as data collection methods
observe verbal/non verbal behavior what is their level of functioning (ADLS) be alert for s/sx of distress (bleeding, pain, LOC) assess immediate environment (safety, temp, oder, who is in room)
Nursing interventions for spiritual distress
offering presence letting patient express feelings therapeutic communication contacting spiritual advisor providing for religious rituals
Critial Thinking: a continuous process characterized by
open-mindedness continual inquiry perseverance
yuo are responsible for carryig out a doctors order unless:
order is in error, violates hospital policy, or is harmful to the patient
What happens in the interview and nsg history?
organized conversation with pt 1st step in data collection gives subjective data done ASAP focus on getting to know pt physical exam follows
6 benefits of nursing Proces
organizing framework human response structured decision making patient involvement control over practice common language
Sources of data
patient support people pt record other health care members nursing/health care literature
What does the patient's health record contain?
patient identification and demographic data, informed consent for treatment or procedures, admission data, nursing diagnoses or problems and nursing or interdisciplinary care plan, record of nursing care treatment and evaluation, medical history and physical examination, medical diagnoses, therapeutic orders, medical and other health discipline progress notes, results of diagnostic and therapeutic test and procedures, patient education, advance directives, summary of operative procedures, discharge diagnosis, plan and summary
informed consent
patients agrrement to follow through with treatment with a full disclusure
middle eastern
patriarch no eye contact stand close to others when talking cheese and olives breakfast do not discuss sex planning with Arab teens male HCP do not take care of women
restoring health
performing assessments that detect an illness refering questions and findings to other healthcare providers, providing direct care, collaborating, planning, teaching and carrying out rehabilitation for illnesses, working in rehab programs
Characteristcs of a chronic illness
permanent change irreversible alterations in normal anatomy and physiology requires special pt edu for rehab requires long period of support
chronic illness
persists longer than 6 months
Sterotyping
person/group with upon with reconceived idea
Terminal illness causes fear of
physical pain, isolation, the unknown, and dying (Potter 735) Potter, Patricia A., RN, MSN, PhD, FAAN, Anne Perry, RN, EdD, FAAN, Patricia Stockert, RN, BS. Fundamentals of Nursing, 9th Edition. Mosby, 022016. VitalBook file.
Roles of Medicine vs. roles of nursing?
physicians: medical dx, orders for tx, S&S, lab work, dx test Nursing: focus on pt needs
Focus charting
places less emphasis on patient problems and instead focuses on patient concerns D:Data A: Action P: Patient response
The Interview as sources of data
planned communication need strong interview skills think about distance of nurse an pt body language think about how you can ask questions to get most response
prejudice
preconceived opinion that is not based on reason or actual experience, judgment about a person
unemancipated minors may consent for specific medical conditions like:
pregnancy, a minor parent for their child, STDS Substance abuse mental health
Colonization
presence and growth of microorganisms within a host without tissue invasion or damage.
developmental theory
process of growth and development of humans as orderly and predictable, beginning with conception and ending with death
national organ transplant act
prohibits sale and ourchase of organs
promoting health
promoting good physical, mental and emotional health by identifying, analyzing, and maximizing the patient's strengths as components of preventing illness, restoring health and facilitating coping with disability or death
Beneficence
promoting good, considering the patients best interest
Jean Watson
promting restoring health preventing illness caring for sick
HIPAA
protects a patient from losing health insurance because of a preexisting illness when changing job, sets rules guarding patients protected health information
Near death experience
psychological phenomenon close to clinical death or recovered after declared death
Problems r/t data collection
pt variables : anxiety, pain, language inapproriate organization of data omission of pertinent data irrelevant data duplicated data errors in data misinterpreted data failure to build good rapport/trust
who are partners in nursing process?
pt, family, community
Patient Care partnership (PCP)
pts bill of right , what can be expected
Characteristics of data:
purposeful prioritized complete systematic factual/accurate relevant recorded
QSEN
quality and safety education for nurses meet the challenge of preparing future nurses who will have knowledge, skills, and attitudes (KSA) for prelicensure programs
Factors that Influence health disparities? (8)
racial/ ethnic groups poverty gender/age mental health edu level disabilities sexual orientation health insurance/ access to health care
What are cultural influences on healthcare?
reactions to pain mental health biological sex roles language and communication orientation to space and time food/nutrition family support socioeconomic factors
Clinical reasoning vs. clinical judgement
reasoning- specific term, ways of thinking about pt care issues. Determining preventing problems judgement- result or outcome, the conclusions decisions, opinions, you make
preventing illness
reduce the risk of illness by avoiding or achieving early detection of illness or to maintain function within the constraints of an illness. Teach by example, educational programs, community programs, literature, and health assessments
Difference between Religion and Spirituality
religion- system of beliefs, values, rituals, based on teachings of god or spiritual leader. Monotheistic, polytheistic, atheistic Spirituality- spirt of the body, mind, and environment individuals expression of religious belief expressions of individual and how relates to things of the word
Virginia Henderson
requires help to reach independence independent, autonomous, self help concepts
culture competency
requires that the nurse makes a commitment to consider the cultural background of each pt and provide appropriate care
Due Process
requires the board to notify the nurse of the listed charges or violations
human dignity
respect for inherent worth and uniqueness
preparatory phase
review past medical records watch for sterotypes and prejudices ensure private/relaxed environment free of distractions
Nursing and other health care literature as sources of data
review to gain knowledge helps guide nurse to assess and care appropriately
utilitatian
right or wrong of action depends on consequence of the action
autonomy
right to self determination
Define scientifically based beliefs
scientific research, if proven its accepted as truth, not proven is myth ex. brushing teeth, hand washing, immunizations
3rd phase of illness- assuming dependent role
seeks help, accepts the dx. and follows tx plan , may ask for second opinion.
Concepts of spirituality
self-transcendence connectedness faith hope
felony
serious crime resulting in serious harm to another individual
Culture
shared set of beliefs, values, knowledge, and patterns of behavior common to a group of people
acute illness
short duration and severe
Define risk factor
something that increases a person's chances for illness or injury ex. Age, genetic factors, physiological factors
inductive reasoning
specific to general
Nurses contribute to a sense of well-being and provide hope for recovery when they
spend time with their patients (establish presence)
standard of nursing care is established by?
state nurse practice act job description hospital P&P patients nursing care plan
4 factors that inhibit sensitivity to diversity
stereotyping cultural imposition cultural blindness cultural conflict
common pieces of equipment used during a physical assessment
stethescope, snellen chart, opthalmoscope, otoscope
Types of Data
subjective-what pt says usually symptoms objective- what nurses see/observe
assessing
systematic and continuous collection validation and communication of client data
critical thinking
systematic way to form and shape ones thoughts, functions with purpose
Characteristics of nursing process
systematic-sequential order dynamic- steps overlap, all 5 can occur at once, open to change interpersonal- humans (heart of nursing) center pt , clients strengths goal orientated- nurses and clients work together on goals and wellness promo universally applicable - offers direction of activities
Infection
the invasion of a susceptible host by pathogens or microorganisms; results in disease.
Planning
the nurse prioritizes a patient's various nursing diagnoses, establishes short- and long-term goals, chooses outcome indicators, and identifies interventions to address patient goals.
ethics
the study of principles about what is right and wrong, fair and unfair
transcultural nursing
the study of various cultures with the goal of providing care specific to each culture
Illness
the unique response of a person to a disease; an abnormal process involving changed level of functioning
Contrast how hygiene care for the older adult client differs from that for the younger client.
their skin is thinner and more fragile. Some don't like soap, lotion after bathing. they get cold faster, some have dentures, depression (feeling of helplessness)
Nevr Events
these are preventable events which are like falls, utis preventable from improper catheters
What is person centered /holistic care? (8 aspects)
think about the whole person Intellectual, emotional, mental, environment, spiritual, physical, socioeconomic, sexual.
when caring for a patient, always____________
think ahead
palpation
touching-assess temp with back of hand, turgor-pinch fold of skin, moisture, texture, shape-masses/lumps
what are the sources of knowledge?
traditional knowledge authoritave scientific
Madeline Leininger (1978)
transcultural nursing caring central theme
correlation research
type and degree of relationships between two or more variables.
Beliefs, Values and Spirituality are
unique to each individual even if same religion or upbringing self-reflect and do not impose or assume our beliefs, values and spirituality change as we change/age nurses at high risk of not meeting patient needs nurses at risk of spiritual distress themselves (how to stay balanced and meet patient needs)
Family/sig other as sources of data
unresponsive/confused pt must consent if able remind of confidentially document where data comes from if other than pt.
case management plan
uses an interdisciplinary approach to document patient care and focuses on providing quality care in a cost-effective manner -specific guidelines for care that describes patient treatment and outline the sequence and timing of interventions for meeting the goal efficiently
illness behavior variables -external
visibility of symptoms, social groups, cultural background, economics, and accessibility to health care
evaluate the results
was the outcome achieved-did the pt have a bowel movement within two days?
identify expected outcomes
what do we want the patient to achieve as a result of nursing care?
what is the health belief model?
what people perceive to be true about themselves in relation to health
Health Care Acquired Wnfection (HAI)
when a patient develops an infection that was no present or incubating at the time of admission to a health care setting it is called:
cultural blindness
when one ignores differences and proceeds as though they do not exist
Ethical dilemma
when the right thing to do is not clear or when members of a health care team cannot agree on the right thing to do
Nurse Entrepreneur
A nurse, usually with an advanced degree, who may manage a clinic or health-related business, conduct research, provide education, or serve as an adviser or consultant to institutions, political agencies, or businesses
Nurse Educator
A nurse, usually with an advanced degree, who teaches in educational or clinical settings; teaches theoretical knowledge and clinical skills; conducts research
Decision making
Focuses on problem resolution: `recognize and define problem `assess all options `weigh each option against personal criteria `tests possible options `makes final choice
"Evaluating the information"
Include assumptions and evidence
Evaluation
Look at all situations objectively and systematically. Use criteria to determine results of nursing ACTIONS. Reflect on you own hehavior and how it affects the evaluation process
Fairness
Look at each situation objectively. Ignore any bias you might have. Imagine what it is like in pt situation--appreciate each situation's complexity.
Inference
Look at the meaning and significance of findings. Are there relationships between findings? Do findings help to see that a problem exists?
Creativity
Look for different approaches if interventions are not working.. Tailor unique approaches to pt's specific needs.
Compassion fatigue
Loss of satisfaction from providing good patient care
National League for Nursing (NLN)
Professional organization whose members represent multiple disciplines. The National League for Nursing conducts many types of programs, including accrediting nursing education programs.
Nurse Midwife
Provides prenatal and postnatal care, delivers babies with uncomplicated pregnancies.
What are 6 areas for prelicensure?
Pt centered care teamwork and collaboration EBP Quality improvement safety informatics
What does QSEN and what does it focus on?
Quality and safety education for nurses. Focuses on knowledge skills, and attitudes
Five components of critical thinking model
Specific Knowledge Base, Experience in Nursing Critical Thinking Competencies, Critical Thinking Attitudes, Intellectual and Professional Standards
Discipline:
Take time to be thorough, and manage your time effectively. Follow an orderly approach. Ensures your decision making is systematic, accurate, and comprehensive.
Self-Confidence
Trust your own reasoning
Nurse Administrator
Various levels of management , management and admin of resources and personnel involved in care
As critical thinking skills grow, you learn that solutions to problems are no longer right or wrong, but....
alternative and perhaps conflicting solutions exist.
Scope of practice is best defined as?
limitations/allowance for what you can do as nurses
With Basic Critical Thinking, answers are :
right or wrong
Isabel Hampton Robb
A leader in nursing and nursing education; organized the nursing school at Johns Hopkins Hospital; initiated policies that included limiting the number of hours in a days work and wrote a textbook to help student learning; the first president of the Nurses Associated Alumnae of the United States and Canada (now American Nurses Association).
Clinical Nurse Specialist
A nurse with an advanced degree, education, or experience who is considered to be an expert in a specialized area of nursing; carries out direct patient care; consultation; teaching of patients, families, and staff; and research
Collaberator
Nursing Roles: The effective use of skills in organization communication, and advocacy to facilitate the functions of all members of the health team as they provide patient care.
Counselor
Nursing Roles: The use of therapeutic communication skills to provide information, make appropriate referrals, and facilitate the patients problem solving and decision making skills.
Caregiver
Nursing Roles: ______________________care to patients that includes both the art and science of nursing meeting physical, emotional, intellectual, sociocultural, and spiritual needs.
Researcher
Nursing roles:The participation in or conduct of research to increase knowledge in nursing and improve patient care.
"Analyzing information related to the problem"
Review clinical data