NSG 117 Exam #2 Study Guide
What do you have to keep in mind when teaching an older adult?
("Remember when") Must meet patient where they are at mentally and take them at a pace where they can understand/follow. (meet them where theyre at) Set mutual goals -Teach when patient is alert and rested, -involve adult in discussion or activity, -focus on wellness and personal strength, -use approaches that enhance patient's reception of stimuli when he or she has a sensory impairment, - keep teaching sessions short.
Sim's Position
- Differs from the side-lying position in the distribution of the patient's weight. - Patient places the weight on the anterior ileum, hummerus, and clavicle.
Side Lying position
- Lateral position, patient lays on side with the major portion of the body weight on the dependent hip and shoulder, - 30 degree lateral position is recommended for patients at risk for pressure injuries, - need to maintain the structural curve of the spine, head needs to be supported in line with the midline of the trunk, and rotation of the spine needs to be avoided.
Prone position
- Lies face or chest down, often has head turned to one side, - pillow under head needs to be thin enough to prevent cervical flexion or extension and maitian alignment of the lumbar spine, - placeing a pillow under the lower leg permits dorsalflexion of the knee and ankles, - rarely used in practice, only used alternatively for patients in acute respiratoru distress syndrome and acute lung injury
Supine position
- On back, alignment the same as for standing position, - use pillows, trochanger rolls and hand rolls or hand splints to increase comfort and reduce injury to the skin or muscular skeletal system, - mattress needs to be firm enough to be supported and the elbows are slightly flexed to control the shoulder rotation, - a foot support prevents foot drop and maintains proper alignment
Orthopneic/Tripoding
- Patient sits over bed side table with the head resting on the table with multiple pillows. -Used for patients with severe trouble breathing, also called tripoding.
What are the nursing interventions for immobility?
- Primary prevention-Regular physical activity, protection against injury, optimal nutrition, fall prevention measures - Secondary prevention-Osteoporosis screening,Fall assessment screening - Collaborative interventions-Frequent turning (q2hrs) positioning, alignment,Skin assessment and skin care, Range of motion, Deep breathing, Weight bearing (if possible), Measures to optimize elimination, Nutrition -- Exercise therapy ØAmbulation ØJoint mobility ØStretching ØBalance --Pharmacologic agents ØAntiinflammatory agents ØAnalgesics ØMuscle relaxants ØNutrition supplementation --Surgical interventions ØCurative versus palliative (fixing the problem Vs --Imobilization ØCasts and splints, braces, traction, slings, shoulder immobilizers, pillows, etc. --Assistive devices and patient handling technology Crutches, canes, walkers, wheelchairs, prostheses
Trendelenburg position
- Used in patient's with low blood pressure, - lower head of bed, raise the feet so the feet are higher than the head
What is gait and what are you looking for when assessing gait?
-The style of walking, including rhythm, cadence, length of stride, and speed. -Assessing gait allows for conclusions about balance, posture, and the ability to walk w/out assistance. -While a patient walks, look for conformity, a regular smooth rhythm, and symmetry in the length of leg swing, smooth swaying related to the gait phase, and a smooth, symmetrical arm swing. -An abnormal gain is a common risk factor for patient falls. -May indicate neurological and musculoskeletal problems
What are some of the possible complications associated with Immobility?
- bed sores, GI- constipation decreased urinary output, foot drop (to prevent this, encourage foot pumps, put patient in a boot/brace to help stretch or keep achilies in a stretched position), kifosis, lordosis, scoliosis, -Cardiovascular system- reduced cardiac capacity, decreased cardiac output, orthostatic hypotension, venous stasis, deep vein thrombosis.(DVT protocol) -Respiratory system- reduced lung expansion, atelectasis, pooling of respiratory secretions. - Musculoskeletal system- reduction in muscle mass and atrophy, contracture of joints, bone demineralization. - Integumentary system- skin breakdown - GI- reduced peristaltic motility, constipation, Urinary system- renal calculi, urinary stasis, infection
What are the steps in the research process?
-(ASSESSMENT)Identify area of interest or clinical problem-review literature, formulate theoretical framework,reflect on personal practive and/or discuss clinical issues with experts to better define the problem. --(DIAGNOSIS) Develop research questions/hypotheses. ---(PLANNING)- determine how study will be conducted, select research design/methodology, identify plan to recruit sample, taking into consideration population, number, and assignment to groups, identify study variables, specific interventions (independent variable) and outcomes (dependent variable), select data collection methods, select approach for measuring outcomes, questionnaires, surveys, physiological measures, interviews, observations, formulate plan to analyze data, statistical methods to answer research questions/hypotheses. ----(IMPLEMENTATION) Conduct the study, obtain necessary approvals, recruit and enroll subjects, implement the study protocol/collect data. -----(EVALUATION) analyze results of the study, continually analyze study methodology, (is study consistently carried out, all investigators following study protocol?), interpret demographics of study population, analyze data to answer research questions/hypothesis, interpret results:including conclusions, limitations.(use the findings- formulate recommendations for further research, determine implications for nursing, disseminate the findings:presentations, publications, need for further study, how to apply findings in practice.)
What are the steps in Evidence Based Practice
-0. Cultivate a spirit of inquiry. -1. Ask a clinical question in PICOT format. P = Patient population of interest I = Intervention of interest C = Comparison of interest O = Outcome T = Time -2. Search for the best evidence. -3. Critically appraise the evidence. -4. Integrate the evidence. -5. Evaluate the outcomes of practice decision or changes. -6. Communicate the outcomes of the evidence-based practice decision.
What are the possible nursing diagnoses for immobility?
-A patient who is experiencing an alteration in mobility often has one or more nursing diagnoses, -2 diagnosis most directly related to moility problems are impaired mobility, and risk for dissue syndrome- imobile patient at risk for multisystem problems because of inactivity. Other potential diagnoses are: Imparied airway clearance, Impaired sleep Risk for impaired skin integrity/ imparied skin integrity Risk for constipation Social isolation Ways to diagnoses/tests=Radiographic tests ØX-ray ØMRI ØCT scans ØBone scan ØBone mineral density ØMyelogram Arthrography Other diagnostic tests ØArthroscopy ØElectromyography ØBlood tests ØAnalysis of joint fluids ØPathologic analysis of biopsied tissue
What is environmental safety?
-A patient's environment includes physical and pyschosocial factors that influence or affect the life and survival of the patient. -Safe environment meets basic needs, reduces physical factors and reduces spread of pathogens and pollution, and helps improve general health of patient -Be non-judgemental have safe psychological environment -teach patient about home safety-locking doors/windows-fall prevention/ injury prevention,
What is ambulation and what is the therapeutic benefit?
-Act of moving/ changing position, using muscles, lung compacity. -Immobility is a major factor in developing atelectasis, ventilator related pneumonia, and functional limitations including muscle weakness, fatigue (deconditioning) -It is VITAl that patients ambulate early, even just getting them in a chair or to sit up on the side of the bed and dangling helps increase general strength, and lung expansion, include PT. -Watch for orthostatic hypotension -Lower them to the floor if they get dizzy -Wear a gait belt, have someone follow behind with a wheelchair.
How do you evaluate the evidence according to EBP? (describe the pyramid)
-All quality evidence, you will have to look for: *Level of evidence *How well the study (if research) was conducted *How useful are the findings to nursing practice *Does it have an abstract, intro, literature review/background, manuscript narrative-including purpose statement, methods/design, analysis results/conclusions, and clinical implications/limitations. Pyramid showing the levels of evidence, confidence in the evidence goes down from the top of the pyramid to the bottom. (best at peak, worst at base) 1. (BEST) systematic review or meta-analysis of Randomized Controlled Trials (RCT), evidence based clinical practice guidelines based on systematic reviews. 2. A well-designed RCT 3. Controlled trial w/out randomization (quasiexperimental study) 4. Single, non-experiemental study (case control, correlational, cohort studies) 5. Single descriptive or qualitative study 6. (WORST) Opinion of authorities and/or reports of expert committees.
What are the steps in the CDM process?
-Assessment, Diagnosis, Planning, Implementation, Evaluation (nursing process)
What are assistive devices related to immobility or reduced mobility? How do you use a walker? What are some examples of patient handling technology?
-Care on stronger side of the patient -Cane, crutches, walker, wheelchair -When using a walker, move assistive devide first, followed by strong limb, then weak limb, repeat. -Patient-handling technology-mats, slings, lifts, Traction, heat and cold therapy, immobilization devices, medication administration.
What is included in the nursing process?
-assessment, diagnosis, planning, implementing, evaluating
What are the different domains of learning?
-cognitive- understanding, education intended to increase a patient's knowledge of a subject, for example, using methods such as written material, lecture, and discussion. -Affective- (attitudes) education intended to change attitudes, such as viewing the lifestyle modifications associated with the treatment of coronary artery disease as a positive change rather than a burden. -Psychomotor- (motor skills) requires that the patient have opportunities to touch and manipulate equipment and practice skills.
what does VARK stand for and what is it used for?
-visual, auditory, read/write, kinesthetic - describes the different learning styles
What is tanners CJM model.
-Comprehensive approach to CJ -Rests on assumptions about complexities in the environment of care and the interplay of multiple factors -Four aspects of clinical judgement are nurses's knowledge, experience, ethical perspective, and knowing the patient. -The nurse, influenced by background and contextual factors, notices various features of the caregiving situation-clinical assessment findings, labs, data, patient/family demeanor. -Through clinical reasoning patterns and conferring w/ other nurses, collecting additional data as needed, the nurse develops an understanding of the particular clinical situation, a process called interpreting. -Based on the interpretation of the situation, nurse determines appropriate actions, which is termed responding in the model. -Nurse observes the patient's reation to the nursing action and decides if action was correct, needs to be adjusted, or stoped completely= reflection-in-action/ reflection-after -the-fact. -These sections do not have a linear relationship but continuously influence each other in a complex manner.
What are the critical thinking attitudes?
-Confidence- talk w/ confidence w/ patient before nursing procedure, giver patient security knowing they are in good hands + encourages them to ask questions, co-workers appreciate knowledge. -Thinking Independently- Think for yourself, take your knowledge, llok at literature, review material, confere w/ other nurses -Fairness- listen to both sides of discussion, assume care of patient openly, unbiased care -Responsibility/Authority-ask for help when you don't understand/ know how to do procedure, look at material given to you, report problems right away, follow standards for practice in your care. -Risk taking-If knowledge causes you to question a health care provider's orders, do so, be willing to offer alternative treatments/approaches to nursing care when other are having little success w/ patient (combine w/scientific evidence) -Discipline- be thorough in whatever you do, use knownc scientific and practice-based criteria for activities, take your time to do it right, manage time effectively. -Perseverance- be cautious of an easy answer to avoid uncomfortable situations, if given info that seems incomplete= clarify the info or talk to patient directly, bring co-workers together, look for a pattern and find a solution. -Creativity- look for different approaches if interventions are not working, figure it out, -Curiosity- always ask why, be willing to challenge tradition, explore and learn more about a patient so as to make appropriate clinical judgements. -Integrity- recognize when your opinnions conflict w/those of the patient's, review your position and decide how best to proceed to reach outcomes that will satisfy everyone, don't compromise nursing standards or honesty in delivering nursing care. -Humility- recognize when you need more infor to make a decision, when you are new to clinical division-ask for orientation to the area, ask RN's regularly assigned to the area for assistance w/ approaches to care.
What are the different levels of errors? (D,T,P,C)
-Diagnostic errors- result of a delay in diagnosis, failure to employ indicated tests (429) -Treatment errors- occur in the perfomance of an operation, procedure, or test, in administering a treatment, in the dose or method of administering a drug, or in avoidable delay in treatment or in responding to an abnormal test. -Prevention errors- when there are failures to provide prophylactic treatment and inadwquate monitoring or follow-up of treatment -Communication failure- lack of communication or a lack of clarity in communication can lead to many types of errors.
What is an active error and a latent error? Which one is the "blunt" end and which one is the "sharp" end?
-Latent error "blunt end"- organizational/flaw in a system that does not directly lead to an accident but lets the door open to let one happen. -Active error "sharp end"- direct patient care, errors made by healthcare workers in direct care contact with patients- nurse giving the incorrect dose of a med because she didn't check the MAR.
What do we do to prevent falls in the hospital and home setting?
-Make sure 2 side rails are up, call light is within reach, bedside table w/in reach, bed in lowest position, clean area in hospital -Age, fall history, high-risk meds, mobility, cognitiation, assessment needs to be done on admission to identify -patients who are a fall risk- yellow wrist band (Moorse fall assesment--document all findings) -Make sure lights are on in the room, call light w/in reach -Bed alarm on, set for specific patient ( on leg- notifies nurse when patient is close to vertical, nfared on headboard- when patient tries to leave the bed) --Fall risk assessment needs to be done also after a fall, following a change in LOC/condition, and when transferred. -Risk for fall nursing diagnostic process: --Observe patients posture, ROM, gait, strength, balance, body alignment (Decrease in left lower extremity strength, demonstrates unsteady gait, impaired balance when standing) --Assess patient's visual acuity- ability to read, identify distant objects (reports difficulty seeing at night, blurred vision, unable to identify near objects w/out glasses) --Complete a home hazard appraisal. (Poorly lighted home, excessive amount of furniture in living room, rugs not secure through house, carpet on stairs not secure (tacks), no grab bars in bathtub/ restroom (toilet)).
What is included in the nursing assessment for Immobility? (what body systems are involved?)
-Metabolic-inspection, palpation (Ex. slowed wound healing, abnormal lab data, muscle atrophy, generalized edema) -Respiratory- inspection, auscultation (Ex. Asymmetrical chest wall movement, dyspnea, increased respiratory rate, crackles/wheezing) -Cardiovascular-auscultation, palpation (Ex. orthostatic hypotension, increased heart rate, third heart sound, weak peripheral pulses, peripheral edema.) -Musculoskeletal-inspection, palpation (Ex. decreased ROM, erythema, increased diameter in calf or thigh, joint contracture, reduced muscle tone/strength, activity intolerance, muscle atrophy) -Skin-inspection, palpation (Ex. break in skin integrity, wound care) -Elimination-inspection, palpation, auscultation (Ex. decreased urine output, cloudy/concentrated urine, decreased frequency of bowel movements, distended bladder, and abdomen, decreased or increased activity in bowel sounds)
What are NPSG's?
-National Patient Safety Goals -Quality and patient safety improvement program -Established by TJC in 2003, -NPSG- established to help accredatied organisations address specific areas of concern in regard to patient safeyt, identify safety , improve staff communcation, use meds safely, use alarms safely, prevent infections, identiy patient safety risk, prevent mistakes in surgery.
What are some ways to ensure fire safety? (RACE, PASS, oxygen)
-PASS- pull the pin, aim at the base, squeeze, sweep from side to side -RACE- Rescue and remove all patients in immediate danger, Activate the alarm, always do this before attempting to extinguish even a minor fire, Confine the fire by closing doors and windows and turning off oxygen and electrical equipment, Extinguish the fire with an appropriate extinguisher. -Make sure oxygen is grounded, teach patient about safety around oxygen (supplemental oxygen poses a serious fire risk) -Electrical safety- make sure everything is up to date and isn't shorting out, have a maintenance check.
Describe the supported fowlers protective positioning.
15-90 degrees depending on variation o fowlers position, used for helping ease of breathing, pillows behind head, under elbows, and under knees to keep heels off bed.
What is included in seizure safety? (what is a seizure, how long do they last, what are they characterized by, what is an Aura, what do you do once a patient is having a seizure?
-Patients who have experienced some form of neurological injury or metabolic disturbance are at risk for a seizure. -A seizure is hyperexicitation and disorderly discharge of neurons in the brain, leading to a sudden, violent, involuntary series of muscle contraction that is episodic, casing loss of consciousness, falling, tonicity (tensing of muscles), and clonicity (jerking of muscles). -Generalized tonic-clonic, or grand mal seizures last usually less than 2 minutes but no more than 5, characterized by a cry and a loss of consciousness w/ falling, tonicity, clonicity, and incontinence. -Before a convulsive episode some patients report an Aura-often a bright light or a smell or taste. -During a seizure patients often experience shallow breathing, cyanosis, and loss of bladder and bowel control and a postictal phase following the seizure where the patient is confused, has amnesia or sleeps. When a seizure begins, note the time, stay with the patient, and call for help, track duration, notify health care provider immediatly Position patient safely, if standing or sitting, ease the patient safely to the floor and protect the head by cradling in your lap or placing a pad under head Do not lift patient from floor to bed while seizure is in progress. Clear surronding area of furniture and anything else that is hard or sharp. If patient is in bed, remove pillows and raise side railes If possible turn patient onto one side, head tilted slightly forward Do not restrain patient, hold limbs loosely if they are flaling, loosen clothing, remove eyeglasses. Never force apart a patients clenched teeth. Do not palce any objects into the patien'ts mouth such as fingers, medicine, tongue depressors, or airway when teetch are clenched, Insert a bite-block or oral airway in advance only if you recognize the possibility of a tonic-clonic seizure. Stay with the patient, observing sequence and timing of seizure activity. As patient regains consciousness, reorient and reassure. Assist patient to position of comfort in bed whith side rails up (one down for easy exit) and bed in lowest position Conduct a head to toe evaluation, including an inspection of oral cavity for breaks in mucous membranes, from bites or broken teeth look for bruising of skin or injury to bones and joints.
What are the different types of research? (qualitative, quantitative, historical, exploratory, evaluation, descriptive, experimental, correlational.)
-Qualitative- studies phenomena that are difficult to quantify or catergorizem such as patient's perceptions of illness or quality of life. Describes info obtained in nonnumeric form (data in the form of transcribed written transcripts from a series of interview) Aim to understand patient's experiences with health problems and the context in which the experience occur. -Quantitative- precisely measures and quantifies a study's variables. (uses numbers w/data, includes experimental and non-experiemental research) -Historical research- studies designed to establish facts and relationships concerning past events (Ex. study examining the societal factors that led to the acceptance of advanced practice nurses by patients) -Exploratory research- initial study designed to develop, or refine the dimensions of phenomena (facts or events) or to develop or refine a hypothesis about the relationship among phenomena. (Ex. a pilot study testing the benefits of a new exercise program for older adults w/dementia) -Evaluation research-Study that tests how well a program, practice, or policy is working. (Ex. study measuring the outcomes of an informational campaign designed to improve patent's ability to follow immunization schedules for their children.) -Descriptive research- study that measures characteristics of people, situations, or groups and the frequency with which certain events or characteristics occur. (Ex. Study to examin RN's biases towards caring for obese patients) -Experiemental research- study in which the investigator controls the study variable and randomly assigns subjects to different conditions to test the variable. (EX. RCT comparing chlorhexidine w/Betadine in reducing the incidence of IV-site phlebitis.) -Correlational research- study that explores the interrelationships among variables of interest w/out any active intervention by the researcher. (Ex. study examining the relationship between RN's educational levels and their satisfaction in the nursing role.)
What are some ways to ensure surgical safety?
-TJC- identify patients correctly, imporve staff communication, use medicines safely, prevent infection, -identify patient safety risks, prevent mistakes in surgery. -Briefing, signings, time out, sign out, debriefing is now indorsed by NPSA, national patient safety, prevents mistakes in surger- mark/ identify right patient, cut right limb, do right surgery on right patient, get consent when applicable, make sure everyone is on the same page at the same time.
What are the different teaching strategies? (11) (T,P,E,R,V,G,P,D,AR,S)
-Telling- used when there is limited time for teaching info, nurse outlines the task that a patient will perform and gives, simple, explicit instructioins, no opportunity for feedback w/this method. -Participating- nurse and patient set objectives, and become involed in the learning process together. Patient helps decide content, and nurse guides and counsels the patient w/pertinent info, opportunity for discussion, feedback, mutual goal setting, and revision of the teaching plan after each session. -Entrusting- provides the patient the opportunity to manage self-care, the aim is to provide the knowledge ans skills that enable a patient to accepts responsibilities and perform tasks correcltly/ consistently. Nurse observes the patient's progress and temains available to assist w/out introducing more info, -Reinforcing- reinforcing positive or negative, encouraging a desired response and trying to stop an undesirable response w/ praise, nods, smiles, high fives, or toys/food, Negative reinforcement can lead to the patient feeling alienated/ can be less predicable. -Verbal one on one discussion- approach involves sharing info directly w/patientm verbal education w/ patient or family members. Must take into consideration learning style, culture norms, literacy level, educational level -Group instruction- teach a number of patients at one time. Parients are able to interact w/ one another and learn from the experience of others, increases participation, deeper understanding, social support. -Preparatory- letting the patient know what to expect before getting a procedure, can reduce anxiety and let the patient feel like they have some kind of control. The known is less scary than the unknown. -Demonstration- used when teaching psychomotor skills such as preparing a syringe, bathing an infant, crutch walking or taking a pulse, most effective when learners first observe the educator and during the return demonstration have the chance to practice the skill, combine this w/discussion to clarify concepts and feelings -Analogies- when an educator translates complex language or ideas into words or concepts that a patient understands, supplement verbal instruction w/ familiar images that make complex info more real and understandable. -Role-playing-patients are asked to play themselves or others to learn required skills and feel more confident in being able to perform them independently, rehearsing desired behaviors. -Simulation- teaches problem solving, application, and independent thinking, individual or group discussion, pose a pertinent problem or situation for patients to solve.
What is QSEN? What are the QSEN attributes of safety?
-The Quality and Safety Education for Nurses (QSEN) project addresses the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work. -Patient centered care, promotes safety and requires you to recognize your patients or their designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient preferences, values and needs. Partnership is a key factor --Outlines recommended skills to ensure nurse competency in patient safety. Among these skills are those involving sage nursing practice during direct care: Demonstrate effective use of technology and standardized practices that support safety and quality. Demonstrate effective use of strategies to reduce risk of harm to self or others Use appropriate strategies (forcing functions, checklists), to reduce dependency on memory. Communicate observations or conrernes related to hazards and errors to patients, families, and the health care team. Direct nursing interventions toward maintaining a patient's safety in all settings. ---QSEN attributes of safety Knowledge ØFocus of safety is on the execution of skills, as well as on technology and systems level. Skills ØNurses need to use tools to contribute to safer systems. Attitudes ØNurses and other health care professionals need to value their roles in safety and collaboration.
What is included in documentation
A key communication strategy that produces a written account of pertinent patient data, clinical decisions, interventions, and patient responses in a health record. Consists of all info entered into a health record, may be electronic, paper or combo Should reflect current standards of nursing practice and minimize the risk for errors Need to be flexible enough yo allow members of the health care team to efficeiently document and retrieve clinical data, track patient outcomes and facilitate continuity of care Shows who did what with the patient when Reimbursment comes from documentation Enter all assessment data, nursing problems/diagnoses, interventions and evaluation of patient responses. One of the most accurate/ best defenses in court
What are the different communication techniques? (SURETY, AIDET)
Active listening: attentive to what a patent is saying both verbally and non-verbally. (Sit at an angle facing the patient, creates a non-confrontational communication, Uncross you legs and arms, your "open" to what the patient says, Relax. Communicate a sense of being relaxed and comfortable with the patient, Eye contact-etablish and maintain intermittent eye contact to convey your involvement in and willingness to listen to what the patient is saying, Touch-use touch that is respecful to communicate empathy and understnading to the patient, know the paitent's comfort level w/touch, Your intuition, trust your intuition as you frow in confidence to individualize, adapt, and apply communication techniques in your interpersonal encounters w/your patients=SURETY model) Share observations-helps patient share info w/out extensive questioning. Share empathy- the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other person. Key part of communication Sharing hope Sharing humor-when appropriate, know the patient's culture and know if humor is okay to use Sharing feelings/.using touch Using silence Providing information Clarifying Focusing Paraphrasing Validation Asking relevant questions Summarizing Self-disclosure Confrontation AIDET-acknowledge, introduce, duration, explain, thank you
What is an adverse event. near miss, and sentinal event- errors made in nursing practice?
Adverse event ØUnintended harm by an act of commission or omission rather than as a result of disease process Near miss ØError of commission or omission that could have harmed a patient, but harm did not occur as a result of chance Sentinel event ØUnexpected occurrence involving death or serious injury
How do you communicate with an unresponsive
Call patient by name during interactions Communicate both verbally and by touch Speak to patient as though he or she can hear Explain all procedures and sensations Provide orientation to person, place, time Avoid talking about patient to others in his or her presence
what is the data collection process in the nursing assessment?
Can be comprehensive or problem-based focused assessment Interpret data/info, use clinical inferences, and cues to guide you, critically anticipate-continuosly think about what the data tells you and decide whether more data is needed. (always have supporting signs and symptoms before you make an inference) Validate the info you have coleded to avoid making incorrect inferences, comparison of data w/another source to determine data accuracy Phases of the helping relationship-preorientaton, orientation, working, termination.
What is the diagnosis portion of the nursing process, what is considered a correct nursing diagnosis?
Clinical judgement made by a nurse to describe a patient's response or vulnerability to health conditioins or life events that a nurse is licensed and competent to treat. NEVER MEDICAL DIAGNOSIS Use NANDA approved nursing diagnoses 3 part diagnosis- actual problem PES format, problem, etiology (cause, can be known or unknown) (related to) supporting signs/symptoms (defining characteristics in nursing diagnosis textbook) At risk diagnosis (2 parts)- doesn't have any signs or symptoms, only has problem and etiology/cause/r/t. Correct nursing diagnosis- impaired mobility R/T acute pain, AEB: pain rated a 7 on pain scale of 0-10, limits movement of right leg At risk diagnosis- Risk for impaired skin integrity R/T surery incision site/open wound.
What is the evaluating portion of the nursing process, what is included in this?
Determines whether a patient's condition or well-being improved after nursing interventioins were dilivered Critical to knowing a patient's health status Evaluate interventions and outcomes in the areas of health promotion, prevention of illness and injury, and alleviation of suffering. Ongoing process that includes a before-and-after comparison or an after comparison with an established standard Continuously examine results by gathering subjective and objective data from a patient, family, and health care team members. Compare clinical data, patient behavior measures, and patient self-report measures collected before implementation with the evaluation findings gathered after administering nursing care. Evaluate whether the results of care match the expected outcomes and goals set for a patient. Use evaluative measures: (inspect color, condition, measure diameter ect) If goals were not met, figure out how to improve, change intervention, or stop entirely.
What is included in the assesment portion of the nursing diagnosis?
Gather info about patient condition, collect a comprehensive set of data about a patient and recognize/identify patterns that begin to reflect the meaning of a patient's response to heath problems. Patient centered view Data sources- patient, family/caregivers, health care team, medical records, scientific literature, nurses experience, Includes health hx,Biographical information, chief concern or reason for seeking care, patient expectations, present illness or health concerns, past health history/past hospitalizations. family history, psychosocial history, spiritual health, review of systems, observation of patient behavior,diagnostic and laboratory data
Low fowlers position Semi-fowlers position standard fowlers position high fowlers position
HOB raised 15-30 degrees HOB raised 30-45 degrees HOB raised 45-60 degrees HOB raised 60-90 degrees -patient's knees are slightly elevated w/out pressure to restrict circulation in the lower legs. -raising HOB helps with easing the effort of breathing/ helps patients catch their breath easier.
Describe the different types of injections, which sites, syringes, needles, and how to give each injection.
ID=itradermal SUBCUT=subcutaneous (fat tissue) IM=intramuscular IV=intravenous 3 parts to a syringe= tip, barrel, plunger. (1-60 ml) Only recap an injection before giving to patient, after drawing up med from vial, don't recap after administering-activate safety and dispose in sharps container Make sure injection site is free of intecion, necrosis, bruised, abrasions Know location of underlying bones/nerves, major vessels ID- skin testing (allergy+TB) use a 1ml syringe needle gauge between 25-27 and needle length between ½-5/8th. Stretch skin site using forefinger & thumb of non-dominant hand. Angle of insetions is 5-15 degrees with bevel up. Inject med slowly. A bleb shoule appear on the skin surface. Withdrawal needle, apply alcohol swab and gentle pressure, never massage. SUBCUT- sites= abdomen from below the costal margin to iliac crest, anterior aspects of thighs, outer posterior aspect of the upper arms, scapular areas, and upper dorsal gluteal areas. Use 1-3 ml syringe (1.5 max volume), use needle length ⅜-5/8ths and 25-27 gauge needle. Clear the skin in circular motion 2inches from site, angle of insertion 45-90 degrees. Pinch skin (never release with heparin), insert needle quickly, release skin and steady needle with non-dominate hand, inject slow, quickly withdrawal, ingage safety-sharps container, apply gentle pressure with alcohol swab. IM- sites= ventrogluteal, vastus lateralis, and deltoid-vaccines always, use a 3ml syringe, 18-25 gauge needle, 5/8ths-1.5 inches. Immunizations use 23-25 gauge and 5/8ths needle. Clear skin in circular motion 2 inches from injection site, use z-track for everything but vaccines-just make skin tought, insert quickly at 90 degrees. ASPIRATE not w/vaccines- no blood=good to continue, inject med slowly 1 ml/10 sec. Wait 10 seconds the withdrawal needle. Release z-track and apply gentle pressure with alcohol swab.
What are some cultural considerations with nursing assesments?
Involves self-awarness, reflective practice, and knowledge of a patient's core cultural background Adapt each assessment to the uniqueness of each patient Cultural humility requires you to recognize your own knowledge limitations and cultural perspective and thus be open to new perspectives. Show patients respect and understand their indicidual needs/differences Don't impose you own attiudes, biases, or beliefs Avoid stereotyping and assumptions tied to stereotypes=can lead to collection on inaccurate information Ask questions in a constructive way and probing way to allow you to truly know who a patient is.
What do you need to take into considereation when doing a nursing assessment on an older patient?
Listen patiently, older adults are a rich source of wisdom and experience Allow for pauses and give patients time to tell their story Recognize normal changes associated w/aging, older adults symptoms are often muted or less obvious, vague, or nonspecific compaired to younger adults Some patients may not report symptoms beacuse they attribute them to old age or they think nothing can be done for them Patient w/limited hearing or visual impairment, use nonverbal communication when conducting your interview. Maintain eye contact w/patient Affirmative head nodding-regulates an interaction, supports spoken language, and allows for comments on the interaction. Smiling-positive sign that indicated good humor, warmth, and immediacy, help when first establishing the nurse-patient relationship Forward leaning- shows awareness, attention, and immediacy, also suggests interest in person and what they have to say.
What are the risk factors that can lead to roadblocks in patient education?
Literacy- most common adult= 4th grade reading level- must center care around Culture variations- society with male dominates- (360 P&P) Special needs/ disabilities- meet the person where they're at- use pictures/coloring, keep it simple/quick, movies, set the stage for your patient specifically. Table 25.2 348- greif/loss/upset- not a good time to teach someone Cultural factors-348 P&P
What are the objectives in patient education?
Merit to person who is learning it Patient centered care-learning geared toward individual patient Focused on client's needs Important to the recipient If learning is not important to the patient they will not take the teaching to heart. Must use all three domains to get the most effective learning/understanding
What is a hand off report?
Nurses communicate with one another via end of shift or end of day report often called the handoff. Process of nurse to nurse communication in which patient data are shared between shifts and at other points of transition, with the primary intent of ensuring accuracy and continuity of care. Common process for handoff reporting is the SBAR. Handoff and reporting=key components to effective communication and are directly related to safety, health care quality, and patient outcomes.
What is the different between subjective and objective data?
Objective- what you see in patient with your own eyes, V.S, how the patient looks. (Bp 134/90, shallow breathing 24 BPM) Subjective- what the patient reports, or tells you how they are feeling. (My nose hurts alot, my stomach feels weird, ect)
What does PICOT stand for?
P = Patient population of interest I = Intervention of interest C = Comparison of interest O = Outcome T = Time
what is included in the implementing portion of the nursing process?
Performance of nursing and collaborative interventions necessary to achieve the goals and expected outcomes needed to support or to improve a patient's health status. Strong clinical reasoning and decision making help you accurately identify appropriate nursing interventions for patient's specfic nursing diagnoses Delegating-can assign non-invasive, repetitve interventions to AP like skin care, transfer, mobility skills/ROM, hygiene, V.S for patients that are stable, at the end of the day you are responsible for ensuring that you assign each task appropriately and that the AP completes each task according to the standard of care, mus be done correctly, documented, and evaluated
Describe the sims protective positioning.
Patient lies between supine and prone with legs flexed in front of the patient. Arms should be comfortably placed beside the patient, not underneath.
Describe the supported supine protective positioning.
Patient lies flat on back. Additional supportive devices in this picture are added for comfort and to prevent skin and tissue breakdown as well as hip rotation.
Describe the lateral protective positioning.
Patient lies on the side of their body with their top leg over the bottom leg. This position helps relieve pressure on the coccyx but applies pressure to the shoulder hip and lateral aspect of the knee.
What are restraints? What kind are there? When are they used? How often do we check? What do we check for? When do they need to be renewed?
Patients that are confused or agitated or who repeatedly try to remove medical devices may temporarily need physical restraints to keep themselves safe. -Chemical restraints-anxiolytics, sedatives used to manage a patient's condition -Not a solution to a pts problem, only temporary to ensure staff and patient safety not standard treatment, use alternatives first and then go to restraints -Order from doctor-state-location/reason Renewed every 4 hours from doctor for adult, 2 hours for children (9-17), and 1 hour for children (less than 9 yrs old) -24 hour limit on them, under certain circumstances may be kept on for safety -Check every 15 mins for violent patients -Non-violent check ever q2 hours -Check V.S, skin integrity underneath restriants, nutrition, hydration, circulation to an extremity, ROM, hygiene, elimination needs, cognitive functioning, psychological status, and need for restraint. -Assess violent patients continouslyt via audio, video call --Try to get patient off restraints ASAP
What are the four phases to a helping relationship between the nurse/patient?
Pre-interaction phase- before meeting the patient, review available data including medical and nursing history, talk to other caregivers who have info about the patient, plan enough time for the inital interaction. Orientation phase- when you and patient meet and get to know one another, set tone for relationship- be warm, empathetic, caring, let the patient know what your going to be doing, begin to make inferences and from judgements about patient messafes and behaviors, assess patient's health status, prioritize the patient's problems and identify his or her goals, let patient know when relationship will be terminated. (I'll be your nurse until 700) Working phase- when you and paitne work togethe to solve problems and accomplish goals (most of the shift work), take actions to meet goals, use therapeutic communication skills to facilitate successful interactions Termination phase- during the ending of the relationship- remind patient that termination is near- end of shift, evaluate goal achievement for patient, tell patient your leaving but help introduce new nurse to take over for you, hand off report, achieve smooth transition for the patient to other caregivers as needed.
what is body alignment? What are the benefits from proper body alignment, what are the factors that influence body alignment?
Promotes optimal balance& maximal body function, Enhances physical fitness. Prevention fo injury or trauma. Improves health and funtion of those with disease. Relationship of one body part to another. Head, neck, spine, shoud be erect Look for scoliosis, lordosis, kifosis. Correct body alignment decreases strain on musculoskeletal structures, helps maintain muscle tone. Factors that influence body alignment:- poor self esteem, muscle weakness, motor impairments, and skeletal abnormalities.
What is included in the planning of the nursing process?
Setting goal and expected outcomes for patient based on diagnosis, prescribing nursing interventions appropriate for each diagnosis. Goals must be smart- specific, measurable, attainable, realistic, timed goal-a broad statement that describes the desired change in a patient's condition, perceptions, or behavior,short-term or long-term, often based on standards of care or clinical guidelines established for minimal safe practice. Prioritize interventions based on clinical importance, a real problem is more important than a risk, treat what could kill them fastest first and go from there. (Airway, Breathing, Circulation, ABC'S)
What is therapeutic communication?
Theraputic communication is a dynamic and interactive process in which words are used by clinicians and patients to collaboratively achieve identified healthcare outcomes. Becomes an important part of the healing process for patients and families. This type of communication promotes understanding and builds relationships that lead to positive patient outcomes
Reverse Trendelenburg
Used for patients with gerd, and acid reflux, lower bed so feet are lower than the head
What does SBAR stand for and what is it used for?
Used to communicate between health care providers Can be used in a hand off report between nurses/doctors. Situation-who's the patient, what happened and why are you calling? (change in status, reaction ect) Background- most recent labs, V.S, health hx, tell who the patient is and what health problems the patient has, meds, allergies, recent surgeries, ect Assesment- take new V.S after change in patient compare them to the previous V.S/labs and use words like "might be, or could be" Recommendations- say what you think would be helpful or what needs to be changed/done. (x-ray, increase pain meds, order new meds, stop old ones ect)
What are the charting rules?
We as students can't chart If you didn't document it, it didn't happen Don't falsify records to save your behind, hold yourself accountable Can't document for any other patient but your own Can't delegate charting to AP Pg 370-372 P&P Stick to the facts Write in short sentences Use simple, short words Avoid use of jargon/abbreviations Must contain subjective assessment data, objective assessment data, all nursing interventions, medication administration including PRN, patient/family teaching, discharge instructions/planning. Must be factual, accurate, use appropriate abbreviations (don't use U, IU, Q.D/qd,qod, trailing zeros, MS, MSO4 or MgSO4.), must be current/up to date w/ all v.s, pain assessment, admin of medications or treatments, prep for diagnostic tests/surgery, change in LOC/status, admission and or transfers/ death, patients response to intervention/treatment Use military time (24 hour time) Must be organized, concise, clear and to the point, presented in a logical order and complete
Describe the 30 degree lateral protective positioning.
Weight is not on sacrum or trochanter · Head of bed as low as possible This position offers an additional position for rotating clients
What does the nurse have to do when treating a LEP patient or a patient that can't speak English?
When you and the patient do not speak the same language, use trained and certified health care interpreters to provide health care info- can't use family members, for all you know they could be saying something completely different from what you mean-get interpreter. Use non-verbal communication whenever possible-pictures, gestures ect. Speak to patient in normal tone of voice Establish method for patient to ask for assistnce (call light/bell) Use communicatio board, pictures, or cards Translte words from native language into English list for patient to make basic requests Have dictionary (spanish, french) available if patient can read
Delegation with immobillity
can delegate ROM, turning, ambulation, as long as the patient is stable, can't delegate assesment or evaluation or teaching. Make sure the person doing the task knows how to do the task Can not delegate any assessment of the body system affected by being immobilized.
What are the components to critical thinking?
proficiently (hands on procedure, physical examination, that until you have mastered, will distract you from focusing on collecting data, problem solving, & CDM), competence grows w/experience 2.Specific knowledge base- varies according to educational experience that includes basic nursing education, continuing education courses, and additional college degrees, also build knowledge by reading the nursing literature (research based) to maintain current knowledge/theory, knowledge prepares a nurse to better anticipate and identify patient problems by understanding their origin and nature. (knowledge includes: info/theory, holistic view of patient problems, broad knowledge base from basic sciences, humanities, behavorial sciences, and nursing science) 3.Experience- clinical learning experiences are necessary to acquire clinical decision making skills. Knowledge combines w/ clinical expertise from experience defines critical thinking. (clinicals you learn from observing, sensing, talking w/ patients/families, reflecting actively on all experiences) 4. Attitudes- it's important to go into nursing w/ correct attitudes such as confidence (not over confidence/ "know it all attitude=hurt somebody), thinking independently, fairness, responsibility and authority, risk taking (trust your instincts but don't get anyone hurt), discipline, perseverance, creativity, curiosity, integrity, humility) 5.Standards- Intellectual ( guideline for rational thought- precisness, accuracy, consistency, to gather all data to make the most informed CD) Professional standards (refer to ethical critieria for nursing judgements, evidence based critieria used for evaluation, and criteria for professsional responsibility, applications of professional standards requires you to use critical thinking for the good of individuals or groups) --Intellectual standards: Clear/precise/ understandable, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for purpose), fiar --Professional standards: ethical criteria for nursing judgement, criteria for evaluation, professional responsibility.
Mobility
the ability to move freely about an environment without assistance.
Immobility
the inability to move about freely, immobility, can impact limb, skin, whole body system, due to broken bones, or bed ridden.- disrupts metabolic processes, constipation, decreases metabolic rate, urinary output and V.S can be impacted (decreases)
What is EBP's purpose?
use of information from research, professional experts, personal experience, and patient preferences to determine safe and effective nursing interventions with the goal of improving patient outcomes.