Fundamentals I: Exam 1 Study Guide
What are some professional nursing organizations?
- ANA: American Nurses Association - NLN: National League for Nursing - AACN: American Association of Critical-Care Nursing - NSNA: National Student Nursing Association - Specialty practice nursing organizations - International nursing organizations
What are the 10 guiding principles of person-centered care?
- All team members are considered caregivers - Care is based on continuous healing relationships - Care is customized and reflects patient needs, values, and choices - Knowledge and information are freely shared between and among patients, care partners, physicians, and other caregivers - Care is provided in a healing environment of comfort, peace, and support - Families and friends of the patient are considered an essential part of the care team - Patient safety is a visible priority - Transparency is the rule in the care of the patient - All caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient - The patient is the source of control for their care
What are the guidelines for perineal care?
- Assess for perineal or vaginal problems and related treatments - Perform a physical assessment of male and female genitalia - Perform perineal care in matter of fact and dignified manner according to procedure - Cleanse vaginal area with plain soap and water, wipe front to back
What are the general skin care principles?
- Assess the patient's skin daily and after every episode of incontinence - Cleanse the skin when indicated, such as when soiled, using a no-rinse, pH-balanced skin cleaner - Avoid using soap and hot water, avoid excessive friction and scrubbing - Minimize skin exposure to moisture, use a skin barrier product as necessary - Use skin emollients after bathing and as needed - Powder not recommended in obese patients
How to assess the client for the use of mechanical assistive devices
- Assess the patient: know the medical diagnosis, capabilities, and any movement not allowed. Apply braces or any device before helping from bed - Assess the patient's ability to assist with the planned movement. Encourage patients to assist in their own transfers - Assess the patient's ability to understand instructions and cooperate with the staff to achieve the movement
How to decrease risk for injury for neonates & infants
- Avoid behaviors that might harm the fetus - Never leave the infant unattended - Use crib rails - Monitor setting for objects that are choking hazards - Use car seats properly - Handle infant securely while supporting the head - Place infant on back to sleep
Guidelines for preventing spread of C-Diff
- Avoiding use of electronic equipment that is difficult to clean - Disinfecting dedicated patient care items and equipment between patients - Using full-barrier contact precautions (gown and gloves) - Placing patients in private rooms - Performing hand hygiene, SOAP AND WATER REQUIRED - Performing environmental contamination of rooms - Educating health care providers on clinical presentation, transmission, and epidemiology of c-diff
What are the safety concerns when providing care?
- Bed is in lowest position - Bed position is safe for the patient - Bed controls are functioning - Call light is functioning and within reach - Side rails are raised if indicated - Wheels or casters are locked
What are 5 moments for hand hygiene?
- Before touching a patient - Before a clean or aseptic procedure - After a body fluid exposure risk - After touching a patient - After touching patient surroundings
What are the roles of a nurse?
- Caregiver: meeting physical, emotional, intellectual, sociocultural, and spiritual needs - Communicator: use of effective interpersonal and therapeutic communication skills to establish and maintain relationships with all patients - Teacher/educator: use of communication skills to assess, implement, and evaluate individualized teaching plans to meet learning needs of patients and their families - Counselor: interpersonal communication skills to provide info, make appropriate referrals, and facilitate the patient's problem-solving and decision-making skills - Leader: assertive, self-confident practice of nursing when providing care, effecting change, and functioning with groups - Researcher: conduct of research to increase knowledge - Advocate: protection of human or legal rights and securing of care for all patients based on patient rights - Collaborator: use of skills in organization, communication, and advocacy to facilitate the functions of all health care team members
What are the 4 nursing competencies?
- Cognitive - Technical - Interpersonal - Ethical/legal
What is the clinical reasoning model?
- Consider the patient situation (describe or list facts, context, objects, or people) - Collect cues and information (review current information, gather new information, recall knowledge) - Process information (interpret, discriminate relevant vs irrelevant, relate, infer, match) - Identify problems/issues (synthesize facts and inferences to make a definitive diagnosis of the patient's problem) - Establish goal(s) (describe what you want to happen, a desired outcome, a time frame) - Take action (select a course of action between different alternatives available) - Evaluate outcomes (evaluate the effectiveness of and actions outcomes, has the situation improved?) - Reflect on process and new learning (contemplate what you have learned from this process and what you could have done differently)
What are the factors affecting personal hygiene?
- Culture - Socioeconomic class - Spiritual practices - Developmental level - Health state - Personal preferences - Finances
How can a nurse act as a role model in the community?
- Developing individualized care plans, making referrals to community facilities and support groups - Know the location and specialties of health care providers, availability and accessibility of services and supplies, and other public health services, daycare or long-term care facilities, housing, and the number and type of facilities providing services - Provide community services as volunteers in health-related activities and as role models for health practices and lifestyles
What are factors that affect safety in a person's environment?
- Developmental considerations - Lifestyle - Social behavior - Environment - Mobility - Sensory perception - Knowledge - Ability to communicate - Physical and psychosocial health state
What are some equipment & assistive devices?
- Gait belt - Stand-assist and repositioning aids - Lateral-assist devices - Friction-reducing sheets - Mechanical lateral-assist devices - Transfer chairs - Powered stand-assist and repositioning lifts - Powered full-body lifts
How to decrease risk for injury for school-aged children
- Help to avoid activities that are potentially dangerous - Reinforce teaching about symptoms the require immediate attention - Continue immunizations as scheduled - Teach bicycle safety - Teach about child abduction - Wear seatbelts
What are the different types of community-based nursing?
- Home care - Community health centers - School nursing - Occupational nursing - Independent nursing
What is caring?
- Human mode of being - Sensitive to others - Essence of nursing and the moral imperative that guides nursing (education, practice, and research) - Action and competencies that aim toward the good and welfare of others - Special way of being, knowing, and doing with the goal of protection, enhancement, and preservation of human dignity - Culturally diverse and universal, and provides the broadcast and most important means to study and explain nursing knowledge and nursing care practices - Sharing deep and genuine concern about the welfare of another person - Central to all helping professions and enables people to create meaning in their lives - Helps someone grow - Benefits for the one giving the care, provides meaning to their lives - An essential element in providing quality nursing care
How to decrease risk for injury for older adults
- Identify safety hazards in the environment - Modify the environment, as necessary - Attend defensive driving courses or courses designed for older drivers - Encourage regular vision and hearing tests - Ensure hearing aids and eyeglasses are available and functioning - Objective document and report any signs of neglect and abuse
How does a health crisis affect the family?
- If illness is relatively minor, changes in family tasks may be minor and brief - Injury or illness is serious, the roles and responsibilities, as well as functions, of other family members change. Some families find it difficult to adapt to the stress of changes and others find closeness and stability - Members of the family must constantly adjust roles and responsibilities to manage the needs of the ill family member and the family
What are the stages of infection?
- Incubation period - Prodromal stage - Full stage of illness - Convalescent period
What are the factors affecting the risk of infection?
- Intact skin and mucous membranes - Normal pH levels - Body's white blood cells - Age, sex, race, hereditary factors - Immunization, natural or acquired - Fatigue, climate, nutritional and general health status - Stress - Use of invasive or indwelling medical devices
What are some factors that contribute to falls?
- Lower body weakness - Poor vision - Gait and / or balance issues - Problems with feet and/ or shores - Use of psychoactive medications - Postural dizziness - Hazards in the home
Filing a Safety Event/Incident Report and documentation
- Must be completed after any accident or incident in a health care facility that compromises safety - Describes the circumstances of the accident or incident - Details the patient's response to the examination and treatment of the patient after the incident - Completed by the nurse immediately after the incident - It is not part of the medical record and should not be mentioned in
What personal attributes should a nurse have?
- Open-mindedness, humility - Profound sense of the value of the person - Self-awareness and knowledge of your own beliefs and values - A sense of personal responsibility for your actions. - Motivation to do what you do to the best of your ability because you care about the well-being of those entrusted to your care. Bravery to question the "system"
What are the proper uses of restraints and assessing a patient in restraints?
- Order must be obtained prior to being applied, monitored and assessed at least every hour or according to facility policy (hard restraints assessed every 15 minutes, good for 4 hours), document and notify patient's family and health care provider - Assess for skin break down/skin integrity, range of motion Physical device used to limit a patients movement - Does NOT prevent falls - Only use to protect the patient, staff, and others - Must be discontinued at earliest possible time - Use alternatives before physical restraints (ie. Talking with patient, babysitting, etc., Document that alternative is not working) - Last resort - Time limited - Must re-evaluated Q24 hrs
How to safely transfer a client from bed to chair
- Place the bed in the lowest position. Raise the head of the bed to a sitting position or as high as the patient can tolerate - Make sure the bed brakes are LOCKED. Put the chair next to the bed. If available, lock the brakes of the chair. If the chair does not have brakes, brace the chair against a secure object - Encourage the patient to make use of a stand-assist aid, either freestanding or attached to the side of the bed, if available, to move to the side of the bed and to a side-lying position, facing the side of the bed on which the patient will sit - Stand in front of the patient and assess for any balance problems or complaints of dizziness. Allow the patient's legs to dangle a few minutes before continuing - Assist the patient to put on a robe, as necessary, and non-skid footwear - Wrap the gait belt around the patient's waist, based on assessed need and facility policy - Stand facing the patient. Spread your feet about shoulder width apart and flex your hips and knees - Ask the patient to slide his or her buttocks to the edge of the bed until the feet touch the floor. Position yourself as close as possible to the patient, with your foot positioned on the outside of the patient's foot. If a second staff person is assisting, have him or her assume a similar position. Grasp the gait belt - Encourage the patient to make use of the stand-assist device. If necessary, have second staff person grasp the gait belt on opposite side. Rock back and forth while counting to three. On the count of three, using the gait belt and your legs (NOT YOUR BACK), assist the patient to a standing position - Pivot on your back foot and assist the patient to turn until the patient feels the chair against his or her legs. - Ask the patient to use his arm to steady himself on the arm of the chair while slowly lowering to a sitting position. Flex your hips and knees when helping the patient sit in the chair - Assess the patient's alignment in the chair
What are the 4 nursing aims?
- Promote health - Prevent illness - Restore health - Facilitate coping with disability or death
What are the common bed positions?
- Prone - Supine - Fowlers - Semi-fowlers - Lateral - Sims - Trendelenburg
What are the different reflective practices?
- Reflection in action - Reflection on action - Reflection for action
How to decrease risk for injury for adults
- Remind them of effects of stress on lifestyle and health - Enroll in defensive driving course - Counsel about unsafe health habits (reliance on drugs and alcohol) - Evaluate workplace for safety - Counsel about domestic violence
What are health-teaching interventions to promote medication safety with Polypharmacy?
- Report on side effects from medication to your health care provider - Do NOT share medication with others or take their pills - When a drug is discontinued, throw away any remaining medications - Fill all your Rx at one pharmacy
What are some examples of community factors affecting health?
- Social support systems: people who meet financial, physical, and emotional needs, who provide support - Community health care structure: affects health of people living in it, size and location of community determine what services are available - Economic resources: personal finances and health care coverage - Environmental factors: where they live and work can either be helpful or harmful (quality of air and water, lack of services)
How to decrease risk for injury for toddlers & preschoolers
- Supervise child closely to prevent injury - Select toys appropriate for developmental level - Never leave child alone in bathtub - Childproof home environment, prevent poisoning - Be alert to manifestations of child maltreatment or abuse - Use car seats properly - Teach about fire safety/practice emergency evacuation measures
How to decrease risk for injury for adolescents
- Teach safe driving skills and avoiding distracted driving - Teach avoidance of tobacco and alcohol - Emphasize gun safety - Follow healthy lifestyle - Teach about sexuality, STIs, and birth control - Teach risk of infection with body piercing and tattoos - Discuss dangers associated with the Internet
What is nursing as a professional discipline/criteria?
- Well-defined body of specific and unique knowledge - Strong service orientation - Recognized authority by a professional group - Code of ethics - Professional organization that sets standards - On-going research—evidence based practice/newest research - Autonomy and self-regulation
What are nursing interventions to decrease the risk for injury in the healthcare settings?
- assess for history of falls or accidents - note assistive devices - be alert to the history of drug or alcohol abuse - assess mobility status - assess level of awareness or orientation - assess sensory perception - recognize manifestations of domestic violence or neglect - identify potential safety hazards
What are nursing interventions to prevent falls?
- complete a risk assessment - indicate risk for falling on patient's door and chart - keep bed in low position - keep wheels on bed and wheelchair locked - leave call bell within patient's reach - instruct patient regarding use of call bell - answer call bells promptly - leave a night light on, provide non-skid footwear
What are alternatives to using restraints?
- determine whether behavior pattern exists - assess for pain and treat appropriately - rule out causes for agitation (assess respiratory, vital signs, blood glucose, fluid and electrolyte issues, and medications) - involve the family in patient's care - ask family members or significant other to stay with the patient - reduce stimulation - noise and light - distract and redirect - using a calming voice - use low-height beds - assist with toileting at frequent intervals - therapeutic touch
How to promote good body balance
- erect posture - use the longest/strongest muscles for power - work as closely to an object being moved/lifted - face the direction of your movement (avoid twisting) - use the weight of the body for pulling or pushing - slide/roll/push/pull an object rather than lift - use the weight of the body to push by rocking forward (to pull, rock backwards) - broaden base of support - flex the knees - break up heavy loads into smaller loads
Emergency preparedness for bioterrorism or chemical threat
- follow standard precautions - for certain diseases, additional safeguards may be necessary - decontamination if exposure status is uncertain, requires swift transfer of portable decontamination units, equipment, and trained personnel to the site of the chemical attack
What is the infection cycle?
- infectious agent - reservoir - portal of exit - means of transmission - portal of entry - susceptible host
What are the different types of families?
- nuclear - extended - blended - single-parent
What are the lower-level needs of Maslow's hiearchy?
- safety & security - physiologic (lowest)
What is Maslow's hierarchy of basic human needs?
- self actualization - self esteem - love & belonging - safety & security - physiologic
What are the higher-level needs of Maslow's hiearchy?
- self actualization (highest) - self esteem - love & belonging
What are critical thinking attitudes?
- self-aware - genuine/authentic - effective communicator - curious and inquisitive - alert to context - reflective and self-corrective - analytical and insightful - logical and intuitive - confident and resilient - honest and upright - autonomous/responsible - careful and prudent - open and fair-minded - sensitive to diversity - creative - realistic and practical - proactive - courageous - patient and persistent - flexible - health-oriented - improvement-oriented
What are 3 approaches to problem solving?
- trial-and-error problem solving - scientific problem solving - intuitive problem solving
What is the proper technique to move a client up in bed?
1. decide if the patient can assist. If capable, allow patient to complete movement independently with supervision 2. if only partially able, encourage patient to assist using a repositioning aid or cues 3. if patient is not able to assist, use a full-body sling lift and 2 or more caregivers. Friction-reducing sheets or other devices should be used
What is the nursing process?
ADPIE - Assessment - Diagnosis - Planning - Implementation - Evaluation - Major guidelines for nursing practice - Helps nurses implement their roles - Integrates art and science of nursing - Allows nurses to use critical thinking and clinical reasoning - Defines the areas of care that are within the domain of nursing
How to assess muscle strength
Assess by asking the patient to move actively against resistance
How to assess muscle tone
Assess by flexing and extending the elbow or knee and noting the degree of resistance to these movements
How to assess muscle mass
Assess throughout the body and compare one muscle group to another using tape measurements
Who was the founder of professional nursing?
Florence Nightingale - established first nursing school - believed healthy environment is essential for healing - believed nursing is separate and distinct from medicine - 2 components of nursing: health and illness - maintained accurate records
Stress related to safety
Stressful situations tend to narrow a person's attention span and make the person more prone to accidents - Effects: depression, confusion and disorientation, reduced awakeness or concern for environmental hazards
Define intuitive problem solving
a direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible
What is C. Difficile (C-Diff/CDI)?
a health care-acquired infection (HAI)
Define person-centered care
a model of patient care based on holistic roots in which the nurse or other caregiver uses every clinical encounter to assess how the person is doing and to communicate respect, compassion, and care
What are the tasks of families with older adults?
adjust to retirement, adjust to loss of spouse, may move from family home
Define infectious agent (infection cycle)
bacteria, viruses, and fungi - can be categorized by shape, gram-positive/gram-negative, aerobic/anaerobic
Define a therapeutic relationship
between the caregiver and patient, is focused on promoting or restoring health and well-being of the patient
Define safety & security needs (Maslow)
both physical and emotional components, being protected from potential or actual harm
What are the tasks of couples and families with young children?
establish mutually satisfying marriage, plan to have kids or not, have and adjust to infant, support needs of all members
How to assess endurance
evaluate the patient's ability to turn in bed, maintain correct alignment when sitting or standing, ambulate, and perform self-care activities
Define reflection in action
happens in the here and now of the activity and is also known as "thinking on your feet"
Define reflection for action
helps the person to think about how future actions might change because of reflection
Define means of transmission (infection cycle)
how an organism may be transmitted from its reservoir - direct or indirect contact
Define extended family
includes aunts, uncles, grandparents
Define healthcare-associated infection
infections that are acquired during/after hospitalization that patient did not have prior to, transmitted via contaminated hands of health care workers - Catheter-associated UTI - Surgical site infection (SSI) - Central-line associated bloodstream infection - Ventilator-associated pneumonia
How to promote safe patient handling and movement
involve the use of patient assessment criteria, algorithms for patient handling decisions, and proper use of patient handling equipment. Keep the patient in good alignment and protect the patient from injury while being moved
Define nursing practice acts and licensure
laws established in each state in the U.S. to regulate the practice of nursing - Define legal scope of nursing practice - Create a state board of nursing to make and enforce rules and regulations - Define important terms and activities in nursing, including legal requirements and titles for RNs and LPNs - Establish criteria for the education and licensure of nurses - Nurse Licensure Compact (NLC): allows a licensed nurse to practice in another member state without additional licensure - Enhanced Nurse Licensure Compact (eNLC): increases access to care while maintaining public protection at the state level
Define prone position
lying on abdomen, facing downward (head may be turned to one side)
What are the tasks of families with adolescents and young adults?
maintain open communications, support moral and ethical family values, maintain supportive home base
What are the tasks of families with middle-aged adults?
maintain ties with younger and older generations, prepare for retirement
Define single-parent family
may be separated, divorced, widowed, or never married
Define isokinetic exercise
muscle contraction with resistance - ex. rehab exercises for the knee, lifting weights
Define isometric exercise
muscle contraction without shortening - ex. holding a yoga pose
Define isotonic exercise
muscle shortening and active movement - ex. walking, performing ROM exercises, swimming
Define reservoir (infection cycle)
natural habitat of the organism
Define reflection on action
occurs after the fact and involves thinking through a situation that has occurred in the past
Define incubation period (stages of infection)
organisms growing and multiplying
Define physiologic needs (Maslow)
oxygen, food, elimination, temperature, sexuality, physical activity, and rest must be met minimally to maintain life
Define prodromal stage (stages of infection)
person is most infectious, vague and nonspecific signs of disease
Define portal of entry (infection cycle)
point at which an organism enters a new host
Define portal of exit (infection cycle)
point of escape from reservoir
Define full stage of illness (stages of infection)
presence of specific signs and symptoms of disease
What is the importance of hand hygiene?
proper hand hygiene and glove use can interrupt the transmission of dangerous bacteria from nurses to patients - hand washing with plain soap and water, alcohol-based products, or surgical hand antisepsis
Define convalescent period (stages of infection)
recovery from the infection
Define scientific problem solving
systematic, seven-step problem-solving process that involves: (1) problem ID (2) data collection (3) hypothesis formulation (4) plan of action (5) hypothesis testing (6) interpretation of results (7) evaluation, resulting in a conclusion or revision of the hypothesis
Define trial-and-error problem solving
testing any number of solutions until one is found that works for that particular problem
Define susceptible host (infection cycle)
the degree of resistance the potential host has to the pathogen
Define self esteem needs (Maslow)
the need for a person to feel good about him/herself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments. Positive self-esteem facilitates the person's confidence and independence
Define self actualization needs (Maslow)
the need for people to reach their full potential through development of their unique capabilities. Each lower level of need must be met to some degree for this to be satisfied
Define critical thinking
thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned - a systematic way to form and shape one's thinking that functions purposefully and exactingly
Define nuclear family
traditional family (2 adults and children)
Define blended family
two parents and their unrelated children from previous relationships
Define love & belonging needs (Maslow)
understanding and acceptance of others in both giving and receiving love, and the feeling of belonging to groups such as families, peers, friends, and community
Define transmission-based precautions
used in addition to standard precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by: - airborne (N95, gown, gloves, goggles) - droplet (mask, gown, gloves, goggles) - contact routes (contact- gown and gloves, contact+ - soap and water)
Define standard precautions
used in the care of all hospitalized patients regardless of diagnosis or infection status - Apply to blood, all body fluids, secretions, and excretions except sweat, non-intact skin, and mucous membranes - Respiratory hygiene/cough etiquette
