NUR 126 - Exam 1

Quality and safety

" how do we insure safety of our patients and provide quality care?"

Medical diagnosis identifies a disease condition and is treated by the physician. The nursing diagnosis is

"A clinical judgement concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, or community" (Potter & Perry, 2017); is treated by the nurse and the diagnosis changes based on patient's needs

Safe Environment Definition

"A safe health care environment is one that reduces the risk of injury, including minimizing falls, patient-inherent accidents, procedure-inherent accidents, and equipment-related accidents"

A nurse is implementing nursing care measures for patients with challenging communication issues. Which types of patients will need these nursing care measures?

A child who is developmentally delayed. An older adult patient who is demanding. A female patient who is outgoing and flirty. A teenager frightened by the prospect of impending surgery

You are about to irrigate a patient's open wound. Besides gloves, which other item of personal protective equipment (PPE) must you wear

A face shield

Bladder Voiding is

Bladder contraction + urethral sphincter and pelvic floor muscle relaxation

Abnormal Stool color: Red

Bleeding from lower gastrointestinal tract (rectum), some foods (beets)

Erikson's Developmental Stages: 1 - 3 years:

AUTONOMY vs SHAME AND DOUBT: Mastering self-care activities (walking, feeding, & toileting), Growing more independent and develops an ability to make choices

Cranial Nerves: VI

Abducens: Extraocular eye movement (lateral eye movement). Assess 6 directions of gaze

Pathophysiology of Pain: Neuropathic Pain

Abnormal processing of sensory input by peripheral or CNS. Injury to PNS or CNS. Impaired ANS. Pain along periph nerves

Abnormal Stool color: Clay or white

Absence of bile pigment (bile obstruction) or diagnostic study using barium

Risks in the Health Care Agency: Patient-Inherent Accidents

Accidents other than falls in which the patient is the primary reason for the accident, Self-inflicted cuts, injuries, and burns, Ingestion or injection of foreign substances, Self-mutilation, Fire setting

A patient has a healthcare-associated infection (HAI). This terminology means that the patient

Acquired the infection while hospitalized

Therapeutic Communication Techniques

Active Listening, Sharing Observations, Sharing Empathy, sharing hope, Providing Information, Clarifying, Focusing, Paraphrasing, Asking Relevant Questions, Summarizing, Self-Disclosure, Confrontation

Stages of Health Behavior Changes: Action

Actively engaged in strategies to change behavior; lasts up to 6 months

Learning Activities Include

Activities, Theory, Scenarios, Videos, Reading, ATI, Demo labs, Clinical Teaching Tools

Sleep Implementation

Acute care: Environmental controls, Promoting comfort, Establishing periods of rest and sleep, Promoting safety, Stress reduction

Physiological Responses to Pain

As pain impulses ascend the spinal cord toward the brainstem and thalamus, the stress response stimulates the autonomic nervous system (ANS). Fight or flight

Pathophysiology of Pain: Somatic

Bone, joint, muscle, skin, & connective tissue (aching/throbbing and localized)

Nursing Care Delivery: Case Management

Care-management approach designed to coordinate and link health care services across all levels of care for patients and their families; streamlines costs and quality. Focuses on achieving patient outcomes within timeframes and available resources

Nurse/Patient Relationship

Caring relationships are the foundation of clinical nursing practice. Therapeutic relationships promote a psychological climate that facilitates positive change and growth

Risks in the Health Care Agency: Procedure-Related Accidents

Caused by health care providers and include medication and fluid administration errors, Improper application of external devices, Accidents related to improper performance of procedures such as dressing changes or urinary catheter insertion

Erik Erikson's Developmental Theory

Certain tasks must be mastered at each developmental level in order to progress to the next stage. Each task is framed with opposing conflicts and are tested again and again with new situations. Stages range from birth to old age.

Nursing Implications for Health Behavior Changes: Maintenance stage

Changes must be integrated into the patient's lifestyle in order to sustain.

Communication Styles

Child, Adolescent, Older Adult

Types of Pain: Idiopathic

Chronic pain without identifiable, physical or physiological cause

Physiology of Sleep

Circadian rhythms: 24 Hour- Day/Night Cycle, Affected by light, temperature, social activities, and work routines. The biological rhythm of sleep frequently becomes synchronized with other body functions.

Stages of Adult Sleep Cycle

Four stages of NREM: Sleep goes through stages 1 to 4, then reversal from 4 to 3 to 2, followed by REM. Sleep cycle lasts 90 to 100 minutes.

Erikson's Development Stages: Middle age

GENERATIVITY vs STAGNATION: Supporting future generations through parenthood, teaching, mentoring, and community involvement

Maslow's Hierarchy of Needs: Self-esteem

Gaining and giving respect, Possessing self-confidence

Nursing Process Assessment

Gathering info from patient or other sources (friends, family, medical record, health professionals); Deliberate and systematic; establishes a database.

General Survey of a patient includes

General appearance and behavior, Gender and race, Age, Signs of distress, Body type, Posture, Gait, Body movement, Hygiene and grooming, Dress, Body odor, Affect and mood, Speech, Signs of patient abuse, Substance abuse

National Patient Safety Goals: Improve staff communication

Get important test results to the right staff person on time

Quality Pain Questions

How do you describe your pain?

Cranial Nerves: XII

Hypoglossal: Position of tongue. Ask patient to stick out tongue and move it from side to side

A patient says you are the worst nurse I have ever had. Which response by the nurse is most assertive?

I feel uncomfortable after hearing that statement

Erikson's Development Stages: Puberty

IDENTITY vs ROLE CONFUSION: Sexual maturation occurs during this stage, Preoccupation with appearance and body image, Answers the question "who am I?" and ensures a sense of identity

Erikson's Developmental Stages: 6 - 11 years

INDUSTRY vs INFERIORITY: Learn to work and play with peers, Learn socially productive skills, Active participation in health treatments

Erikson's Developmental Stages: 3 - 6 years

INITIATIVE vs GUILT: Environment is explored through fantasy and imaginative play, Play therapy is instrumental in invasive and noninvasive procedures

Erikson's Development Stages: Old age

INTEGRITY vs DESPAIR: The ability to review life with a sense of satisfaction rather than despair and regret, Possible loss of status and function due to the aging process, Help elderly patients feel valued, appreciated, and needed

Erikson's Development Stages: Young Adult

INTIMACY vs ISOLATION, Search for meaningful friendships and intimate relationships, Benefit from support of their partner/significant other during hospitalization

Types of HAIs (Health Care Associated Infections)

Iatrogenic: from a procedure, Exogenous: from microorganisms outside the individual, Endogenous: when the patient's flora becomes altered and an overgrowth results

Identify 3 of the 7 National Patient Safety Goals

Identify patients correctly, Improve staff communication, use medicines safely, use alarms safely, prevent infection, identify patient safety risks, and prevent mistakes in surgery

Types of Pain: Chronic/persistent noncancer

Is not protective, has no purpose, may or may not have an identifiable

Timing Pain Questions

Is your pain constant, intermittent, or both?

Implementation: Health Promotion

Maintaining wellness, help patient understand, Health literacy. Patients actively participate in their own well-being whenever possible.

Physical Assessment: Auscultate

Listen to sound created in body organs; Detected variations from normal, by using the stethoscope; Characteristics of sounds (frequency, loudness, quality, duration)

Pharmacological Pain Therapies: Local anesthesia

Local infiltration of an anesthetic medication to induce loss of sensation to a body part. Regional anesthesia

Abnormal masses on breast tissue should be palpated to determine

Location, Diameter, Shape, Consistency, Tenderness, Mobility, Discreteness

A patient just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy?

This must be hard news to hear.

A nurse is about to use the Wong-Baker FACES pain level. Which of the following should the nurse know in order to use this pain scale?

This scale is useful for adult patients who have cognitive impairments

Thorax: Order of Assessment

Thorax: 1. Inspection, 2. Palpation: Chest excursion, Tactile fremitus. 3. Auscultation of lung sounds

General Adaptation Syndrome (GAS) Stages

Three stages: Alarm, Resistance (adaptation), Recovery or exhaustion

A patient is aphasic and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication?

Use a picture board

National Patient Safety Goals: Identify patients correctly

Use at least two patient identifiers (name and date of birth)

PGAS Resistance

Use of coping mechanisms, able to solve problems, able to cope

Which behaviors indicate the nurse is using critical thinking standards when communicating with patients?

Uses humility. Portrays self-confidence. Demonstrates independent attitude.

Professional Identity is

Using ethics as a nurse

Cranial Nerves: X

Vagus: Movement of vocal cords, sensation of the pharynx, mucus membrane glands. Ask the patient to say "ah" and assess movement of the palate and pharynx (uvula)

Forms of Communication

Verbal and Nonverbal

Subjective Information

Verbal description of health problem and can only be provided by patient. Includes: Patients perceptions/feelings, Patients reports of symptoms of health status. Examples: "I am anxious about the upcoming procedure", "I have a headache"

Verbal Communication Includes

Vocabulary, Denotative and connotative meaning, Pacing, Intonation, Clarity and brevity, Timing and relevance

Nursing Judgement

We teach students how to use the problem solving process as it relates to nursing care of patients

Questions to ask a patient to assess their stress level

What does this mean to you? How is this going to affect your life? What is happening in your life today? What happened in your life that is different?

Incident Report: As the nurse you are responsible for providing detailed information about the occurrence

What happened, what you observed, and the follow-up actions taken. Also include that the patient's health care provider was notified. Only include actual data, not potential

Palliative or Provocative Pain Questions

What makes your pain worse?

A yearly exam by a provider is recommended for anyone with

a family history of breast cancer.

Reservoir

a place where microorganisms survive, multiply and await transfer to a susceptible host. Examples: humans, animals, food, water

Stress Definition

a process beginning with an event that evokes a degree of tension or anxiety.

Smegma

a sebaceous secretion in the folds of the skin, especially under a man's foreskin

Data clusters

a set of cues, the signs or symptoms gathered during assessment.

Standards are also used for

accreditation purposes

Flatulence

accumulation of gas in the intestines causing the walls to stretch

actively engaged in strategies to change behavior; lasts up to 6 months

action stage

Lung Sounds: Adventitious sounds

added sounds over normal breath sounds; abnormal sounds (crackles, wheezes, rhonchi)

Factors influencing infection prevention and control

age, nutritional status, stress, disease process, treatments or conditions that compromise the immune response

Isolation Precautions

airborne, droplet, contact, and protective environment

Women who are a high risk should consider additional testing such as

an MRI.

Health Promotion Nursing Diagnosis

clinical judgment concerning motivation & desire to increase well-being & actualize human health potential. Has only defining characteristics. (Example: Readiness for enhanced nutrition as evidence by expressed knowledge of healthy food choices)

Nursing Diagnosis Risk

clinical judgment concerning the vulnerability of client for developing an undesirable human response. Has only Risk Factors: No related factors or defining characteristics. (Example: Risk for falls as evidence by history of falls and 67 years old)

Types of Nursing Diagnosis: Problem-Focused Nursing Diagnosis

clinical judgment concerning undesirable human response to health condition/life process that exists. Related Factor: etiological or causative factor. Defining Characteristics: observable assessment cues that support Dx. (Example: Impaired physical mobility related to obesity as evidence by impaired ability to reposition in bed)

Asymptomatic

clinical signs and symptoms are not present

Symptomatic

clinical signs and symptoms are present

A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with

constipation

Diagnostic Statements: 2-part statements

contain the diagnostic label and risk factors; Risk diagnosis. (Example: Risk for bleeding AEB impaired liver function)

Diagnostic Statements: 3-part statements

contain the diagnostic label, related factors, and signs and symptoms of diagnosis (defining Characteristics); Actual diagnoses. (Example: Ineffective Airway Clearance r/t excessive mucus AEB dyspnea and cyanosis)

Considering a change within the next 6 months

contemplation

Standard Precautions for Respiratory hygiene/cough etiquette

cover nose/mouth when coughing or sneezing, use tissues to contain respiratory secretions and dispose with procedure or surgical mask, maintain at least 3 feet separation from others if they are coughing

Normal breast tissue feels

dense, firm, and elastic

Nurses who make the best communicators

develop critical thinking skills

Hemorrhoids

dilated, engorged veins in the lining of the rectum

NLN Competencies Purpose

direct and maintain safe and clinically competent nursing practice = the standard.

Mode of transmission

each disease has a specific mode of transmission. Examples: spread through direct contact

Regions of stomach

epigastric, umbilical, and suprapubic

Local Adaptation Syndrome (LAS) Alarm

erythema, discharge, edema, open, ecchymosis, pain.

Competencies/Outcomes have been written

for each clinical nursing course (NUR 126, 131, 141, 212, 211, 222)

Local Adaptation Syndrome (LAS) Exhaustion

gaping wound, massive bleeding, body can no longer adapt

During a physical examination, the nurse will

gather baseline data about the patient's health status; Supplement, confirm, or refute subjective data obtained in the nursing history; Identify and confirm nursing diagnoses; Make clinical decisions about a patient's changing health status and management; Evaluate the outcomes of care.

The graduate competencies/outcomes say this is what a

graduate nurse should be able to do by the time they finish a nursing program.

Cancerous lesions are often

hard, fixed, non-tender, irregular in shape, and unilateral.

Patients at a greater risk for HAIs (Health Care Associated Infections)

have multiple illnesses, older adults, poorly nourished, compromised immune system

Inspiratory rhonchi are auscultate over the lungs initially. What should the nurse do next?

have the patient cough

In cases of low specific gravity, a person may be drinking too much fluid or have a condition that makes them thirsty. Further testing is often needed to determine if the patient has a

heart condition, kidney problem, or metabolic disorder is the cause of the abnormal result. Low specific gravity suggests that urine is too diluted.

Having a spirit of Inquiry

helps offer new insights, provide safe, quality care to our diverse patient population and their families

Stress Appraisal Definition

how a person interprets the impact of the stressor.

Human Flourishing Nurses

identify concepts learned to promote personal growth of self, patients and their families

Nursing Process Diagnosis

identify patient problems

A patient has trouble speaking words, and the patient's speech is garbled. Which nursing diagnosis is most appropriate for this patient?

impaired verbal communication

Incontinence

inability to control passage of feces and gas to the anus

In the Head and Neck Region Lymph Nodes region, tenderness almost always indicates

inflammation.

The nurse teaches parents how to have their children learn impulse control and cooperative behaviors. This would be during which of Erikson's stages of development

initiative vs guilt

When conducting an abdominal assessment, the first skill a nurse puts to use is

inspection

When conducting an abdominal assessment, the first skill a nurse puts to use is what

inspection

Uncircumcised penis is called

intact

Transpersonal Communication

interaction within a persons spiritual domain

Your patient explains that she is a registered nurse and knows what is needed for a healthy balanced diet. She is also up to date with recommended screening and health physicals. Her knowledge of health and wellness is positively affected by which type of variable?

internal

Polyuria

is excessive or an abnormally large production or passage of urine

The National League for Nursing

is the premier organization for nurse faculty and leaders in nursing education.

Self-Breast examinations positions includes

laying on back and placing that hand behind your head, hands firmly on hips, arms slightly raised and arms down

Local Adaptation System Characteristics

localized response, adaptive: a stressor is needed to stimulate it, short term, assists in restoring homeostatic to the body part, blood clot, wound healing

Lung Sounds: Bronchial sounds

loud, high pitched and hollow, expiration > inspiration; normal to hear over trachea; caused by air rushing in through trachea; abnormal when heard in lung fields

Vesicular lung sounds (soft, breezy, insp.>expiratory) are heard in what region of the lungs?

lung periphery

Patient Restraint: Not a solution to the patient's problem but a temporary means to

maintain patient safety and should be discontinued at the earliest possible time. Alternative methods should always be attempted first!

Sustained change over time; begins 6 months after action has started and continues indefinitely

maintenance stage

Being "healthy" not only includes physical well-being, but also

mental, social, and spiritual well-being. Not all people who are free of disease are equally healthy.

Infectious agent Examples

microbes that cause infectious diseases: bacteria, viruses, fungi and protozoa

High Specific gravity results above 1.010 can indicate

mild dehydration. The higher the number, the more dehydrated you may be. High urine specific gravity can indicate that you have extra substances in your urine, such as: glucose

QSEN defines safety as

minimizing risk of harm to patients and providers through both system effectiveness and individual performance

Lung Sounds: Bronchovesicular

more blowing quality, medium pitch and intensity; inspiration = expiration; heard between scapula posterior. Anteriorly over bronchioles to sternum at first and second intercostal spaces; caused by air moving through larger airways; normal

Physical Assessment Gastrointestinal includes the

mouth, neck, abdomen and urinary bladder

Defenses against Infection

natural defenses: normal floras, body system defenses, organs and inflammation

Closing the gate is the basis for

nonpharmacological pain relief interventions

What is the normal specific gravity of urine?

normal specific gravity values range from 1.010 to 1.030.

Nursing Process allows nurses to apply knowledge and skills in an organized, goal-oriented fashion and helps

nurses communicate to other healthcare professionals regarding patient care; defines the nurses role in patient care and is an ongoing process.

Evidence based practice

nursing decisions are based on research and expert opinion

When Ryan was 3 months old, he had a toy train; when his view of the train was blocked, he did not search for it. Now that he is 9 months old, he looks for it, reflecting the presence of

object permanence

Intrapersonal Communication

occurs within an individual

Interpersonal Communication

one on one interaction between two people

Portal of Entry

organisms enter the body through the same routes used for exiting. Examples: blood, skin, mucous membranes, etc.

Spirit of Inquiry is the

persistent sense of curiosity that informs both learning and practice

When preparing a 4 yo child for a procedure, which method is developmentally most appropriate for the nurse to use?

play therapy: preparing the child through play with a doll and toy medical equipment

Not intending to make changes within the next 6 months

precontemplation

Colonization

presence and growth of microorganisms within a host without tissue invasion or damage

A factory requires its employees to wear hearing protection and hard hats while on the job. Protection against occupational hazards is an example of which level of preventive care?

primary

Nursing Judgement Identifies

problems and uses evidence to support quality nursing actions

Surgical asepsis includes

procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area

Patient restraints are sometimes necessary to

protect the patient and keep them safe

You are caring for a patient diagnosed with mycoplasmal pneumonia. Droplet precautions have been instituted, so you must

protect your eyes

A nurse infused by a spirit of inquiry will

raise questions, challenge traditional, existing practices, and seek creative approaches to problem-solving

National Patient Safety Goals: Identify patient safety risks

reduce the risk for suicide

Metacommunication Definition

refers to all factors that influence communication

Pathophysiology of Pain: Injuring one or more of the nerves can result in

repeated transmissions of pain, Burning, itching, and prickling pain

NLN Members

represent nursing education programs across the spectrum of higher education, health care organizations and agencies.

Local Adaptation System

response of a body tissue or organ to the stress of trauma, illness or physiological stress.

A nursing diagnosis is of a standardized language that defines the patient's

response to a problem

Hospital/Health Care Associated Infections

result from delivery of health services in a health care facility

Impaction Bowel definition

results from unrelieved constipation; a collection of hardened feces wedged in the rectum that a person cannot expel

High risk men (those who have a first-degree relative with breast cancer) may be encouraged to have

routine mammograms

Identifying disease at an early stage and intervening as early as possible will limit disability by averting or delaying the consequences of advanced disease. This is an example of this type of preventive care

secondary

Elizabeth, who is having unprotected sex with her boyfriend, comments to her friends, "Did you hear about Jenna? You know, she fools around so much; I heard she was pregnant. That would never happen to me!" This is an example of adolescent

sense of invulnerability

During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is known as

sleep apnea

A health care provider may suspect that a patient is experiencing urinary retention when the patient has

small amounts of urine voided two or three times per hour

Lung Sounds: Vesicular

soft breezy, low pitched; inspiratory > expiratory; heard over lung periphery; caused by air moving in small airways; normal

Benign (fibrocystic) breast disease is described as cysts that are palpated bilaterally and are

soft, well differentiated, moveable, and tender.

For patients that do not speak English

speak to the patient in a normal tone of voice, establish a method for the patient to ask for assistance (call light or bell), provide a professional interpreter, use communication board, pictures or cards

A patient has bibasilar pneumonia. You would expect vibrations through tactile fremitus to get

stronger

Susceptible Host

susceptibility to an infectious host depends on an individual's degree of resistance to pathogens, a person's natural defenses against infection and certain risk factors such as nutrition, chronic disease, trauma affect susceptibility.

A patient suffers from sleep pattern disturbance. To promote adequate sleep, the most important nursing intervention is

synchronizing the medication, treatment, and vital sign schedule

All LPNs (licensed practical nurses) and RNs (Registered nurses)

take a national licensure exam and eligible to practice in all 50 states of the United States once they pass the licensure exam

Stressors Definition

tension producing stimuli operating within or on any system of a stressor.

A patient with a spinal cord injury must learn to use a wheelchair and perform ADLs independently, the nurse knows that this level of care is

tertiary

There are graduate level competencies starting from

the LPN level and extending to the RN, terminating with a doctoral degree

Asepsis

the absence of pathogenic (disease producing) microorganisms

"Nursing diagnosis is a clinical judgment about an individual, family, or community response to actual or potential health problems or life processes. Nursing diagnosis provides

the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability." (NANDA, 2008)

Communicable disease

the infectious process that can be transmitted from one person to another

Infection

the invasion of a susceptible host by pathogens or microorganisms; results in disease

To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because

the mass colonic peristalsis occurs at this time

Diagnostic Label

the name of the nursing diagnosis as approved by the NANDA-I

Maslow's Hierarchy of Needs: The focus of patient care should always be individualized by

the nurse and strict adherence to this hierarchy is not always best.

A nursing diagnosis allows

the nurse to diagnose and treat the identified problem; to communicate what is done with other professionals, and refocuses the nurse on the nursing scope of practice.

Hypospadias

the opening of the urethra is on the underside of the penis instead of at the tip

Priority Setting

the ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions.

Aseptic technique refers to

the practices/procedures that help reduce the risk for infection

Isolation is

the separation and restriction of movement of ill persons with contagious diseases. Examples: Barrier precautions, Standard precautions, Isolation precautions

Medical asepsis is

the use of medical asepsis techniques used for all patients even when no infection is diagnosed. Examples of medical asepsis are hand hygiene, barrier techniques, and routine environmental cleaning

Educational standards are written

to guide schools of nursing. These standards provide a blueprint for schools of nursing

Aphasia: Motor (expressive)

understands written or verbal speech but cannot write or speak appropriately when attempting to communicate. Can be a combination of both receptive and expressive aphasia

Spirit of Inquiry

uses evidence based nursing actions to support quality care

Assessment Documentation: Document all information collected during health history and physical examination

using clear, concise, appropriate terminology; Used as a baseline. Data Clusters: Provides a way to organize data, Organized by actual or potential problems

Pathophysiology of Pain: Visceral

visceral organs (GI and Pancreas)

When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate?

"It must be difficult not to know what the surgeon will find. What can I do to help?"

Erikson's Developmental Stages: Birth

1 year TRUST vs MISTRUST: Establishing a basic sense of trust in the caregivers (parents), Will then be able to trust in self, others, and the world

Fight or Flight Response

1. Release of cortisol, 2. Release of ADH, 3. Endorphins are secreted, 4. Cardiovascular, 5. Gastrointestinal, 6. Renal

To measure chest excursion, the examiners thumbs must be placed at what ribs on the posterior chest?

10th

Male genital self-examination: All men ages

15 years and older need to perform this examination monthly.

Glasgow Coma Scale: Alert and oriented is a

15. Pt has a spontaneous eye opening response, good verbal response, orientated to date, time, location and obeys commands.

Testicular Cancer is most common in men aged

18 to 34 years

A normal pulse strength is graded at what number?

2+

Breast self-examination (BSE) should be performed monthly for women how many years old

20 years and up

The Anterior-Posterior diameter of the chest should be what ratio to the transverse length?

2:1

Where is the Aortic listening post of the heart?

2nd ICS R sternal border

Where is the pulmonic listening post of the heart?

2nd ICS left sternal border

Women ages 20-40 should have a clinical breast exam done by a provider every

3 years. Women over the age of 40 need this done yearly.

Where is Erb's Point listening post of the heart?

3rd ICS L sternum

The best time to complete a Breast self-examination is

4-7 days after the menstrual cycle

A screening mammogram is recommended by the age of

40 and then annually after that.

Where is the tricuspid listening post of the heart?

4th ICS L sternum

Where is the mitral listening post of the heart?

5th ICS L of sternum, ½ to MCL

Crisis Intervention Situational Adventitious

A major natural or man-made disaster or a crime of violence can create an adventitious crisis.

Specific Gravity Urine Test

A urine specific gravity test compares the density of urine to the density of water. This quick test can help determine how well your kidneys are diluting your urine.

Physiology of Pain: Modulation

Inhibits pain impulse. A protective reflex response occurs with pain reception

Nursing Process steps are

ADPIE (Assessment Diagnosis Planning Implementation Evaluation)

We follow:

ANA Code of Ethics for Nurses, ANA Scope and Standards of Nursing Practice

Nursing Process and Infection Control: Assessment includes a thorough investigation of

Defense mechanisms, susceptibility, and knowledge of how infections are transmitted; Review of systems, travel history; Immunizations and vaccinations; Early recognition of risk factors

Portal of Exit

After microorganisms find a site to grow and multiply, they need a portal of exit in order to enter a new host. Examples: blood, skin, mucous membranes, etc.

Physical Assessment- Reproductive System: Factors to consider

Age, Gender, Pregnancy, Menstrual cycle status, Past surgeries, Medications, Lifestyle choices (sexual practices), Family history, Culture and ethnicity

Factors Impacting Neuro Assessment

Age, Pregnancy, Past surgeries, Gender, Medications, Lifestyle choices (i.e. diet, exercise, smoking, etc), Family History, Culture and ethnicity, Environment, Past and present illnesses, Stressors (i.e. worries, concerns, distractions, etc.)

Factors Influencing Pain: Physiological

Age, fatigue, genes, neurological function. Fatigue increases the perception of pain and can cause problems with sleep and rest

Psychological GAS (PGAS)

Alarm: anxious, nervous, depressed, crying, jittery. Resistance: use of coping mechanisms, able to solve problems, able to cope. Exhaustion: destructive behaviors, severe additions

Psychological GAS (PGAS) includes

Alarm: anxious, nervous, depressed, crying, jittery. Resistance: use of coping mechanisms, able to solve problems, able to cope. Exhaustion: destructive behaviors, severe additions

LAS Stages

Alarm: erythema, discharge, edema, open, pain. Resistance: approximated, no erythema, no edema, no discharge. Exhaustion: gaping wound, massive bleeding, body can no longer adapt

GAS Stages

Alarm: increase of vital signs, change of blood work, increased alertness, fight or flight, decreased output. Resistance: vital signs return to normal, blood work back to normal. Exhaustion: energy to maintain adaption is depleted, body unable to defend itself, death.

A confused older-adult patient is wearing thick glasses and a hearing aid. Which intervention is the priority to facilitate communication?

Allow time for the patient to respond.

Patient Controlled Analgesia

Allows patient to self-administer with minimal risk of overdose. Maintains a constant plasma level of analgesic

Nursing Implications for Health Behavior Changes: Contemplation

Ambivalence may be present, but patients will more likely accept information since they are contemplating make a change.

Nonverbal Communication Includes

Appearance, Posture and gait, Facial expressions, Eye contact, Gestures, Sounds, Territoriality and personal space

Psychological Factors Influencing Pain:

Anxiety, Coping style, Pain tolerance, Cultural

Nursing Diagnoses for Patients undergoing Stress

Anxiety, Denial, Fear, Powerlessness, Situational or Chronic Low Self-Esteem, Stress Overload, Ineffective Coping, Caregiver Role Strain

PGAS Alarm

Anxious, depressed, crying, nervous, jittery

Listening Posts

Aortic: 2nd ICS R sternal border, Pulmonic 2nd ICS left sternal border, Erbs point: 3rd ICS L sternum, Tricuspid: 4th ICS L sternum, Mitral: 5th ICS L of sternum, ½ to MCL

Non-Therapeutic Communication Techniques

Asking personal questions, giving personal opinions, Changing the subject, Automatic responses, False reassurance, Sympathy, Asking for explanations

Physical Assessment: Palpate

Assess body parts through the sense of touch; light and deep palpitation. Areas examined by palpation = skin temperature, texture, organs, glands, blood vessels

Nursing Diagnosis for Infection Process Includes

Assessing risk for Infection; Imbalanced Nutrition: Less than Body; Impaired Oral Mucous Membrane; Risk for Impaired Skin Integrity; Readiness for Enhanced Immunization Status; Impaired Tissue Integrity

Factors Influencing Pain: Social

Attention, previous experiences, family and social support, spiritual. Spirituality includes active searching for meaning in situations, with questions such as "Why am I suffering?".

Cranial Nerves: VIII

Auditory: hearing. Assess ability to hear spoken word. Whisper test

What do you need to teach family caregivers when a patient has fecal incontinence as a result of cognitive impairment?

Initiate bowel or habit training program to promote continence

Maslow's Hierarchy of Needs

Basic human needs are at the base of the pyramid. These needs are necessary for survival and health. When the basic needs are met (food, water, and safety) then one can fulfill other needs higher on the pyramid (love and belonging).

What breaks the chain of infection?

Basic medical aseptic techniques

Culture Sensitivity

Be culturally aware and avoid stereotyping; Consider health beliefs; Respect cultural differences

Restraint Safety Proper initial documentation should include

Behaviors that necessitated the use of restraints, Alternative methods attempted, Which type of restraint is being used, Evaluation of the patient's response

Abdomen auscultation

Bowel motility, Peristalsis: involuntary movements of the muscles; Borborygmi (growling Sounds); Vascular sounds

You would suspect all symptoms for arterial insufficiency except which finding?

Brown pigmentation around ankles

A nurse is planning to administer a dose of intravenous morphine sulfate for a postoperative patient. Which of the following is a pain management protocol that should be used by the nurse in this situation?

Have an opioid antagonist available during the administration

Types of Pain: Cancer

Can be acute or chronic

Objective Information

Can be measured or observed. (Measured using acceptable scale (Celsius/Fahrenheit, pain scale, inches, pounds). Examples: vital signs, clean and dry dressing, pt. walked 100 feet independently

The posterior lung apex can be found at what vertebra

C7

Which 3 cranial nerves can be assessed with the 6 directions of gaze?

CN III, CN IV, CN VI

Which cranial nerve are you assessing by eliciting a gag reflex?

CN IX

Looking for symmetry while the patient smiles, frowns, puffs out cheeks, and raises and lowers eyebrows assesses which cranial nerve?

CN VII

Having the patient say "ah" assesses which cranial nerve?

CN X

Piaget's Theory of Cognitive Development: 7 - 11 years

CONCRETE OPERATIONS: The child can now think about an action or describe a process without physically performing it. Can sort objects by length, weight, or other characteristics.

Behavioral Responses to Pain

Clenching the teeth, facial grimacing, holding or guarding the painful part, and bent posture are common indications of acute pain. Chronic pain affects a patient's activity. Lack of pain expression does not indicate that a patient is not experiencing pain.

Directive interviewing

Closed ended question that can be answered with a yes or no or other short factual answer, begin with who, when, where, do (did, does) and is (are, were). Used for easily categorized information, an emergency situation, patient with communication difficulties.

Implementation for Health Promotion: Nonpharmacological pain-relief interventions

Cognitive and behavioral approach, Relaxation and guided imagery, Distraction, Music, Cutaneous stimulation

Mouth assessment is completed looking for

Color, Texture, Hydration, Contour, Lesions

Ego Defense Mechanisms

Compensation, Conversion, Denial, Displacement, Identification, Dissociation, Regression

Compensation Ego Defense Mechanism

Compensation: Make up for perceived inadequacy in ourselves.

Incident Reports are sent to Risk Management (and they work to identify further possible risks, analyze them, act to reduce the risks, and evaluate the steps taken to reduce them)

Confidential and kept separate from medical records, DO NOT document in a patient's record that you filed an incident report

Sleep Deprivation Symptoms

Confused and disoriented, Increased sensitivity to pain, Irritable, Withdrawn, Apathetic, Agitated, Hyperactive, Decreased motivation, Excessive sleepiness

Stages of Health Behavior Changes: Contemplation

Considering a change within the next 6 months

Message

Content of the message

Nursing Diagnosis: Related Factors

Contributing factors that influence the change in health status; Can be pathophysiologic (biologic, or psychosocial); treatment-related; situational (environment or personal) or maturational

Physiology of Pain: Transduction

Converts energy produced by these stimuli into electrical energy, Begins in the periphery when a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential. Once transduction is complete, transmission of the pain impulse begins.

GAS Resistance Stage

Coping with the stressor (adaptation), Body tries to maintain homeostasis, Physical adaptations help the heart rate, BP, cardiac output, respiratory function, and hormone levels return to normal

Pharmacological Pain Therapies: Topical analgesics

Creams, ointments, patches

A provider order is required for restraints. The order must be

Current, State the type and location or restraints: 2-point (wrist), 4-point (wrist and ankle). Specify the duration and circumstances under which it will be used. Never ordered as needed: Orders are renewed in a specific time frame

GAS Alarm Stage

Includes: Increased VS; Change in blood work; Increased alertness; Flight or fight; Decreased output

Denial Ego Defense Mechanism

Denial: Total failure to acknowledge an event, idea, memory; refusing to believe the facts

According to the North American Nursing Diagnosis Association (NANDA), the nursing diagnosis

Describes actual or potential health problems

Nursing Diagnosis: Definition

Describes the characteristics of human response; Assists in identifying a patient's correct diagnosis

PGAS Exhaustion/recovery

Destructive behavior and severe additions

Nursing Process Evaluation

Determine if the goals were achieved. Did your patient meet his or her desired outcome?. Possible outcomes: Goal met, Goal partially met, Goal not met. What would you change about this plan, based upon your evaluation?

Stress Crisis Types

Developmental Crisis: marriage or birth of a child. Situational Crisis: Job change, MVA. Adventitious Crisis: Major Natural disaster or violent crime

Crisis Intervention Developmental

Developmental crises occur as a person moves through the stages of life.

Factors Affecting health and Illness: Internal variables

Developmental stage (child or adolescent vs. adult), Intellectual background (knowledge or lack of knowledge), Perception of functioning (objective and subjective health data), Emotional factors (mental health and coping), Spiritual factors (values and beliefs)

Reactions to Pain: Sympathetic

Dilation of bronchial tubes and increased respiratory rate, Increased HR, Peripheral Vasoconstriction, Increased BG levels, Increased cortisol level, Diaphoresis, Increased muscle tension

Displacement Ego Defense Mechanism

Displacement: Discharge feelings away from actual source because it is not safe to express them directly

If you find a piece of faulty equipment, place a tag on it to prevent it from being used on another patient and promptly report any malfunctions

Do not operate monitoring or therapy equipment without adequate instruction

Process of Infection

Incubation, prodromal, Illness, convalescence, localized versus systemic infection

Abnormal Stool color: Black or tarry

Drug (iron), bleeding from upper gastrointestinal tract diet high in red meat and dark green vegetables (spinach)

Factors influencing sleep

Drugs and substances, Lifestyle, Usual sleep patterns, emotional stress, environment, Exercise and Fatigue, Food and calorie intake

National Patient Safety Goals: Prevent mistakes in surgery

Ensure correct surgery, on the correct patient, and the correct site, perform a pause before surgery

National Patient Safety Goals: Use alarms safely

Ensure use of necessary alarms and respond in a timely manner

Nursing Rationales: Nursing is an evidence-based practice

Every intervention must have its own rationale!!! The rationale is the WHY of WHAT we do. Rationale is based upon supporting literature.

Stress Theory

Every stress leaves an indelible scar, and the organism pays for its survival after a stressful situation by becoming a little older." Hans Selye (1907-1982)

GAS Recovery or Exhaustion (Final Stage)

Final effort to adapt. Adaptation ineffective = Exhaustion, Adaptation effective = Recovery. Exhaustion: Energy to maintain adaption is depleted, Body unable to defend itself, Death

Proper documentation for female genitalia physical assessment

External genitalia and urethral opening free of inflammation, irritation, lesions, or discharge. No fissure, hemorrhoids, or skin lesions in perianal area.

Crisis Intervention Situational

External sources such as a job change, motor vehicle crash, death, or severe illness provoke situational crises.

Abnormal Heart Sounds

Extra sounds (S3 and S4) and murmurs, S3, or a ventricular gallop, occurs after S2, S4, or an atrial gallop, occurs just before S1 or ventricular systole

Piaget's Theory of Cognitive Development: 11 years - adult

FORMAL OPERATIONS: Transition from concrete to formal operational thinking. Prevalence of egocentric thought, thinking that their thoughts and feelings are unique and that they are invulnerable (indestructible). By the end of this stage they learn that their feelings and thoughts are not so unique and that they are shared by almost everyone. Eventually abstract and theoretical thinking is possible

Cranial Nerves: VII

Facial: Facial expressions. Look for symmetry while the patient smiles, frowns, puffs out cheeks, and raises and lowers eyebrows. Have the patient identify salty or sweet taste on front of tongue

Interpersonal Variables

Factors that influence communication

Risks in the Health Care Agency: Falls

Falls can result in bruises, fractures, and head trauma and increase the risk for premature death. Can extend the patient's length of stay

Factors Affecting health and Illness: External variables

Family practices (family influence), Psychosocial/Socioeconomic factors (relationships/social network and economic status), Cultural background

Stress Scientific Knowledge Base

Fight or flight response. Neurophysiological responses: Medulla oblongata, Reticular formation, Pituitary gland

Cranial Nerves: IX

Glossopharyngeal: taste, swallowing, gag. Use tongue blade to assess gag reflex

Nursing Process Planning

Goals and interventions are developed. Goals must be patient-centered- A patient's highest possible level of wellness and independence in function, based on patient needs, abilities, and resources. Use SMART acronym for writing goals and expected outcomes (Specific, Measurable, Attainable, Realistic, Timed)

National Patient Safety Goals: Prevent infection

Hand hygiene, prevent surgery, catheter, and central line associated infections

Nursing Process Implementation for Infection

Health promotion; Preventing an infection from developing or spreading; Acute care; Treating an infectious process includes eliminating the infectious organisms and supporting the patient's defenses

Nursing Implications for Health Behavior Changes: Action

Help the patient to identify and overcome barriers to change.

Learning Activities

Help the student achieve the level of competencies/outcomes needed to graduate

Wellness-Illness Continuum: Wellness

High level, good health and optimal health

Team Member Desirable Characteristics

Honest, Dependable, Willingness to learn, Willingness to change, Patience, Self motivated

Health Belief Model

Individual perception of susceptibility to an illness, Individual perception of the seriousness of this illness, Likelihood of action taken by the individual

Normal stool color for infants

Infants: Dark green 1st week then yellow

Chain of Infection Elements

Infectious agent or pathogen, reservoir or source for pathogen growth, portal of exit, mode of transmission, portal of entry, Susceptible host

Contact precautions would be mandated for a hospitalized adult patient diagnosed with

Infectious diarrhea

Techniques of Physical Assessment

Inspection, Auscultation, Palpation, Percussion

What relates to us as Nursing students

Integrity, accountability, responsibility, and commitment to our patients as a nurse and a member of the disciplinary team

Small Group Communication

Interaction with a small number of people

Public Communication

Interaction with an audience

Communication Process (Circular Transactional Model)

Interpersonal (Variables); Channel message is sent to receiver (referent) and back to sender (referent); feedback (environment)

Levels of Communication

Intrapersonal, Interpersonal, Small Groups, Public

The nature of pain includes

Involves physical, emotional, and cognitive components, Pain is subjective and individualized, reduces quality of life, not measurable objectively

National Patient Safety Goals: Use medicines safely

Label medications, provide complete medication lists at discharge, use precautions with patient's taking blood thinners

Formulating a Nursing Diagnosis Steps

Label, Definition, Related Factors, Defining Characteristics, Risk Factors

To inspect body parts accurately

Make sure good lighting is available; Position and expose body part; Inspect each area for size, shape, color, symmetry, position and abnormalities; compare each are to be inspected with the other side.

Stages of Health Behavior Changes: Preparation

Making small changes in preparation for a change in the next month

Abnormal Stool color: Pale

Malabsorption of fats, diet high in milk and milk products and low in meat

Physical restraints

Material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely

Channels

Means of conveying and receiving messages

Chemical restraints

Medications (anxiolytics and sedatives) used to manage a patient's behavior and are not a standard treatment or dosage for the patient's condition

Rest contributes to

Mental relaxation, Freedom from anxiety, State of mental, physical, and spiritual activity. Bed rest does not guarantee that a patient will feel rested.

Feedback

Message the receiver returns

Human Flourishing Definition

Nurses practicing as virtue guided moral agents pursuing excellence in the clinical details of their practice and in their relationships with their patients. We advocate, teach and study

Referent

Motivates one to communicate with another

During a pain assessment, a nurse asks questions about the quality of an adult patient's pain. Which of the following statements by the patient refers to pain quality?

My pain feels like I'm being stabbed by a knife

Nursing Diagnosis: Label

Name of the nursing diagnosis as approved by NANDA-I; Describes essence of patient's response to health conditions in as few words as possible.

Stages of Health Behavior Changes: Precontemplation

No intention of making a change within 6 months

Proper documentation for male genitalia physical assessment

No lesions, inflammation, or discharge from penis. Scrotum-testes descended, symmetric, no masses. No fissures, hemorrhoids, or skin lesions in perianal area.

The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use?

Nonverbal

Pathophysiology of Pain: Nociceptive Pain

Normal stimulation of special peripheral nerve endings

Quiz Question: You are caring for a patient who underwent surgery 48 hours ago. On physical assessment, you notice his wound appears red and swollen. The patient's WBCs are elevated. You should

Notify the provider

Maslow's Hierarchy of Needs: Physiological

Oxygen, Food and water, Shelter, Sleep, Sex

Nursing Diagnosis: Defining Characteristics

Observable assessment cues that support diagnostic judgement; Used with Problem-Focused and Health Promotion Nursing Dx

Interviewing Techniques

Observation, Open-ended questions, Leading questions, Back channeling, Probing, Direct Closed-Ended Questions

Sleep Functions: Dreams

Occur in NREM and REM sleep. Important for learning, memory, and adaptation to stress.

Types of Pain: Chronic episodic

Occurs sporadically over an extended duration

Cranial Nerves: III

Oculomotor: Extraocular eye movement (inward, up & inward, up & outward, down & outward). Assess 6 directions of gaze and measure pupillary reaction to light reflex and accommodation

Cranial Nerves: I

Olfactory: Smell. Pt. identifies an aroma (such as coffee)

Severity Pain Questions

On a scale from 0-10, how ad is your pain now? What is the worst pain you have had in the last 24 hours? What is the average pain you have had in last 24 hours?

Where are the base of the anterior lungs located?

On diaphragm at 5th or 6th MCL

Sender and receiver

One who encodes and one who decodes the message

Nondirective interviewing

Open ended questions, used to build a rapport with the patient, or help the patient to express feeling. The patient is allowed to control the subject matter. Questions are specific but phrased to encourage the patient to elaborate. Allows you to find out what is important to the patient.

Cranial Nerves: II

Optic: Vision. Assess visual acuity with a Snellen chart

Neurological Assessment: Mini-Mental State Examination (MMSE)

Orientation to time: "What is the date?" Registration: repeat three words. Naming: "What is this?" (Point to a pencil or pen.) Reading: "Please read this and do what it says."

Origin of Stress Theory

Original research and theory developed by Hans Selye. General Adaption Syndrome (GAS). Others have added research and evidence to application and theory

Piaget's Theory of Cognitive Development: 2 - 7 years

PREOPERATIONAL: Egocentrism- only see objects and people from their own point of view. Personification of objects (the thought that inanimate objects have thoughts and feelings of their own). Fantasy and magical thinking. Play therapy is useful during this time for the hospitalized or ill child.

Types of Stress

PTSD and Crisis. PTSD begins with a traumatic event and responds with feeling helpless. A crisis implies that a person is facing a turning point in their life.

Physiology of Pain: Gate-control theory of pain

Pain has emotional and cognitive components, in addition to a physical sensation. Gating mechanisms in the central nervous system (CNS) regulate or block pain impulses. Pain impulses pass through when a gate is open and are blocked when a gate is closed.

Nursing Assessment Questions for Pain (PQRST)

Palliative or Provocative factors, Quality, Region, Severity, Timing

Reactions to Pain: Parasympathetic

Pallor, Nausea and Vomiting, Decreased HR and BP, Rapid, Irregular Breathing

Quality and Safety Education for Nurses (QSEN) focuses on

Patient Centered Care, Teamwork and Collaboration, Evidence-Based practice, Quality Improvements, Safety, Informatics

Reasons to file an incident report

Patient fall or injury, Failure to follow health care provider orders, A patient or family complaint, Malfunctioning device, An error in technique or procedure, Medication errors, Needlesticks

Restraint ongoing assessment is also necessary to document and should include

Patient tolerance, Necessity of continuation of restraints, Skin assessment under restraints, Frequency of documentation is determined by agency policy, If restraints are removed, a new provider order is needed for reapplication

Pain Assessment

Patient's expression of pain, Pain is individualistic. Characteristics of pain: Timing, Location, Severity

Quality and Safety Education for Nurses (QSEN) Competencies: QSEN identifies 6 competencies that are necessary for graduate student nurses to function effectively in the role of an RN

Patient-centered care, Teamwork and collaboration, Evidence-based practice, Quality improvement, Safety, Informatics

When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true?

Patients are the best judge of their pain.

Crisis Intervention: Three factors affect Resolution

Perception, Support, Coping mechanisms

Health education, fitness classes, and nutritional programs would be considered which type of preventive care?

Primary Care: Health Promotion

Standard Precautions for Hand Hygiene

Perform hand hygiene before and after patient contact. Wash hands if visibly contaminated.

Nursing Process Implementation

Perform interventions. The nurse initiates interventions to help the patient achieve their goals and outcomes; NOT a doctor's order

Surgical Asepsis is used when

Performing sterile procedures, Donning and removing caps, masks, and eyewear, opening sterile packages, preparing a sterile field, pouring sterile solutions, Surgical scrub, applying sterile gloves, donning a sterile gown

Which product can affect the permeability of gloves

Petroleum-based hand lotion

Maslow's Hierarchy of Needs include

Physical Needs, Safety, Love and Belonging, Esteem, Self Actualization

Maslow's Hierarchy of Needs: Safety & Security

Physical and psychological safety/health, Financial security

Physical Illness and Sleep

Physical illness can cause pain, physical discomfort, anxiety, depression, and sleep disturbances: Hypertension, Respiratory disorders, Nocturia, Restless leg syndrome (RLS)

Communication Factors

Physical, Emotional, Cultural

Neurological Assessment: Language

Point to a familiar object and ask the patient to name it. Ask the patient to respond to simple verbal and written commands such as "Stand up" or "Sit down." Have the patient read simple sentences outloud.

Wellness-Illness Continuum: Illness

Pre-mature Death, Disease and Poor Health

The role of the nurse in health promotion

Primary Prevention (Health Promotion): Prevention of disease. Secondary Prevention (Illness Prevention): Early diagnosis and prompt treatment. Tertiary Prevention (Health Restoration): Rehabilitation and preventing complications

Position of bedpan

Prevent muscle strain and discomfort, Elevate head of the bed 30 to 45 degrees, Wear gloves when handling bedpans

Nursing Process Planning: Common goals of care applicable to patients with infection often include the following

Preventing exposure to infectious organisms; Controlling or reducing the extent of infection; Maintaining resistance to infection; Verbalizing understanding of infection prevention and control techniques (e.g., hand hygiene)

Professional Communication Includes

Privacy and Confidentiality

Airborne Isolation Precautions (droplet nuclei are smaller than 5 microns)

Private room with negative-pressure airflow, mask or respirator device, (N95 respirator, depending on condition). Examples: Measles, Chickenpox, etc.

Contact Isolation Precautions (Direct patient or environment contact)

Private room, gloves, gowns. Examples: MRSA, Herpes, Scabies

Droplet Isolation Precautions (droplets larger than 5 microns)

Private room, mask or respirator required if within three feet of the patient. Examples: Rubella, Scarlet Fever, Pneumonia, Streptococcal pharyngitis, etc.

Diagnostic Statements: 3-part statements (PES)

Problem: Diagnostic label (as related to) Etiology: contributing factor (as evidenced by) Symptom: defining characteristics

Physical Assessment: Inspection

Process of observation, to detect, body parts, normal characteristics, & physical signs.

Patient teaching related to mouth includes

Proper oral care including brushing and flossing, Early and late signs of oral cavity or Pharynx CA, Encouraging regular dental checkups.

Types of Pain: Acute/Transient Pain

Protective, identifiable, short duration; limited emotional response

PGAS

Psychological Adaptation

A nurse wants to present information about flu immunizations to the elderly in the community. Which type of communication should the nurse use?

Public

Rationalization Ego Defense Mechanism

Rationalization: conscious attempt to explain behavior through causes other than actual ones that are more socially acceptable; face-saving device.

Maslow's Hierarchy of Needs: Self-actualization

Reaching one's full potential

Patient Restraint Intended use includes

Reducing the risk of injury from falls, Prevent interruption of therapy (i.e. IV, NG, foley catheter, traction), Prevent patients who are confused or combative from removing life-support equipment, Reduce the risk of injury to self or others

Regression Ego Defense Mechanism

Regression: Returns to an earlier method of behaving.

Purpose of Sleep

Remains unclear, Physiological and psychological restoration, Maintenance of biological functions

An incident or occurrence report should be filed

Reporting provides a database for further investigation in an attempt to determine deviations from standards of care, to identify corrective measures needed to prevent recurrence, and to alert risk management to a potential claim situation (lawsuit)

Nursing Care Delivery: Patient and Family Centered Care

Respect and dignity, Information sharing, Participation, Collaboration

Risks in the Health Care Agency: Equipment-Related Injury

Result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard, Regular safety checks of equipment should be completed by the clinical engineering department.

Maslow's Hierarchy of Needs: Love & Belonging

Romantic and familial relationships, Friendship

Heart Sounds

S1 "Lub" First heart sound: Caused by closure of AV valves (mitral and tricuspid), Beginning of systole (ventricle contractions). S2 "Dub" Second heart sound: Caused by closure of semilunar valves (aortic and pulmonic), Beginning of diastole (filling)

Piaget's Theory of Cognitive Development: Birth - 2 years

SENSORIMOTOR: Exploration of environment through motor and reflex actions (looking, grasping, kicking, sucking), Object permanence - no longer out of side out of mind.

Physiology of Pain: Transmission

Sending of impulse across a sensory pain nerve fiber (nociceptor), Nerve impulses, Pain impulses

Region Pain Questions

Show me where you hurt.

Factors Influencing Stress Response

Situational factors: Arise from job changes, illness, caregiver stress. Maturational factors: Vary with life stages. Sociocultural factors: Environmental, social, and cultural stressors perceived by children, adolescents, and adults

Nursing Diagnosis: Risk Factors

Situations which increase vulnerability for a patient or group; Environmental, physiological, psychological, genetic, or chemical elements that place client at risk for health problem; Only used in Risk Nursing Dx

Neurological Assessment of Ears and Nose includes

Size, shape, skin, color, and the presence of deformity or discoloration, ear symmetry, nose nares

Local Adaptation Syndrome (LAS)

Specific to a part of the body

Cranial Nerves: XI

Spinal accessory: Movement of head and shoulders. Ask patient to shrug shoulders and turn head against passive resistance

A patient had surgery for a total knee replacement a week ago and is currently participating in daily physical rehabilitation sessions at the surgeon's office. In what level of prevention is the patient participating

Tertiary

Definition of Health

State of complete physical, mental, and social well-being, not merely the absence of disease" (World Health Organization)

Surgical Asepsis

Sterile technique prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment, and maintains a sterile field for surgery

Restraint Safety

Strictly follow agency policy and procedures related to initiation, observation, documentation, and discontinuation

Stages of Health Behavior Changes: Maintenance stage

Sustained change over time; begins 6 months after action has started and continues indefinitely

Entry Level Nurse Competencies

Systems focus to see "Big Picture", Understanding of environment of care, Manage care of patients, Prioritization of basic patient care needs, Critical thinking, Effective communicator, Team member and collaboration, Patient focused

Physical Assessment: Percussion

Taping the body with fingertip or striking one object with another to produce sound or vibration to aid in diagnosis. Direct and indirect used. Used to = evaluate the size, borders of body cavity,

In 1973, the first national conference on Nursing Diagnosis was held. Nurse leaders created 80 nursing diagnoses at that conference. Today that group is called

The North American Nursing Diagnosis Association International (NANDA-I) created

Nursing Care Delivery: Total Patient Care

The original care delivery model developed during Florence Nightingale's era. RN responsible for all aspects of care for one or more patients during a shift. Primarily found in Critical Care environments

Nursing Implications for Health Behavior Changes: Preparation

The patient believes that advantages outweigh disadvantages of change. They need assistance in planning for the change.

Nursing Implications for Health Behavior Changes: Precontemplation

The patient is not interested in information about the behavior and may be defensive when confronted with it.

Physiology of Pain: Perception

The point at which a person is aware of pain. The somatosensory cortex identifies the location and intensity of pain, whereas the association cortex, primarily the limbic system, determines how a person feels about it. There is no single pain center.

Environment

The setting for sender-receiver interactions

Nursing Care Delivery Methods

Traditional models: Team nursing, Primary nursing. Today's models: Patient-centered care, Total patient care, Case management

Purposes for a physical examination

Triage for emergency care, Routine screening to promote health and wellness, to determine eligibility for Health insurance/Military service, A new job, To admit a patient to a hospital or long-term care facility

Cranial Nerves: V

Trigeminal: Sensory nerve to skin of face, jaw muscles. Lightly touch cornea with wisp of cotton to assess corneal reflex. Measure sensation of light pain and touch across skin of face. Palpate temples as patient clenches teeth

Cranial Nerves: IV

Trochlear: Extraocular eye movement (downward & inward). Assess 6 directions of gaze

Common Urinary Elimination Problems

Urinary Retention, Urinary Tract Infection (UTI)Urinary Incontinence, Urinary Diversion or urostomy

The nurse is aware that preschoolers often display a developmental characteristic that makes them treat dolls or stuffed animals as if they have thoughts and feelings. This is an example of

animism

Standard Precautions

apply to blood, body fluids, secretions, and excretions.

Local Adaptation Syndrome (LAS) Resistance

approximated, no erythema, no edema, no discharge

NLN competencies

are program outcomes that graduates are expected to know and follow

Appropriate Documentation for Breast Examination findings

as follows: Breasts symmetrical. Skin color appropriate for race with and no rash, lesions, or dimpling. No nipple retractions or discharge. Breast contour and consistency firm and equal bilaterally. No masses or tenderness palpated. No lymphadenopathy appreciated.

"Nursing process"

assessment, nursing diagnosis, planning, intervention, and evaluation

Bronchovesicular sounds (blowing quality, med. Pitch and intensity; insp.=expiratory) are heard in what region?

between scapula posterior and anteriorly over bronchioles

With an indwelling catheter, never place the bag above the patient's

bladder. It will cause the urine to go back in.

Professional Identity Includes

both personal and professional development, integrity, accountability, responsibility, and commitment to patients as a nurse and member of the interdisciplinary health care team

Emphasize the importance of knowing her "normal" when it comes to

breast self-examinations

Aphasia: Sensory (receptive)

cannot understand written or verbal speech

Nursing Core Values

caring, integrity, diversity, excellence

Menopausal women who no longer have a menstrual cycle should

choose a date and perform a BSE on this date each month.