Concepts final
5 Preparatory Activities for the Implementation Process
1. Reassessing the client 2. Reviewing and revising the existing nursing care plan 3. Organizing resources: -Equipment -Personnel -Environment -Client 4. Anticipating and preventing complications -Areas of assistance 5. Implementation Skills -Cognitive Skills -Interpersonal Skills -Psychomotor Skills
A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first? 1. Reconnect the drainage tubing 2. Inspect the condition of the IV dressing 3. Obtain the next IV fluid bag from the medication room 4. Explain when the health care provider is likely to visit
1. Reconnect the drainage tubing The nurse must reconnect the drainage tube for the priority of patient safety. There is no reason to suspect a problem with the IV dressing unless the fluid is not infusing on time. The nurse must prepare the next bottle of solution after reconnecting the drainage tube. At that time the nurse can check the condition of the IV dressing. As the nurse performs her care, she can inform the patient about when the physician will round, unless she is uncertain and needs to contact the physician.
Types of Multidisciplinary Communication
1. Record or chart- confidential, permanent legal documentation 2. Report- oral, written, or audio-taped exchanges of information 3. Consultations- a form of discussion where one professional caregiver offers formal advice about the care of a client to another caregiver
Priority Classifications `
1. high - if untreated could result in harm to the client -Physiological & Psychological Dimensions -Maslow -ABCs, LOC (level of consciousness 2. intermediate - involve non-emergent or non-life threatening needs of the client 3. low -nursing diagnoses for client needs that may not be directly related to specific illness or prognosis, but may affect the client's future well-being -May focus on the client's long-term health needs
Tonya sets out to formally plan Mr. Jacobs' care. For the nursing diagnosis of impaired physical mobility related to incisional pain, Tonya identifies the goal of "Patient will walk 100 yards three times a day"; and the outcome she lists is, "Patient will report pain below level of 4 and will not splint incision when moving within 48 hours." The interventions she selects for her plan include administering the ordered analgesic, progressive relaxation, and splinting the incision when the patient gets out of bed. The following three questions apply to the case study. 1. Critique the goal and outcomes that Tonya set and explain if they were written correctly. 2. Among the interventions that Tonya selected, which ones are independent, dependent, and collaborative? 3. What interventions will possibly increase the likelihood that the patient's goals of care and outcomes will be met?
1. The goal set by Tonya is not written correctly, instead it is written as an intervention. The outcome statement is not singular, instead it includes two outcomes. The correct wording would for the goal would be, "Patient will achieve pain relief". The two outcome statements would be stated as "Patient will report pain below level of 4 in 24 hours" and "Patient will not splint incision when moving within 48 hours." 2. The independent intervention is offering progressive relaxation and splinting the incision when the patient gets out of bed. The dependent intervention is administering the analgesic. There is no collaborative intervention. 3. The intervention should include a frequency and could also include more details about the method. For example, Use relaxation following each analgesic administration and play patient's preferred music.
Which of the following factors does a nurse consider for a patient with the nursing diagnosis of Disturbed Sleep Pattern related to noisy home environment in choosing an intervention for enhancing the patient's sleep? (Select all that apply.) 1. The intervention should be directed at reducing noise. 2. The intervention should be one shown to be effective in promoting sleep on the basis of research. 3. The intervention should be one commonly used by the patient's sleep partner. 4. The intervention should be one acceptable to the patient. 5. The intervention should be one you used with other patients in the past.
1. The intervention should be directed at reducing noise. 2. The intervention should be one shown to be effective in promoting sleep on the basis of research. 4. The intervention should be one acceptable to the patient. Select interventions that alter the etiological factor, in this case noise. Choose interventions that have a research base and are acceptable to patients.
Always begin your goals and outcomes with:
"The client will..."
Nursing interventions always begin with:
"The nurse will...."
Evaluation Statements always begin with:
"The outcome was (met, partially met, or not met) AEB...."
Nursing initiated intervention
(Independant) the response of the nurse to the client's needs and nursing diagnosis. -No supervision is required. - No order needed if it is within our scope of practice.
secondary health care
(screening) interventions aimed at increasing the probability that a person with a disease will have that condition diagnosed at a stage when treatment is likely to result in cure. Ex: BP screenings, mammograms, colonoscopy
normal grief
(uncomplicated) is common and universal reaction characterized by complex emotional, cognitive, social, physical, behavioral and spiritual responses to loss and death.
Internal Variables include what?
* Developmental stages * Intellectual Background *Perception of Functioning * Nature of Illness *Emotional Factor *Spiritual Factor
What are some external variables?
* Family Practice * Socioeconomic factors *Cultural background *Visibility of symptoms (to others) *Social group and support *Accessibility of the health care system
What sets nursing apart as a profession?
* Requires a basic liberal foundation and an extended education. * Theoretical body of knowledge *Provides a specific service * Autonomy in decision making * Has a code of ethics.
Why do we document?
*****To Establish Database * minimize errors * save time * reimbursement * comply with standards of care (behavioral expectation) * legal protection * avoid redundancy * show accountability
Moderate
*30-34C* (*86-93F*) is classified as _________ *HYPO*thermia
Mild
*34-36C* (93.2-96.8F) is classified as _______ *HYPO*thermia
Severe
*<30* ( 86 F) is classified as ________ *HYPO*thermia
HYPERpyrexia
*EXTREMELY High* temperature. -*40.0 or 41.5 °C* (104.0 or 106.7 °F)
CMS (Center for Medicare/Medicaid services )
*Emphasize error prevention
HYPO;TACHY; Dec
*Excessive* body temp can lead to ________tension , _______cardia and _______ Cardiac output - *Reduced* perfusion and *Coagulation* - *Cerebral edema* , CNS degeneration , renal *Necrosis*
Vector
*External* mechanical transfer ex: Flies
Dx, Tx and preventative errors
*Fall Risk* assessment Tool Heinrich *Get up and go* National Safety goals Alarms-bed/chair Restraints Pain management Quiet hour
Malignant Hyperthermia
*HYPER*metabolic disorder of skeletal muscle triggered by induction of *Anesthetics* ( succinylcholine)
Immobility
*Inability* to move
Brown adipose
*Infants* have a unique source of heat from ________ adipose which is associated with *Intensified* metabolism -*Inc* metabolism and *02* consumption
Stress
*Involuntary* leakage of small volumes of urine -Assoc with *Inc Intraabdominal pressure*, incompetent urinary sphincter - Laughing, coughing, exercise, walking, getting up from chair
Range of Motion
*Maximum* amount of movement available at a joint in one of the three planes Sagital , frontal , transverse
Shiver, Nonshivering
*Newborn infants* generally do not __________ A process called ____________ thermogenesis ( involves Inc metabolism and o2 consumption)
600
*Perspiration* provides a significant source of heat reduction accounts for _____mL of water loss per day
Thermoregulation (Pic depicts Posterior Hypothalamus innervation)
*Reverse* the process and stimulate sweat glands when body temp is *Elevated* (Anterior Hypothalamus) - *Negative-feedback*
Active measures
*Rewarming with blankets* - heat pads, warm water bath - Place pt. in *Heated Environment*
surgical aseptic
*Sterile* technique
SRE (Serious Reportable Events)
*Surgery*: performed on wrong body part *Patient* : Infant discharged to wrong person *Care* Management : Death or disability *Device* *Enviroment* *Criminal*
Fever
*Temporary* elevation in body Temp -Response to bacteria, parasite, fungi, virus, toxins, drugs -*Pyrogens* Inc hypothalamus thermostatic set point -Thought to *Inc* production of *WBC*
100 %
*Thyroid* hormones increase *BMR* by _______ %
Adverse Event
*Unintended harm* to the patient by an act of commission ( did not provide care correctly) or omission ( did not provide care)
HYPERthermia S/S
*vasoDILATION*: Skin *flushed* and *warm*, hot to touch -Diaphoretic or Dry(Heat stroke) (Depending on exposure & duration) -Dec Urinary Output -*Seizures!!!* -Confusion / coma
Sharp end
- *Active* Errors -Made by providers (Physician , Nurses, Techs) who are providing care , responding to pt. needs
Negative Nitrogen Balance
- *Deficiency* in calories and protein -*Dec* appetite secondary to *immobility* -Body *excretes* more Nitrogen than *Ingests*
Nosocomial , Catheterization
- *Hospital acquired* Most common cause is ______________ (CAUTI)
Blunt end
- *Latent* Error - Flaw in the system that does not immediately lead to an accident but establishes a situation in which a triggering event may lead to an error
Functional
- *Loss* of continence because of causes *Outside* the urinary tract -Related to *Immobility*, cognitive impairment , poor motivation , environmental barriers
Heat Exhaustion
- *Profuse diaphoresis* results in excess water and electrolyte *Loss* Tx: Remove pt. from *Hot environment*
Heat stroke Tx
- *Remove from environment* - *Ice packs* placed in the Axillary, groin, Neck -IV fluids, cool pt.
Who's at risk for UC?
- < 30 years old -race and ethnicity (caucasians, ashkenuzi jewish) -genetics (positive family history)
Planning
- A category of nursing behaviors in which client-centered goals and expected outcomes are established. - All about the patient - 3rd step of the nursing process - Requires deliberate decision-making and problem-solving skills (& critical thinking) - Dynamic (continuous) - Based on the full nursing diagnosis
Standing order
- A pre-printed document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures. -Tell us "WHAT TO DO" -Must be signed by the physician -Common in critical care settings -Ex. Adult Heparin Sliding Scale Cardiology, Adult Insulin Sliding Scale Nephrology, Pharmacy Management of MRSA
Protocols
- A written plan specifying the procedures to be followed during care. -Tell us "HOW TO" - Provides a standard of care (i.e. clinical guideline) - Ex. Eye medication application, Shaving, BP Assessment
Active Nursing Intervention
- Addresses a nursing action which truly attempts to achieve the outcome -Ex) The nurse will immediately 2 tabs of acetaminophen/hydrocodone as prescribed.
Common Documentation Forms
- Admission History (H&P- history & physical) - Flow Sheets and Graphs - Shift Report, Nurse Snapshot -Acuity Records- has to do with how sick patient is -Standardized Care Plans - Discharge Summary - Additional forms for nurses working in home health and LT care settings
Risk for falls
- Age - fall Hx -elimination habits - high-risk med -Mobility/ Cognition (Braden scale) Assessment for Risk for _________
some federal statutory issues:
- Americans with disabilities act - emergency medical treatment and active labor act - advanced directives (living will and power of attorney) - HIPAA - restraints
Quality Improvement
- An approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others. -Ex) Med administration, diet management, wound care, and discharge planning
What do we document?
- Any ADPIE that is done - Any change in status
What do we document?
- Any ADPIE that is done - Any change in status -Pertinent data
Nursing Interventions:
- Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes - designed to assist the client in moving from their present level of health to that which is described in the goals and outcomes - linked to outcomes
What is Documentation?
- Anything written or printed that is relied on as a record or proof for authorized persons - Provides a detailed account of the level of quality care delivered to clients - Ensures continuity of care, saves time, and minimizes errors - Enables health care institution to recover costs
Through Pt. eyes
- Assessment needs to be *Patient Centered* - Include the pt.s *Own perception* of his or her risk factors Assessment Through ____ _______
Physician-initiated Interventions
- Based on a physician's response to treat or manage a medical diagnosis - *Think invasive procedures* - Require specific nursing responsibilities and technical nursing knowledge - Ex. Administering a medication; changing a dressing; inserting a Foley catheter, applying restraints
What charting is used at OSF
- Charting by exceptions - Electronic Medical Record
Indirect Care Activities
- Communication Interventions -Especially for Interdisciplinary plans of care -Delegating -Supervising -Evaluating -Ex) Documentation, delegation, order transcription, environmental management, data entry, telephone consultation, shift report, specimen management, transport
Vehicle
- Contaminated items, water, drugs , solutions, blood, food (Improperly handled), stored, or cooked; fresh or thawed meat
Foot drop
- Debilitating contracture of the foot - Foot is permanently fixed in *Plantar flexion* -Pt. CANNOT dorsiflex the foot
National Safety Goals
- Establish National Safety goals -Help accredited programs address specific concern in regard to patient safety. Goals -Identify patient correctly -Improve staff communication -Use Medicines safely
Documentation Criteria
- Factual and Accurate - Complete (Pointed phrases, not wordy) - Specific - Organized - Current (use military time)
Evaluation
- Final step in the nursing process - Nurse determines whether or not the client's condition or well-being has improved -Ex. Pain management -Determines the usefulness and effectiveness of nursing practice - Informs the nurse of the need to change or revise the plan of care. - Links directly to the Plan - On-going process
Intervention for HYPERthermia
- Find *Etiology* - *Remove* excessive blankets/clothing -*Hydration*/nutrition support - *Cool Packs* to Axillary, groin -*Antipyretics* ( Naproxen, Ibuprofen, ASA, Tylenol) -*Dantrolene* ( MH)
Computerized Documentations
- Growing trend - Standardized language and format - Quick and Efficient - Variety of interfaces -Keyboard entry, Graphic, Automated Speech Recognition, Point of service, Notebook-sized computers - Legal risk - Correcting errors can be challenging - Transition from paper to electronic
Disuse Syndrome
- Immobilization causes *two* skeletal changes 1.) *Impaired* Ca metabolism & Joint abnormalities 2.) Bone tissue is *less* dense -High risk for *fractures* -*If you don't use it, you lose it*
Nursing Hx
- Includes data about a patients level of wellness to determine if underlying condition exist that pose threat to safety ex: Pt. taking diuretics is going to frequently get up and void ( Risk for fall ) Assessment ___________ Hx
"Secondary to"
- May be used to include the medical diagnosis in the nursing diagnosis - Not required - Ex. "Secondary to Mastitis"
Examples of opioids?
- Morphine - Hydromorphone - Oxymorphone - Butorphanol - Hydrocodone - Fentanyl - Etorphine - Buprenorphine - Pentazocine - Methadone - Codeine - Tramadol - Diphenoxlate, Loperamide, Apomorphone
What is unique about "risk for" diagnosis
- No defining characteristics - They have risk factors - Ex. "Risk for infection related to impaired skin integrity."
What is unique about "risk for" diagnosis
- No defining characteristics - They have risk factors - Ex. "Risk for infection related to impaired skin integrity." - Will have a goal but no outcome.
Do we ALWAYS establish priorities based on severity or physiological importance?
- Not always - Sometimes we have to focus on emotional side first
Do we ALWAYS establish priorities based on severity or physiological importance?
- Not always - Sometimes we have to focus on psychological side first
Health Insurance Portability & Accountability Act HIPPA
- Nurses may not discuss a client's examination, observation, conversation, or treatment with other clients or staff not involved in the client's care. - Only involved staff has legitimate access to client's medical records - Nurses are responsible for protecting records from unauthorized readers.
When do we document?
- Ongoing
Consequences of Hypothermia
- Prolonged vaso*CONSTRICTION* leads to peripheral tissue ischemia , intermittent reperfusion -Prolonged *HYPO*thermia leads to reduced perfusion ( *Inc Viscosity* of blood , reduced blood flow and coagulation)
Direct Care Activities
- Require competent and safe practice - ADLs - Physical Care Techniques - Counseling - Teaching - Controlling for Adverse Reactions and Preventative Measures
Mobility
- State or quality of being mobile or *movable* -Gross and fine motor
nursing legal guidelines are based upon:
- Statutory (Federal law) - Regulatory (Administrative) - Common law (Judicial)
Active Core rewarming
- Temp falls *below 30 C* (86.0 F) -*Warm IV fluids* -*Gastric Lavage* -*Cardiopulmonary Bypass* / Arteriovenous rewarming
Defining Characteristics
- The exceptional assessment data that led you to the problem - Defines the problem - Specific subjective and/or objective data - Essentially what you started with - Ex. "As evidenced by pain 8/10, diaphoresis, fever of 102.3"
Nurse-initiated Interventions
- The independent response of the nurse to the client's needs and nursing diagnoses. - No supervision or direction required - Within the legal scope of nursing (as delineated in nurse practice acts) - Ex. Turning client every 2 hours - Ex. Holding a BP medication if the BP is too low
Diagnostic Label
- The problem - Based on your data, think of the priority problems. - Refer to NANDA list for appropriate language - Ex. "Acute Pain"
Implementation
- The step of the nursing process where nurses provide care to patients - Begins after the nurse develops a plan of care - 4th step of nursing process -Occurs when the nurse initiates or completes INTERVENTIONS necessary for achieving the goals and expected outcomes of nursing care -Continuous process
Collaborative Interventions
- Therapies that require the knowledge, skill, and expertise of multiple health care professionals - Critical Pathways - Ex. Involvement of PT, RT, OT, D&N, and nursing following a CVA.
Related Factor/Etiology
- What is causing (or contributing to) the problem? - Can nursing impact this cause? (it must for etiology to work) - Should NOT be a piece of equipment -Should not be blameful -Often NOT the same as a medical diagnosis - Ex. "related to Inflammation"
Outcome
- a specific, measurable change in a clients status that is expected to occur in response to nursing care - the ultimate definition of effectiveness and efficiency for nursing interventions
Act of Urination
- brain structures influence bladder function (healthy NS) -voiding: bladder contraction + urethral sphincter and pelvic flood muscle relaxation STEPS: 1. stretching of bladder wall signals the micturition center in the sacral spinal cord 2. impulses from the micturition center in the brain respond to or ignore this urge, thus making urination under voluntary control 3. when a person is ready to void, the external sphincter relaxes, the micturition reflex stimulates the detrusor muscle to contract, and the bladder empties
four types of reports
- change of shift - telephone - transfer - incident
purposes of the clients chart
- communication - legal documentation - financial billing - education - research - auditing-monitoring
negligence
- conduct falls below standards of care - most common with nurses
common law
- court decisions - most common source of law for malpractice issues - ex. informed consent
administrative law
- created under the administrative boards - guidelines for reporting unethical or incompetence related to: -- child abuse -- elder abuse -- communicable diseases -- EMTALA violations - required to report unethical behavior by law
criminal law
- defines crimes and punishments - ex. diversion of narcotics - felony versus misdemeanor
statutory law
- formal written laws (federal, state, or local) - basis for standard of care - ex. nurse practice act
JCAHO standard of documentation (what must be documented?)
- initial assessment - client and family teaching - discharge planning - evaluation of outcomes - multidisciplinary care
malpractice
- injury occurs as a result of what a nurse does or fails to do - doctors and APNs more common
Direct care
- interventions are treatments performed through interactions with patients. (a patient receives a direct intervention in the form of medication administration, insertion of an IV, or counseling for grief)
state statutory issues
- licensure - good samaritan laws - public health laws - uniform determination of death act - physician assisted suicides
lawsuits nurses can positively impact:
- medication errors - negligent supervision - informed consent - accidental injury - nosocomial and wound infection - pain and suffering, emotional distress - lack of teamwork and communication - inadequate charting
methods of documentation
- narrative (coldspa) - progress notes (SOAPIE and DAR) - charting by exception (type we use) - critical pathways
what is Commitment?
- person anticipates when to make choices without assistance from others and accepts accountability for choices made (expert level of knowledge)
civil law
- protects a persons individual rights within our society - encourages fair treatment - ex. tort law
types of multidisciplinary communication
- record or chart - report - consultations - referrals
Consequences of incontinence
- skin breakdown (peri area constantly wed and moist) -changes in daily activities (withdrawal from social events; embarrassed) -changes in social relationships (isolation)
Client outcomes should be:
- specific and measurable - derived from the goal - address defining characteristics
Client outcomes should be:
- specific and measurable - derived from the goal - address defining characteristics - must be realistic
what is Basic critical thinking
- thinking is concrete and based on a set of rules or principles. Following step by step regardless of patients' needs
areas of negligence:
- treatment - communication - medications -monitoring
Indirect care interventions
- treatments performed away from the client but on the behalf of the client. (safety and infection control, looking up meds before you go into room, delegation, and setting up task beforehand)
Direct care interventions
- treatments performed through interactions with the client. (a client receives a direct intervention in the form of medication administration, insertion of an IV, or counseling for grief)
proving malpractice
- what your duty not fulfilled? - was there a breach of duty through omission? - casual connection between breach and harm? - was there actually harm or damage?
intentional tort
- willful or intentional act or wrongdoing that violates another persons rights or property - assault and battery, medical battery, false imprisonment, trespass, defamation
Western Biomedical Belief
-"white mans perspective" -imbalance in body-> causing illness -scientific culture
IOM: Take away points
-*User Center Design* : Build on human strength -*Avoid Reliance on memory*: Protocols & checklist -*Attend to Work safety*: Work hours, staffing ratios -*Avoid Reliance on Vigilance*: use checklist, alarms, signals These are several IOM _____ ______ ______
Never Event
-Adverse events that should *Never* occur in health care Examples -Foreign object *after* surgery -Pressure ulcer *Stages III / IV* -Catheter associated UTI ( *CAUTI*)
IOM
-Alerted Health care industry and the public to the problem of death from *preventable errors* -Ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors
Near Miss
-An error of commission or omission that could have harmed pt. BUT serious harm *did not* occur as a result of chance
Complicated fracture
-Comminuted: bone fragments -damage to other tissues or organs
Anterior Hypothalmus
-Controls temp if *High* at set point - Creates heat *Loss* by *sweating* & *Vasodilation*
Interrelated concepts
-Culture: different culture, different values and beliefs -Development: ability to express, too much pain can stunt development -Spirituality: being punished, method for pain relief -Sleep: sleep disturbances -Tissue integrity: pressure ulcers -Mobility: not going to move around
What are the components of the Nursing Practice Act
-Definition of Nursing -Licensure requirements -Revocation or suspension of license. -Reciprocity of license -Members of the Board of Nursing .
Health Care Environment
-Determine if any *hazards* exist in immediate care setting ex: *Drainage bags*, *IV pumps*, furniture Assessment of _______ _______ Environment
Types of interventions: (planning nursing care)
-Independent nursing interventions -Dependent nursing interventions -Collaborative nursing interventions
Dimensions of Cultural Attributes
-Individualism vs. Collectivism -Power Distance -Masculinity vs. Femininity -Long Term vs. Short Term orientation -Religiosity
You are preparing to ambulate a client who had abdominal surgery 24 hours ago. The client weighs 270 pounds and is 6 feet tall. He has a PCA (Patient Controlled Analgesia) system for pain control. He has IV fluids running and IV antibiotics scheduled to run every 6 hours. What questions do you need to answer before you attempt to ambulate this client?
-LOC -Need to urinate -Vitals -Pain level -Last push of PCA -Have push again to prevent pain -Personnel help we need -How are we ambulating with IV fluids -Personnel just for IV pole? -BP in case of orthostatic hypotension
Theoretical Links to Culture
-Leininger's Theory of Culture Care Diversity and Universality -Interprofessional Theory of Social Suffering
Non opioid
-NSAIDS -ibuprofen -ketovolae -celecoxib -naproxen
OPQRST
-Onset (duration) -Provocative/palliative (allieviating or relieving factors) -Quality -Region (location) -Severity (intensity) -Time -Understanding (effect of pain on quality of life and functional status, comfort and function goal)
Consequences of untreated pain
-Prolonged stress response: increased HR and BP, muscle tension -Reduced immune competence: compromised immune system -Cardiovascular instability: cardiovascular collapse or shot -Respiratory dysfunction: short breaths not moving secretions -Genitourinary disturbances: urinary retention, UTI -Decreased gastrointestinal motility: bas circulation to GI, reduced appetite -Metabolic imbalance: glucose levels up -Developmental issues: no energy to continue with development, regress to seek comfort -Increased chronic post surgical pain syndromes: mysterious, rewiring brain perpetuating pain syndromes
QSEN
-Quality and Safety Education for Nurses -Prepares future nurses who have the knowledge , skills, and attitudes necessary to continuously improve the quality and safety of health care system.
What are some examples of the standards of professional performance
-Quality of practice -Education -Professional Practice Evaluation -Collaboration -Communication -Ethics -Evidence-based practice and research -Resources -Leadership -Environmental health
Scope and categories
-Secular Humanism to varying degrees of devotion to religious practice -multiple faith traditions throughout the world
correct way to give an enema
-Wear gloves to prevent the transmission of fecal microorganisms -Explain the procedure, including the position to assume, precautions to take to avoid discomfort and length of time to retain the solution before defecation -Enema is given in the Sim's position -the IV pole is positioned so the enema bag is 12 inches above the anus and approximately 18 in above the mattress (depending on the patient's size) -insert the tip of the tube slowly by pointing tip in direction of patient's umbilicus. -Length of insertion varies: Adult and adolescent 7.5 to 10 cm (3 to 4 inches) Child: 5 to 7.5 cm (2 to 3 inches) Infant: 2.5 to 3.5 cm (1 to 1 ½ inch) -If patient is self-administering advise them to use the side lying position, do not do while sitting on the toilet
Fracture
-a break or disruption in the continuity of a bone -stress applied overcomes the resistance -can occur anywhere in body -cause neuropathic pain
Culture
-a pattern of shared attitudes, beliefs, and self-definitions, norms, roles, and values -critical in providing patient centered care
Flatulence
-accumulation of gas in the intestines causing the walls to stretch -lactose intolerant
Complications of fractures
-acute compartment syndrome -crush syndrome -hypovolemic shock (bleeding out) -fat embolism (blood clot of fat) -venous thromboembolism (blood clot in legs, break off into circulation) -infection -ischemic necrosis (lack of blood supply, death of tissue) -delayed union (bones don't heal back together)
Assessment of otitis media
-affected hearing -discolored/inflamed tympanic membrane -sleep affected -fever -decreased appetite -refusing to nurse -pain -loss of balance -headache
Renin (kidney functions)
-affects blood pressure -starts chain of events that cause water retention, thereby increasing blood volume
Prostaglandin E2 and Prostcyclin (kidney functions)
-affects blood pressure -aid vasodilation
Risk factors of otitis media
-age (shape of ear in children, poorly developed immune system in children) -group child care -infant feeding -seasonal factors (pollen counts) -poor air quality (second hand smoke)
Where is this concept encountered in nursing practice?
-all settings of care, particular roles include parish nursing -times of life transition -traumatic events -end of life (at any age)
Ethnocentrism
-an expression of the belief that one's culture of origin is the best approach to life -blocks effective communication by creating biases and misconceptions about human behavior
Culturally aware nurses...
-are conscious of culture as an influencing factor between themselves and others -understand the basis of their own behavior -recognize that health is expressed differently
Prevention of fractures for teens
-avoid alcohol and drugs -graphic videos -safety equipment -be aware of peer pressure
Communication
-biggest barrier -verbal and nonverbal
Race
-biologic variation within a population (genetic physical markers) -race differences: growth and development, skin color, enzymatic differences, susceptibility to disease, and laboratory test findings -same race may be of different cultures -race is explicit (can tell race when look at a person)
Things to Consider with Cultural Diversity
-biological variations -personal space -perception of time -environmental control -social organization -communication -nutrition -religion
Incontinence Management
-bladder or bowel retraining -biofeedback (sensor attached to muscle, see level of contraction) -timed and prompted voiding -use of protective pads -skin care (wash skin)
What are Collaborative nursing interventions?
-both independent and dependent
Ulcerative Colitis (UC)
-can happen anywhere within colon -affects mucosa of colon -narrow colon -affects flow of stool
Risk factors for pain
-cancer -arthritis -shingles -cluster headaches -fractures -kidney stones -child birth -acute pancreatitis -reposition and turning
Health Literacy
-capacity to obtain and use health information
Personal Space
-certain distance acceptable for certain cultures
Populations at greatest risk
-children (dont have mental capacity to control elimination) -pregnant women (more urgency, constipation, uterus putting pressure on bowels and bladder) -older female adults: urinary incontinence (lose tone in pelvic muscle) -older male adults: prostates enlarge (BPH: benign prostatic hypertrophy)
Social Determinants of Health
-circumstances of life and outside forces
Cultural Competence is guided by three principles:
-client centered -incorporate the cultural norms and values of the client -self empowerment
Three-Tier Cultural Competence
-clinical (provider at bedside) -organizational (healthcare institution) -structural (policies and procedures)
Culturally Sensitive
-cognition = awareness -affective = sympathetic -psychomotor = some skills Outcome = neutral
Culturally Competent
-cognition = knowledgeable -affective = committed to change -psychomotor = highly skilled Outcome = good, positive (constructive)
Culturally Incompetent
-cognition = oblivious -affective = apathetic -psychomotor = no skills Outcome = poor (destructive)
Three Dimensions of Developing Provider Cultural Competence
-cognitive (thinking) -affective (feeling) -psychomotor (doing)
Data Collection Phase
-collect self identifying data -ask questions that elicit client's perception of why he or she is here, his or her condition, and past and anticipated treatments -postnursing diagnosis, identify cultural factors that may influence effective nursing care actions
Characteristics or urine
-color: pale straw to amber color -clarity: transparent unless pathology is present -odor: ammonia in nature
caring for a deceased
-confirm that health care provider certified the death and documented time of death and actions taken -determine if autopsy is requested -validate organ donation status -identify patient
Culturally Competent Nursing Interventions
-cultural preservation -cultural accommodation -cultural repatterning -cultural brokering
Three Stages of developing Provider Cultural Competence
-culturally incompetent -culturally sensitive -culturally competent
Common Attributes of Culture
-culture is learned -culture is changing and adapting -values, beliefs, and behaviors are shared by members of the cultural group
Risk factors of spiritual distress
-death: actively dying, death of significant other, exposure to death, aging, illness, pain -loss: increasing dependence on others, loneliness, loss of body part, loss of function -life transitions: birth of a child, unexpected life event -social and self alienation
What to do with diarrhea:
-diet/fluid (oral rehydration therapy) -skin care -medications: antidiarrheal medications (Imodium, codeine phosphate, opium tincture), anticholinergic agents, others
Nutrition
-different dietary patterns -may predispose to certain things
Hemorrhoids
-dilated, engorged veins in the lining of the rectum -pregnant women, heart failure, liver dysfunction
Two Types of Cultural Encounter
-direct (face to face) -indirect (shared between one's own peers)
Factors influencing urination
-disease conditions -medications and medical procedures (diuretics, sleeping pill, antidepressants, lower GI procedure, brain procedure) -socioeconomic factors (need for privacy) -psychological factors (anxiety, stress, privacy) -fluid balance
Biculturalism
-duel pattern of identification
Cause of otitis media
-enlarged adenoids -congestion/mucus
Marginalization
-exclusion
Cultural Competence in Nursing
-expected component of professional nursing practice -requires underlying acceptance of patient's health beliefs -requires adapting care to meet unique needs and perspectives of individual
Behavioral signs of pain
-facial expressions -restlessness -change in activity (infant more restless) -crying (child) -assessment tool *apply to developmentally disabled, dementia, unconscious, in coma, children, infants
Lab tests
-fecal characteristics -fecal specimens (for diarrhea)
Immigration Health Care Challenges
-financial constraints -language barriers -differences in social, religious, and cultural backgrounds between immigrant and provider -use of traditional healing practices unfamiliar to their health care providers -providers' lack of knowledge of high risk diseases in the specific immigrant groups
Organization Phase
-gather data related to client's/family's views on optimal treatment choices, plus differences between cultural needs and goals of western medicine
Biological Variations
-gives us knowledge on the diseases more common with certain races -health promotion and prevention
Attribute of spiritual care
-healing presence -therapeutic use of self -intuitive sense -exploration of the spiritual perspective -patient centeredness -meaning centered therapeutic intervention -creation of spiritually nurturing evironment
What to do if constipated:
-hydrate -medicate (laxatives) -enema -suppository -increase fiber in diet
Causes of bowel retention
-ignoring the urge to go or decreased peristalsis -leads to: stool dies and hardens, constipation, impaction
Pain management for fractures
-immobilization -elevation -hot and cold -drugs -distractions -acupuncture -RICE (rest, ice, compression, elevation)
Consequences of untreated acute otitis media
-impaired hearing -speech or developmental delays -spread of infection -tearing of the eardrum
Adjuvant
-in addition to other drugs -cyclobexaprine -gabapentin -nortryptyline
Bowel Incontinence
-inability to control passage of feces and gas to the anus
Diarrhea
-increase in number of stools and passage of liquid, unformed feces -food poising, crohns disease, stress, lactose intolerance -complications: skin breakdown, dehydration, and electrolyte imbalance
Disparities in Health
-inequity in social structures based on characteristics -historically linked to discrimination
Cultural Nursing Assessment
-initial contact with a client -in depth cultural assessment -takes place over time Two Phases: -a data collection phase -an organization phase
The Nine Cultural Strategies
-interpreter services -increased minority representation -training in cultural competence and sensitivity -coordinate with community's traditional healers -use community health workers -incorporate cultural notions of health -include families and community members in care and decision making -provider immersion into another culture and administrative and organizational accommodation -linguistically appropriate information
Cultural Desire
-intrinsic motivation to engage in the four (previous) elements necessary to provide culturally competent care -based on the humanistic value of caring for the individual -cannot be taught in the classroom
Characteristics of Culture
-learned -integrate -shared -tacit -dynamic
Four categories of foreign-born
-legal immigrants -refugees -nonimmigrants -unauthorized immigrants
Descriptors of pain
-location: region/radiation -intensity: severity, scale 1-10, face diagram -frequency: timing, when did it start, how long did it last, every month, every few hours, standing, sitting, intermittent, constant
Traditional Health Belief
-magicoreligious -get sick because of something spiritual or sin -holistic view -balance of nature (ying and yang)
Consequences of spiritual well-being
-maintain or improve health status -dignified life closure -grief resolution -hope -psychosocial adjustment -quality of life -social involvement
Non pharmacological interventions
-massage -positioning and body alignment -splinting -thermal interventions (heat and cold) -mind body therapies
Attributes
-meaning making, finding purpose -unfolding mystery; experience of transcending the self -connectedness/experiencing relation -spiritual activities/practices
Special factors affecting bowel elimination
-more diarrhea for infants -constipation in elderly -constipation during pregnancy -constipation while in pain
Opioid
-narcotics -morphine -fentanyl -hydromorphone -oxycodone
Environmental control
-nature controls environment: individual has control over themselves -nature and environment equal harmony: cant control illness but can manage symptoms -environment has mastery over nature: my disease has master over me, there is nothing i can do
Hierarchy of pain measures
-obtain patient self report -consider patient condition or exposure to painful procedures -observe for behavioral signs of pain -evaluate physiological indicators -conduct an analgesic trial (giving a pain relieving med and seeing reaction)
risk of constipation
-opioid use/medications -impaired physical mobility/physical inactivity -irregular bowel habits and ignoring urge to defecate -chronic illnesses (Parkinson's, MS, RA, chronic bowel disease, depression, eating disorders) -low fiber diet high in animal fats (meats, and carbs), low fluid intake -stress (illness of family member, death of loved one, divorce) -changes in life or routine such as pregnancy, aging and travel -neuro conditions that block nerve impulses to the colon (stroke, spinal cord injury, trauma) -chronic bowel dysfunction (colonic inertia, irritable bowel)
Perception of Time
-past, present, future orientation -different for each culture
Chronic pairn
-persistent -lasted more than 3 months -lacks autonomic signs -no protective function -brain can create source of pain
Jean Watson's caring theory
-practice of loving, kindness and equanimity -authentic presence: enabling deep belief of other -cultivation of one's own spiritual practice toward wholeness of mind, body, spirit-- beyond ego -"being" the caring, healing environment -allowing miracles (openness to the unexpected and inexplicable life events)
Disease Conditions Affecting Urination
-prerenal, renal, postrenal classification -conditions of the lower urinary tract -diabetes mellitus and neuromuscular diseases such as multiple sclerosis -benign prostatic hyperplasia -cognitive impairments (ex. alzheimers) -diseases that slow or hinder physical activity -conditions that make it difficult to reach and use toilet facilities -end stage renal disease, uremic syndrome
Enculturation
-process by which a person learns norms, values, and behaviors of another culture
Assimilation
-process by which person gives up his or her original identity and develops a new cultural identity by becoming absorbed into the dominant cultural group
Acculturation
-process of acquiring new attitudes, role, customs, or behaviors
Cultural Knowledge
-process of searching for and obtaining a sound educated understanding about culturally diverse groups -emphasis is on learning about the clients' worldview from an emic (native) perspective
Erythropoietin (kidney functions)
-production of erythropoietin is essential to maintaining a normal RBC volume -erythropoietin stimulates bone marrow to produce RBCs and prolongs the life of mature RBCs
Surgical Interventions
-prostate surgery (enlarged, cause obstruction -bladder surgery (no muscle tone) -urinary diversion -surgery for renal calculi (kidney stones) -stents to relieve obstruction
Health Equity and Social Justice
-providing impartiality and objectivity at a systems or governmental level
Diagnostic exams
-radiologic imaging, with or without contrast -endoscopy (requires consent) -ultrasound -CT or MRI
Risk factors for fractures
-recklessness in adolescents -occupation -nutrition (anorexia) -driving/accidents -unsafe house -postural instability -osteoporosis -small maternal pelvis, large baby -impaired cognitive ability -athletes/sport -proprioception (not balanced) -age -tobacco and alcohol -poor vision with aging -multiple medications
Working with Immigrant Populations
-recognize the values, beliefs, and practices that comprise your own culture -identify the client's preferred language -learn clientele's health seeking behaviors -get to know immigrant community -get to know some traditional practices and remedies used by families and communities -learn how cultural subgroups explain common illnesses or events -consider and accommodate client viewpoint -conduce a cultural assessment
When t use non pharm interventions
-refusing drugs -going into surgery -end of dose period -while waiting for drugs to work *not for acute severe pain*
Ear anatomy and role of the eustachian tubes
-regulate air pressure in the middle ear -refresh air in the ear -drain normal secretions from the middle ear
Health Disparities and Socioeconomic Status
-relationship reflected in life expectancy, infant death rates, low birth rates, and many other health measures
Impaction
-results from unrelieved constipation -collection of hardened feces wedged in rectum that a person cannot expel
Prevention of fractures for older adults
-safe driving -keep hoe free of clutter -glasses -hearing aids -yearly physical -monitoring meds -canes, walkers, wheelchairs
Prevention of fractures for infants
-safe home environment -getting enough calcium and vitamin D -demonstrating car seat use -proper infant development -safe clothing -secure sleeping
Cultural Competence and Interrelated Constructs
-self awareness -cultural skill -cultural knowledge
Ethnicity
-shared feeling of peoplehood among a group of individuals -related to cultural factors (nationality, geographic region, culture, ancestry, language, beliefs, and traditions) Equally influenced by: -education -income -cross cultural experiences
Physical Assessment
-skin and mucosal membranes (assess hydration) -kidneys (flank pain may occur with infection or inflammation -bladder (distended bladder rises above symphysis pubis (retention) -urethral meatus (observe for discharge, inflammation, and lesions)
Religion
-some culture, religion permeates in everyday life -dress, talk, worship
Barriers to Developing Cultural Competence
-stereotyping -prejudice -racism -ethnocentrism -cultural imposition -cultural conflict -culture shock
Constipation
-symptom, not disease -frequent stool and/or hard, dry small stools that are difficult to eliminate -dehydration, opiates, depressed -common in elderly; not common in children
Bowel Diversion
-temporary or permanent artificial opening in the abdominal wall (stoma) -surgical opening in ileum or colon
Clinical manifestations of fractures
-tenderness/pain (tissue damage) -swelling (hematoma, inflammatory process) -decrease function of use/inability to bear weight (bone is broken) -may be bruised -severe muscular rigidity (tendons and muscle tightens, spasm) -crepitus crispy sounds (bone fragments scrapping) -in hip leg may appear shortened, externally rotated, foot turned out
Cultural Skill
-the ability of nurses to effectively integrate cultural awareness and cultural knowledge when conducting a cultural assessment and to use the data to meet the specific client's needs
Acute compartment sydrome
-the compartment is an area where muscles, vessels and nerves are surrounded by fascia, which is not elastic --fascia does not stretch --increases pressure --pressure on nerves and blood vessels --shut off circulation -increased pressure occurs within a compartment caused reduced circulation to the area -pressure can be internal (blood or fluid accumulation) or external (a tight bandage or cast) -Symptoms: severe pain, pain intensified with passive movement, pain unrelieved by analgesics, paresthesias, pale, weakening pulses --different pain, sensations --pain when moving passively -treatment: --go in surgically and cut fascia --relieve pressure --surgical emergency --can occur because of cast also
Cultural Encounter
-the process that permits nurses to seek opportunities to engage in cross cultural interactions
Cultural Awareness
-the self examination and in depth exploration of one's own beliefs and values as they influence behavior
Culture occurs among:
-those who speak a particular language -those who live in a defined geographic region
Causes of fracture
-trauma (common in kids) -motor vehicle accidents (common in kids and older adults) -falls (common in older adults) -abuse (common in kids)
Urine Tests and Diagnostic Examinations
-urinalysis (determines UTI from an increase in nitrates and WBCs) -specific gravity (ability to concentrate urine) -culture (pathogens) -noninvasive procedures (dyes) -invasive procedures (cystoscopy; risk of infection, informed consent)
Management of otitis media
-wait and see approach -managing pain -facilitating drainage, ear tubes (reoccuring) -family education (prevention) -emotional support (for child and family) -antibiotic therapy (education about side effects)
Things you may notice with elimination problems:
-weird color -lack of bowel sounds -presence of blood -consistency of stool
What does outcomes of nursing presence include?
1) Alleviating suffering 2) Decreasing a sense of isolation 3) Decreasing a sense of vulnerability 4) Personal growth
While working in a community health clinic, it is important to obtain nursing histories and get to know the patients. Part of history taking is to develop the nurse-patient relationship. Which of following apply to Peplau's theory when establishing the nurse-patient relationship? (select all that apply) 1) An interaction between the nurse and patient must develop. 2) The patient's needs must be clarified and described. 3)The nurse-patient relationship is influenced by patient and nurse preconception. 4) The nurse-patient relationship is influenced only by the nurses preconceptions.
1) An interaction between the nurse and patient must develop. 2) The patient's needs must be clarified and described. 3)The nurse-patient relationship is influenced by patient and nurse preconception.
When using ice massage for pain relief, which of the following are correct? (Select all that apply.) 1) Apply ice using firm pressure over skin. 2) Apply ice for 5 minutes or until numbness occurs 3) Apply ice no more than 3x a day 4) Limit application of ice to no longer than 10 minutes. 5) Use a slow circular steady massage. .
1) Apply ice using firm pressure over the skin 2) Apply ice for 5 minutes or until numbness occurs 5) Use a slow circular steady message.
Match the following caring behaviors with their definitions. 1. Knowing A) Sustaining faith in one's capacity 2. Being with to get through a situation 3. Doing for 4. Maintaining B) Striving to understand an event's belief meaning for another person. C) Being emotionally there for another person. D) Providing for another as he or she would do for themselves.
1) B 2)C 3)D 4)A
A nurse demonstrates caring by helping family members: 1) Become active participants in care. 2) Provide activities of daily living 3) Remove themselves from personal care 4) Make healthcare decisions for the patient.
1) Become active participants in care
Which of the following statements apply to theory generation? (Select all that apply) 1) Builds scientific knowledge base of nursing 2) Discovers relationships of phenomena to practice 3) Tests specific phenomena 4) Identifies observations about a phenomenon
1) Builds scientific knowledge base of nursing 2) Discovers relationships of phenomena to practice 4) Identifies observations about a phenomenon
Match the following components of systems theory with the definitions of that component. 1) Feedback A. Data entering the system 2)Input B. End product 3) Content C. Data related to system functioning 4) Output D. Product and information obtained from the system
1) C 2)A 3)D 4) B
A health care provider writes the following order for a patient who is opioid naive who returned from the operating room following a total hip replacement: "Fentanyl patch 100mcg, change every three days." On the basis of this order, the nurse takes the following action: 1) Calls the HCP and questions the order 2) Applies the patch the third post-operative day 3) Applies the patch as soon as the patient reports pain. 4) Places the patch as close to the hip dressing as possible.
1) Calls the HCP and question the order.
Which of the following closely aligned with Leininger's theory? 1) Caring for patients from unique cultures 2) Understanding the humanistic aspects of life 3) Variables affecting a patient's response to a stressors 4) Caring for patients who cannot adapt to internal and external environment demands.
1) Caring for patients from unique cultures
A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of this disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch? 1) Caring touch 2) Protective touch 3)Task-oriented touch 4)Interpersonal touch
1) Caring touch
Nursing diagnosis is based on what?
1) Characteristics 2) Expected Outcomes 3) Research Based 4) Feasibility 5) acceptability of Pt. 6) Capability of the nurse
What is the purpose of the clients chart
1) Communication 2) Legal documentation 3) Financial billing 4) Education 5) Research 6) Auditing-Monitoring
What are the multiple forces that affect nursing?
1) Demographic changes in population 2) Human rights 3) Increase number of medially undeserved 4) Threat of bio terrorism
What happens in shift change?
1) Discuss the patients plan of care and overall progress. 2) Current and relevant info 3) Nurses collaborate and share info prevents errors or delays.
As an art nursing relies on knowledge gained from practice and reflection on past experiences. As a science nursing relies on (Select all that apply) 1) Experimental research 2) Nonexperimental research 3)Research from other disciplines 4) Professional opinions
1) Experimental research 2) Nonexperimental research 3)Research from other disciplines
Four Types of errors in writing nursing interventions
1) Failure to precisely or completely indicate nursing actions. 2) Failure to indicate frequency 3) Failure to indicate quantity 4) Failure to indicate method.
What are the goals of the Theoretical Nursing Model
1) Identify the domain and goals of nursing 2) Provide knowledge to improve nursing administration, practice, education, and research. 3) Guide research and expand the knowledge base of nursing. 4) Identify research techniques and tools used to validate nursing interventions. 5) Formulate legislation governing nursing practice, research, and education. 6) Formulate regulations interpreting nurse practice acts. 7) Develop curriculum plans for nursing education 8) Establish criteria for measuring quality of nursing care, education, and research. 9) Guide development of a nursing care delivery system. 10) Provide systemic structure and rationale for nursing activities.
What are three problems that can arise if sleep disorders go untreated?
1) Insomnia 2) Abnormal movements 3) Sensation during sleep or when waking up at night 4) Excessive daytime sleepiness.
What is 4 things to keep in mind when dealing with aspects of care within different cultures?
1) Know the patient's cultural norms for caring practices. 2) Know the patients cultural practices regarding end-of-life care. In some cultures it is considered insensitive to tell the patients, 3) Determine if a member of the patient's family or cultural group is the best resource to use for caring practices such as providing presence or touching . 4) Know the patient's cultural practices regarding the removal of life support.
What are the nursing principles of administering analgesics?
1) Knowing the patients previous response to analgesics. 2) Select the proper medication when more than one is ordered. 3) Know the accurate dosages 4) Assess the right time and interval for administration.
What are the three areas for competency in critical thinking?
1) Knowing the scientific rational for the intervention 2) Possessing the necessary psychomotor and interpersonal skills. 3) Being able to function within a particular setting to use the available HC resources effectively.
A nurse is applying Henderson's Theory as a basis for theory based-nursing practice. What other elements are important for theory-based nursing practice? (Select all that apply) 1) Knowledge of nursing science 2) Knowledge of related sciences 3) Knowledge about current health care issues 4) Knowledge of standards of practice
1) Knowledge of nursing science 2) Knowledge of related sciences 4) Knowledge of standards of practice
Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about tobe sarted on a PCA of morphine? SATA 1) Only the patient should push the button 2) Do not use the PCA until the pain is severe 3) The PCA system can set limits to prevent overdoses from occuring. 4) Notify the nurse when the button is pushed. 5) Do not push the button to go to sleep.
1) Only the patient should push the button 3) The PCA system can set limits to prevent overdoses from occuring. 5) Do not push the button to go to sleep.
What are six competencies for a nurse?
1) Patient Centered Care 2) Teamwork and collaboration 3) Evidence based practice 4) Quality improvement 5) Safety 6) Informatics
A patient rates his pain as a 6 on a scale of 0-10. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? 1) Patients self-report 2) Behaviors 3) Surrogate report 4) Vital sign changes.
1) Patients self-report
What are the 7 Domains?
1) Physiological Basic 2) Physiological Complex 3) Behavioral 4) Safety 5) Family 6) Health Systems 7) Community
What are the CON's 3 main goals
1) Preparing the graduate to practice professional nursing in a variety of roles and healthcare settings. 2) Provide the essential foundation for undergraduate study in nursing 3) Foster a commitment to personal and professional growth and dignity
What is step 3 in the stages of sleep
1) Stage lasts 15-30 minutes 2) It involves initial stages of deep sleep. 3) Muscles are completely relaxed. 4) Vital signs decline but remain regular.
What is step 4 in the stages of sleep
1) Stage lasts approximately 15-30 minutes 2) It is the deepest stage of sleep 3) If sleep loss has occurred, sleeper spends considerable part of the night in this stage. 4) Vital signs are significantly lower than during hte waking hours.
What is involved in REM sleep
1) Stage usually begins about 90 mins after sleep has begun. 2) Duration increases with each sleep cycle and averages 20 minutes. 3) Vivid full color dreaming occurs; less vivid dreaming occurs in other stages. 4) Stage is typified by rapidly moving eyes, fluctuating heart and respiratory rates, increased or fluctuating BP, loss of skeletal muscle tone and increase in gastric secretions. 5) It is very difficult to arouse sleeper
What are the 3 categories of touch?
1) Task oriented 2) Caring touch 3) Protective Touch
A postoperative patient currently is asleep. Therefore the nurse knows that: 1) The sedative administered may have helped him sleep, but it is still necessary to assess pain. 2) The IV pain medication given in recovery is relieving his pain effectively. 3) Pain assessment is not necessary. 4) The patient can be switched to the same amount of medication by the oral route
1) The sedative administered may have helped him sleep but it is still necessary to assess pain.
Nurses follow HCP orders unless?
1) They believe the orders are in error or can harm the patient. 2) Violate agency policy 3) Harmful to the Pt.
A patient has returned form the operating room, recovering form repair of a fractured elbow, and states that her pain level is 6 on a 0/10 pain scale. She received a dose of hydromorphone just 15 minutes ago. Which interventions may be beneficial for this patient at this time? SATA 1) Trans-cutaneous electrical nerve stimulation (TENS) 2) Administer naloxone 2mg interveniously 3) Provide a back massage 4) Reposition the patient 5) Withhold any pain medication and tell the patient that she is at risk for addiction?
1) Trans-cutaneous electrical nerve stimulation (TENS) 3) Provide a back massage 4) Reposition the patient
While caring for a patient with cancer pain the nurse knows that a multimodal analgesia plan includes? SATA 1) Using analgesics such as nonsteroidal anti-infalmmatory drugs (NSAIDS) along with opioids. 2) Stopping acetaminophen which the pain becomes very severe. 3) Avoiding polypharmacy by limiting the use of medication to one agent at a time. 4) Avoiding total sedation, regardless of the severity of the pain 5) The use of adjuvants ( co-analgesics) such as gabapentin to manage neuropathic type pain.
1) Using analgesics such as nonsteroid anti-inflammatory drug (NSAIDS) along wiht opioids. 5) The use of adjuvants (co-analgesics) such as gabapentin to manage neuropathic type pain.
What are some nursing assessment questions regarding pain?
1) What is the worst pain you have had in the past 24 hours? 2) What medication/herbs are you taking now 3) Which nonpharmacololgical treatments have you tried to relieve the pain? 4) What level of daily exercise can you maintain with your pain? 5) What is the average pain you have had in the past 24 hours? 6) Is your pain constant, intermittent, or both? 7) Have you used any recreational drugs or alcohol to alleviate the pain?
What are some nursing assessment questions regarding sleep deprevation
1) When did you notice this problem 2) Are you taking any new prescriptions or OTC medications 3) How has the loss of sleep affected you? 4) How often during the week do you have trouble falling asleep 5) Do you have a physical illness that affects your sleep?
Match the following theories with their definitions. 1) Grand theory A) Addresses specific phenomena and reflect practice 2) Middle- Range B) First level in theory Theory development and describes phenomenon 3) Descriptive Theory C) Provides a structural framework for broad concepts about nursing 4) Prescriptive Theory D) Linked to outcomes (consequences of specific nursing interventions)
1)C 2)A 3)B 4)D
Nursing as a Profession -Professions possess the following characteristics:
1. A theoretical body of knowledge leading to defined skills, abilities, and norms 2. Has a code of ethics for practice 3. An extended education of its members, as well as a liberal arts foundation 4. Members have autonomy in decision-making and practice 5. Provides a specific service
Nursing as a profession possess what characteristics
1. A theoretical body of knowledge leading to skills, ability and norms. 2. Code of Ethics for Practice (ANA) 3. Extended education of its members, as well as a liberal arts foundation (BSN) 4. Members have autonomy in decision making process 5. Provide a specific service
Steps for collecting evidence for evidenced-based practice
1. ASK (Ask a clinical question) 2. COLLECT EVIDENCE (collect the most relevant and best evidence) 3. APPRAISE (critically appraise the evidence you gather) 4. INTEGRATE INFO (integrate all evidence with ones clinical expertise and patient preferences and values in making a practice decision or change) 5. EVALUATE (evaluate the practice decision or change) 6. SHARE (share the outcomes of EBP changes with others)
Nigel is a nursing student assigned to Mr. Hannigan, a 72-year- old Caucasian with a diagnosis of pneumonia who is admitted to the medical-surgical unit. Mr. Hannigan is a one-pack-per-day smoker who experiences chronic problems with bronchitis and pneumonia as a result of his smoking. Nigel's immediate tasks are to complete an admission history and physical examination and design a care plan for Mr. Hannigan. 1. Which of the following of Mr. Hannigan's assessment findings can Nigel group together to formulate a data cluster? (Select all that apply.) A. Respirations 32 breaths/min B. Crackles in right and left lung bases C. Pain at incision site D. Shortness of breath with ambulation E. Hematuria 2. Nigel develops nursing diagnoses for Mr. Hannigan's care plan. Impaired gas exchange is a ______ nursing diagnosis for pneumonia. 3. Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. The acronym PES stands for _________ ______________ ___________________.
1. Answer: A, B, D Rationale: A data cluster is a set of signs or symptoms gathered during assessment that are grouped together in a logical way. Respiratory rate, lung sounds, and shortness of breath are respiratory assessment findings that may be grouped together to manage a respiratory problem. Pain at the incision site and hematuria aren't directly related to respiratory issues. 2. Answer: Risk Rationale: A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. Impaired gas exchange is a risk nursing diagnosis for pneumonia. 3. Answer: Problem, etiology, symptoms Rationale: The acronym PES stands for problem, etiology or related factor, and symptoms or defining characteristics.
Lalani is a nursing student who provides nursing care to a Vietnamese neighborhood as part of her community health rotation. The residents of this community typically do not speak English, nor do they have health insurance or access to medical care. Many of the older residents do not have reliable transportation. Lalani visits Ms. Lam, a 68-year-old with a history of breast cancer. Ms. Lam underwent treatment for breast cancer 5 years ago, including radiation and chemotherapy. She has not had a mammogram since completion of the cancer therapy. Lalani works with her to schedule a mammogram at the county hospital free clinic. 1. Lalani needs to call the county hospital free clinic to arrange an interpreter for Ms. Lam for her mammogram. Rank in order the steps Lalani should take for ensuring a successful phone consultation. A. Summarize the problem. B. Have all of the necessary information available. C. Think through possible solutions to the problem. D. Assess the patient. 2. Lalani reviews Ms. Lam's care plan to ensure accuracy. The main purpose of clinical pathways is to present an overview of the patient's care goals. A. True B. False 3. Lalani updates Ms. Lam's care plan. Care plans for community-based settings require a thorough assessment of ___________, _______, and _______.
1. Answer: B, D, C, A Rationale: To ensure a successful phone consultation, perform the following: have all of the necessary information available before making the call; assess the patient yourself before making the call; think through some of the possible solutions to the problem; and summarize the problem. 2. Answer: B Rationale: The main purpose of clinical pathways is to deliver timely care at each phase of the care process for a specific type of patient. 3. Answer: Community, home, and family Rationale: Planning care for patients in community-based settings involves using the same principles of nursing practice. However, in these settings a more comprehensive assessment of the patient's community, home, and family is required.
A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.) 1. Assess condition of skin before making the call 2. Rely on the nurse specialist to know the type of surgery the patient likely had 3. Explain the patient's response emotionally to the repeated leaking of stool 4. Describe the type of bag being used and how long it lasts before leaking 5. Order extra colostomy bags currently being used
1. Assess condition of skin before making the call 3. Explain the patient's response emotionally to the repeated leaking of stool 4. Describe the type of bag being used and how long it lasts before leaking The nurse should have as much information as possible available before making the call to the nurse specialist. It is also important for the nurse to interpret and explain the problem. In addition, it is important to explain the patient's perspective. Assuming that the nurse specialist knows the extent of the surgery is not appropriate. Ordering extra supplies is not a guaranteed solution that the existing bag is beneficial to the patient.
Nursing Process
1. Assessment: 2. Diagnosis 3. Outcomes Identification 4. Planning 5. Implementation 6. Evaluation
Standards of Care
1. Assessment: 2. Diagnosis 3. Outcomes Identification 4. Planning 5. Implementation 6. Evaluation
4 Types of Reports
1. Change-of-shift 2. Telephone -Use SBAR format with MDs -Situation, Background, Assessment, Recommendation 3. Transfer 4. Incident
Goals of care
1. Client-centered -Reflects client's highest possible level of wellness and independence of function -Ex. The client will perform self care hygiene independently from this day forward. -Ex. The client will remain infection-free from this day forward. 2. Realistic and based on client needs and resources 3. Meet immediate needs and strive for prevention and rehabilitation 4. When possible, clients should be involved in goal setting
Purposes of Client's Chart
1. Communication 2. Legal Documentation 3. Financial Billing 4. Education 5. Research 6. Auditing- Monitoring
Planning requires:
1. Decision-making skills 2. Problem-solving skills 3. Critical thinking
What are the Kubbler-Ross stages of grief? (5)
1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance (No particular order or time frame)
6 Factors for Choosing Interventions
1. Desired or expected client outcome 2. Characteristics of the nursing diagnosis 3. Evidence Base 4. Feasibility 5. Acceptability to the client 6. Capability of the nurse
Components of an Actual Nursing Diagnosis
1. Diagnostic label (the problem) 2. Related factor/Etiology 3. "Secondary to" (not required) 4. Defining Characteristics
Components of an Actual Nursing Diagnosis
1. Diagnostic label (the problem) 2. Related factor/Etiology 3. Defining characteristics
What are the 6 types of transmission of pathogens?
1. Direct: person to person 2. Indirect: Personal contact with inanimate object 3. Droplet: Large particle that travels up to 3 feet 4. Airborne: Droplet Nuclei, small particles that travel through air. specific mask needed. 5. Vehicle: Contaminated items 6. Vector: External transfer such as insect/bug
A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort? 1. Engage the patient in setting mutual outcomes for distance he is able to walk 2. Confirm with the patient's health care provider about ambulation goals 3. Have physical therapy assist with ambulation 4. Refer to medical record regarding nature of patient's physical problem
1. Engage the patient in setting mutual outcomes for distance he is able to walk All goals and outcomes of care should be patient centered whenever possible. An approach for ensuring patient centered goals is having the patient involved so goals can be mutually set and realistic to the patient. Confirming with the physician and checking the medical record help the nurse understand the extent of exercise in which a patient can participate. But these approaches are not examples of mutual patient-centered goal setting. Having physical therapy assistance would not make a goal patient centered.
A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. What does the nurse need to determine before setting the goal of "patient will self-administer insulin?" (Select all that apply) 1. Goal within reach of the patient 2. The nurse's own competency in teaching about insulin 3. The patient's cognitive function 4. Availability of family members to assist
1. Goal within reach of the patient 3. The patient's cognitive function 4. Availability of family members to assist
The Evaluation Process
1. Identifying Criteria and Standards- knowing what to look for -Refer back to the specific goals and outcomes from planning phase of NP -Nursing Outcomes Classification (NOC) 2. Collecting Data- to determine if the criteria or standards are met -Repeating your assessment again: Use evaluative interventions 3. Interpreting and Summarizing Findings -Comparing expected and actual findings in an objective manner 4. Documenting Findings -Clear, accurate, and precise 5. Terminating, Continuing, or Revising the Care Plan -Requires critical thinking
Examples of some NANDA's for Gas exchange problems.
1. Ineffective airway clearance 2. Ineffective breathing pattern 3. Risk for aspiration
JCAHO Standards for Documentation
1. Initial assessment of physical, psychosocial, environmental, self-care, client education, and discharge planning needs. 2. Client and family teaching 3. Discharge planning 4. Evaluation of Outcomes 5. Multidisciplinary care plans/Critical Pathways
Three areas of competency (before initiating interventions)
1. Knowing the scientific rationale for the intervention. 2. Possessing the necessary psychomotor and interpersonal skills. 3. Being able to function within a particular setting to use the available healthcare resources effectively.
What are the parts of a nursing diagnosis?
1. NANDA approved diagnosis 2. Related to factor 3. Secondary to factor (Medical Diagnosis) 4. AEB defining characteristics
Methods of Documenting
1. Narrative -COLDSPA and Cardinal Techniques 2. Progress notes -SOAPIE format -DAR format 3. Charting by exception (CBE) -"WDL except..." -Only document the exception 4. Critical Pathways
3 Types of interventions
1. Nurse-initiated interventions 2. Physician-initiated interventions 3. Collaborative interventions
Scenario: At the beginning of her shift, the nurse assesses her client and discovers the following: T= 101.4° F (Tylenol PO) Accu check= 300 (Glucophage PO) Reported nausea (Compazine IV) Pain 7/10 (Morphine IV) How will the nurse prioritize her care for this client?
1. Pain first- Pain can affect vital signs and glucose - Give Morphine/Compazine first 2. Wait 30 min- Pain eval 3. Glucophage 4. Tylenol
The six P's
1. Pain: PQRST 2. Pulse: check circulation 3. Pallor: pale/whiteness 4. Paresthesia: numbness or tingling 5. Paralysis: no feeling or movement 6. Pressure: ability to sense pressure *worried about nerve and blood supply loss, could lose limb*
A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply.) 1. Policy for conducting hourly rounds 2. Staffing level 3. Interruption by staff nurse colleague 4. RN's years of experience 5. Competency of patient care technician
1. Policy for conducting hourly rounds 2. Staffing level 3. Interruption by staff nurse colleague Many factors within the health care environment affect your ability to set priorities, including model for delivering care, the workflow routine and staffing levels of a nursing unit, and interruptions from other care providers. Available resources (e.g., policies and procedures) also affect priority setting. The nurse's years of experience and the competency of the patient care technician are not part of the environment.
What are the 5 stages of health behavior change?
1. Pre-contemplation 2.Contemplation 3. Preparation 4. Action 5. Maintenance
Nursing Interventions Classification (NIC) 7 Purposes:
1. To develop a standardized language for the actions used to deliver nursing care. 2. To expand nursing knowledge about connections between nursing diagnoses, treatments, and outcomes. 3. To develop nursing and health care information systems. 4. To teach decision-making to nursing students. 5. To determine cost of services provided by nurses. 6. To better plan for resources in all types of nursing practice settings. 7. To articulate with the classification systems of other health care providers.
Purposes of Nursing Diagnoses
1. To offer a standardized language to promote understanding between nurses about clients' health problems so as to facilitate communication and care planning 2. To distinguish the nurses role from that of the physician 3. To help nurses to focus on the role of nursing in client care
It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (Select all that apply.) 1. Using a standardized checklist for essential information 2. Asking the wife to briefly leave the room 3. Completing the hand-off without inviting questions 4. Doing prework such as checking laboratory results before giving a report 5. Including the wife in the hand-off discussion
1. Using a standardized checklist for essential information 4. Doing prework such as checking laboratory results before giving a report 5. Including the wife in the hand-off discussion Using standardized forms or checklists and doing thorough prework enhance the nurse's ability to communicate the plan of care effectively during a hand-off. It is also important to include patient and family when possible. The other two options are barriers to an effective hand-off.
Included in writing intervention:
1. WHAT is the intervention? 2. WHEN should the intervention be implemented? 3. HOW should the intervention be performed for a specific client? 4. WHO should be involved in each aspect of intervention? -Ex) The nurse will turn the client every 2 hours as follows: 0800- supine; 1000- left side-lying; 1200- right side-lying; 1400- left Sims.
Four common issues in malpractice cases:
1. Wrong time 2. Verbal orders (not recorded or signed by MD) 3. Charting in advance 4. Incorrect data
Pre-HTN
120-139/80-89
What did Henderson's theory focus on?
14 basic needs, assisting patients in gaining independence, helps gain strength.
Urine output should be
1500-1700 ml
Water intake should be
1500-1700 ml/ day
HTN crisis definition
180+/120+
Americans with Disabilities Act
1990; rights of disabled people; treatment of workers and patient's affected with HIV
Health Insurance Portability and Accountability Act (HIPPA)
1996; protects privacy and sensitivity of health info
Reassess pain every _______ hours if uncontrolled?
2 hours
Constipation
2 or fewer BMs a week, change in bowel patterns, tumor, obstruction, inflammation
A patient is admitted to an acute care area. The patient is an active business man who is worried about getting back to work. He has had severe diarrhea and vomitting for the last week. He is weak, and his breathing is labored. Using Maslow's hierarchy of needs, identify this patients immediate priority. 1) Self-actualization 2) Air, water, and nutrition 3) Safety 4) Esteem and self-esteem needs
2) Air, water, and nutrition
A patient is prescribed morphine patient-controlled analgesia (PCA). What is the correct order for administering PCA? 1. Program computerized PCA pump to deliver prescribed medication dose and lockout interval. 2. Check label of medication 3 times: when removed from storage, when brought to bedside, when preparing for assembly . 3. Administer loading dose of analgesia as prescribed. 4. Attach drug reservoir to infusion device, prime tubing, and attach needleless adapter to end of tubing. 5. Identify patient using two identifiers. 6. Insert and secure needleless adapter into injection port nearest patient.
2) Check the label of medication 3x, when removed from storage, when brought to bedside, when preparing for assembly. 5) Identify patient using two identifiers 1) Program computerized PCA pump to deliver prescribed medication dose and lockout interval 4) Attach drug reservoir to infusion device, prime tubing, and attach needlesless adapter to the end of tubing. 6) Insert and secure needleless adapter into injection port nearest patient. 3) Administer loading dose of analgesia as prescribed.
Which of the following theories describes the life processes of an older adult facing chronic illness? 1) Systems theory 2) Developmental Theory 3) Interdisciplinary theory 4) Health and wellness models
2) Developmental theory
A Muslim woman enters the clinic to have a woman's health examination for the first time. Which nursing behavior applies Swanson's caring process of "knowing the patient"? 1) Sharing feelings about the importance of having regular woman's health examinations. 2) Gaining an understanding of what a woman's health examination means to the patient. 3) Recognizing that the patient is modest; obtaining gender congruent caregiver. 4) Explaining the ristk factors for cervical cancer.
2) Gaining an understanding of what a woman's health examination means to the patient.
A patient with diabetes is controlling the disease with insulin and diet. The nursing health care provider is focusing efforts to teach the patient self-management. Which of the following nursing theories is useful in promoting self Management? 1) Neuman 2)Orem 3)Roy 4) Peplau
2) Orem
A patient with a 3 day hx. of a stroke that left her confused and unable to communicate returns from the international radiology following placement of a Gtube. The patient has been taking hydrocodone/APAP 5/325 1 tab, per gtube q4 PRN. Which action by the nurse is most appropriate? 1) No action is required by the nurse because the order is appropriate. 2) Request to have the order changed to around the clock for the first 48 hours. 3) Ask for a change of medication to meperidine 50mg IVP, Q3 PRN 4) Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain.
2) Request to have the order changed to around the clock for the first 48hrs.
A new medical resident writes an order for oxycodone CR 10mg PO q2 PRN. Which part of the order does the nurse question? 1) The drug 2) The time interval 3) The dose 4) The route
2) The time interval
Helping a new mother through the birthing experience demonstrates which of Swansons 5 caring processes? 1) Knowing 2)Enabling 3)Doing for 4) Being with
2)Enabling
A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. What are the steps for making a nursing diagnosis in the correct order, beginning with the first step? 1. Considers context of patient's health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical information 3. Clusters clinical cues that form a pattern 4. Chooses diagnostic label
2, 3, 4, 1
A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient? 1. Achieving wound healing of the foot ulcer 2. Enhancing patient knowledge about the effects of diabetes 3. Providing a dietitian consultation for diet retraining 4. Improving patient adherence to diabetic diet
2. Enhancing patient knowledge about the effects of diabetes The high priority for this patient is wound healing. If the ulcer is left untreated, it will cause more serious harm; an infection is likely, and it could spread. Providing a diet consultation is an intervention. Improving patient adherence to her diet is an intermediate outcome. Adherence to the diet is important but not life threatening when unmet. Since the patient has had diabetes for 10 years, enhancing knowledge is important because of her poor adherence but a lower priority than the others.
A theory is a set of concepts, definitions, relationships, and assumptions that; 1) Formulate legislation 2) Explain a phenomenon 3) Measure nursing functions 4) Reflect the domain of nursing practice
2. Explain a phenomenon
Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? (Select all that apply.) 1. Numbered order of diagnosis on the basis of severity 2. Notion of urgency for nursing action 3. Symptom pattern recognition suggesting a problem 4. Mutually agreed on priorities set with patient 5. Time when a specific diagnosis was identified
2. Notion of urgency for nursing action 3. Symptom pattern recognition suggesting a problem 4. Mutually agreed on priorities set with patient These three factors are considered in setting priorities for a patient's nursing diagnoses or collaborative problems. The other options are inappropriate because a numbering system and time of identification hold little meaning when a patient's condition changes.
A nurse assesses a 78-year-old patient who weighs 240 lbs and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of risk for impaired skin integrity. Which of the following goals are appropriate for the patient? (Select all that apply) 1. Patient will be turned every 2 hours within 24 hours. 2. Patient will have normal bowel function within 72 hours. 3. Patient's skin will remain intact through discharge. 4. Patient's skin condition will improve by discharge.
2. Patient will have normal bowel function within 72 hours. 3. Patient's skin will remain intact through discharge
A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, IV infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0 to 10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply) 1. The family comes to visit the patient. 2. The patient expresses concern about pain control. 3. The patient's vital signs change, showing a drop in blood pressure. 4. The charge nurse approaches the nurse and requests a report at end of shift.
2. The patient expresses concern about pain control 3. The patient's vital signs change, showing a drop in blood pressure
How many CEU's is required every 2 years
20 CEU's
Malpractice Percentage of Nurses Involved
20% 10 years ago; 35% now
Presence involves a person-to-person encounter that: 1) Enables patients to care for self. 2) Provides personal care to a patient. 3) Conveys a closeness and a sense of caring. 4) Describes being in close to contact with a patient.
3) Conveys a closeness and a sense of caring.
Which of the following is a strategy for creating work environments that enable nurses to demonstrate more caring behaviors? 1) Increasing the working hours of the staff 2) Increasing salary benefits of the staff 3) Creating a setting that allows flexibility and autonomy for staff 4) Encouraging increased input concerning nursing functions from physicians.
3) Creating a setting that allows flexibility and autonomy for staff
Which of the following statements about theory-based nursing practice is incorrect? 1) Contributes to evidence-based practice 2) Provides a systematic process for designing nursing interventions 3) Is not linked to nursing outcomes 4) Guides the nurse's assessment
3) Is not linked to nursing outcomes
A patient is being discharged home on an around the clock opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medications? 1) Opioid antagonists 2) Antiemetics 3) Stool softeners 4) Muscle Relaxants
3) Stool softeners
A nurse enters a patients room, arranges the supplies for a Foley catheter insertion, and explains the procedure to the patient what to expect; just before the inserting the catheter, she tells the patient to relax and that, once the catheter is in place, she will not feel the bladder pressure. The nurse then proceeds to skillfully insert the catheter. This is an example of what type of touch? 1) Caring touch 2) Protective touch 3) Task-oriented touch 4) Interpersonal touch
3) Task-oriented touch
The nurse reviews a patients MAR and finds that the patient has received oxycodone/acetaminophen (Percocet)(5/325), two tabs PO Q3 for the past 3 days. What concerns the nurse the most? 1) The patients level of pain 2) The potential for addiction 3) The amount of daily acetaminophen 4) The risk for gastrointestinal bleeding?
3) The amount of daily acetaminophen
A nurse is caring for an older adult who needs to enter an assisted living facility following the discharge from the hospital. Which of the following is an example of listening that displays caring? 1) The nurse encourages the patient to talk about his concerns while reviewing the computer screen in the room. 2) The nurse sits at the patients bedside, listens as he relays his fear of never seeing his home again, and then asks if he wants anything to eat. 3) The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story. 4) The nurse listens to the patient talk about his fears o fnot returning home and then tells him to think positively.
3) The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story.
To practice in today's health care environment, nurses need a strong scientific knowledge base from nursing and other disciplines such as the physical, social, and behavioral sciences. This statement identifies the need for which of the following? 1) Systems theory 2) Developmental theories 3) Interdisciplinary theories 4) Health and wellness models
3) interdisciplinary Theories
Of the 5 caring processes described by Swanson, which describes "knowing the patient"? 1) Anticipating the patients cultural preferences. 2) Determining the patient's physician preference 3)Establishing an understanding of a specific point 4) Gathering task-oriented information during assessment.
3)Establishing an understanding of a specific point
During the implementation step of the nursing process, a nurse reviews and revises a patient's plan of care. What is the correct order of steps for this? 1. Modify care plan as needed. 2. Decide if the nursing interventions remain appropriate. 3. Reassess the patient. 4. Compare assessment findings to validate existing nursing diagnoses.
3, 4, 2, 1 Reassessment allows you to review a patient's care plan by validating the nursing diagnoses and determine whether the nursing interventions remain the most appropriate for the clinical situation. When changes are needed, you modify the plan of care.
A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? 1. Giving the enema on time 2. Talking with the patient about her past experiences with illness 3. Talking with the patient about her concerns and acknowledging her sense of unfairness 4. Beginning instruction on postoperative procedures
3. Talking with the patient about her concerns and acknowledging her sense of unfairness The patient is obviously emotionally upset. Her concerns, whether they are about surgery or cancer or both, need to be addressed first for her to be able to be instructed and be comfortable for the enema. Talking with the patient about her past experiences may be appropriate in the long term but is less important than the other three priorities.
A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 ½ NS infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.) 1. IV site not tender 2. Uses cane to walk 3. Walked to end of hall 4. No shortness of breath 5. Slept better during night
3. Walked to end of hall 4. No shortness of breath The goal for improving activity tolerance will require an outcome that is a measure of changes in activity tolerance such as no shortness of breath during exercise or walking a set distance.
Normal urine output per hour
30 mL/hr
How long must you wait to reassess pain after PO meds?
30 minutes
How many calories are in one gram of carbs?
4 calories
How many calories in one gram of protein?
4 calories
Reassess pain every _______ hours if controlled?
4 hours
What are the nursing paradigm's 4 links?
4 links: Person Health Environment/situation Nursing
Having a BSN degree
4 years at a college, includes liberal arts, critical thinking component
A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the bible with his nurse, who recommends a favorite bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The patient's nurse replies: 1) "Spiritual care should be left to a professional." 2) "You are correct, religion is a person decision." 3) "Nurses should not force their religious beliefs on patients." 4) "Spiritual, mind, and body connections can affect health"
4) "Spiritual, mind, and body connections can affect health"
An example of a nurse caring behavior that families of acutely ill perceive as important to patients's well-being is: 1) Making health care decisions for patients 2) Having family members provide a patient's total personal hygiene. 3) Injecting the nurse's perceptions about the level of care provided. 4) Asking permission before performing a procedure on a patient.
4) Asking permission before performing a procedure on a patient.
Listening is not the only "taking in" what a patient says' it also includes: 1) Incorporating the views of the physicians 2) Correcting any errors in the patient's understanding 3) Injecting the nurse's personal views and statements. 4) Interpreting and understanding what the patient means.
4) Interpreting and understanding what the patient means.
A patient wiht chronic low back pain who took an opioid around the clock for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: 1) Opioid Toxicity 2) Opioid Tolerance 3) Opioid addiction 4) Opioid withdrawal
4) Opioid withdrawal
When teaching a patient about transcutaneous electrical nerve stimulation, which information do you include? 1) TENS works by causing distraction 2) TENS therapy does not require a health care provider's order. 3) TENS requires an electrical source for use. 4) TENS electrodes are applied near or directly on the site of pain medication.
4) TENS electrodes are applied near or directly on the site of pain medication.
Which of the following are components of the paradigm of nursing? 1) The person, health, environment, and theory 2) Health, theory, concepts, and environment 3) Nurses, physicians, health, and patient needs. 4) The person, health, environment/situation , and nursing.
4) The person, health, environment/situation , and nursing.
Theory-based nursing practice uses a theoretical approach for nursing forward as a science. Suggests that: 1) One theory will guide nursing practice. 2) Scientists will decide nursing decisions. 3) Nursing will only base patient care on the practice of other sciences. 4) Theories will be tested to describe or predict patients outcomes
4) Theories will be tested to describe or predict patients outcomes
A nurse hears a colleague tell a nursing student that she never touches a patient unless she is performing a procedure or doing an assessment. The nurse tells the student that from a caring perspective: 1) She does not touch the patient either 2) Touch is a type of verbal communication 3) There is never a problem with using touch 4) Touch forms a connection between nurse and patient.
4) Touch forms a connection between nurse and patient.
When a nurse helps a patient find the meaning of cancer by supporting beliefs about life, this is an example of: 1) Installing hope and faith 2) Forming a human-altruistic value system 3)ICultural caring 4) Being with
4)Installing hope and faith
A patient has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? 1. Provide frequent mouth care. 2. Maintain IV infusion at 100 mL/hr. 3. Administer prochlorperazine (Compazine) via rectal suppository. 4. Consult with dietician on initial foods to offer patient. 5. Control aversive odors or unpleasant visual stimulation that triggers nausea.
4. Consult with dietician on initial foods to offer patient.
A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? 1. Patient will be turned every 2 hours within 24 hours. 2.Patient will have normal bowel function within 72 hours. 3. Patient's skin integrity will remain intact through discharge. 4. Erythema of skin will be mild to none within 48 hours.
4. Erythema of skin will be mild to none within 48 hours. Turning the patient every 2 hours in a 24-hour period is an intervention. Both "Patient will have normal bowel function within 72 hours" and "Patient's skin integrity will remain intact through discharge" are goals.
A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 ½ NS. Which intervention is a dependent intervention? 1. Reporting hand-off at change of shift 2. Ambulating patient down hallway 3. Sleep hygiene 4. IV fluid administration
4. IV fluid administration Administering IV fluids required a health care provider's order. The other three interventions are independent nursing activities.
Setting a time frame for outcomes of care serves which of the following purposes? 1. Indicates which outcome has priority. 2. Indicates the time it takes to complete an intervention. 3. Indicates how long a nurse is scheduled to care for a patient. 4. Indicates when the patient is expected to respond in the desired manner.
4. Indicates when the patient is expected to respond in the desired manner.
The nurse writes an expected-outcome statement in measurable terms. An example is: 1. Patient will be pain free. 2. Patient will have less pain. 3. Patient will take pain medication every 4 hours. 4. Patient will report pain acuity less than 4 on a scale of 0 to 10.
4. Patient will report pain acuity less than 4 on a scale of 0 to 10.
The nurse writes an expected outcome statement in measurable terms. An example is: 1. Patient will have normal stool evacuation. 2. Patient will have fewer bowel movements. 3. Patient will take stool softener every 4 hours. 4. Patient will report stool soft and formed with each defecation.
4. Patient will report stool soft and formed with each defecation. Stool that is soft and formed at each defecation is measurable upon observation. "Patient will have normal stool evacuation" is a goal. Indicating that the patient will have fewer bowel movements is not specific enough for measuring improvement, and having a patient take a stool softener every 4 hours is an intervention.
Risk factors for colon CA
50+, polyps of the colon or rectum, family hx, IBD, exposure to radiation, diet high in animal fat
S/s of ulcerative colitis
6-10 diarrhea stools with blood and mucus, fever, anorexia, weakness
What percentage of body weight is water?
60-70%
How many calories in one gram of fat?
9 calories
what is normal body temperature
96.8-100.4
What is a client centered goal?
A behavior or response that reflects a client's highest possible need.
Goal
A broad statement that describes change in a patients condition or behavior, what will be accomplished
Nursing Diagnosis Definition
A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes
What is a nursing diagnosis
A clinical judgment by a nurse. (Us identifying the problem.)
Affect
A feeling that you get about someone in a given moment.
What is the difference between Misdemeanor and felony?
A felony is a crime of serious nature that has an penalty of imprisonment for longer than 1 year or even death. A misdemeanor is a less serious crime with penalty or imprisonment or less than 1 year.
durable power of attorney for health care
A legal document designating a person to make healthcare decisions for a patient when he/she is unable to.
Expected outcome
A measurable criterion to evaluate goal achievement (SMART)
Consent
A patients agreement to have a medical procedure after full disclosure of risks, benefits, alternatives, and consequences.
Nursing Paradigm
A pattern of thought that is useful in describing the domain of discipline
Autonomy
A person's independence for making decisions
Informed consent
A persons agreement to allow something to happen such as a surgery
Addiction
A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations
What is a Theory
A set of concepts, definitions, assumptions, or propositions that explain a phenomenon.
Code of ethics
A set of guiding principles that all members of a profession accept, this helps when questions arise
Theory
A set of interrelated concepts that explain and predict phenomena in nursing. Tested and Validated through research.
Drug tolerance
A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time
Physical Dependence
A state of adaptation that is manifested by a drug class-specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
What does "Health" mean to a nurse?
A state of complete physical, mental, and social well being, not merely the absence of disease or infirmity
Health
A state of complete physical, mental, and social well being. Not merely the absence of disease or infirmity.
Nursing
A way that we learn to provide care
Living Will
A written document expressing a patients wishes in the event of a terminal illness or condition.
Fat soluble vitamins
A, D, E, K
Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.) A. Checks scientific literature or policy and procedure B. Reassesses the patient's condition C. Collects all necessary equipment D. Delegates the procedure to a more experienced nurse E. Considers all possible consequences of the procedure
A. Checks scientific literature or policy and procedure B. Reassesses the patient's condition C. Collects all necessary equipment E. Considers all possible consequences of the procedure The nurse does not delegate a procedure to a more experienced nurse. Instead the nurse has another nurse (e.g., staff nurse, faculty, nurse specialist) who has completed the procedure correctly and safely provide assistance and guidance.
Before consulting with a physician about a female patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? A. Cognitive B. Interpersonal C. Psychomotor D. Consultative
A. Cognitive This is an example of a cognitive skill, being used before consultation. It involves critical thinking and decision making so the nurse is able to deliver a relevant nursing intervention.
A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the nursing diagnosis of Nausea related to effects of postoperative anesthesia. The nurse has been asking the patient to rate his nausea over the last several hours after administering antiemetics and using comfort measures such as oral hygiene. The nurse reviews the patient's responses over the past 10 hours and notes how the patient's self-report of nausea has changed. This review an example of: A. Comparing outcome criteria with actual response. B. Gathering outcome criteria. C. Evaluating the patient's actual response. D. Reprioritizing interventions.
A. Comparing outcome criteria with actual response. The key to this question is observation for change. The nurse compares the patient's actual self-report rating of nausea with the expected outcome of a reduction in nausea. Gathering outcome criteria simply involves having the patient rate nausea. Evaluating the behavior or self-report is the determination of the patient's actual response.
A nurse reviews all possible consequences before helping a patient ambulate such as how the patient ambulated last time; how mobile the patient was before admission to the health care facility; or any current clinical factors affecting the patient's ability to stand, remain balanced, or walk. Which of the following is an example of a nurse's review of this situation? A. Critical thinking B. Managing an adverse event C. Exercising self-discipline D. Time management
A. Critical thinking The process of reviewing consequences for a patient is an example of critical thinking and clinical decision making. Managing an adverse event occurs after consequences have occurred. Exercising self-discipline is a critical thinking attitude that guides you in reviewing, modifying, and implementing interventions, which occurs after reviewing consequences. This is not an example of time management.
A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.) A. Data collection. B. Data clustering. C. Data interpretation. D. Making a diagnostic statement. E. Goal setting.
A. Data collection. C. Data interpretation. This is an example of an error in interpretation and data collection. When making a diagnosis, the nurse must interpret data that he or she has collected by identifying and organizing relevant assessment patterns to support the presence of patient problems. In the case of the two diagnoses in this question, there can be conflicting cues. The nurse must obtain more information and recognize the cues that point to the correct diagnosis.
The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? (Select all that apply.) A. Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs B. Allows physicians and allied health staff to communicate with nurses how they provide care among themselves C. Helps nurses focus on the scope of nursing practice D. Creates practice guidelines for collaborative health care activities E. Builds and expands nursing knowledge
A. Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs C. Helps nurses focus on the scope of nursing practice E. Builds and expands nursing knowledge The use of nursing diagnosis creates a common language for nurses to communicate patient care needs, allows nurses to focus on the realm and scope of nursing practice, and helps to develop nursing knowledge. It is not a language for physicians and allied health staff because they do not rely on providing nursing interventions. Terminology in nursing diagnosis may be familiar to other health care providers but not in a way for directing nursing interventions. Nursing diagnosis has the purpose of creating practice guidelines for nursing.
A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? (Select all that apply.) A. How is your diabetic diet affecting you and your family? B. You seem to not want to follow health guidelines. Can you explain why? C. What worries you the most about having diabetes? D. What do you expect from us when you do not take your insulin as instructed? E. What do you believe will help you control your blood sugar?
A. How is your diabetic diet affecting you and your family? C. What worries you the most about having diabetes? E. What do you believe will help you control your blood sugar? Asking "How is your diabetic diet affecting you and your family?" "What worries you the most about having diabetes?" and "What do you believe will help you control your blood sugar?" are open-ended and allow the patient to share his values and health practices. The statements "You seem to not want to follow health guidelines. Can you explain why?" and "What do you expect from us when you do not take your insulin as instructed?" both show the nurse's bias.
Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) A. Impaired Skin Integrity related to physical immobility B. Fatigue related to heart disease C. Nausea related to gastric distention D. Need for improved Oral Mucosa Integrity related to inflamed mucosa E. Risk for Infection related to surgery
A. Impaired Skin Integrity related to physical immobility C. Nausea related to gastric distention The related factors in diagnoses "Fatigue related to heart disease" and "Need for improved oral mucosa integrity related to inflamed mucosa" are incorrect. The related factor of a medical diagnosis (in Fatigue related to heart disease) cannot be corrected through nursing intervention. In "Need for improved oral mucosa integrity related to inflamed mucosa" there is no diagnosis, but instead a goal of care. "Risk for infection related to surgery" is incorrect; risk nursing diagnoses do not have defining characteristics or related factors because they have not occurred yet.
A nurse is conferring with another nurse about the care of a patient with a stage II pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcer management. The use of a standardized guideline achieves which of the following? (Select all that apply.) A. Makes it quicker and easier for nurses to intervene B. Sets a level of clinical excellence for practice C. Eliminates need to create an individualized care plan for the patient D. Delivers evidence-based interventions for stage II pressure ulcer E. Summarizes the various approaches used for the practice concern or problem
A. Makes it quicker and easier for nurses to intervene B. Sets a level of clinical excellence for practice D. Delivers evidence-based interventions for stage II pressure ulcer Even though a standardized clinical practice guideline offers evidence-based solutions for clinical excellence that nurses can quickly and easily apply in practice, a nurse remains accountable for individualizing even standardized interventions when necessary. A guideline is not a summary of various approaches used by clinicians for a practice issue; it is a summary of the most relevant evidence-based information.
The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? A. Physical care technique B. Activity of daily living C. Indirect care measure D. Lifesaving measure
A. Physical care technique Administering a tube feeding is an example of a physical care, a direct care technique.
A nurse in a community health clinic has been caring for a young teenager with asthma for several months. The nurse's goal of care for this patient is to achieve self-management of asthma medications. Identify appropriate evaluative indicators for self-management for this patient. (Select all that apply.) A. Quality of life B. Patient satisfaction C. Use of clinic services D. Adherence to use of inhaler E. Description of side effects of medications
A. Quality of life C. Use of clinic services D. Adherence to use of inhaler Relevant and appropriate evaluative indicators of self-management include self-efficacy, health behavior or attitude, health status, health service use, quality of life, and psychological indicators. In this case the patient's quality of life, use of clinic services, and adherence (behavior) to use of an inhaler are all appropriate. Patient satisfaction is a perception and not an indicator of self-management. Ability to describe medication side effects is a measure of knowledge but does not necessarily equate with successful self-management.
A nurse working on a surgery floor is assigned five patients and has a patient care technician assisting her. Which of the following shows the nurse's understanding and ability to safely delegate to the patient care tech? (Select all that apply.) A. The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test. B. Determining what is the patient care technician's current workload. C. The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test. D. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure. E. The nurse confers with another registered nurse about organizing priorities.
A. The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test. C. The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test. D. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure. A nurse must consider priorities of all assigned patients in deciding which activities should be delegated to NAP. When the decision is between vital signs versus a patient arriving from a diagnostic test, delegation of routine vital signs is appropriate. Ensuring that a NAP is competent to perform an activity is also important. Conferring with another RN about organizing and checking the tech's personal workload are not factors that will assist the RN's own priority setting.
In which of the following examples are nurses making diagnostic errors? (Select all that apply.) A. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data B. The nurse who measures joint range of motion after the patient reports pain in the left elbow C. The nurse who considers conflicting cues in deciding which diagnostic label to choose D. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping E. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.
A. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data D. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping E. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia. When the nurse observes the patient wincing and holding his left side but does not gather additional assessment data, he or she makes a data collection error by omitting important data (i.e., pain severity). A nursing diagnosis cannot be made on basis of a single defining characteristic, as seen when the nurse identifies a diagnosis on the basis of a patient reporting difficulty sleeping. A nursing diagnosis needs to be related to a patient's response, not a medical diagnosis such as pneumonia. The nurse who measures joint range of motion after the patient reports pain is correctly validating findings. Considering conflicting clues ensures that the nurse does not make an interpretation error.
Purposes of the Nursing Outcomes Classification (NOC) include which of the following? (Select all that apply.) A. To identify and label nurse-sensitive patient outcomes B. To test the classification in clinical settings C. To establish health care reimbursement guidelines D. To identify nursing interventions for linked nursing diagnoses E. To define measurement procedures for outcomes
A. To identify and label nurse-sensitive patient outcomes B. To test the classification in clinical settings E. To define measurement procedures for outcomes
Direct cares include
ADLS, physical care techniques, lifesaving measures, counseling, teaching, controlling adverse reactions
Criteria for writing goals & expected outcomes: (________ must be met)
ALL criteria must be met. 1. Client-centered 2. Singular (one at a time) 3. Measurable 4. Time-limited 5. Mutual (agreed with client whenever possible) 6. Realistic
Physician Assisted Suicide
ANA has states that nurses should not participate in assisted suicide because it is an act that violates the code for nurses and the ethical traditions of the profession
What is the ANA
ANA: Fosters high standards of nursing and to promote development and general/ economic welfare of nurses. (ICN is the same but Internationally parallel)
A - pain
ASK about pain regularly
Each outcome statement addresses ________________ for a given nursing diagnosis.
AT LEAST one Defining Characteristic
Accountability
Ability to answer for ones actions
What is "exceptional data"?
Abnormal data
Define Exceptional Data
Abnormal data or data outside the normal range
Distributive/vasogenic shock
Abnormal distribution of blood flow in capillaries (septic, neurogenic, anaphylactic)
Cheyne Stokes breathing
Abnormal respiration pattern with periods of apnea followed by periods of deep breathing
Apnea
Absence of respirations for 15 seconds or longer
Defining characteristics of ineffective airway
Absent cough, inability to remove airway secretions, orthopnea, diminished breath sounds
What are examples of non-opioids
Acetaminophen Aspirin
Opioid MOA
Act on CNS, relieve pain by binding to receptor sites in nervous system
What stage of health behavior change? Actively changing behavior.
Action
Prescriptive theory
Action oriented, nursing interventions
Fluid loss 15-30%
Activates sympathetic response can restore CO and BP
Inspiration
Active process
Healthy Behaviors
Activities related to maintaining, attaining, or regaining good health illness.
What are the two types of pain that you observe in patients
Acute Chronic
types of pain
Acute/transient pain Protective, identifiable, short duration; limited emotional response Chronic episodic Occurs sporadically over an extended duration Inferred pathological Musculoskeletal, visceral, or neuropathic Cancer Can be acute or chronic Idiopathic Chronic pain without identifiable physical or psychological Chronic/persistent noncancer Is not protective, has no purpose, may or may not have an identifiable cause
The difference between acute and chronic pain
Acute: short duration, severe, may affect functioning in any dimensions Chronic: persists for 6+ months, may affect functioning in any dim
prescriptive
Address nursing interventions for a phenomenon, and predict the consequence of a specific nursing intervention
Regulatory
Administrative
Pain Management protocol
Admission, after pain producing events, new report of pain, every 8 hours, discharge
Some level of experience even if its only observation but can identify meaningful aspects of principles of nursing care.
Advanced Beginner
What domain of learning deals with expression of feelings and acceptance of attitudes, opinions or values
Affective
What is the largest minority group?
African Americans
S/S of pain
Age, fatigue, genes, neurological function Fatigue increases the perception of pain and can cause problems with sleep and rest.
Fidelty
Agreement to keep promises
Fidelity
Agreement to keep promises, pain control
For patients to be part of goal setting they need to be?
Alert, some degree of independence with daily activities
Federal statutory laws:
Americans with disabilities Advanced directives: Living wills, and Power of Attorney
Activity Tolerance
Amount of exercise or work that a person is able to perform WITHOUT *undue* exertion or possible injury
Impaired gas exchange
An actual or potential decrease in passage of gases between alveoli of lungs and capillary
What is the most frequent route of a registered nurse education
An associates degree or BN
What is spirituality?
An awareness of ones inner self and a sense of connection to a higher being, nature, or some purpose greater than oneself.
Interpersonal interaction
An exchange between 2 people
Assault
An intentional threat with no contact.
Which instructional method has to do with explaining something in a way the other person would understand
Analogy
Nursing diagnosis includes ________________ the data to discover if there is indeed a _______________ and the problem is related to a cause that the nurse can ______________.
Analyzing Problem Impact
Accountability
Answering for ones actions.
Meds for impaired tissue/local perfusion
Anticoagulants (heparin), thrombolytics (TPA), lipid-lowering agents (statins), vasodilators, anti-platelet agents and platelet inhibitors (aspirin)
Oxygenation meds
Antihistamines, glucocorticoids, mucolytics, expectorants, antiinflammatorys
Meds for impaired central perfusion
Antihypertensives, antiarrythmics, inotropic (rate and strength of contraction: digoxin), antianginal agents (nitroglycerin), vasopressors (epinephrine, dopamine), vasodilators (nitroglycerine)
What is an example of Protective touch
Any touch you use when you are preventing harm towards the patient.
Main functions of colon
Arteries and veins carry O2 and nutrients, eliminates indigestible food residue from the body, absorbs salts, water and vitamins
Tissue perfusion
Arteries; volume of blood that flows to target tissue; requires patent vessels, adequate hydrostatic pressure, capillary permeability
Silence is important to which cultural groups?
Asian and native americans
What are some UTI interventions?
Assess color, odor, amount and clarity of urine. Personal Hygiene Catheter Care Fluid intake by measuring I/O Empty Catheter bag frequently Culture Urine Bladder Schedule every 2-3 hours Anti-infectives, phenopyridine, and urinary analgesics
Documentation criteria can be applied to all of ADPIE but most important for ________________.
Assessment
What are the standards of care
Assessment Diagnosis Planning Implementation Evaluation
Steps of the nursing process
Assessment Diagnosis Planning Implementation Evaluation
Assessment
Assessment collection of subjective and objective data: includes 2 steps: The collection of information from a primary source (a patient) and secondary sources (e.g. family or friends, health, professionals, and the medical record) The interpretation and validation of data to ensure a complete database
What are the ANA standards of nursing practice? (ADPIE)
Assessment, Diagnosis, Outcome identification/Planning, Implementation, Evaluation.
What is the difference between an atheist and an agnostic?
Atheist- Does not believe in a god. Agnostic- believes there is no known ultimate reality
Specific causes of impaired tissue/local perfusion
Atherosclerosis, hyperlipidemia, HTN, PAD, pulmonary embolism, stroke, venous thrombosis
What are the 5 leadership styles?
Autocratic- "Boss" 2. Democratic- Leader involves followers in decision making process 3. Laissez Faire: No Boss interference, they stand at a distance giving freedom. 4. Transactional- Rewarding and correcting 5. Transformational- changes individuals, long term and involves people and organizations.
Roles of a Professional Nurse
Autonomy, caregiver, responsibilities, advocate, educator, communicator, manager
What are the professional responsibilities and roles of a nurse
Autonomy/accountability Caregiver Advocate Educator Communicator Manager Career development
Nonmaleficence
Avoidance of harm or hurt, no lasix to a pt with low potassium
A faculty member is reviewing a nursing student's plan of care, including the interventions the student provided for a patient with dementia. The student reviewed clinical guidelines on a professional website to identify interventions successful in reducing wandering in patients with dementia. The faculty member should evaluate which of the following? (Select all that apply.) A. Number of interventions B. Appropriateness of the intervention for the patient C. The prior use of interventions by other nursing staff D. Correct application of the intervention for the patient care setting E. The time it takes to provide interventions
B. Appropriateness of the intervention for the patient D. Correct application of the intervention for the patient care setting In this situation the faculty member reviews the plan for the appropriateness of the intervention and its correct application. Because the nursing student selected proven interventions from a professional website, it is likely the interventions represent an accepted standard of care and meet the criteria of appropriateness. The number of interventions is not important. Whether an intervention has been used by other nurses is not important in the context of evaluating this nurse's plan of care. However, if other interventions are known to be effective for this patient, the student might choose to revise the plan later and add such interventions.
A nurse is visiting a patient in the home and is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.) A. Reviewing the family caregiver's availability during medication administration times B. Making a judgment of the value of improved adherence for the patient C. Reviewing the number of medications and time each is to be taken D. Determining all consequences associated with the patient missing specific medicines E. Reviewing the therapeutic actions of the medications
B. Making a judgment of the value of improved adherence for the patient D. Determining all consequences associated with the patient missing specific medicines Tips for making good clinical decisions during implementation include making a judgment of the value of the consequence to the patient, reviewing all possible consequences associated with each nursing action, determining the probability of all possible consequences, and reviewing the set of all possible nursing interventions for a patient's problems.
The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n): A. Risk nursing diagnosis. B. Problem-focused nursing diagnosis. C. Health promotion nursing diagnosis. D. Wellness nursing diagnosis.
B. Problem-focused nursing diagnosis. This is an example of a problem-focused nursing diagnosis with a related factor, based on NANDA-I diagnostic terminology. Most health promotion diagnoses do not have established related factors based on NANDA-I; their use is optional. Wellness diagnoses are not one of the types of NANDA-I diagnoses.
A nurse is caring for a complicated patient 3 days in a row. The nurse attends an interdisciplinary conference to discuss the patient's plan of care. In which ways can the nurse develop trust with members of the conference team? (Select all that apply.) A. Is willing to challenge other members' ideas because the nurse disagrees with their rationale B. Shows competence in how to monitor patients' clinical status and inform the physician of critical changes C. Asks a more experienced nurse to attend the conference D. Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly E. During the meeting focus on similar problems the nurse has had in delivering care to other patients.
B. Shows competence in how to monitor patients' clinical status and inform the physician of critical changes D. Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly Showing competence and exercising effective communication are important for developing trust with interdisciplinary team members. Having another nurse attend the conference who might be less familiar with the patient would not promote trust. Challenging other ideas just because of disagreement does not foster trust. Changing the focus from the patient to the problems of the nurse will not foster trust.
Which of the following nursing diagnoses is stated correctly? (Select all that apply.) A. Fluid Volume Excess related to heart failure B. Sleep Deprivation related to sustained noisy environment C. Impaired Bed Mobility related to postcardiac catheterization D. Ineffective Protection related to inadequate nutrition E. Diarrhea related to frequent, small, watery stools.
B. Sleep Deprivation related to sustained noisy environment D. Ineffective Protection related to inadequate nutrition The correct diagnoses of Sleep Deprivation and Ineffective Protection are worded with related factors that will respond to nursing interventions. Nursing interventions do not change a medical diagnosis or diagnostic test. Instead nurses direct nursing interventions at behaviors or conditions that they are able to treat or manage. The first two incorrect diagnoses use a medical diagnosis and diagnostic procedure respectively as related or etiological factors. These are not conditions that nursing interventions can treat. The last diagnosis is incorrect because it is related to an assessment finding of a symptom or a defining characteristic.
The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (Select all that apply.) A. The application of the skin barrier is a dependent care measure. B. The call to the ostomy and wound care specialist is an indirect care measure. C. The cleansing of the skin is a direct care measure. D. The application of the skin barrier is an instrumental activity of daily living. E. Inspecting the skin in a direct care activity.
B. The call to the ostomy and wound care specialist is an indirect care measure. C. The cleansing of the skin is a direct care measure. The call to the specialist is a referral and an indirect care measure on the patient's behalf. Cleansing of the skin is an example of direct care. Application of a skin barrier is an independent measure and it is not an instrumental activity of daily living. Inspecting the skin is assessment, not direct care.
A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? A. Incorrect clustering B. Wrong diagnostic label C. Condition is a collaborative problem. D. Premature closure of clusters
B. Wrong diagnostic label The more appropriate nursing diagnosis for this patient would be Risk for Impaired Skin Integrity because the patient's skin is clean and intact. A risk nursing diagnosis is appropriate because the patient has two risk factors, radiation and secretions on the skin.
BRATY diet - treat diarrhea
BANANA, RICE, APPLESAUCE, TEA, or YOGURT
B- pain
BELIEVE the patient and family in their report of pain
Infectious agent
Bacteria, viruses, fungi, protozoa
Signs and symptoms of emphysema
Barrel chest, pink sputum, pursed lip breathing
Levels of critical thinking
Basic critical thinking -Complex critical thinking- -Commitment-
What are some impacts that illness can have on the client and family members
Behavioral and emotional changes Impact on body image Impact on self-concept Impact on family roles Impact on family dynamics
Planning is a category of nursing __________ in which _______________ and ______________ are established. The plan is all about ________________. Planning is the _____ step of the nursing process.
Behaviors Client-centered goals Expected outcomes The patient 3rd
What theorist believed caring is an interpersonal interaction?
Benner
We need protein for
Blood clotting, fluid regulation, and acid-base balance
Signs and symptoms of bronchitis
Blue cyanotic/hypoxia, Recurrent cough/ increased sputum
Fluid loss <15% (500-700 ml)
Body can compensate
Human Trait
Born with the ability to care
Impaired tissue/local perfusion interventions
Bypass and/or graft surgery, stent or angioplasty, endarterectomy
Water soluble vitamins
C and B-Complex
Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient? A. Knowing the source of the guideline B. Reviewing the evidence used to develop the guideline C. Individualizing how to apply the clinical guideline for a patient D. Explaining to a patient the purpose of the guideline
C. Individualizing how to apply the clinical guideline for a patient Individualizing patient care is still the important principle for implementing care, even when a clinical guideline is used. Explaining any interventions in a guideline to the patient is important but not the most critical factor in implementing care. Reviewing the source of the guideline and applicable evidence do not directly benefit a patient.
A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error? A. Insufficient cluster of cues B. Disorganization C. Insufficient number of cues D. Evidence that another diagnosis is more likely
C. Insufficient number of cues It is likely the charge nurse suspects that the student has not collected enough cues to support the diagnosis. A change in blood pressure and mental status changes are significant findings that can be attributed to fluid volume excess and other diagnoses. The recommendation of the symptom cluster by the registered nurse would allow the student to have sufficient data to confirm a deficient fluid volume.
What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey? A. Measures a nurse's competency in interdisciplinary care B. Measures the number of adverse events in a hospital C. Measures quality of care within hospitals D. Measures referrals to a health care agency
C. Measures quality of care within hospitals HCAHPS is a survey that has become a standard for measuring and comparing quality of hospitals. It is a survey of patient perceptions.
A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor? A. Infant crying at breast B. Infant unable to latch on to breast correctly C. Mother's deficient knowledge D. Lack of infant weight gain
C. Mother's deficient knowledge In this scenario the related factor is the mother's deficient knowledge. A related factor is a condition, historical factor, or etiology that gives a context for the defining characteristics, in this case the infant crying, inability to latch on to breast, and absent weight gain.
For the nursing diagnosis of Deficient Knowledge a nurse selects an outcome from the Nursing Outcome Classification (NOC) of patient knowledge of arthritis treatment. Which of the following are examples of an outcome indicator for this outcome? (Select all that apply.) A. Nurse provides four teaching sessions before discharge. B. Patient denies joint pain following heat application. C. Patient describes correct schedule for taking antiarthritic medications. D. Patient explains situations for using heat application on inflamed joints. E. Patient explains role family caregiver plays in applying heat to inflamed joint.
C. Patient describes correct schedule for taking antiarthritic medications. D. Patient explains situations for using heat application on inflamed joints. The patient must exhibit behaviors that measure knowledge of arthritis treatment. This would include describing his medication schedule and explaining when to apply heat to inflamed joints. The nurse providing teaching sessions is not a patient outcome. The patient denying joint pain is not an evaluative indicator of knowledge. Explanation of the family caregiver's role is not a measure of the patient's knowledge of treatment.
tests for temperature
CBC with diff, cultures, urinalysis, CXR, sed rate, CRP
Tests for cardio-pulmonary functioning
CBC, PEFR , Bronchoscopy, sputum specimens, Thoracentesis
C- pain
CHOOSE pain control appropriate for patient
Diagnostic tests of perfusion
CK, ANP, Troponin, Sserum lipids, EKG, Stress test, CXR, ultrasound, arteriogram
What is the treatments for sleep apnea?
CPAP/BIPAP
What is a concept?
Can be simple or complex and relate to an object or event that comes from individual perceptual experiences.
"Risk for diagnosis"
Can have goal, but no outcomes; no defining characteristics
Specific causes of impaired central perfusion
Cardiac dysrhythmias, shock, heart failure, pulmonary HTN
Cause of impaired central perfusion
Cardiac output is inadequate
Consequences of uncontrolled HTN
Cardiac: CAD, LV hypertrophy Neurovascular: TIA, stroke, PAD Renal: chronic failure, increased creatinine levels Eyes: retinopathy
Opportunistic pneumonia
Caused by pathogens that take advantage of an opportunity not normally available such as a host with a weakened immune system
The types of sleep apnea
Central Obstructive Mixed apnea
Ineffective breathing pattern
Change in rate, depth or pattern of breathing that alters normal gas exchange; insp or expir not providing adequate ventilation
Four types of report
Change-of-shift, telephone, transfer, incident
Ineffective breathing characteristics
Changes in resp rate, change in chest excursion, SOB, use of accessory muscles
Where do we get our data?
Charts Their family Labs Previous institutions Other members of the Healthcare team Nurses experience
Nursing monitoring for colon diversions
Check I&O, low residue diet, skin protection, coping difficulties, decision making support, emotional support, monitor foods to decrease odor and gas, choose foods that thicken stool
types of diet
Clear liquid (No red dyes) Full liquid (Broth, yogurt, water, juice) Pureed (Blended food) Mechanical Soft (For people that have trouble swallowing; cut up in small pieces) Soft/Low Residue High Fiber Low Sodium Low Cholesterol Diabetic
The order of priorities changes as _______________ changes, sometimes within a matter of ___________.
Client's condition changes Minutes
Examples of advanced practice career roles in nursing
Clinical nurse specialist (CNS) Certified nurse practitioner (CNP) Certified nurse midwife (CNM) Certified RN anesthetist (CRNA)
Treatment of fractures
Closed reduction and immobilization -didn't cut open to do surgery -cast/splint -align bones Open/surgical reduction and fixation -goes to surgery -screws or hardware -keep in place Traction -use weights and pulleys outside of limb to keep bone in place
What domain of learning includes all intellectual behaviors
Cognitive
What are the domains of learning
Cognitive Affective Psychomotor
What are the 3 learning domains?
Cognitive (intellectual) Psychomotor (ex: performing an insulin check) Affective (implementation, ex: teaching diet and then using it at home)
3 Implementation Skills
Cognitive- application of critical thinking in the nursing process. Using good judgment and sound clinical decisions Interpersonal- developing a trusting relationship to express a level or caring, and to communicate clearly. (Important to keep patient informed, individualized patient teaching) perception of verbal and nonverbal Psychomotor- integration of cognitive and motor skills. Knowing a skill and being able to demonstrate it effectively
Implementation skills are based on? (3 terms)
Cognitive- application of critical thinking in the nursing process. Using good judgment and sound clinical decisions Interpersonal- developing a trusting relationship to express a level or caring, and to communicate clearly. (Important to keep patient informed, individualized patient teaching) perception of verbal and nonverbal Psychomotor- integration of cognitive and motor skills. Knowing a skill and being able to demonstrate it effectively
Accidental Hypothermia
Cold water submersion , inadequate clothing in cold weather are examples of ?
Narrative Documentation
Coldspa and cardinal techniques
Type of intervention: Administering a breathing treatment every 4 hours.
Collaborative
Function of micro minerals
Collagen formation and wound healing
Exogenous
Comes from microorganisms found *outside* the individual ex: Salmonella
Malpractice
Commonly referred to as professional negligence.
What are some things to take into consideration when assessing culture?
Communication, Time, and Space
2-3 clinical years of experience, specific type of care performed like oncology or surgical, able to anticipate care and establish long range goals.
Competent
types of incontinence
Complaint of any involuntary loss of urine" Functional- altered mobility and manual dexterity, poor motivation, environmental barriers Stress- weak pelvic floor muscles, trauma after childbirth, radical prostatectomy, small volume Urge- overactive bladder, leaks Reflex- May not completely empty bladder, when bladder reaches certain level.
what is nursing theory
Conceptualizes an aspect of nursing to describe, explain, predict, or prescribe nursing care.
Collaboration
Concerted work with individuals and groups to attain a shared goal
What are the psychological symptoms of sleep deprevation
Confused and disoriented Increased sensitivity to pain Hyperactive Agitated
Give three examples of a nursing diagnosis that are also a medical diagnosis
Constipation Anxiety Chronic Pain
What are some nursing diagnoses that are also medical diagnoses
Constipation Anxiety Chronic pain
What stage of health behavior change? Considering change in next 6 months
Contemplation
what is continuing in education mean
Continuing education- involves formal, organized educational programs offered by universities, hospitals, state nurses associations, professional nursing organizations, and educational health care institutions
Hospital acquired pneumonia
Contracted by the patient who has been in the hospitalization at least 48-72 hours
Posterior Hypothalmus
Controls temp if *Low* at set point -Conserves heat by *vasoconstriction* and *Shivering*
Mucolytics, expectorants
Cough up mucus
Nursing diagnosis requires __________ and good _________________.
Critical thinking Clinical judgment
Signs of impaired tissue/local perfusion
Cyanosis, numbness, pain, gangrene, pressure ulcer, unilateral slow refill, dizziness, local edema, weak unilateral pulse, decreased urine output (loss of perfusion to kidneys)
What is an appropriate action by a nurse when providing care for an 18 year old with respiratory problems caused by excessive smoking? A) Remind the client that excessive smoking could lead to cancer. B) Exhibiting a expression of disapproval by staying silent C) Asking the client why he started smoking at a young age D) Suggesting methods and provide resources to assist with smoking cessation.
D) Suggesting methods and provide resources to assist with smoking cessation.
A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: A. Collaborative data set. B. Diagnostic label. C. Related factors. D. Data cluster.
D. Data cluster. A data cluster is a set of cues (i.e., the signs or symptoms gathered during assessment).
A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format? A. Disturbed Sleep Pattern evidenced by frequent awakening B Disturbed Sleep Pattern related to family caregiving responsibilities C. Disturbed Sleep Pattern related to need to improve sleep habits D. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested
D. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested A nursing diagnosis in a PES format includes the diagnostic label, related factor, and the defining characteristics by which the diagnosis is evidenced. The second nursing diagnosis is the correct format in the two-part format for writing a diagnosis. The first diagnosis has no related factor. The third diagnosis is an error, using a goal as a related factor.
A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement? A. Identifying the clinical sign instead of an etiology B. Identifying a diagnosis on the basis of prejudicial judgment C. Identifying the diagnostic study rather than a problem caused by the diagnostic study D. Identifying the medical diagnosis instead of the patient's response to the diagnosis.
D. Identifying the medical diagnosis instead of the patient's response to the diagnosis. Intestinal colitis is a medical diagnosis. The related factor in a nursing diagnostic statement is always within the domain of nursing practice and a condition that responds to nursing interventions. Nursing interventions do not change a medical diagnosis.
A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient's bed and adjusts the room lighting to illuminate the work area. A patient care technician comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit? A. Environment B. Personnel C. Equipment D. Patient
D. Patient In preparing to administer the enema, the nurse did not prepare for the patient's physical and psychological comfort.
D- pain
DELIVER interventions in a timely and logical manner
Revising a care plan
Date any new data, delete any irrelevant nursing diagnosis, revise specific interventions that correspond to new nursing diagnosis
HTN collaborative care
Decrease to 140-/90-
Reason for cheyne stokes
Decreased blood flow or injury to the brainstem
Ischemia
Decreased blood supply to a body part such as skin tissue or to an organ such as the heart
QSEN Definition on safety
Defines safety as "Minimizing risk of harm to patients and providers through both systems effectiveness and individual performance"
What 5 components does every states Nurse Practice Act have?
Definition of Nursing Licensure Requirements Revocation or suspension of license Reciprocity of license Members of the Board of Nursing
What are 5 signs of caregiver stress
Denial Anger Social withdrawal Depression Anxiety
What are 5 signs of caregiver stress
Denial Anger Social withdrawal Depression Anxiety Sleeplessness Short focused Health problems
Susceptible Host
Depends on an individuals degree of *resistance* to pathogens - An individual becomes susceptible to the *strength* and *Numbers* of microorganisms
What is magnet status?
Describes the best of the best, it draws people in and is expensive to apply, these hospitals provide excellent care.
What are the components of an actual nursing diagnosis
Diagnostic label (problem) Cause/Etiology "Secondary to" Defining characteristics
What are some examples of "Coping with impaired functions"
Diet Activity Medication home care physical therapy Speech therapy (the nurse must consider each patient on individual basis)
How to complete a nutritional assessment
Diet history 24 hours or 3 days diet history Medication history Lab finding Lipid panel, Albumin, Protein, Iron, Creatinine, CBC, and Hemoglobin Physical history Bowel movement→ in elimination listen in lower right quadrate Anthropometry Mid-arm circumference, BMI, pinch, body fat measurement
Primary prevention
Diet, exercise, non smoking
Which of the following signs or symptoms in a patient who is opioid-naive is of greatest concern to the nurse when assessing the patient one hour after administering an opioid? 1) Oxygen saturation of 95% 2)Difficulty arousing the patient 3) Respiratory rate of 10 breaths/minute 4) Pain intensity rating of 5 on a scale of 0-10.
Difficulty arousing the patient.
When revising a care plan what do you do?
Discontinue current care plan, modify, reassess, re-define diagnosis, change goal/ expected outcome as well as interventions, and re-evaluate.
What are some examples of "Restoration of Health"
Disease or condition Cause of disease Expected effects on other body systems medications tests Therapies
causes of sleep apnea
Disorder characterized by the lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep. Occurs when muscles or structures of the oral cavity or throat relax during sleep Deviated septum, nasal polyps, certain jaw configurations, larger neck circumference, enlarged tonsils
What are some non-pharmacological pain relief interventions?
Distraction Prayers Relaxations Guided imagery Music.
Name 5 nonpharmacologic interventions
Distraction, Relaxation, Hot/cold therapy, Deep breathing, Guided imagery.
Anti-HTN meds
Diuretics (furosemide/Lasix), ACE inhibitors (prils), Alpha-adrenergic blocking agents (sins), Beta-adrenergic blockers (lols), Ca channel blockers, Centrally acting sympatholytics, Vasodilators
Cardiac chest pain
Does not occur with respiratory variations
Beneficence
Doing good for others.
Self Care theory
Dorothea Orem developed the ______-_______ deficit theory - Focus on performance and practice of activities that *Individuals initiate* and perfom on *their own* behalf to maintain life - Used in *Rehabilitation centers*
Airborne
Droplet nuclei or residue or evaporated droplets suspended in air during coughing, sneezing or carried in dust particles
Patient-controlled analgesia (PCA)
Drug delivery system that allows patients to self-administer analgesic medications on demand. with minimal risk of overdose.
Dantrolene sodium
Drug that Can *Reverse* the effects of *Malignant*HYPERthermia -Intracellular *Calcium* levels are *elevated* in MH - _________ _________ Reduces *Muscle tone* and *metabolism*
Passive Measures of Hypothermia
Dry, Warm clothing, warm liquids PO, exercise
Spreading disease
During Prodromal *Specific symptoms* Patient may be capable of _________ ___________ to others
E- pain
EMPOWER patients and their families, ENABLE them to control course as much as possible
Emergency Medical treatment and Labor Act
EMTALA; 1996; proper treatment/evaluation prior to transfer
Modes of transmission
Each disease has a *specific* _______ of _____________ ex: Direct, Indirect, Droplet, Airborne, Vehicles , Vector
Secondary HTN
Elevated due to identifiable cause (Cirrhosis, meds, endocrine or neuro disorders, renal disease, pregnancy, sleep apnea)
Primary HTN
Elevated with no identifiable cause (genetics, sodium retention, altered renin-angiotensin-aldosterone mechanism, stress, insulin resistance, endothelial dysfunction)
EMTALA
Emergency Medical Treatment and Active Labor Act. This ensures public access to emergency services regardless of ability to pay. This is to prevent "patient dumping" which means the medical staff can't refuse to treat the pt. if they are unable to pay.
Nursing considerations for shock
Emergency measures, fluid resuscitation, patient legs elevated 20 degrees w/ trunk horizontal and HOB 10 degrees (circulation to brain and kidneys), oxygen, monitoring fluid status
Health Promotion
Emphasizes Maintenance and Enhancement.
Confidentiality
Ensuring that information is accessible only to those who are authorized to have access.
What are 2 modifiable risk factors
Environment Lifestyles
What is the 4 things learning depends on
Environment Motivation Learning preference/Learning styles Ability
Organizing Resources:
Equipment -decide beforehand supplies needed and determine availability along with knowledge to use safely. Personnel -how nursing is organized and how the personnel delivers care (Who is accountable for what) (delegation or performance of intervention) Environment -needs to be safe and conducive to implement therapy. Patient safety is first concern. (Using privacy in exposing situations, limiting distractions in room) Patient -awareness of patients physical and physiological needs before implementation to ensure comfort and opportunity (alleviating pain before implementation, making sure their endurance and pain level is acceptable beforehand)
Organizing resources and care delivery: ensures timely, efficient, and skilled care: (how do these relate...?) equipment, personnel, environment, patient....
Equipment- decide beforehand supplies needed and determine availability along with knowledge to use safely. Personnel-how nursing is organized and how the personnel delivers care (Who is accountable for what) (delegation or performance of intervention) Environment- needs to be safe and conducive to implement therapy. Patient safety is first concern. (Using privacy in exposing situations, limiting distractions in room) Patient- awareness of patients physical and physiological needs before implementation to ensure comfort and opportunity (alleviating pain before implementation, making sure their endurance and pain level is acceptable beforehand)
Professional ethics
Ethical standards and expectations of a particular profession
Bioethics
Ethical surroundings surrounding biological sciences
What are the ANA standards of professional performance
Ethics Education EBP Quality Communication Leadership Collaboration Professional practice evaluation Resources Environmental health
Standards of professional performance
Ethics, education, evidence based practice, quality of practice, communication, leadership, collaboration
Standards of Professional Performance
Ethics: Education Evidence-Based Practice and Research -Quality of Practice Communication Leadership Collaboration Professional Practice Evaluation Resources Environmental Health
Cognitive Skills
Ex) Recognizing the possible complications of blood transfusion.
Evaluative Nursing Intervention
Ex) The nurse will reassess the patient's pain status in 30 minutes.
Goals of care (types)
Examples include patient-centered, short term, and long term
Sodium ; Dehydration
Excessive & prolonged *sweating* coupled with sustained *High* body temp can result in _________ *loss* & ______________
Interventions to help perfusion
Exercise, weight control, decrease smoking and alcohol, nutrition, SCD hose, doppler studies
Diverse experience, skilled at identifying patient centered problems and problems related to healthcare system, considered a mentor.
Expert
Interdisciplinary Theory
Explains a systemic view of a phenomenon specific to the discipline of inquiry.
paradigm
Explains the linkages between nursing science, philosophy, and theory; Directs the activity of the profession.
Obstructive shock
External force stops heart from beating
Diagnostic tests for colon CA
FOBT, flexible sigmoidoscopy every 5 years, barium enema every 5 years, colonoscopy every 10 years, CEA, CBC, CT, MRI
What did Nightingale's theory focus on?
Facilitates wellness by manipulating patients environment to include appropriate noise, nutrition, hygiene, light, comfort, socialization, and holistic care.
Metacommunication
Factors that compose the context of the message
Guidelines for quality documentation and reporting (FACCO)
Factual-descriptive, objective, what hear see smell Accurate-exact accurate measurements Complete-complete with appropriate essential info Current-timely entries, delays lead to unsafe care Organized-logical order, clear and to the point
Justice
Fairness
Justice
Fairness, transplant criteria
The nurse removes the epidural catheter. T or F
False, the anesthesiologist should remove or modify epidural.
Statutory
Federal law; formal written law; basis for standard of care; e.g. nurse practice act
Definition
Flow of blood through arteries and capillaries delivering nutrients and oxygen to cells and removing cellular waste products
Medical treatment for shock
Fluids for volume replacement (normal saline 0.9% or lactated ringers, plasma expanders like albumin or synthetics to take place of blood/pull fluid into vasculature, blood)
What did Peplau's theory focus on?
Focuses on nurse/patient interaction, interpersonal relationships
What is the best way to prevent Malpractice?
Follow standards of care, give competent healthcare, and communicate with health care providers.
Glucocorticoid, antiinflammatory, bronchodilators
For lower airway
Shared governance
Fosters a decentralized style of management that creates an environment of empowerment
Safety
Freedom from psychological & physical injury , is a basic human need
Pleuritic pain
From inflammation of the pleural space of the lungs. the pain is peripheral and radiates to scapular regions
Parenteral Nutrition
GI tract is not functioning, provides proper nutrients and calories
What are examples of Adjuvants?
Gabapentin Tricyclic Antidepressants
Central perfusion
Generated by cardiac output to the peripheral vascular system
What are 2 non-modifiable risk factors
Genetic and physiological factors age
What is the correct order of removing PPE?
Gloves--> Goggles--> Gown--> Mask
Goal or Outcome: Client will increase ambulation progressively during postoperative period.
Goal
Goal or Outcome: Client will maintain adequate peripheral tissue perfusion by discharge.
Goal
What is the difference between a Goal and Expected outcome?
Goal: Long term (by discharge) Expected outcome: Within a short period of time (by end of shift)
What is the correct order of putting on PPE?
Gown--> Mask--> Goggles--> Gloves
Which theory is the hardest to test
Grand theory
What are 3 causes of peptic ulcer disease?
H. Pylori, NSAID use, and Stress
48-72
HAP (Hospital acquired pneumonia) refers to any pt. contracted pneumonia *at least* ____-____ hours AFTER being admitted
types of report
Hand off report-necessary information the next nurse needs to know Telephone order report-health care provider gives therapeutic orders over the phone to the RN Incidence-example- if a patient falls Transfer-example if a patient transfers from the hospital to the nursing home.
What are some teaching strategies for healthy sleep-hygiene habits?
Have patients keep a sleep log for a week Teach the patient sleep hygiene measures Encourage the patient to drink a cup of chamomile tea or warm milk at bedtime Help the patient to develop a pan for exercise log.
Influences on Nursing:Health Care Reform
Health Care Reform Demographic changes Medically underserved Bioterrorism Rising Health Care Costs Nursing Shortage
definition of confidentiality
Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates confidentiality and protection of patients' personal health information. In practice you cannot share information about a patient's medical condition or personal information to anyone not involved in the care of the patient.
Planning
Health care team planning, interpersonal collaboration, determining implementation methods
What are 3 purposes of client education
Health maintenance and promotion and Illness prevention Restoration of health Coping with impaired functions
Airborne precautions
Healthcare workers must follow standard precautions along with a *fitted Mask* -Mask will not allow microscopic particles to be inhaled by the nurse ex: TB, Chicken pox
What are some modifiable risk factors?
Healthy diet Weight control Regular exercise No smoking Limited alcohol consumption Routine health assessments Environment Lifestyle
Cardiogenic shock
Heart is not pumping enough
Primary prevention
Heart-healthy lifestyle
Heat stroke
Heat *depresses* hypothalamic function temp of *104 F* or *above* Characteristics -ALOC -hot, *Dry*, skin
Respiration
Heat is also lost during ____________ Elevated Resp rates are seen in pt.s who are *Hyperthermic* and *Dec* for pt.s who are *hypo*thermic
What are some anthropometry factors?
Height/weight, BMI, Wrist measurement, Mid arm circumference, Skin fold measurement
What did Orem's theory focus on?
Help patient attain total self care, nursing is necessary when patient is unable to do so.
Causes of hypovolemic shock
Hemorrhage, GI loss (vomiting, pooping blood), fistula drainage, diabetes insipidus, hyperglycemia, diuresis
Risk factors of perfusion
High BP, high cholesterol/triglycerides, smoking, diabetes, sedentary lifestyle, inflammation from diseases
symptoms of pneumonia
High fever up to 105 F Coughing out greenish, yellow, or bloody mucus Chills that make you shake Feeling like you can't catch your breath, especially when you move around a lot Feeling very tired Low appetite Sharp or stabby chest pain (you might feel it more when you cough or take a deep breath) Sweating a lot
Modifiable risk factors for HTN
High sodium, low K, Ca, Mg, obesity, excess alcohol, insulin resistance, stress
What is an example of caring touch
Holding a hand when given news.
Facilities that provide restorative care
Home health care- Rehabilitation- Extended care facility(SNF)-
What are the 5 perspectives on caring
Human Trait Moral Imperative Affect Interpersonal Interaction Therapeutic Intervention
Five perspectives on caring
Human trait, moral imperative, affect, interpersonal interaction, therapeutic intervention
five perspectives on caring
Human trait-born with it Interpersonal interaction Moral imperative-right vs. wrong Affect-feelings you have Therapeutic interventions
The major sleep study in the body is ?
Hypothalamus
Secondary prevention
Identifying diseases early so treatment can be initiated; screenings or diagnostic tests
When does patient abandonment occur?
If you leave the patient without properly transferring or handing them to a capable person, you are liable for patient abandonment and are responsible for any injury suffered after you leave them. "Failure to Act".
Consequences of impaired tissue/local perfusion
Impaired blood flow to affected body tissue (localized); ischemia and infarction
A 72-year-old patient has come to the health clinic with symptoms of a productive cough, fever, increased respiratory rate, and shortness of breath. His respiratory distress increases when he walks. He lives alone and did not come to the clinic until his neighbor insisted. He reports not getting his pneumonia vaccine this year. Blood tests show the patient's oxygen saturation to be lower than normal. The physician diagnoses the patient as having pneumonia. Match the priority level with the nursing diagnoses identified for this patient: 1. Impaired gas exchange_____ a. long term 2. Risk for activity intolerance______ b. short term 3. Ineffective self-health management_____ c. intermediate
Impaired gas exchange- short term Risk for activity intolerance- intermediate Ineffective self-health management- long term
Nurses ______________ interventions.
Implement
Implementation
Implementation: formally begins after you develop a plan of care. This step involves teaching and following through with plans
What is the difference between a nursing diagnosis and a medical diagnosis
In a nursing diagnosis we can't say "The diagnosis" we can provide evidence to the provider. Medical diagnosis is for the doctor.
Professional responsibilities
Include responsibility to the profession and to oneself, patients, employers, and community.
What does it mean to have a BSN degree?
Includes 4 years of study in a college or university Focuses on basic sciences, theoretical and clinical courses, and courses in social sciences, arts, and humanities to support nursing theory
Interdisciplinary care
Includes contributions from all disciplines involved in patient care, is designed to improve the coordination of all patients therapies and communication.
advanced directive (living will)
Includes living will, health care proxies, and durable powers of attorney for healthcare
Kussmauls breathing
Increase in respiration and expiration with breaths usually 35 breaths or greater. and increase in depth
Personal ethics
Individuals own ethical foundation
Systemic Infection
Infections require measures to control fever and usually require *IV antibiotics*
Localized infection
Infections require monitoring of fever, antibiotics and may require measures to *remove debris* or dead tissue to facilitate healing
Describe the steps of chain of infection.
Infectious organism --> Reservoir for pathogen---> Portal of exit from host--> Mode of transmission--> Portal of entry to host---> A susceptible host
A symptom that patients experience when they have chronic difficulty falling asleep, frequent awakenings from sleep, and/ or a short sleep or nonrestorative sleep
Insomnia
skin break down
Integument system complication of *immobility*
Battery
Intentional offensive touching without consent or lawful justification.
Collaborative nursing interventions
Interdependent interventions, require combined knowledge, skill, and expertise of multiple health care professionals
PAD definition
Interferes with arterial blood flow to the lower extremities, increasing risk for paresthesias, neuropathy, unsealing ulcers in legs, necrosis, gangrene, amputation
NANDA changed it's name to NANDA __________ to better reflect the international utility of nursing diagnosis for the global health community.
International
Incubation
Interval between *Entrance* of pathogen into body and appearance of *First symptom* ex: Chicken pox 14-16 days after exposure -Common cold 1-2 days -Influenza 1-4 days
incubation stage
Interval between entrance of pathogen into body and appearance of first symptoms (ex. Chickenpox, 14 to 16 days after exposure; common cold, 1 to 2 days; influenza, 1 to 4 days; measles, 10 to 12 days; mumps, 16 to 18 days; Ebola 2 to 21 day)
Prodromal
Interval from *Onset of non-specific signs* (Malaise, low-grade fever, fatigue) to *More specific symptoms* ex: HSV
prodromal stage
Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to more specific symptoms. (During this time microorganisms grow and multiply, and patient may be capable of spreading disease to others.) For example, herpes simplex begins with itching and tingling at the site before the lesion appears.
Convalescent
Interval when *Acute symptoms* of infection *Disappear* -Length of recovery depends on severity of infection and patients host resistance.
Convalescence
Interval when acute symptoms of infection disappear. (Length of recovery depends on severity of infection and patient's host resistance; recovery may take several days to months.)
Illness
Interval when patient manifest signs and *symptoms specific to type of infection* ex: Strep throat is manifested by sore throat, pain, swelling
illness stage
Interval when patient manifests signs and symptoms specific to type of infection. For example, strep throat is manifested by sore throat, pain, and swelling; mumps is manifested by high fever, parotid and salivary gland swelling.
Nurses implement ______________.
Interventions
Implementation occurs when the nurse initiates or completes _________________ necessary for achieving the __________ and ______________ of nursing care.
Interventions Goals Expected outcomes
Types of communication
Intrapersonal communication: "self talk" self-self Interpersonal communication: one-on-one communication Small-group communication: the interaction that occurs when a small number of people meet Public communication: interaction with an audience Electronic communication: the use of technology to create ongoing relationships with patients and their health care teams
Urge
Involuntary leakage of *Large amounts of urine* Assoc with *strong sense of urge*, OVERACTIVE bladder caused by *neurological problems* , bladder *inflammation* , obstruction
How is a BSN degree different from other types of nursing degree
Involves courses in social sciences, arts, and humanities to support nursing theory
examples of micro minerals
Iron, Zinc, Manganese, Iodine fluoride, Copper,
Asepsis
Is the Absence of pathogenic microorganisms _______ Technique refers to practices keeping a client as free from microorganisms as possible - 2 types
Societal ethics
Issues such as abortion, physician assisted suicide, embryonic stem cell; society provides a strong normative basis for ethical behavior
What is the primary purpose of the nurse practice act in each state?
It describes and defines the legal boundaries of nursing practice. ADA protects the rights of individuals who are disabled in the workplace, educational institutions and through out our society.
Why is nursing theory important
It is a three fold practice it guides research, establishes and improves practice
Describe the descriptive theory
It is more concrete Describe what is going on Erickson theory describes what we can expect from a stage. Does not tell you what to do.
What is the Nursing Practice Act
It legally states what a nurse can do in practice. Explains what is expected of their nurses per state.
Common Law
Judicial
Most common source of law for malpractice issues:
Judicial Branch (e.g. informed consent)
Pleuritic pain is described as
Knifelike, lasting for minutes to hours, always in association with inspiration
Stage 2: NREM
Lasts 10 to 20 minutes Period of sound sleep Relaxation progresses Arousal relatively easy
Stage 4: NREM
Lasts 15 to 30 minutes Deepest stage of sleep Very difficult to arouse
Stage 3: NREM
Lasts 15 to 30 minutes Initial stages of deep sleep Difficult to arouse
Stage 1:NREM
Lasts a few minutes Includes lightest level of sleep Easily arouse person
American Disabilities Act
Law that prohibits employers from discriminating against people with physical disabilities
Standards of care
Legal requirement for nursing practice that describe minimal acceptable nursing care
What theorist focused on a trans-cultural perspective
Leininger
What are some I/O abnormals?
Less than 30mL of urine out every 2 hours is a concern Polyuria- more than 2000-2500 mL a day is also a concern.
State statuatory issues in nursing practice
Licensure-minimum educational requirements (NCLEX) Good Samaritan laws- limit liability and offer immunity in hopes that nurses and medical professionals will act in times of emergency Uniform determination of death act-standards for determination of actual death. Cardiopulmonary standards and whole-brain standards (irreversible cessation of function) Autopsy- postmortem exam if requested by family, or suspicious death Physician-assisted suicide- Oregon death and dignity act- competent individual ANA- nurse participation is against ethics
Bristol stool type 3
Like a sausage but with cracks on the surface
Bristol stool type 4
Like a snake, smooth and soft
What are three caring behaviors in nursing
Listening Touch Knowing the client
what is a living will
Living wills represent written documents that direct treatment in accordance with a patient's wishes in the event of a terminal illness or condition. Living wills are often difficult to interpret and not clinically specific in unforeseen circumstances. Thus you are required to know how your state interprets living wills and under which circumstances a nurse implements them.
Infarction can cause?
Local death of the tissue
Arteriosclerosis
Loss of elasticity, thickening/calcification of arterial walls; manifestation of atherosclerosis
Cause of impaired tissue/local perfusion
Loss of vessel patency or permeability, inadequate central perfusion
Hypovolemic shock
Low blood volume
What theorist stated "Caring is the essence and central, unifying and dominant domain that distinguishes nursing from other health disciplines. It is also an essential human need, necessary for the health and survival of all individuals. This theorist had a transductional view.
Madeleine Leininger
Nursing considerations for PAD
Maintain perfusion and slow atherosclerotic process, stop smoking, foot care, peripheral pulses, color, pain, temperature, refill, regular and progressively strenuous activity
What stage of health behavior change? Sustained change over time
Maintenance
Functions of lipids
Make cell membrane, brain tissue, Carry fat soluble vitamins ADEK, Store fuel in adipose, Meal satiation Maintains temp, insulates and protects internal organs
Describe interdisciplinary theory
Maslows theory Derived from other theories but we use them in ours.
Cause of kussmauls
Metabolic acidosis, acidic rate causes an increase in respiration rate
Systemic changes which may occur with immobility
Metabolic- Negative Nitrogen Balance Respiratory- congestion, increase secretions in lungs,narrow bronchial tube Cardio-orthostatic hypotension,increase workload of heart, thrombus formation MS- foot drop, decreased muscle tone, sensory alterations, osteoporosis Elimination- calculi, urine stasis, constipation Integumentary- stage 1-4 wounds, ulcers, pressure areas, friction/shear
Portal of Exit
Microorganisms need to find a *portal of exit* sites include -Blood, skin, mucous membranes, resp tract, GU, GI
Tertiary prevention
Minimizing the effects of disease or disability; treatment, pt, ot, rehab
Lifestyle modifications: physical activity
Moderate-intensity aerobics at least 30 min most days Vigorous intensity aerobics at least 20 min 3x/week Muscle-strenghtening 2x/week Flexibility and balance 2x/week
In what group of risk factors can we provide patient education
Modifiable
three types of carbohydrates
Monosaccharides, Complex, disaccharide
MPOC
Multidisciplinary Plan of Care
Adverse effects of opioids
N/V, constipation, altered mental status, drowsiness, respiratory depression
Protocols for Nasal Cannula.
NC up to 4L then humidification is needed. 6L-15L must wear mask Non-rebreather: bag attached collects CO2 Venturi mask- % of O2 needed plus the liters needed COPD- No more than 2L because it cuts off resp. Drive
Enteral Tube Examples
NG, Nasointestinal, Gastrostomy, Jejunostomy, PEG, PEJ, G/J tube
What is NLN?
NLN: National League of Nurses, Advances nursing education and prepares RN to meet needs of diverse population.
Does a "Risk For" diagnosis need a goal and an outcome statement?
NO outcome ONLY goal
What is step one in the Stages of the sleep cycle?
NREM 1) Stage lasts a few minutes 2) Includes the lighted sleep 3) Decreased physiological activity begins with gradual fall in vital signs and metabolism. 4) Sensory stimuli such as noise easily arouse the person.
Different between implementations and interventions
NURSES IMPLEMENT INTERVENTIONS
Some methods of documenting
Narrative, Progress notes, charting by exception, critical pathways
Oxygen delivery systems
Nasal cannula, face mask, partial and nonbreather masks, oxygen conserving cannula
What is special about a J tube
Never aspirate a J tube!!
Antimicrobial
Nicotine replacement therapy
Can patient look at own chart?
No, they may not look at chart without supervision of primary physician or other appointed personell
Can a patient look through their own chart while in hospital or clinic?
No- can be misinterpreted. There is a format.
What are three types of analgesics?
Non-opioids Opioids Adjuvants
Manifestations of HTN
None unless severe: fatigue, dizziness, palpitations, angina, dyspnea
Normal sleep involves what 2 phases?
Nonrapid eye movement sleep Rapid eye movement
Lifestyle modifications: weight loss
Normal body weight (loss of 22 lbs. may lower systolic by 5-20)
Descriptive theory
Not directed towards nursing activity, cause and effect, first level
What are some Characteristics of Chronic pain
Not protective serves no purpose Has a dramatic effect on a person's quality of life
HIPAA
Not sharing your information without consent. It protects individuals from losing their health insurance when changing jobs, by providing probability. The creation of rules to protect patient rights to consent to the use and disclosure of their protected health information. This limits who has access to their records.
Nursing student with no previous level of experience
Novice
What are Benner's levels of nursing? (5
Novice Advanced Beginner Competent Proficient Expert
types of nursing interventions
Nurse initiated interventions: the independent response of a nurse to client needs Physician initiated interventions: Based on physician response (need an order) Collaborative interventions: Physical therapy or dietitian.
Contact Precautions
Nurses must wear gown and gloves and must not take materials into the patients room that will be taken into other peoples rooms or used on other pt.s example: C-diff
Type of intervention: Delegating a bed bath to a nursing student.
Nursing
Type of intervention: Lifting a patient from the bed to the commode with a ceiling lift.
Nursing
Type of intervention: Taking a BP after a patient complains of dizziness
Nursing
Type of intervention: Teaching a patient about the side effects of a medication
Nursing
Type of intervention: Turning a patient every 2 hours.
Nursing
what is the nursing paradigm
Nursing Environment Health Patient
Any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes
Nursing Intervention
Facilities that provide continuing care
Nursing centers/facilities- Assisted living- nurse on call Respite care- Adult day care centers-
Goals represent predicted resolution of a _______________, must be ___________, do not need to be ____________, and address ________ behaviors or responses.
Nursing diagnosis (problem) REALISTIC Measurable 1
Conducting a basic exam at least 1x per shift.
Nursing pro
What are the areas of agreement within the different nursing theories
Nursing, health.person.environment/situation
Type of intervention: Holding the digoxin medication when the patients apical pulse rate is 52 BPM
Nursing/Physicians
Collaborative interventions
Nutrition, activity, exercise, positioning, stop smoking, meds
What are some risk factors for sleep apnea
Obesity Hypertension Type II Diabetes Positive Family Hx of OSA Smoking Heart Failure Alcohol
What are the 2 types of classifications of data?
Objective Subjective
Infarction
Obstruction of the blood supply to an organ or region or tissue, typically by a thrombus or embolus
Iatrogenic
Obtained from a *Diagnostic test* ex: Bronchoscopy & Tx with broad-spectrum antibiotics
S/S of hyperthermia
Occurs when the body temperature rises above 37.6 C with an unchanged hypothalamic set point. The condition of having a body temperature greatly above normal. Undress the patient and start cooling them down with fluids or rags.
S/S of hypothermia and nursing interventions
Occurs when the core body temperature decline below 37.6 C The condition of having an abnormally low body temperature. Take the patient's clothes off and put dry/warm clothes on them.
What is statutory Law?
Of or related to laws enacted by as legislature branch of the government.
Each goal and outcome should address only?
One behavior or response
What are the types of instructional methods? (7
One on one Group Demonstration Analogy Role Play Simulation Teach back Nurse must be aware of patient's ability to learn, learning needs, motivation to learn, teaching environment, health literacy, and functional illiteracy. After teaching is done nurse must document to evaluate effectiveness.)
What are the 7 different kinds of instructional methods
Ono-on-one Group Preparatory instruction Demonstration Analogy Role Play Simulation
What is used for severe pain?
Opioid Analgesics
Priority setting
Ordering the nursing diagnosis or problems using urgency to determine
Vitamins
Organic substances present in foods that are essential to normal metabolism
Portal of entry
Organisms enter the body through the same routes they exit ex: Venipuncture , organisms enter the body if proper skin preparation is not performed first.
Risk management
Organizations system of ensuring appropriate nursing care by identifying potential hazards and eliminating them
What relationship phase? (ex: Observing pt. set tone by your manner, getting to know someone via first impression)
Orientation
Goal or Outcome: Client will achieve incentive spirometer goal of 90% every 2 hours for the next 24 hours.
Outcome
Goal or Outcome: Client will sit up in chair for 20 minutes 3x per day without abnormal HR by day 2 post-op.
Outcome
PICOT
P- population of interest I-Intervention of interest C-comparison of interest O-outcome T-time
Can be given by IV, Brown color, Comes from manufacturer
PPN (partial parenteral nutrition)
Central perfusion medical interventions
Pacemaker, electrical cardioversion, ablation therapy, itraaortic balloon pump, cardiac valve surgery, cardiac transplant
Radiating
Pain feels as though it travels down or along the body part, intermittent, or constant.
Deep or visceral
Pain is diffuse and radiates in several directions. Duration varies but usually lasts longer. Pain is sharp, dull or unique to involved organ.
Referred
Pain is in part of body separate from source of pain an assumes any characteristic.
Superficial or cutaneous
Pain is short in duration and localized, usually is a sharp sensation.
Symptoms of bad perfusion
Pain, dyspnea, edema, dizzy, faint, decreased pulses, cramping in legs
types of documentation
Paper electronic health records Narrative documentation Problem oriented medical record: is a method of documentation that emphasizes patient's problems. Data are organized by problem or diagnoses. Ideally each member of the health care team contributes to a single list of identified patient problems.
what is a paradigm?
Paradigm: pattern of thought that is useful in describing the domain of a discipline. A paradigm links the knowledge of science, philosophy, and theories accepted and applied by the discipline. 4 Links person, health, environment/situation, and nursing
Expiration
Passive process
What are some error reduction techniques? (7)
Patient ID SALAD Time Out Needleless system Barcode scanning with EPIC Med Reconciliation Tallman Lettering
Med error reduction
Patient identification SALAD drugs Time out Needleless system Bar code scanning/ EPIC Med Reconciliation ISM Tallman lettering Standard order sheets
Invasion of privacy
Patient protection from unwanted intrusion into his or her private affairs.
A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. Which of the following patient care goals are long-term? 1. Patient will explain relationship of insulin to blood glucose control. 2. Patient will self-administer insulin. 3. Patient will achieve glucose control. 4. Patient will describe steps for preparing insulin in a syringe.
Patient will achieve glucose control
Patient centered goal
Patients highest possible level of wellness and independence in function, realistic
What theorist focused on understanding events, projects, and things matter to people and talked about interpersonal interaction.
Patricia Benner
To keep on top of changes, we must ____________________ all the time.
Perform assessment
Therapeutic intervention
Performed by nurses to achieve goals/outcomes
Chronic illness
Persists for 6 months or more, may affect functioning; copd, renal failure
What are some characteristics of a chronic illness
Persists for at least 6 months May affect any functioning in any dimension
Describe chronic?
Persists longer than 6 months May affect any functioning in any dimension.
What are the 6 overlying concepts for the nursing curriculum at the SFMC CON
Person Health Nursing Environment Society Student Centered Learning
Ineffective airway clearance definition
Person unable to clear secretions, or obstructions from the respiratory tract to maintain clear airways
Community acquired pneumonia
Person who contracts pneumonia with little contact with the health care system
Links of a Nursing Paradigm
Person, health, environment/situation, nursing
direct
Person-to-person (Fecal, oral ) physical contact between *source* and *susceptible host*
Indirect
Personal contact of susceptible host with *contaminated* inanimate object ex: Needles or sharp objects, dressings, environment
interventions for pain:pharmacological
Pharmacological pain relief Acute pain management Analgesics Nonopioids Opioids Adjuvants/co-analgesics Delivery systems Patient-controlled analgesia (PCA) Local/regional anesthesia Topical agents
Type of intervention: Administering a pain medication
Physician
Type of intervention: Conducting a wound dressing change every day
Physician
Type of intervention: Inserting an IV catheter
Physician
Type of intervention: Transfusing Blood
Physician
Dependent nursing interventions
Physician initiated interventions, require an order
What are Maslow's hierarchy of needs? (5)
Physiological 2. Safety 3. Belonging 4. Self Esteem 5. Self Actualization You must meet each level before trying to attain the next.
Reservoir
Place where *microorganisms survive* ex: Humans, animals, organic matter on inanimate surfaces (Fomites)
PAD meds
Platelet inhibitors (aspirin, Plavix), Cilostazol (mild vasodilator that improves claudication), Trental (reduces viscosity to move like water)
Community acquired pneumonia
Pneumonia acquired outside of hospitals of extended care facilities
Interventions for chest wall movement
Postural drainage, positioning, coughing, chest physiotherapy, acapella, suctions, nebulizers, vaccines, types of 02 delievery
Psychosocial factors of HTN
Poverty, isolation, lack of support, stress, negative emotions
What stage of health behavior change? Not intending on changing with in 6 months
Pre-contemplation
What relationship phase? (ex: reviewing data with previous RN)
Pre-interaction
Condtions that affect chest wall movement
Pregnancy, lack of exercise, smoking, substance abuse, physical anatomy, stress, poor nutrition, muscular skeletal abnormalities.
Patients at Risk for Nutrition Problems
Premature birth, Eatting disorders, Obese, Surgery, CA
What stage of health behavior change? Making changes for a change in the next 6 months
Preparation
Which instructional method would you explain verbally or put it out on a piece of paper before doing a procedure
Preparatory Instruction
Musculoskeletal pain
Present following exercise, rib trauma, and prolonged coughing episodes. Inspiration worsens the pain.
What are 5 challenges for todays nurses
Pressure to deliver high quality Time constraints Cost constraints Technological advances Limited autonomy
Immunizations, fluoride in water, preconception folic acid supplements are examples of what level of care?
Primary Prevention
This type of prevention has interventions aimed at preventing disease, injury, or disability. Includes wellness efforts and illness prevention.
Primary Prevention
Which level of preventative care? Aimed at health optimization and disease prevention. Health education for optimal nutrition, exercise, hygiene, sanitation, protection from environmental hazards like allergens, toxins and carcinogens.
Primary Prevention
What are the levels of preventive care
Primary Prevention Secondary Prevention Tertiary Prevention
A gray area exists between what 2 levels of care?
Primary and Secondary
What are the 3 levels of preventative care?
Primary, Secondary, and Tertiary
Goals address _______________; Outcomes address ______________.
Problems Defining Characteristics
3+ years experience, perceives a patient as a whole, managing care instead of managing and performing skills.
Proficient
What did Watson's theory focus on?
Promote health and restore patient to health and prevent illness, interventions to meet human needs
Confidentiality
Protection for private patient information in the healthcare setting.
Illness prevention
Protection from actual or potential threats to health.
How is nursing defined
Protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and population. ANA: diagnosis and treatment of human responses to actual or potential health problems
What are some characteristics of acute pain?
Protective Has an identifiable cause Short duration Limited tissue damage
Reverse Isolation
Protective , reducing microorganisms for compromised patients
Americans with disability acts
Protects the right of people with physical or mental disabilities
What did Leininger's theory focus on?
Provides care consistent with nursing science as a central focus, transcultural, caring is what unifies nursing knowledge and practice.
Good Samaritan Law
Provides limited protection to someone who voluntarily chooses to provide first aid. Protected as long as you act without gross negligence.
What are the 10 caring behaviors in nursing?
Providing presence 2. Touch 3. Task oriented 4. Caring 5. Protective 6. Listening 7. Knowing the client 8. Spiritual caring 9. Relieving pain 10. Family care
caring behaviors in nursing
Providing presence, touch, task oriented, caring, protective, listening, knowing the client, spiritual caring, relieving pain and suffering, and family care.
What domain of learning involves acquiring skills that require the integration of mental and muscular activity.
Psychomotor
What is the single most reliable indicator of pain?
Pt's self report of pain
200 ; Greater
Pt. usually has a *feeling to go* when there is approx __________*mL* of urine in bladder Urinary *Urge* is __________ than *200* mL of urine in bladder
Hospital ; Long
Pt.s who contract __________ acquired pneumonia (Nosocomial) usually live in ________ -term care facilities
What are the physiological symptoms of sleep apnea?
Ptosis Blurred vision Fine motor clumsiness Decreased reflexes Cardiac arrrhythmia
Signs of impaired central perfusion
Pulmonary edema, shortness of breath, slow capillary refill, dizziness, hypotension
What is data clustering?
Putting like data together, primarily done with exceptional data
When you think of the word JCAHO what do you think of
Quality
What is the SFMC CON devoted to
Quality Personal and professional development Service Agility
what does RACE stand for when there is a fire
R- Rescue A- Activate the alarm C- Confine the fire by closing doors and windows E- Extinguish the fire with appropriate extinguisher.
Stage where vivid dreams occur, averages 20 minutes, rapid moving of the eyes, increase in gastric secretions, and loss of skeletal muscle tone.
REM sleep
Positioning for immobile patients
ROM and transferring
What does it mean to prioritize?
Rank order based on importance
HTN crisis manifestations
Rapid onset, blurred visit, headache, confusion, motor/sensory deficits
A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the IV line, and the patient asking to be turned. Which of the following does the nurse perform first. 1. Reconnect the drainage tubing 2. Inspect the condition of the IV dressing 3. Improve the patient's comfort and turn her on her side. 4. Obtain the next IV bag from the medication room.
Reconnect the drainage tubing
Consequences of impaired central perfusion
Reduced CO leads to reduction of oxygenated blood reaching body tissues (systemic); may lead to shock, ischemia (hurts), infarction (kills)
Professional behaviors
Refer to discipline-related knowledge and skills, appropriate relationships with patients and colleagues, and acceptable appearance and attitudes.
HYPERthermia
Refers to a body temperature *Above* normal range *>37.6C*
HYPOthermia
Refers to a body temperature *below* normal range *< 36.6 C* (97.8 F)
Professional Parameters
Refers to the legal and ethical issues.
Legislation purposes
Regulate, authorize, proscribe, provide, sanction, grant
Non-pharmacological pain relief intervention
Relaxation, guided imagery Biofeedback, Distraction, music Cutaneous stimulation, Massage, transcutaneous electrical nerve stimulation (TENS), heat, cold, acupressure Herbals and Reducing pain perception
NSAID MOA
Relieves pain by acting on peripheral nerve endings at injury site and decreased level of inflammatory mediators generated at site of injury
Exp of a portal of entry into the host
Respiratory system
Can responsibility or Accountability be delegated?
Responsibility
What is the difference between accountability and responsibility
Responsibility can be delegated where accountability cannot.
Manifestations of PAD
Rest pain, intermittent claudication, paresthesias, diminished/absent peripheral pulses, pallor when elevated, inflammation when dangling, thin and shiny and hairless skin, thickened toenails, skin breakdown and discolored areas
Leg with critical limb ischemia
Revascularization via bypass, protect from trauma, decrease ischemic pain, prevent/control infection, improve arterial perfusion
Making decisions during implementation you should?
Review all possible nursing interventions for patients problem, review all consequences, determine probability of consequences, make a judgement of value of consequence
Moral Imperative
Right vs. wrong or value (nurture)
What is SOAP?
S- Subjective Data O- Objective Data A- Assessment (diagnosis based on this data) P- Plan (interventions)
IOM STEEP
S: Safety T: Timely (Reduce wait) E: Effective (Evidence base) E: Equitable ( Fair) P: Patient Centered
What happens in hypovolemic shock
SV, CO, BP drop, and SVR does not compensate
Braden Scale
Scale used to assess Skin break down risk *No Risk*: 19-23 *Severe Risk* 6-9 *Perception* *Activity* *Moisture* *Nutrition* *Friction/shear*
Which nursing theory do we practice?
Science/Domain: The worldview or perspective of the discipline.
Secondary prevention
Screening, early diagnosis, prompt treatment
Secondary prevention
Screenings, BP, lipid tests
This type of prevention has interventions aimed at increasing the probability that a person with a disease will have that condition diagnosed with treatment will be cured.
Secondary Prevention
Which level of preventative care? Identify individuals in an early state of disease process so prompt treatment can be started such as skin cancer screenings mammograms, and colonoscopies
Secondary Prevention
BP screenings, mammograms, colonoscopy, and bone density scans are examples of what level of care?
Secondary Prevention (screening)
Consultation
Seeking the expertise of a specialist to handle problems
Altruism/Respect for person
Selfish Concern for the welfare of others
braden skin assessment
Sensory Nutrition Friction and shear Activity Moisture
Complications of PPN
Sepsis/infection, Pneumothorax, Air embolism Hyper/hypo glycemia
90
Septic *Heart rate* is a HR *greater* than ______ bpm
20 , 32
Septic Respiratory rate is *greater* than _______ breaths per minute or a *PaCo2* *less than* ________ *mmhg*
96.8 F ; 100.4 F (36-38C)
Septic Temperature is *Less* than _________ or *Greater* than ____________
4,500; 10,000 ul/mm3
Septic WBC count *Less than* ___________ or *Greater than* ____________ ul/mm3
Planning
Setting priorities, identifying patient centered goals,expected outcomes
Native American culture
Shaman combination of prayers, chanting, and herbs to treat illness
Fluid loss of 1000+ ml
Shock progresses, multiple organ failure, death
Describe Acute?
Short duration Severe May affect functioning in any dimension.
What are some characteristics of an acute illness
Short in duration Severe May affect functioning of any kind..
SBAR
Situation Background Assessment Recommendation
What is SBAR
Situation, Background, Assessment, Recommendation. Used when you call the doctor regarding the patient
A disorder characterized by the lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep.
Sleep apnea
Modifiable risk factors
Smoking (vasoconstriction), hyperlipidemia (atherosclerosis), sedentary lifestyle, obesity, diabetes (atherosclerosis), HTN (myocardium works harder), stress
Bristol stool type 5
Soft blobs with clear-cut edges
Prescriptive
Something that must be done
Proscriptive
Something that must not be done
Droplet precautions
Spread *within 3 feet* of the patient - gown, gloves, *Regular mask*
What is step 2 in the Stages of the sleep cycle?
Stage lasts 10-20 minutes 2) It is a period of sound sleep 3) Relaxation progresses. 4) Arousal remains relatively easy.
Complex
Starches and fiber
NORMOthermia
State in which body temperature is *WDL* - *36.2 C - 37.6 C* (97.0 F- 100.0 F)
What are some examples of "Health Maintenance and promotion and illness prevention".
Stress management Immunizations Screenings Prenatal care Safety checks
Components of a SOAP note
Subjective-verbalization: "im worried about what surgery will be like" Objective-measured and observed: wife present Assessment-based on data: deficient knowledge Plan-caregiver plan to do: explaining surgical routine to patient
Internal transmission
Such as *parasitic* conditions between *Vector* and *Host* ex: Mosquito, louse, flea , tick
Advocacy
Supporting the cause
UTI symptoms
Symptoms include *dysuria*, cystitis, *Hematuria*, and pyelonephritis
Research
Systemic controlled investigation of hypothetical questions about relationships.
Definition of HTN
Systolic 140+, diastolic 40+ based on average of 3 separate readings or current use of antihypertensive drugs
What is a telephone or verbal order? How do you document?
TO, VO Ex) Administer 10mg Morphine IVP now. -T.O. Dr. Smilth/G. Beckwith SFNS
White, mixed by pharmacy, must be wasted if unused, given through central line.
TPN (total parenteral nutrition)
Beneficence
Taking positive actions to help others, patient advocacy
What is the difference between teaching and learning
Teaching is an Interactve process that promotes learning and the patient knows what is expected of them. Learning is the purposeful acquisition of new knowledge, attitudes, behaviors, and skills. The learner identifies a need for knowledge or acquiring and ability to do something.
What relationship phase? (ex: termination is near , evaluate, reminisce, separate by relinquishing care from patient)
Termination
Medical Treatment, Rehab, and Hospice are examples of what level of care?
Tertiary Prevention
This type of treatment is aimed at disability limitation and rehabilitation from disease or disability.
Tertiary Prevention
Which level of preventative care? Minimizing effects of disease/ disability, Restorative care, managing condition and minimizing complications to achieve highest level of health possible.
Tertiary Prevention
why do nurses have a code of ethics
The Code of Ethics is the philosophical ideas of right and wrong that define the principles you will use to provide care to your patients All members of a profession accept a code of ethics (it is a collective statement about the group's expectations and standards of behavio
Who is responsible for directing medical treatment?
The Healthcare Provider
Purdue University
The Virginia Henderson international nursing library is located at _________________
Perfusion
The ability of the cardio system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs
Anoxia
The absence of oxygen
As nurses, we base our priorities on ___________.
The data/problems collected
As nurses, we base our priorities on ___________.
The data/problems collected Maslow's Hierarchy of needs and ABC's LOC
Central perfusion
The heart; force of blood movement generated by cardiac output; requires cardiac function, BP, blood volume (CO= SV x HR)
fall risk assessment
The higher the score the greater the fall risk Fall assessment tool Heinrich get up and go SBAR (Irene) National safety goal
Analgesics
The most common and effective method for pain relief.
circadian rhythm
The most familiar rythem is the 24 hour, day-night cycle known as diurnal or_____________________.
Planning
The nurse collaborates with a patient and family (as appropriate) and the rest of the healthcare team to determine urgency of the identified problems and prioritizes patient needs. Ex:choosing interventions
Code of Ethics Provision 1
The nurse in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by consideration of social or economic status, personal attributes, or the nature of health problems
Code of Ethics Provision 4
The nurse is responsible and accountable for individuals nursing practice and determines the appropriate delegation of tasks consistent with the nurses obligation to provide optimum patient care.
Code of Ethics Provision 5
The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth
Code of Ethics Provision 6
The nurse participates in establishing maintaining, and improving health care environments, and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession.
Code of Ethics Provision 7
The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.
Code of Ethics Provision 3
The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
Code of Ethics Provision 2
The nurse's primary commitment is to the patient, whether an individual, family, group, or community.
Standards of care is what
The nursing process
What is a care plan
The nursing process in written form
What is patient centered care
The patient is the center of therapy, be respectful of and responsive to individual preferences.
If there is a procedure to be done who should be the one to do the informed consent?
The person doing the procedure
Ventilation
The process of moving gasses into and out of the lungs.
Diffusion
The responsibility of moving the respiratory gases from one area to another by concentration gradients
Privacy
The right of patients to keep personal information from being disclosed.
What are the standards of professional Performance (ANA)
The standards describe a competent level of behavior in the professional role of nursing.
What is the nursing process?
The work that we do. ADPIE
Maslow's Hierarchy of Needs is what kind of model?
Theoretical model
Benner
Theorist who focused on patients need for caring as a means of coping with stressors of illness.
Watson
Theorist who said we should promote health, restore patients to health, and prevent illness.
Watson
Theorist who said we should promote health, restore patients to health, and prevent illness. (Caring is essential care to the essence of nursing)
Leininger
Theorist who stated we should provide care consistent with nursing's emerging science and knowledge with caring as a central focus
King
Theorist whose goal was to use communication to help patients reestablish positive adaptation to the environment.
Henderson
Theorist whose goal was to work interdependently with other health care workers, assisting patients in gaining independence as quickly as possible' help patients gain lacking strength.
Henderson
Theorist whose goal was to work interdependently with other health care workers, assisting patients in gaining independence as quickly as possible' help patients gain lacking strength. (Nurses help Perform Needs)
Roy
Theorists whose goal for nursing was to identify the types of demands placed on the patient, assess adaptation to demands and to help patients adapt.
Nighingale
Theorists whose goal was to facilitate the reparative processes of the body by manipulating the patients environment.
Nighingale
Theorists whose goal was to facilitate the reparative processes of the body by manipulating the patients environment. (Hygiene, light, comfort, and socialization)
Neuman
Theorists whose goal was to help individuals, families, and groups attain and maintain maximal level of total wellness by purposeful interventions.
Neuman
Theorists whose goal was to help individuals, families, and groups attain and maintain maximal level of total wellness by purposeful interventions. (Stress reduction)
Describe the prescriptive theory
Theory that tells us what to do It gives nursing interventions
Collaborative Interventions
Therapies that require the knowledge, skill, and expertise of multiple health care professionals.
treatment for pneumonia
Therapy for underlying cardiac respiratory complications and emotional problems that occur as a result of the symptoms of this disorder cPAP machine Sleep schedule
Why are there so many nursing theories
There is a lack of consensus about a single nursing theory or which theory is the most useful.
What is so different about health promotion and illness prevention?
There is an overlap between these two definitions but they are used interchangeably.
Where are water soluble vitamins stored?
They aren't stored in the body
What is an assessment and why is it important?
This is the first step in the nursing process it is objective and subjective so we have all the data we need an can look at it carefully. Assessment has to be correct or the whole thing is wrong.
Battery: Assault:
Threat Action
When or where does teaching occur in the nursing process
Throughout the nursing process, timing is important
Infarction
Tissue death
What is nursing
To care for a person as a whole. Mentally, spiritually, and physically to provide a positive outcome and well-being.
North American Nursing Diagnosis Association (NANDA) Purpose:
To develop, refine, and promote a "language for nursing problems" for use by professional nurses
What is the purpose of NANDA
To develop, refine, and promote a language for nursing problems.
What is the biggest purpose of the nursing diagnosis
To distinguish the nurses role from that of the physicians
What is the code of Ethics for nurses
To provide safe and compassionate care
In service education
To remain current in nursing skills, knowledge and theory
parts of a cultural assessment
Touch, personal space Language Time orientation
Radiation
Transfer of *Heat* between 2 objects with out touch body ex: Environment ; blankets on skin
Evaporation
Transfer of heat energy when *Liquid changes to a gas* ex: Sweating
Conduction
Transfer of heat from one object to another by *direct contact*
Convection
Transfer of heat through *air movement* ex: Fan
HTN crisis treatment
Treat within 1 hour; decrease BP by no more than 25% within minutes to 1 hour, then to 160/100 within 2-6 hours (too quickly can lead to rebound issues)
Indirect care
Treatments performed away from the client, but on behalf of the client.
Direct Care
Treatments performed through interaction with the client.
Shock definition
Triggered by sudden drop in MAP; BP is sustained by CO and PVR
T/F Ignorance of the law of standards of care is Not a defense against malpractice
True
T/F The presence of risk factors, does not mean that a disease will occur. Risk factors do increase the chances for experiencing a particular disease or dysfunction though.
True
T/F Theory enables you to answer all the important "why" questions
True
True or False: There is an overlap between Health profession and illness prevention
True
What is Primary Prevention
True prevention that lowers the chances that a disease will develop
What are some examples of task-oriented touch?
Turning a patient and giving immunizations
Mixed
Typically a combination of *stress* and *urgent* symptoms: Urine leakage when sneeze, cough, laugh, exercise or lift something heavy
what is a UTI
UTI's are one of the most common health acquired infection, with almost all caused by instrumentation of the urinary tract. The risk for UTI increases in the presence of an indwelling catheter, any instrumentation of the urinary tract, urinary retention, urinary and fecal incontinence, and poor perineal hygiene practices.
Use for enteral tube
Unable to ingest food but is still able to digest and absorb nutrients.
Sentinel event
Unexpected occurrence involving *Death* or serious physical or psychological injury -Need for *immediate* investigation
False imprisionment
Unjustified restraints of a person.
interventions for pneumonia
Use spirometer Breathing treatment High Fowlers position Collect sputum in morning
Deconditioned
Used to describe a *loss* of physical fitness -Pt.s who do not maintain optimal physical activity or *extended periods of immobility*
Psychomotor skills
Using good coordination and precision when giving an injection
How does a nurse address the need for evidence-based practice
Using your clinical expertise and considering patient's' values and preference ensures that you will apply the evidence in practice both safely and appropriately.
REM sleep
Usually begins about 90 minutes after sleep has begun Duration increases with each sleep cycle and averages 20 minutes Vivid, full-color dreaming occurs Rapid eye movement Very difficult to arouse sleeper
Diagnosis
Validation of health care needs and priorities, analysis of assessment findings
Medications for perfusion
Vasodilators, Vasopressors, Diuretics, Antidysrhthmics, Anticoagulants, Antiplatelets, Thrombolytics, Lip lowering agents
High flow oxygen delivering device
Venturi mask
Assessment
Verbal interviewing, medical records, data gathering
verbal communication
Verbal: use of spoken or written words Vocabulary: words and phrases Denotative and connotative meaning: some words may have several meanings Pacing: communication is more successful at an appropriate pace Intonation: tone of voice Clarity and brevity: effective communication is simple, brief, and direct Timing and relevance: timing is critical
Describe the Grand Theory
Very abstract and large Theories on nursing Cannot be tested because they are tested.
14 needs, games
Virginia Henderson created the *Need* theory and has _____ Needs which includes ________
ANA hall of fame
Virginia henderson was inducted to what *Hall of fame* ?
Exp of portal of exit from reservoir
Visitor removing flowers from a vase that included a pseudomonas
50%
Voluntary movements or *Shivering Inc BMR* by _____ %
Bristol stool type 7
Watery, no solid pieces, entirely liquid
MH ( Malignant Hyperthermia)
What *Hyper*metabolic disorder is related to an Autosomal dominant disorder* ?
Cardiac Capacity; Cardiac output ; stasis (DVT)
What are some *Cardiovascular* complications of *Immobility* ? - Reduced _________ __________ - Dec ________ _________ - Venous ___________ ( )
Peristaltic; constipation
What are some *GI* complications of *immobility* -Reduced ________________ motility - ______________
Contracture; Demineralization ; Atrophy
What are some *Musculoskeletal* complications of *Immobility* - Joint _______________ - Bone _________________ - Muscle __________________
expansion; Atelectasis ; Pooling
What are some *Respiratory* complications of *immobility* ? - Reduced lung _________ - ____________ ( collapse of Aveoli ) - ___________ Secretions
Stasis; Calculi ; tone
What are some *Urinary* complications of *Immobility* ? - Urinary ____________ - Renal ____________ due to *Inc* Circulating *Calcium* resulting from *bone* reabsorption
Biphosphates; SERMS
What two specific meds *inc* chance of skin breakdown ? ________________ (Meds for *Osteopenia* / *Osis* ________________ (*estrogen Modulator*)
Writing a Nursing Intervention
What, When, How, Who; "The nurse will.."
ROM; gait; Activity
When *Assessing* mobility , focus on ____________ _________ Exercise and ___________
Hypoventilation
When alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate CO2
Arteriosclerosis
When blood vessels become thick and stiff and restrict blood flow to the organs and tissues
30C (86F)
When does the body *stop shivering* ?
Slander
When one person speaks falsely about another.
Hyperventilation
When the lungs remove CO2 quicker that it is produced by cellular metabolism
Charting by exception
When things only outside of the norm are charted
Are priorities mutually-agreed upon by the nurse and client?
Whenever possible
Are priorities mutually-agreed upon by the nurse and client?
Whenever possible, makes it smoother.
Functional Incontinence
Which type of *Incontinence* is a DIRECT result of caregiver *NOT RESPONDING* in a timely manner ?
Avoid Dysrhythmias !!!
Why do we *slowly* Rewarm *Severely* hypothermic pt.s ?
Responsibility
Willingness to accept ones professional obligatons
What relationship phase? (ex: involving, collaborating, setting goals and putting plan into action)
Working
Living will
Written documents that direct treatment in accordance to a patients wishes during a terminal illness
Do you need all 5 characteristics to be considered a professional nurse
Yes
What is a nursing care plan
You must be able to identify appropriately written nursing diagnoses, goal statements, expected outcomes, and nursing interventions Assessment-subjective and objective data Nursing Diagnosis-NANDA label, related to, secondary, as evidence by Goal Outcomes (SMART) Specific, Measurable, Attainable, Realistic, and Timely. Nursing interventions- done by the RN Evaluation-if the outcomes were met or not.
What is a client centered goal?
a behavior or response that reflects a clients increased possible level of wellness and independence of function
definition of metacommunication
a broad term that refers to all factors that influence communication
case management
a care-management approach designed to coordinate and link health care services across all levels of care for patients and their families while streamlining costs and maintaining quality.
Nursing Diagnosis
a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes
Diagnosis
a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, or community that a nurse is licensed and competent to treat. Ex: impaired gas exchange, ineffective breathing pattern, acute pain, impaired mobility, etc.
What is a SOAP note?
a method of documentation for initial and ongoing treatment
patient and family centered care
a model of nursing care in which mutual partnerships among the patient, family, and health care team are formed to plan, implement, and evaluate the nursing and health care delivered Respect and dignity Information sharing Participation Collaboration
complicated
a person has a prolonged or significantly difficult time moving forward after a loss, person experiences chronic and disruptive yearning for the deceased, has trouble accepting the death and trusting others, feels bitter, numb and anxious about the future. Occurs more frequently in those who had a conflicted relationship with the deceased or multiple losses, mental health issues or lack of support.
Informed consent
a persons agreement to allow something happen such as a surgery or invasive procedure based on full disclosure of risks, benefits, alternative and consequences of refusal
Standing order
a pre-printed document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures; pre-printed physician orders (e.g. sliding scale)
Occurrence report
a risk management system to keep track of how often a hazard is happening to attempt to determine deviations from standard care (patient falls)
Pain perception
ability to perceive the location, severity, and character of pain, the ability to apply past coping mechanisms, and the ability to interpret the intensity and quality based on culture and past experiences
Continence
able to control voiding
Impaired gas exchange characteristics
abnormal ABGs, abnormal resp rate/rhythm, confusion, tachy, hypoxia
heat exhaustion
abnormal condition causes depletion of body fluid and electrolytes due to intense heat
hypothermia
abnormal lowering of the core body temperature below 95 F usually due to prolonged exposure to cold
Neuropathic pain
abnormal processing in nervous system -nerve damage -burning, sharp, shooting
Dependent nursing interventions
actions that require an order from a physician or another health care professional
Nursing interventions
actions that the nurse initiates that do not require another health care professional, based on scientific rationale
Independent nursing interventions
actions the nurses initiate and do not require an order from a provider
Chronic pain affects
activity, emotions and thinking
Quasi-intentional torts
acts in which intent is lacking but volitional action and direct causation occur such as in invasion of privacy and defamation of character
Quasi intentional acts
acts where intention is lacking, but direct causation is occurring such as invasion of privacy
Combination
acute and chronic pain
Behavioral response of pain
acute pain, clenching teeth, grimacing, guarding,
Acculturation
adapting to a new culture
unintended act of omission or comission
adverse event
When do we document?
after each intervention (when we do something)
Factors that affect bowel elimination
age, diet, fluid intake, bacteria, parasites, physical activity, psychological factors, personal habits, positioning, pain, pregnancy, anesthesia, medications
factors affecting temperature
age, exercise, hormone level, stress, diet, medications, environment
What are some non modifiable risk factors?
age, gender, genetics, ethnicity, and physiological factors.
fidelity means
agreement to keep promises
Complications of TPN
air embolism
Which of transmission of pathogens? Droplet Nuclei, small particles that travel through air. specific mask needed.
airborne
Pain management is defined as
alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient
Humanism
also called Secular Humanism, views human existence without reference to religion, the Transcendent, a higher power, or ultimate truth
Urinary Retention
an accumulation of urine due to the inability of the bladder to empty
Quality improvement
an approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others (e.g. med admin, diet management, wound care, D/C planning)
self limiting pain
an end of pain is in sight
Outcome
an expected outcome is specific measurable changes in a client's status that is expected to occur in response to nursing care; derived from goal; each outcome statement addresses a pertinent piece of assessment data (defining characteristics); "The client will..."
Otitis media
an inflammation of the middle ear
Acute otitis media
an inflammation of the middle ear with a rapid onset of the signs and symptoms of acute infection, such as fever and pain
Glycogenesis
anabolism of glucose to glycogen for storage in liver and muscle
medications to help with thermoregulation
analgesics, anti-inflammatory, anti-infectives, antibiotics, antivirals, antifungals
what is complex critical thinking
analyze and examine choices more independent to look beyond expert opinion and thinking abilities begin to change (may seek opinions still)
medications for UTI
antiinfectives, phenopyridine, urinary analgesics,
Albumin and insulin
are simple proteins
Complications of enteral tube
aspiration or respiratory distress
NSAIDs include
aspirin, ibuprofen, acetaminophen
based on subjective and objective data
assessment
Nursing diagnoses flow from the __________________.
assessment data
interventions for UTI
assessment of urine, personal hygiene, cath care, fluid intake, I&O, empty drainage back frequently, UA culture and sensitivity, bladder schedule every 2 hours
shared leadership
associated with work teams is shared leadership, an approach in which employees are empowered to distribute leadership responsibilities broadly within a group. Effective with professionals and with project-focused workgroups
what does nonmaleficence mean
avoidance of harm/hurt
Nonmaleficence
avoiding harm
For a given client, an outcome statement is "The client will state 5 symptoms that indicate a possible problem that should be reported. The client will do this within 24 hours." At evaluation time, if the client can only state 3 symptoms, the evaluation statement would be: a. The goal was met AEB the client being able to state 3 symptoms. b. The goal was partially met AEB the client being able to state 3 symptoms. c. The goal was not met AEB the client being able to state 3 symptoms.
b. The goal was partially met AEB the client being able to state 3 symptoms.
thermoregulation
balance between heat lost and heat produced
Physician-initiated interventions
based on a physician's response to treat or manage a medical diagnosis; based on order; more invasive (admin med, foley, change dressing); require specific nursing responsibilities and technical nursing knowledge
Evaluative measures
basically assessment skills, you perform this at a point of care when you make decisions about the patients status and progress
Anticipatory Grief
before the actual loss or death occurs, especially in situations of prolonged or predicted loss
Digestion
begins in mouth and finishes in the small and large intestine
Client-centered goal
behavior/response that reflects their highest level of function; should be realistic and based on clients needs and resources; clients should be involved; meet immediate needs and strive for prevention and rehab
Religion
beliefs and practices related to the Transcendent -often organized as a community but can be practiced alone and exist outside of an organization
Race
biological term for persons who share distinguished physical features and genetic traits
Medications for immobility
bisphosphonates, selective estrogen receptor modulators
Preventative care
blood pressure and cancer screening, immunizations, mental health counseling and crisis prevention
Open/Compound fracture
bone broken through skin
How can you become a part of an ethnic group?
born into or adapt
Complications assoc with colon CA
bowel obstruction, perforation, metastasis
Simple/Closed fracture
break, no open wound, internal bleeding, swelling, bruising, hematoma (internal blood)
Biots breathing
breathing in clusters
grand theory
broad in scope, complex, require specification
Grand theory
broad, large segments of the physical, social or behavioral world
Protein is essential for
building of body tissue in growth, maintenance and repair
testing for immobility
calcium labs, imaging, bone density, fall risk score, stress test, assess for DVT
Examples of macro minerals
calcium, phosphorus, sodium potassium, magnesium, chloride
elimination changes associated with immobility
calculi, urine stasis, constipation
Describe the mid-range theory
can be hard to test a little more narrow it is over 1 or 2 concepts
six categories of nutrition
carbs, proteins, fats, vitamins, minerals, water
Uniform determination of death act
cardiopulmonary standard, whole brain standard, definitions of the above facilitate organ recovery for transplant
Benner
caring means that persons, events, and things matter to people, an interpersonal interaction
Gluconeogenesis
catabolism of amino acids and fat into glucose for energy when body exceeds glycogen storage
Planning
category of nursing behaviors in which client-centered goals and expected outcomes are established; 3rd step; requires deliberate decision making and problem solving skills; dynamic; based on nursing diagnosis
what is a CAUTI
catheter associated UTI, are ongoing problem for hospitals because they are associated with increased hospitalizations, increased morbidity and mortality, longer hospital stays, and increased hospital costs
Warning s/s of colon CA
change in bowel habits, diarrhea and constipation, weight loss, anorexia, anemia, occult bleeding
causes of UTI
change in flora, short urethra, hygiene measures, CAUTI, frequent sex, instruments in the urethra
Fluids and Electrolytes (interrelated concept)
changes in electrolyte balance can interfere with smooth muscles, reducing or increasing intestinal peristalsis; hypokalemic
Metabolism
chemical and physical process going on in living organisms
Shallow, deep, shallow breaths followed by periods of apnea (30 seconds) Can be caused by stroke, TBI, Carbon Monoxide poisoning. Agonal Breath (Big yawn)
cheyne stokes
enema administration
child: 300-500ml adult: 500-1,000ml
Ulcerative colitis
chronic inflammatory bowel disorder lasts 1-3 months, intervals for years, occurs in distal colon
Crohn's disease
chronic inflammatory disorder affects ascending and terminal ileum
Tort
civil wrong made against a person or property
Torts
civil wrong made against a person or property
Medical aseptic
clean technique
medical asepsis
clean technique
Examples of therapeutic diets
clear liquid, full liquid, pureed, mech. soft, soft to chew, high fiber, low sodium, low cholesterol, diabetic
Prep for flexible sigmoidoscopy
clear liquids then NPO, laxative or fleets enema
Prep for fiberoptic colonoscopy
clear liquids, then NPO, Mag citrate or Citrate magnesium, check for bleeding, chills ,pain , fever and avoid high fiber diet for 2 days following polyp removal
Kock Pouch
colon is gone; make pouch out of ilium; catheter pouch and drain stool
Ileoanal Pouch Anastomosis
colon removed: connect ilium to rectum
Mixed Incontinence
combination of stress and urge
Surrogate
communicating to the practitioner about the pain of the patient (parent for child)
What does "SBAR" stand for?
communication is hospital situation, background, assessment, recommendation
Purpose of Client's chart
communication, legal documentation, financial billing, education, research, auditing-monitoring
Proteins
composed of amino acids, contains C, H, O2, N
Fever (affect on urine)
concentrated urine
Negligence
conduct falls below standard of care; nursing areas of negligence: treatment, communication, medications, monitoring
respiratory changes associated with immobility
congestion, increased secretions in the lungs, narrow bronchial tube
Give two examples of a nursing diagnosis that is also a medical diagnosis
constipation and anxiety
Standing order
contains orders for routine therapies, monitoring guidelines, or procedures for a specific patient
vehicle transmission
contaminated items such as water, drugs, solutions, blood, and improperly handled food
heat stroke
continued exposure to extreme heat that raises the core body temperature to 105 F or higher
Interdisciplinary care plan
contributions from all disciplines involved in patient care, made to improve the coordination of all therapies
anterior hypothalamus
control temp if high via sweating and vasodilation
posterior hypothalamus
control temp of low via vasoconstriction and shivering
Administrative law
created under the administrative board (e.g. state boards of nursing); guidlines for reporting unethical or incompetence related to: child abuse, elder abuse, communicable diseases, emergency medical treatment and active labor act violations
Water
critical component of the body
Cognitive implementation skills
critical thinking, using good judgment, know the rationale for interventions
Macrominerals
daily requirement = 100mg or more
micro minerals
daily requirements is 100mg or less
Nociceptive pain
damage to body tissue and usually described as sharp, aching, throbbing
affective learning
deals with expression of feelings and development of values, attitudes, and beliefs.
Antihistamines
decongestant for upper airway, suppress cough
Oliguria
decrease urine production
Causes of constipation
decreased activity, low fiber, low fluid, meds,
Patient lives in future?
defer things for now to meet future goal and do use preventative care
Criminal law
defines crimes and punishment; e.g. signing RN when you haven't completed NCLEX, diversion of narcotics; felony vs misdemeanor
Transient Incontinence
delirium, infection, atrophy, pharmaceuticals, excess urine output, restricted mobility, stool impaction (DIAPERS)
total patient care
delivery was the original care delivery model developed during Florence Nightingale's time. In this model the RN is responsible for all aspects of care for one or more patients during a shift of care, working directly with patients, families, and health team members.
Which instructional method has to do with "showing"
demonstration
physician-initiated intervention
dependent nursing actions, involving carrying out physician-prescribed orders. - Think invasive procedures.
Physiological changes associated with immobility
depression, behavior changes, sleep alteration, coping, social isolation
descriptive
describe phenomena, speculate on why phenomena occur, and describe the consequences of phenomena.
Durable Power of Attourney
designate person to healthcare decisions when the patient can no longer make them for himself
Six factors for choosing nursing intervention
desired or expected client outcome, characteristics of nursing diagnosis, evidence based, feasibility, acceptability of the client, capability of the nurse
primary nursing
developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. It is typically not practiced today because of the high cost of an all RN staffing.
Interpersonal implementation skills
developing a trusting relationship, express level of caring, communicate clearly with family
Nutritional assessment
diet hx, med hx, physical exam, anthropometry, lab findings,
Which of transmission of pathogens? Person to person
direct
Double barrel colostomy
distal colon bypassed, mucus fistula, proximal functioning
Urinary Diversion
diversion of urine to external source
Laissez-Faire Leaders:
do not interfere with employees and their work. They stand at a distance, giving followers freedom to make decision and accomplish their work.
What are -Independent nursing interventions?
don't need a doctors order (giving water, patient teaching for side effects of medication)
Pain reassessment
done after medicine is given
Which of transmission of pathogens? Large particle that travels up to 3 feet
droplet
airborne transmission
droplet nuclei or residue if evaporated droplets suspended in air during cough, sneeze, or carried on dust particles
Sources of law
elected officials and congress create statutory laws. (nurse practice act to define nurse legal boundaries) Common law comes from judicial decisions made in courts, Civil laws protect the rights of individuals of our society. Criminal laws protect society as a whole.
function of macrominerals
electrolyte balance
fever
elevation in the hypothalamic set point so body temperature is regulated at a higher level
Secondary/tertiary care (types of care, and institutions)
emergency care, acute medical-surgical care, radiological procedures for acute problems Hospitals- Intensive Care- Psychiatric Facilities- Rural hospitals-
Good Samaritan Laws
encourage HCP to assist in emergency situations; some states have duty to rescue laws that requires training professionals to stop and help
What do we need carbs for?
energy
S/S of diverticulitis
episodic pain, constipation, diarrhea, IBS, weakness, fatigue, bleeding in stools, abdominal distention and low grade fever
EGD
esophagogastroduodenoscopy
Cultural assessment
ethnic hx, bioculture hx, social organizations, religious or spiritual beliefs, communication patterns, touch, personal space, time orientation
examples of this include: pain score, how far ambulated, teach back?
evaluation
Elimination
excretion of waste from the body
Pain modalities of gait theory include
exercise, heat or cold, massage, TENS
What are some complications of pain?
exhaustion (physical and emotional), immobility, sleep deprivation
Situational factors affecting pain
expectation, control, relevance
Voiding
expel
Defecation
expel stool
Micturition
expel urine
interdisclipinary
explain systematic views of phenomena specific to the discipline of inquiry (basic human needs, developmental, psychosocial, systems)
Communication
expressing and exchanging ideas
Affective domain
expression of feelings, values, attitudes and beliefs
vector transmission
external mechanical transmission, and internal transmission such as parasites
What makes up nonverbal communication?
facial expression, eye contact, body posture
Metacommunication
factors that compose the context of the message
justice means
fairness
Name a few reasons why health care system is being transformed
family and patient engagement, providing patient centered care, population health, Safety- eliminating errors, Compassionate care (DNR) Reducing overuse and waste
chronic pain can cause what?
fatigue, insomnia, anorexia, depression, withdrawal and anger
Where are fat soluble vitamins stored?
fatty components of the body
emotional factors affecting pain
fear, anger, frustration
Evaluation
feedback, comparison of actual and expected outcomes, update of care plan,
Mambo
female
heat loss does not keep up with heat production
fever
Stereotyping behavior
fixed concept of how all members think or act, can be learned and unlearned
methods of elimination
flax seed, acupressure, massagem reflexology, aroma therapy, stress management
Bristol stool type 6
fluffy pieces with ragged edges, a mushy stool
transactional leaders
focus on the daily operations of an organization and develop an exchange relationship with their followers. They reward followers when they do well and correct them when needed
What does nursing focus on
focuses on care
Mid range theory
focuses on only a piece of human reality or experience
Anabolism
food is built up into protoplasm
Musculoskeletal changes associated with immobility
foot drop, decreased muscle tone, sensory alterations, osteoporosis
Pathologic fracture
fracture in bone that has been weakened by disease
definition of autonomy
freedom from external control
Overactive Bladder
frequent, sudden urges to urinate
Common law
from judicial decisions made in courts when individual legal cases are decided
Lifestyle modifications: DASH diet
fruits, veggies, fat-free or low-fat milk, whole grains, fish, poultry, beans, seeds, nuts
deconditioning
functional loss
Psychological factors affecting pain
gender, age, cognitive level, previous pains, family learning culture
What is a standing order for?
general symptom, procedure and order for "chest pain" by heart doctors. Need a doctor's order to perform this type of procedure. (dealing with medication)
African American culture
granny midwife, spiritualist, voodoo practitioners
Generalizations
group similarities applied to an individual
how does acute pain threaten recovery?
hampering the patient ability to become involved
What is a complete amino acid?
has all the 9 essential amino acids (fish, chicken, soybeans, turkey)
Evaluative nursing intervention:
have to back to assess pain in 30 min
HAI
health care associated infection
Profuse diaphoresis results in excess water and electrolyte loss.
heat exhaustion
heat production
heat is a byproduct of metabolism the chemical reaction in cells from breakdown of food
BMR
heat produced by the body at rest
heat depress hypothalmic function, temp of 104
heat stroke
selective estrogen receptor modulators
help prevent osteoporosis
Asian American culture
herbalist, acupuncture, fortune teller, shaman
HDL
high density lipoprotein (GOOD)
Treatment for diverticulitis
high fiber, high residue diet
Pain causes release of
histamine, bradykinin, potassium
Retention
holding waste
nosocomial infection
hospital acquired, catheterization most common cause
A nurses knowledge, experience, ethical perspective, and knowing the patient all contribute to:
how to make judgements
Many nursing scholars disagree on whether the concept of caring is a nature or nurture issue. The perspective of caring which describes the concept as part of human nature and essential to human existence is:
human trait
Retention Prevention
hydration, fiber, mobility
cardio changes associated with immobility
hypotension, increase workload of heart, clot formation
Nursing actions for cultural differences
identify potential conflicts, meet client on their terms, resist stereotyping, understand yourself and your attitudes, constrain prejudices and tendencies to judgement
Evaluation Process
identifying criteria and standards (knowing what to look for), collecting data (repeat assessment to see if better), interpreting and summarizing findings, documenting findings, terminating, continuing, or revising the care plan
Ileostomy
ileum small intestine, usually colon, rectum and anus completely removed
Identify the interval when a patient progresses to manifesting signs and symptoms specific to a type of infection:
illness stage
fats
important for wound healing but can be dangerous
Physiological response of pain
impulse travels up spinal cord to stem and thalamus > fight or flight response > deep pain > chronic pain
Cognition (interrelated concept)
inability to recognize cues for elimination, leading to incontinence
Advanced directives
include living wills, health care proxies, durable power attorneys
thyroid hormones
increase BMR 100%
voluntary movements or shivering
increase BMR 50%
Diuresis
increase urine production
Barborygami
increased peristalsis
stages of infection
incubation, prodromal, illness, convalescent
Fiber
indigestible polysaccharide which is a dietary factor in disease prevention and treatment, essential for peristalsis
Which of transmission of pathogens? Personal contact with inanimate object
indirect
indirect or direct care?... Communicating nursing interventions- written, electronic, oral
indirect
Assimilation
individual adapts and incorporates characteristics of the dominant cultureu
Which age group has greatest % of total body water?
infants
Biggest concern with foley catheter:
infection
systemic
infections require measures to control fever and usually require IV antibiotics
localized
infections require monitoring of fever, antibiotics, and may require measure to remove debris or dead tissue to have appropriate tissue healing
Enteroclysis
injection of liquids into the colon
acute pain follows
injury disease or surgery, rapid onset that varies with intensity and length
Malpractice
injury occurs as a result of what a nurse does or fails to do
what does an in-service education mean
instruction or training provided by a healthcare agency or institution; designed to increase the knowledge, skills, and competencies of nurses and other healthcare professionals employed by the institutions (on the job)
Cognitive domain
intellectual skills, thinking, and acquisitions of nursing
Clinical judgement
interpretations and inferences that influence actions in clinical practice
incubation
interval between entrance of pathogen into the body and appearance of first of first symptoms
prodromal
interval from onset of nonspecific signs and symptoms to more specific symptoms
convalescent
interval when acute symptoms of infection disappear
illness
interval when patient manifests signs and symptoms specific to type of infection
how to achieve a goal for patient
intervention
tertiary health care
interventions are aimed at disability limitation and rehabilitation from disease, injury, or disability. Attempts to reduce (or prevent) further disability or loss of function. Ex: PT/OT, Hospice
Indirect care
interventions are treatments performed away from the patient but on the behalf of the patient or group of patient. (safety and infection control, looking up meds before you go into room, delegation, and setting up task beforehand)
Direct care
interventions that are performed through interactions with the patient, med administration
What do we document?
interventions that we perform on behalf of the patient
infection
invasion of a susceptible host of pathogens of microorganisms resulting in disease
Urinary Incontinence
involuntary leakage of urine
Urge Incontinence
involuntary loss of urine tat usually occurs when a person has a strong, sudden need to urinate
democratic leaders
involve followers in the decision-making process by using a participatory leadership style. Effective when followers are experienced workers, particularly when they have professional education and socialization.
Intermediate Priority
involve the non-emergent, non-life threatening needs of the client (they do relate to why client is there)
psychomotor learning
involves acquire coordination and the integration of mental and physical movements (perception, response, adaptation, and origination)
Unintentional tort
involves negligence and malpractice
unintentional tort
involves negligence and malpractice
maturational loss
is a form of necessary loss and includes all normally expected life changes across the lifespan. Ex: toddler experiences separation anxiety from mom when starting preschool, grade school child does not want to lose favorite classroom or teacher.
Clinical practice guideline- (protocol)
is a set of statements that help guide nurses, physicians, and other health care providers to make decisions about appropriate health care for specific clinical situations (DVT, low back pain) how to do a dressing change, what if a patient experiences hypoglycemia. HOW TO
Pain assessment
is essential for pain management, must be initiated by nurse, BELIEVE the patient
Chronic pain
is prolonged, related to tumor, chemotherapy or fistulas
Three area of Competency (before initiating interventions)
knowing the scientific rationale for the intervention, possessing necessary psychomotor and interpersonal skills, being able to function within a particular setting to use the available health care resources effectively
Evidenced-based knowledge
knowledge based on research, clinical expertise, that makes one a critical thinker
Type of hyperventilation deep and rapid. Late stage of metabolic acidosis, DKA. Patient is air hungry, decreased pH and blowing off lots of CO2.
kussmauls
cause of diarrhea
lactose not broken down and absorbed, cholera or E. coli, increase water secretions in colon, unabsorbed dietary fat, mucosal inflammation
droplet transmission
lare particles that travel up to 3 feet via cough, sneeze, or talking
Good Samaritan
laws to protect health care workers when helping at scenes of accidents
Spanish American culture
lay midwife, herbalist bonesetters, spiritualists
urge incontinence
leakage of small amounts of urine at unexpected times including during sleep
stress incontinence
leakage of small amounts of urine during physical movement such as coughing, sneezing, exercising
Culture is
learned, shared and transmitted practices that guide in decision making and actions in patterned ways
Standards of care (law):
legal requirements for nursing practice that describe minimum acceptable nursing care. Standards reflect the knowledge and skill ordinarily possessed and used by nurses actively practicing in the profession
Acute diarrhea
less than once a week
Interpretivist approach
life experiences are culturally bound, experiences are on the basis of the encounters of their culture
unsaturated fat
liquid at room temperature
Patient lives in present?
live only for now and not use preventative behaviors
Epidural analgesia
local anesthesia, controls without sedative effects of opiates
LDL
low density lipoprotein (BAD), oxidized and deposit on vascular walls
VLDL
low density lipoprotein, high triglycerides
normal body temperature
lowest between 4a and 6a highest between 4p and 6p
autocratic leaders
make all the decisions and are generally most concerned with the tasks to be accomplished. They maintain distance from their follower, motivating them through the threat of punishment and offer of rewards as incentives.
Calcium and Phosphorus
make up 80% of all minerals in the body
Nonverbal communication
makes up 65% of message perceived
Hougan
male
sweating
may loose 1 L of body fluid with exercise for 1 hour in hot conditions
two types of aseptic technique
medical asepsis and surgical asepsis
Lawsuits nurses can positively effect:
medication errors, negligent supervision, informed consent, accidental injury, nosocomial and wound infections, pain and suffering, emotional distress, lack of teamwork and communication, inadequate charting
Control
mental control (level of consciousness), muscle control
exogenous
microorganism found outside the individuals
Advanced practice career roles
midwife, nurse anesthetist, researcher, practitioner, educator, administrator
NSAIDs work for which type of pain?
mild to moderate pain
Mobility (interrelated concept)
mobility helps with stimulation of peristalsis
Goal for pain
modify or minimize pain, enhance ability to control pain, demonstrate actions to control pain symptoms, setting priorities
Paralytic ileus
monitor first 24-48 hours post op
monitoring pt with opioid use
monitor vitals, monitor for breakthrough pain,
Patient has "scientific view"
more comfortable with western medicine
middle range
more limited in scope, less abstract
hispanic culture
more sedentary and believe house work and caring for family is exercise
Chronic diarrhea
more then 3-4 times a week
Psychomotor
motor skills, mental and physical movements such as walking
airborne precautions
must follow standard precautions and wear a specifically fitted mask
What are dependent nursing interventions?
must have a doctor order (walking patient, giving meds)
contact precautions
must wear gown and gloves, dedicated equipment
droplet precautions
must wear gowns, gloves, and a regular mask
Mutual factors
mutually set goals and expected outcomes
Patient has "holistic view"
natural approach, against western medicine
nonverbal communication
ncludes the 5 senses and everything that does not involve the spoken or written word Personal appearance: physical characteristics, facial expression, and manner of dress and grooming Posture and gait: manner or pattern of walking are forms of self-expression Facial expression: face is the most expressive part of the body. Facial expressions convey surprise, anger, fear, happiness, and sadness. Eye contact: people signal readiness to communicate through eye contact Gestures: emphasize, punctuate, and clarify the spoken word Sound: such as sighs, moans, groans, and sobs Territoriality and personal space: territoriality is the need to gain, maintain, and defend one's right to space. When personal space is invaded people become defensive.
error that could have harmed the patient
near miss
Psychological considerations
negative body image, risk for sexual dysfunction
metabolic changes associated with immobility
negative nitrogen balance
what age group does not shiver?
neonates
Macedo-Malone Antegrade Continence Enema (MACE)
neurogenic problems with bowels; someone who may have anatomical dysfunction; make artificial flap where enema is given
Placebos
no effect, highly unethical,
Anuria
no urine
Paralinguistic
nonverbal exchange of symbols such as eye contact, facial expressions
Paralinguistic
nonverbal exchange of symbols, eye contact or facial expressions
essential amino acids
not made in the body come from diet
4 goals of IOM/Robert Woods Foundation:
nurses should: -practice to the full extent of their education and training -achieve higher levels of education -become full partners with physicians and other health care providers -improve data collection for effective workplace planning and policy making
Acuity rating systems
nurses use this to determine hours of care and number of staff for a group of patients in 24 hours
Low Priority
nursing diagnoses for client needs that may not be directly related to a specific illness or prognosis, but may affect the client's future well-being (may focus on long term needs)
treatment of a symptom rather than the disease
nursing diagnosis
NANDA is the leader in _________________ and is endorsed by the ________ as having the responsibility to do so.
nursing diagnosis classification ANA
any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes
nursing intervention
Narrative documentation
nursing interventions recorded in timed order of completion
Caron's disease at risk for
obstruction, fistula, decreased nutrient absorption
Iatrogenic
obtained from a diagnostic test
Which instructional method has to do with being face to face
one-on-one
When does malpractice insurance cover a nurse?
only at work
Charting by exception
only writing down abnormal findings
Treat diarrhea
opium, anticholinergics, absorbants and demulcents, give supplements, fluid and vitamin replacements
Primary prevention
optimizing health and disease prevention;immunizations
Possible opioid routes
oral, transdermal, SubQ, IM, IV, intraspinal, PCA
Uniform anatomical gift act
organ donation that takes effects after death. Gift is made by writing their signature. (patient must be 18+)
End of dose failure
pain at end of dose
Breakthrough pain
pain event though fully medicated
Neuromatrix theory
pain is multidimensional experience produced by characteristic neurological patterns, brain generates pain
Pain transmission
painful stimuli produce nerve impulses that travel along afferent peripheral nerve fiber, perception, CNS extracts information (location, duration or quality), impulses are sent to cereal cortex, hypothalamus and limbic system
PPN
partial parenteral nutrition through IV
Bowel elimination
passage and dispelling of stool through the intestinal tract by means of intestinal smooth muscle contraction
Urinary elimination
passage of urine out of urinary tract through the urinary sphincter and urethra
Absorption
passing nutrients into blood or lymph system, occurs in intestines
Advanced directives
patient self discrimination act (1991); mandatory signed documentation (e.g. living wills and durable power of attorney)
Living will
patient wishes in the event of a terminal illness or condition
Patient adherence
patients and families invest time in carrying out required treatments
endogenous
patients flora becomes altered
Ulcerative colitis risks
perforation, hemorrhage, infection
direct transmission
person - person, physical contact
uniform anatomical gift
person 18 or older that can make an organ donation
indirect transmission
personal contact of susceptible host with contaminated inanimate object
Factors affecting respirations
physiological factors, developmental, lifestyle, and enviornment
Epidural use
post-op, traumatic, chronic, non-cancer, and cancer pain
pathophysiological changes associated with immobility
postural abnormalities, trauma, bed rest, growth and development
Primary care (health promotion)
prenatal, baby care, nutrition counseling, family planning, exercise classes
Instrumental ADL's
preparing meals, shopping, house cleaning, writing checks
Standing order
preprinted document with continuing order for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures. What to do for chest pain. WHAT TO DO
bisphosphonates
prevent loss of bone mass
Civil law
protect a person's individual rights within our society; encourages fair treatment; e.g. tort law
Criminal law
protect society as a whole and provide punishment
reverse percautions
protective, reducing microorganisms for immunocompromised patients
disuse syndrome
protein breaks down and muscle mass decreases
Clinical practice guideline
protocol, helps health care workers make decisions about appropriate health care for specific situations
What type of procedure is a dressing change/ cleaning a central line.... (need an order?)
protocol...don't need an order
Catabolism
protoplasm is broken down into energy
Occurrence report
provides a database for further investigation such as falls
defamation of character
publication of false statements that result in damage to a person's reputation
Language includes
quality, tone, rhythm, speed, and pronunciations
what also needs to be stated when choosing the intervention
rationale
Once you have selected the nursing intervention, implementation preparation:
reassessing the client, reviewing and revising the existing nursing care plan, organizing resources (have all supplies), anticipating and preventing complications, implementation skills (cognitive, interpersonal, psychomotor)
Implementation process (continually do these things)
reassessing the patient, reviewing/revising existing care plan
definition of responsibility
refers to a willingness to respect one's professional obligations and to follow through. As a nurse you are responsible for your actions and the actions of those to whom you delegate tasks.
aseptic technique
refers to practices keeping a client as free from microorganisms as possible
definition of accountability
refers to the ability to answer for one's actions. You ensure that your professional actions are explainable to your patients and your employer.
functional nursing
reflect a view of nursing as a broad set of tasks that can be carried out by a variety of workers, presumably in response to factors such as economic and labour-market constraints
Restraints
regulates use of physical and chemical restraints in nursing facilities; only to ensure the physical safety of the resident or to other residents; only on the written order of a physician with a specific duration
Calcium and Phosphate (kidney functions)
regulation affected by kidneys
Patient lives in past?
reistant to change
Transpersonally
relatedness to the unseen, God, or power greater than the self
Goal
relates to the NANDA problem; represent predicted resolution of the nursing diagnosis; must be realistic; do not need to be measurable; "The client will..."
What is telephone or verbal order? How to document?
repeat order back; e.g. Administer 10 mg Morphine IVP now T.O. Dr. Smith/R. Vaughn RN, MSN
Public Health Laws
reporting communicable diseases, school immunizations, abuse and neglect, domestic violence, etc.
JCAHO Standards for Documentation
required: initial assessment of physical, psychosocial, environmental, self-care, client education, and discharge planning needs, client and family teaching, discharge planning, evaluation of outcomes, multidisciplinary care plans/critical pathways
cognitive learning
requires thinking and encompasses that acquisition of knowledge and intellectual skills.
Purpose of lifesaving measures
restores physiological or psychological homeostasis when threatened
UTI
results from catheterization or procedure
possible NANDA labels for thermoregulation
risk for imbalanced body temp, ineffective thermoregulation, hyperthermia, hypothermia
Diverticulitis
sac like projection of mucosa through muscular layer of colon
Bristol stool type 2
sausage shaped but lumpy
Examples of adjuvants or conalgesics
sedatives, anticonvulsants, steroids, antidepressants, anti anxiety agents, muscle relaxants
What should the nurse do if there is more than one problem for the patient
select the priority diagnosis
Standards based approach
selection from options of mutually exclusive possibilities, implying that there is a right decision
Braden scale categories
sensory, nutrition, friction and shear, activity, moisture
occurence involving death or serious physical injury
sentinel event
Bristol stool type 1
separate hard lumps like nuts, hard to pass
Nursing theory `
set of concepts, definitions, and assumptions that explain a phenomenon
Obstipation
severe unretractable constipation
Ethnicity
shared identity related to social and cultural heritage
Acute illness
short duration, severe, may affect functioning; the flu
End colostomy
sigmoid (most common)
Monosaccharides
simple sugars
hyperthermia
situation in which body exceeds the set point
definition of social networking
social networking presents ethical challenges for nurses. On one hand social networking can be a supportive source of information about patient care or professional nursingactivities. Social media can provide emotional support when you encounter hardships at work with colleagues or patients. On the other hand the risk to patient privacy is great. Do NOT post pictures of patients. Also, becoming friends in online chat rooms, on facebook, or on other public sites interferes with your ability to maintain a therapeutic relationship.
Enculturation
socialization into one primary culture as a child
saturated fat
solid at room temperature
Trans dat
solid at room temperature, ex. shortening or lard (WORST KIND)
Cause of Urinary Retention
sphincter does not open for release of urine or blockage of urethra -leads to increased urine volume and bladder distention (back flow to the upper urinary tract, dilation of the ureters and renal pelvis, pyelonephritis and renal atrophy)
Modern Spirituality
spirituality is largely self defines, can mean nearly anything a person wants it to mean
skin changes associated with immobility
stage 1-4 wounds, ulcers, pressure areas, friction, shear
Health
state of complete physical, mental, social, well-being, not merely the absence of disease or infirmity
surgical asepsis
sterile technique
calculi
stones of calcium
Disaccharide
sucrose, milk sugar (lactose),maltose
disituational loss
sudden, unpredictable external events Ex: person in automobile accident sustains an injury with physical changes that make it impossible to return to work or school, leading to loss of function, income, life goal and self-esteem.
Gait control theory of pain
suggests that pain impulses can be regulated/blocked along spinal cord
Treat chron's with
surgery, antibiotics, steroids, antidiarrheal agents
Colectomy
surgical resection and removal of colon or toxic megacolon, perforation, hemorrhage, and cancer
Theoretical model
symbolic depictions of reality showing relationships among concepts
urinary tract infection
symptoms include dysuria, cystitis, hematuria and pyelonephritis
Lipogenesis
synthesis of fatty acids or glucose to fat
nonessential amino acids
synthesized in the body by the body
Root Cause Analysis
systematic process for identifying *"root causes"* of problems or events and an approach for responding to them.
Interdisciplinary theory
systematic view of a specific phenomenon, interacting with other people, Maslow's Hierarchy
Informatics
takes information science and computer science to study the process, management, and retrieval of info.
definition of beneficence
taking positive actions to help others
Implementation
teaching activities, delegation, documentation of patients progress
core temperature
temperatures of deep tissue
Loop colostomy
temporary allows tissue healing for several months
Acute pain
temporary, identifiable cause
Ethnocentrism
tendency to hold ones own way of life as superior to other cultures
team nursing
the RN is the leader who leads a team of other RN's, practical nurses, and nursing assistive personnel who provide direct patient care.
NANDA definition of Spirituality
the ability to experience meaning in life through connectedness with self, others, world, or a superior being
mobility
the ability to move physical using muscular function
asepsis
the absence of pathogenic microorganisms
Traditional Spirituality
the core of what it meant to be religious
Medical diagnosis
the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests and procedures
Nurse-initiated interventions
the independent response of the nurse to the client's needs and nursing diagnoses; within legal scope of nursing practice (e.g. holding B/P med)
Active nursing intervention:
the nurse will administer 2 tabs norco
High Priority
the nursing diagnosis that, if untreated, could result in harm to the client (must be addressed now)
perceived loss
the person experiencing the loss and is less obvious to other people. Ex: some people perceive rejection by a friend as loss, these losses are easily overlooked by others because they are experience so internally and individually, but can be just as painful as an actual loss and grieved in the same way.
Basal Metabolic rate
the rate at which the body uses energy while *at rest* to keep vital functions going, such as breathing and keeping warm.
what is deconditioning
the reform or reversal of previously conditioned behaviour, especially in the treatment of phobia and other anxiety disorders in which the fear response to certain stimuli is brought under control.
Nutrition
the study of food and how it affects the human body and influences health
definition of advocacy
the support of a particular cause. As a nurse you advocate for the health, safety, and rights of patient, including their right to privacy and their right to refuse treatment.
What is a phenomenon?
the term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations
use of restraints
the use of restraints must be clinically justified and a part of the patients prescribed medically treatment and plan of care. A physician's order is required Each original restraint order and renewal is limited to 8 hours for adults, 2 hours for ages 9 through 17, and 1 hour from children under 9. Restraints are not to be ordered PRN
Tissue perfusion
the volume of blood through arteries and capillaries by smooth muscle
Therapeutic communication
therapeutic nurse patient relationship and the nursing process
Collaborative nursing interventions
therapies that require combined knowledge of multiple professionals
Collaborative interventions
therapies that require knowledge, skill, and expertise of multiple health care professionals; deployed by multiple interventions; critical pathways
Transduction of pain
thermal, mechanical, chemical, electrical stimuli
Evaluation
this step is crucial to determine whether, after application of the first four steps of the nursing process, if the patient' condition or well being has improved.
How is an epidural administered?
thought a catheter into epidural space in spinal cord
Culture
thoughts, communication, actions, customs, beliefs,values, and institutions of racial, ethnic, religious or social groups
Nursing Interventions Classification
to develop a standardized language for the actions used to deliver nursing care, expand nursing knowledge about connections between nursing diagnoses, treatments, and outcomes, to develop nursing and health care info systems, to teach decision-making to nursing students, to determine the cost of services provided by nurses, better plan for resources in all types of nursing practice settings, articulate with the classification systems of other healthcare providers
North American Nursing Diagnosis Association (NANDA)
to develop, refine, and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses. - is the leader in nursing diagnosis classification
Goal of health informatics
to enhance to quality and efficiency of care provided by using electronic medical records
What is the purpose of SBAR?
to provide prompt and appropriate communication (AVOIDANCE OF LONG NARRATIVE DESCRIPTIONS)
TPN
total parenteral nutrition via PICC line or central line
Gate control theory
touch and electrical stimulation can close gate and not allow painful stimulations to get to nervous system
Leininger
transcultural perspective, a human trait, caring is the essence and central domain that distinguishes nursing from health care disciplines
radiation
transfer of heat between 2 objects without touching
evaporation
transfer of heat energy when liquid changes to a gas
conduction
transfer of heat from one object to another by direct contact
convection
transfer of heat through air movement such as a fan
authentic leaders
transparent and ethical in their dealings with followers. They are genuine, empathetic, reliable, and believable.
Nursing Interventions for constipation
treat with enema, diet, activity, increase fluid, laxatives
Indirect care
treatments performed away from the client, but on behalf of the client; e.g. talking with other members of the healthcare teams (critical pathway), delegating, evaluating
Indirect care
treatments performed away from the patient but on behalf of the patient, safety
Direct care
treatments performed through interactions with the client; e.g. physical care techniques, counseling, teaching
Types of fats
triglycerides, fatty acids, unsaturated, monounsaturated, saturated, polyunsaturated
primary health care
true prevention, interventions are aimed at preventing disease, injury, or disability Ex: immunizations
Nutrition (interrelated concept)
types of foods and fluids ingested impact stool formation and urinary elimination
What is unique about "risk for" diagnosis
typically do not have defining characteristics because they have no occurred
Incontinence
unable to control voiding
functional incontinence
untimely urination because of physical disability, external obstacles, or cognitive problems that stop a person from reaching the toilet
Intimate space
up to 1.5 feet, much of nursing done here, use of touch may make pt. uncomfortable
Social space
up to 12 feet, comfortable space
Personal space
up to 4 feet, teaching, pt. may back up if need more space
possible NANDA labels for UTI
urinary incontinence, impaired urinary elimination, urinary retention, toiling self care deficit
Polyuria
urinating a lot
Nocturia
urinating at night
transformational leaders
use approaches that change or transform individuals. They inspire and intellectually stimulate followers and recognize their contributions.
What is a NANDA?
used to develop, refine, and promote a taxonomy of nursing diagnostics terminology for use of professional nurses
Functional Incontinence
usually aware of need to urinate, but for one or more physical or mental reasons they are unable to get to bathroom
mixed incontinence
usually occurrence of stress and urge together
surface temperature
varies with blood flow to the skin and amount of heat loss to external environment
HYPOthermia S/S
vasoCONSTRICTION : Skin feels *Cool*, slow cap refill Skin is *Pale* & becomes cyanotic Muscle Rigidity and shivering *DYSRHYTHMIAS* ( A-FIB, V-FIB) due to myocardial irritability.
Which of transmission of pathogens? External transfer such as insect/bug
vector
Which of transmission of pathogens? Transmission through contaminated items
vehicle
Linguistic communication
verbal exchange of messages through spoken words and written symbols, face to face or texting
Linguistic
verbal exchange through spoken words, even cell phones
Flexible sigmoidoscopy
visual exam to diagnose polyps, infection, inflammation
Fiberoptic colonoscopy
visual exam, diagnose tumors, polyps
treatments for immobility
vitamin C and D, surgery, assistive devices
Pain
whatever the experiencing person says it is, existing whenever he says it does -patient report is the most reliable indicator of pain -unpleasant sensory or emotional sensation
Pain is
whatever the experiencing person says it is, existing whenever he/she says it does
actual loss
when a person can no longer feel, hear, see, or know a person or object. Ex: loss of a body part, death of a family member, or loss of a job.
Stress Incontinence
when physical movement or activity-- such as coughing, sneezing, running, or heavy lifting-- puts pressure on bladder
Disenfranchised grief-
when their relationship to the deceased person is not socially sanction, cannot be shared openly or seems of lesser significance. The person's loss or grief do not meet the norms of grief acknowledged by his or her culture, thereby cutting the person off from support system.
Quasi-intentional torts
where intent is lacking but violational action, privacy/defamation
Intentional tort
willful or intentional act or wrong doing that violates another person's right or property; assault and battery, medical battery, false imprisonment, trespass, defamation and intentional infliction of emotional distress
Interpersonally
with others and the natural environment
Intrapersonally
within oneself
What do we need protein for?
wound healing
4 common issues in malpractice
wrong time, verbal orders, charting in advance, incorrect data
population at risk for immobility
young, elderly, obesity