NUR 323 Lecture Exam 1

What does implementing a care plan mean?

With implementation, the nurse is carrying out the planned evidence-based nursing intervention. Nurses use specialized abilities to: 1. Determine the patient's new or continuing need for nursing assistance 2. Promote self-care 3. Assist the patient to achieve valued health outcomes. As you implement the care plan, you are constantly engaging in clinical reasoning about what you are doing - Since patient conditions can change dramatically in minutes, you must reassess the patient for changes in status that may dictate a different set of interventions (what is the scientific rationale - does the evidence support this as the BEST intervention?; if not, the plan of care is revised (better intervention, change in how intervention carried out, etc.) to indicate a better way to address the causes of problems/nursing diagnoses).

How are wounds classified?

*1. Mechanism or How the Wound was Acquired:* Intentional: - Purposefully created for therapeutic purposes (e.g. result from surgery, intravenous therapy, and lumbar puncture). - Wound edges are clean and bleeding controlled. - Risk for infection is decreased, and healing facilitated because wound created under sterile condition with sterile supplies and skin preparation Unintentional: - Accidental from unexpected trauma (accidents), forcible injury (e.g. stabbing or a gunshot), and burns. - Wound edges are jagged (multiple wounds are common) and bleeding uncontrolled - At high risk for infection due to contamination (wounds occur in an unsterile environment) and require a longer healing time. *2. Extent of Exposure of Underlying Skin Structures and Whether the Wound Follows the Normal, Timely Healing Process or Not:* Open: - Occurs from intentional or unintentional trauma. - Skin surface is broken, creates portal of entry for microorganisms - Bleeding, tissue damage, and increased risk for infection and delayed healing may accompany open wounds (e.g. incisions, abrasions) Closed: - Results from a blow, force and strain caused by trauma (fall, assault, car accident). - Skin surface is not broken - Soft tissue is damaged, there is internal injury and hemorrhage may occur (e.g. ecchymosis and hematomas) Acute: - Acute wounds usually the results of a surgical incisions - Wound edges are well approximated (edges meet to close skin surface) and - Risk of infection is low - Wound heals within days to weeks progressing through the healing process without interruption. Chronic: - Wounds remain in the inflammatory phase of healing, healing process is impeded, do not progress through the normal sequence of repair and includes any wound that does not heal along the expected continuum (e.g., diabetes, arterial or venous insufficiency, and pressure injuries). - Wound edges are often not approximated - Risk of infection is increased; healing time is delayed (>30 days)

Describe the Multiple Characteristics of a Chronic Disease that Nurses must Understand.

*Psychological and social issues:* - Managing the issues associated with a threatened identity, role changes, altered body image, and disrupt lifestyles. -> require continuous adaptation and accommodation -> each decline in functional ability requires physical, emotional, and social adaptation for patients and their families. *Phases of illness:* - Many different phases occur over the course of a person's lifetime. - There are acute periods (exacerbations), stable and unstable periods (exacerbations), flare-ups, and remissions -> each phase brings physical, psychological, and social problems -> each requires its own regimens and types of management *Therapeutic regimens:* - Keeping control requires persistent adherence to therapeutic regimens. - Non-adherence to a treatment plan or inconsistent adherence increases the risks of developing complications and accelerating the disease process (nurse's role is to understand from the patient's perspective barriers to adherence and facilitate ways the patient could lessen or eliminate the barriers). - Realities of daily life (culture, values, and socioeconomic factors) affect the degree of adherence *Managing a chronic illness:* - Takes time - Requires knowledge and planning - Can be uncomfortable and inconvenient (medication side effects worse than disease symptoms) *Development of other chronic conditions:* - One chronic condition/disease can lead to the development of another - Example: diabetes can lead to neurologic & vascular changes which leads to visual, cardiac, and kidney diseases and erectile dysfunction - The presence of a chronic illness contributes to a higher risk of morbidity and mortality & greater utilization of clinical services, resources *Family life:* - Chronic illness affects the entire family. - Family life can be dramatically altered as a result of: role reversals, unfilled roles, loss of income, time required to manage the illness, decreases in family socialization activities, costs of treatment - Family members often become caregivers while trying to continue to work and keep the family intact. - Stress and caretaker fatigue are common *Home life:* - The day-to-day management largely the responsibility of people with the disorder(s) and their families - The home is the center of care - Adjuncts or backup services to daily home management include: hospitals, clinics, physicians' offices, nursing homes, nursing centers, and community agencies (home care services, social services, and disease-specific associations and societies) *Self-management:* - Becomes a process of discovery - People can be taught how to manage their conditions but requires each person to discover how their own body reacts under varying circumstances. *Collaborative process:* - Many different health care professionals working together with patients and their families - To provide services needed at home (medical, social, and psychological) *Health care costs:* - Management is expensive. - Expenses may be covered by health insurance, state and/or federal agencies (Medicare & Medicaid). - Costs include: hospital stays, diagnostic tests, equipment, medications, and supportive services *Lost income:* - Direct out-of-pocket expenses - Is a significant percent of income, especially in low- and middle-income families - Expenses include: high copays and deductibles -> have difficulty paying for care leading to bankruptcy or having to rely on family or friends to pay for health insurance or health care. -> If a family's primary income earner becomes ill with chronic diseases can result in drastic loss in income with inadequate funds for food, education, and health care. Affected families may become unstable and impoverished *Ethical issues:* - Problematic questions include - How to establish cost control (individual and community-based) - How to allocate scarce resources - What constitutes quality of life and when life support withdrawn *Living with uncertainty:* - Health care providers may be aware of disease progression; no one can predict with certainty a person's illness course (individual variation) - Even though a person may be in remission or be symptom free, there is a fear of illness reappear

To complete the Disability Assessment, here are some questions to ask to ensure quality health care:

*Usual Health Considerations:* - Does the health history address the same issues that would be included when obtaining a history from a person without disabilities, including sexuality, sexual function, and reproductive health issues? *Disability-Related Considerations:* - Does the health history address the patient's specific disability and the effect of disability on the patient's ability to obtain health care, manage self-care activities, and obtain preventive health screening and follow-up care? - What physical modifications and positioning are needed to ensure a thorough physical examination, including pelvic or testicular and rectal examination? *Abuse:* - Is the increased risk for abuse (physical, emotional, financial, and sexual) by various people (family, paid care providers, strangers) addressed in the assessment? - If abuse is detected, are men and women with disabilities who are survivors of abuse directed to appropriate resources, including accessible shelters and hotlines? *Depression:* - Is the patient experiencing depression? - If so, is treatment offered just as it would be to a patient without a disability, without assuming that depression is normal and a result of having a disability? *Aging:* - What concerns does the patient have about aging with a preexisting disability? - What effect has aging had on the patient's disability, and - What effect has the disability had on the patient's aging? *Secondary Health Conditions:* - Does the patient have secondary health conditions related to their disability or its treatment? - Is the patient at risk for secondary health conditions because of environmental barriers or lack of access to health care or health promotion activities? - Are strategies in place to reduce the risk for secondary health conditions or to treat existing secondary health conditions? *Accommodations in the Home:* - What accommodations does the patient have at home to encourage or permit self-care? - What additional accommodations does the patient need at home to encourage or permit self-care? *Cognitive Status:* - Is it assumed that the patient is able to participate in discussion and conversation rather than assuming that he or she is unable to do so because of a disability? - Are appropriate modifications made in written and verbal communication strategies? *Modifications in Nursing Care:* - Are modifications made during hospital stays, acute illness or injury, and other health care encounters to enable a patient with disability to be as independent as he or she prefers? - Is "people-first language" used in referring to a patient with disability, and do nurses and other staff talk directly to the patient rather than to those who accompanied the patient? - Are all staff informed about the activities of daily living for which the patient will require assistance? - Are accommodations made to enable the patient to use their assistive devices (hearing/visual aids, prostheses, limb support devices, ventilators, service animals)? - If a patient with disability is immobilized because of surgery, illness, injury, or treatments, are risks of immobility addressed and strategies implemented to minimize those risks? - Is the patient with a disability assessed for other illnesses and health issues (e.g., other acute or chronic illness, depression, psychiatric/mental health, and cognitive disorders) not related to their primary disability? *Patient Education:* - Are accommodations and alternative formats of instructional materials (large print, Braille, visual materials, audiotapes) provided for patients with disabilities? - Does patient instruction address the modifications (e.g., use of assistive devices) needed by patients with disabilities to enable them to adhere to recommendations? - Are modifications made in educational strategies to address learning needs, cognitive changes, and communication impairment? *Health Promotion and Disease Prevention:* - Are health promotion strategies discussed with people with disabilities along with their potential benefits: improving quality of life and preventing secondary health conditions (health problems that result because of preexisting disability)? - Are patients aware of accessible community-based facilities (e.g., health care facilities, imaging centers, public exercise settings, transportation) to enable them to participate in health promotion? *Independence Versus Dependence:* - Is independence, rather than dependence, of the person with a disability the focus of nursing care and interaction? - Are care and interaction with the patient focused on empowerment rather than promoting dependence of the patient? *Insurance Coverage:* - Does the patient have access to the health insurance coverage and other services for which he or she qualifies? - Is the patient aware of various insurance and other available programs? - Would the patient benefit from talking to a social worker about eligibility for Medicaid, Medicare, disability insurance, and other services?

What is a check-back and how is it used to improve communication?

- A closed-loop communication strategy used to verify and validate information exchanged. - Involves the sender initiating a message, the receiver accepting the message and confirming what was communicated, and the sender verifying that the message was received.

Describe an Initial Assessment (compared to a focused one)

- Performed shortly after the patient is admitted to a health care facility or service. - The purpose of this assessment is to establish a complete database for problem identification and care planning (Note: everything you assess is a piece of data). The nurse: - Collects data concerning all aspects of the patient's health - Establishing priorities for ongoing focused assessments - Creating a reference baseline for future comparison.

What factors are used in choosing a nursing diagnosis?

1. Desired patient outcomes 2. Characteristics of the nursing diagnosis 3. Research base for the intervention 4. Feasibility for doing the intervention 5. Acceptability to the patient 6. Capability of the nurse

During the outcome identification and planning steps of the nursing process, the nurse works in partnership with the patient and family to:

1. Establish priorities 2. Identify and write expected patient outcomes 3. Select evidence-based nursing interventions 4. Communicate the nursing care plan

In addition to the main purpose, what are the 3 adjuvant purposes of the nursing diagnosis?

1. Identify how a person, group, or community responds to actual or potential health and life processes. 2. Identify factors that contribute to or cause health problems (etiologies). 3. Identify resources or strengths that the person, group, or community can draw on to prevent or resolve problems

Define goal.

An aim to an end.

What is evaluated when an outcome is cognitive, psychomotor, affective or physiologic?

Cognitive: - Describes an increase in patient knowledge or intellectual behaviors Psychomotor: - Describes the patient's achievement of new skills Affective: - Describes changes in patient values, beliefs, and attitudes Physiologic: - Describes changes in patient physiologic parameter

In the second step of data interpretation and analysis, describe the importance of patterns and clusters.

Nursing Diagnoses are ALWAYS derived from clusters of significant data; NEVER a single cue. - The danger with using single cues is making errors in diagnosing leading to inaccurate care and unsafe care.

Describe the different sources from which a nurse collects data: Nursing and Other Healthcare Literature.

Nursing and Other Healthcare Literature can support the nurses full understanding about the disease or illness the patient is experiencing, the disease progression, treatments, etc. In addition, evidence-based literature helps the nurse understand the impact of culture for a particular population and practices that may interfere with usual treatment as well as assist when providing care to patients.

What impedes/affects wound healing?

Pressure: - Pressure disrupts the blood supply to the wound area. Persistent or excessive pressure interferes with blood flow to the tissue and delays healing. -> Activity and exercise - immobility or lack of activity may impact the intensity of pressure. Sitting in a chair for long time can foster an environment ready for impairment Desiccation (dehydration): - Desiccation is the process of drying up. Cells dehydrate and die in a dry environment. This cell death causes a crust to form over the wound site and delays healing. - Wounds that are kept moist (not wet) and hydrated experience enhanced epidermal cell migration, which supports epithelialization (epithelial cell migration to the wound bed; Hess, 2013). Maceration (over-hydration): - Maceration is softening and breakdown of skin, results from prolonged exposure to moisture. - Over-hydration of cells related to urinary and fecal incontinence can also lead to maceration and impaired skin integrity. This damage is related to moisture, changes in the pH of the skin, overgrowth of bacteria and infection of the skin, and erosion of skin from friction on moist skin. Incontinence Trauma or Invasive Procedure: - Trauma (especially if a repeated trauma to a wound area) results in delayed healing or the inability to heal. Edema: - Edema at a wound site interferes with the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue. Infection: - Infection is bacteria in a wound and increases stress on the body, requiring increased energy to deal with the invaders. - Infection requires large amounts of energy be spent by the immune system to fight the microorganisms, leaving little or no reserves to attend to the job of repair and healing. In addition, toxins produced by bacteria and released when bacteria die interfere with wound healing and cause cell death. Excessive Bleeding: - Excessive Bleeding results in large clots. - Large clots increase the amount of space that must be filled during healing and interferes with oxygen diffusion to the tissue. The accumulated blood or drainage of any type is an excellent place for growth of bacteria and promotes infection (Baranoski & Ayello, 2016). Necrosis: - Dead tissue present in the wound delays healing. - Dead tissue appears as slough—moist, yellow, stringy tissue—and eschar appears as dry, black, leathery tissue. - Healing of the wound will not take place with necrotic tissue in the wound. - Removal of the dead tissue must occur for healing to begin (Baranoski & Ayello, 2016; Hess, 2013). Biofilm: - Biofilm is the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins. - This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Baranoski & Ayello, 2016; Hess, 2013). - The bacteria also produce a protective matrix that attaches the biofilm to the wound surface. - Biofilms impair wound healing and contribute to chronic wound inflammation and wound infection (Baranoski & Ayello, 2016; NPUAP, EPUAP, & PPPIA, 2014). Personal hygiene: - Hygiene has an impact on the health of skin in it's ability to protect.

Look over this Nursing Diagnosis example.

Problem/Label: Bathing self-care deficit Etiology/Cause: r/t fear of falling in tub and obesity Defining Characteristics: AEB strong body and urine odor, unclean hair, "I'm afraid I'll fall in the tub and break something," 5'4" & 170 lb.

What criteria is used by the nurse to terminate, modify or continue a plan of care?

Terminate: - Terminate the care plan when each expected outcome is achieved (the nursing diagnosis/problem has been resolved) - outcome is met. Modify: - Modify the care plan if there are difficulties achieving the outcomes - outcome is not met. Continue the Care Plan: - Continue the care plan if more time is needed to achieve the outcomes - outcome is partially met.

Describe the "assessment" part of the nursing process.

The assessment is the foundation of care. - It is the systematic and continuous collection, analysis, validation, and communication of patient data, or information. - It is a vital step in the nursing process critical for safety, accuracy, and efficiency of care. - Data reflects how health functioning is enhanced by health promotion or compromised by illness and injury. - *Collecting patient data creates a database of all the pertinent patient information* and enables partnering with patients to develop a comprehensive and effective plan of care. - Subsequent steps of the nursing process depend on purposeful, prioritized, complete, systematic, accurate, and relevant data.

How might you close the loop of communication if presented with an example?

The sender would verify that the correct message was received by saying "Correct."

How are different disabilities described and categorized?

*Disabilities are sometimes categorized as:* - Developmental: Occur any time from birth to 22 years of age and result in impairment of physical or mental health, cognition, speech, language, or self-care - Acquired: As a result of an acute and sudden injury (e.g., traumatic brain injury [TBI]; spinal cord injury; and traumatic amputation due to traffic crashes, falls, burns, or acts of violence such as intimate partner violence and war and military conflicts), acute non-traumatic disorders (e.g., stroke, myocardial infarction), or progression of a chronic disorder (e.g., arthritis, multiple sclerosis, Parkinson's disease, chronic obstructive pulmonary disease, heart disease, blindness due to diabetic retinopathy). - Age Related: Associated with changes in aging or conditions that result due to the aging process. *When describing the types of disability, descriptions would include:* - Cognitive: limitations in mental functioning and difficulties with communication, self-care, and difficulty with social skills. Examples could be physical disability only, or related to medication and/or genetic conditions: - Developmental: occur any time from birth to 22 years of age; result in impairment of physical or mental health, cognition, speech, language, or self-care.Could be physical along, be associated with intellectual disability and the result of medical or genetic conditions. Examples: spina bifida, cerebral palsy, Down syndrome, muscular dystrophy, dwarfism, and osteogenesis imperfecta; birth trauma or severe illness or injury at a very young age; some developmental disabilities overlap with cognitive and/or intellectual disabilities that affect intellectual functioning and adaptive behavior. - Physical: limitations in physical functioning (mobility, self-care, any activity with required dexterity, strength, tolerance and coordination to complete) - Intellectual: occurs before 18 years of age; characterized by significant limitations in both intellectual functioning as well as in adaptive behavior in everyday social and practical skills. - Sensory: characterized by impairment of the sense of sight, hearing, smell, touch, and/or taste; learning disabilities that affect the ability to learn, remember, or concentrate; affect the ability to speak or communicate; affect the ability to work, shop, and care for oneself, or access health care. Risks associated with sensory disabilities include isolation, reduced cognitive function, poor physical and psychological health, and increased risk of falls and hospitalization (McKee, 2019). - Psychiatric: mental illness or impairment that substantially limits one's ability to complete major life activities (learning, working, and communicating (WHO, 2018b)). - Acquired: disabilities may occur

When interacting and communicating with people with disabilities, patients will feel most comfortable receiving health care if you consider the following suggestions:

*General Considerations:* - Do not be afraid to make a mistake when interacting and communicating with someone with a disability or chronic medical condition. - Keep in mind that a person with a disability is a person first and is entitled to the dignity, consideration, respect, and rights you expect for yourself. - Treat adults as adults. Address people with disabilities by their first names only if extending the same familiarity to all others present. Never patronize people by patting them on the head or the shoulder. - Relax. If you do not know what to do, allow the person who has a disability to identify how you may be of assistance and to put you at ease. - If you offer to assist and the person declines, do not insist. If your offer is accepted, ask how you can best help, and follow directions. - Do not take over. If someone with a disability is accompanied by another individual, address the person with a disability directly rather than speaking through the accompanying companion. - Be considerate of the extra time it might take for a person with a disability to get things done or said. Let the person set the pace. - Do not be embarrassed to use common expressions, such as "See you later" or "Got to be running," that seem to relate to the person's disability. - Use people-first language: Refer to "a person with a disability" rather than "a disabled person" and avoid referring to people by the disability or disorder they have (e.g., "the diabetic"). *Mobility Limitations:* - Do not make assumptions about what a person can and cannot do - Do not push a person's wheelchair or grab the arm of someone walking with difficulty without first asking whether you can be of assistance and how you can assist. Personal space includes a person's wheelchair, scooter, crutches, walker, cane, or other mobility aid. Never move someone's wheelchair, scooter, crutches, walker, cane, or other mobility aid without permission. - When speaking for more than a few minutes to a person who is seated in a wheelchair, try to find a seat for yourself so that the two of you are at eye level. - When giving directions to people with mobility limitations, consider distance, weather conditions, and physical obstacles such as stairs, curbs, and steep hills. - Shake hands when introduced to a person with a disability. - People who have limited hand use or who wear an artificial limb do shake hands. *Vision Loss (Low Vision and Blindness):* - Identify yourself when you approach a person who has low vision or blindness - If a new person approaches or engages with your conversation, introduce him or her - Touch the person's arm lightly when you speak so that he or she knows to whom you are speaking before you begin. - Face the person and speak directly to him or her. Use a normal tone of voice. Do not leave without saying that you are leaving. - If you are offering directions, be as specific as possible and point out obstacles in the path of travel. Use specifics such as "Left about twenty feet" or "Right two yards." - Use clock cues, such as "The door is at 10 o'clock." When you offer to assist someone with vision loss, allow the person to take your arm. This will help you guide rather than propel or lead the person. - When offering seating, place the person's hand on the back or the arm of the seat. Alert people with low vision or blindness to posted information. - Never pet or otherwise distract a canine companion or service animal unless the owner has given you permission. (the American with Disability Act (ADA) provided the right for service animals to be present with them wherever care is provided). *Hearing Loss (Hard of Hearing, Deaf, Deaf-Blind):* - Ask the person how he or she prefers to communicate - If you are speaking through a sign language interpreter, remember that the interpreter may lag a few words behind—especially if there are names or technical terms to be finger spelled—so pause occasionally to allow the interpreter time to translate completely and accurately. - Talk directly to the person who has hearing loss, not to the interpreter. However, although it may seem awkward to you, the person who has hearing loss will look at the interpreter and may not make eye contact with you during the conversation. - Before you start to speak, make sure that you have the attention of the person you are addressing. A wave, a light touch on the arm or the shoulder, or other visual or tactile signals are appropriate ways of getting the person's attention. - Speak in a clear, expressive manner. Do not over enunciate or exaggerate words. Unless you are specifically requested to do so, do not raise your voice. Speak in a normal tone; do not shout. - To facilitate lip reading, face the person and keep your hands and other objects away from your mouth. Maintain eye contact. Do not turn your back or walk around while talking. If you look away, the person might assume that the conversation is over. - Avoid talking while you are writing a message for someone with hearing loss, because the person cannot read your note and your lips at the same time. - Try to eliminate background noise. - Encourage feedback to assess clear understanding. - If you do not understand something that is said, ask the person to repeat it or to write it down. The goal is communication; do not pretend to understand if you do not. - If you know any sign language, try using it. It may help you communicate, and it will at least demonstrate your interest in communicating and your willingness to try. *Speech Disabilities or Speech Difficulties:* - Talk to people with speech disabilities as you would talk to anyone else - Be friendly; start up a conversation. - Be patient; it may take the person a while to answer. Allow extra time for communication. - Do not speak for the person. - Give the person your undivided attention. - Ask the person for help in communicating with him or her. If the person uses a communication device such as a manual or electronic communication board, ask the person the best way to use it. - Speak in your regular tone of voice. - Tell the person if you do not understand what he or she is trying to say. Ask the person to repeat the message, spell it, tell you in a different way, or write it down. Use hand gestures and notes. - Repeat what you understand. The person's reactions will clue you in and guide you to understanding. - To obtain information quickly, ask short questions that require brief answers or a head nod. Avoid insulting the person's intelligence with oversimplification. - Keep your manner encouraging rather than correcting. *Intellectual/Cognitive Disabilities:* - Treat adults with intellectual/cognitive disabilities as adults - Be alert to the individual's responses so that you can adjust your method of communication as necessary. For example, some people may benefit from simple, direct sentences or from supplementary visual forms of communication, such as gestures, diagrams, or demonstrations. - Use concrete rather than abstract language. - Be specific, without being too simplistic. When possible, use words that relate to things you both can see. Avoid using directional terms such as right, left, east, or west. Be prepared to give the person the same information more than once in different ways. - When asking questions, phrase them to elicit accurate information. People with intellectual/cognitive disabilities may be eager to please and may tell you what they think you want to hear. Verify responses by repeating the question in a different way. - Give exact instructions. For example, "Be back for lab work at 4:30," not "Be back in 15 minutes." - Avoid giving too many directions at one time, which may be confusing. - Keep in mind that the person may prefer information provided in written or verbal form. - Ask the person how you can best relay the information. - Using humor is fine, but do not interpret a lack of response as rudeness. Some people may not grasp subtleties of language. - Know that people with brain injuries may have short-term memory deficits and may repeat themselves or require information to be repeated. - Recognize that people with auditory perceptual problems may need to have directions repeated and may take notes to help them remember directions or the sequence of tasks. They may benefit from watching a task demonstrated. - Understand that people with perceptual or "sensory overload" problems may become disoriented or confused if there is too much to absorb at once. Provide information gradually and clearly. Reduce background noise if possible. - Repeat information using different wording or a different communication approach if necessary. Allow time for the information to be fully understood. - Do not pretend to understand if you do not. Ask the person to repeat what was said. Be patient, flexible, and supportive. - Be aware that some people who have an intellectual disability are easily distracted. Try not to interpret distraction as rudeness. - Do not expect all people to be able to read well. Some people may not read at all. *Psychiatric/Mental Health Disabilities:* - Speak directly to the person. Use clear, simple communication - Offer to shake hands when introduced. Use the same good manners in interacting with a person who has a psychiatric/mental health disability that you would with anyone else. - Make eye contact and be aware of your own body language. Like others, people with psychiatric/mental health disabilities will sense your discomfort. - Listen attentively and wait for the person to finish speaking. If needed, clarify what the person has said. Never pretend to understand. - Treat adults as adults. Do not patronize, condescend, or threaten. Do not make decisions for the person or assume that you know the person's preferences. - Do not give unsolicited advice or assistance. Do not panic or summon an ambulance or the police if a person appears to be experiencing a mental health crisis. Calmly ask the person how you can help. - Do not blame the person. A person with a psychiatric disability has a complex, biomedical condition that is sometimes difficult to control. The person cannot just "shape up." It is rude, insensitive, and ineffective to tell or expect a person to do so. - Question the accuracy of media stereotypes of psychiatric/mental health disabilities: Movies and media often sensationalize psychiatric/mental health disabilities. Most people never experience symptoms that include violent behavior. - Relax. Be yourself. Do not be embarrassed if you happen to use common expressions that seem to relate to a psychiatric/mental health disability. - Recognize that beneath the symptoms and behaviors of psychiatric disabilities is a person who has many of the same wants, needs, dreams, and desires as anyone else. If you are afraid, learn more about psychiatric/mental health disabilities.

Describe the 3 components of the nursing diagnosis statement: Problem, Cause/Etiology & Defining Characteristics.

*Problem (label & its definition):* - The label is the name that reflects the focus of the diagnosis - The definition provides a clear, precise description; delineates its meaning and helps differentiate it from similar diagnoses - Identifies what is unhealthy about the patient, indicating what the patient would like to change in his or her health status. - Suggests the Patient Outcomes (expectations for change) *Cause/Etiology (r/t):* - Identifies the factors that maintain the unhealthy patient state and prevent the desired change (contributing to or cause) -> These factors are physiologic/pathophysiologic, psychological, sociologic, spiritual, treatment, developmental/maturational and situational (personal, environmental) and believed to be related to the problem as either a cause or a contributing factor (prevent the desired change). - Unless the etiology is correctly identified, nursing actions might be inefficient and ineffective. - Suggests the appropriate Nursing Interventions *Defining Characteristics (AEB):* - Identify subjective and objective data that signal the existence of the problem (observable cues that reflect the existence of a problem) - Remember that the defining characteristics are part of the assessment data (what is seen, heard, touched, smelled, patient/family tells us). - Suggests Evaluative Criteria

What interventions are used to prevent pressure injury? - Skin Assessment - Skin Care - Nutrition - Reposition & Mobilization - Education

*Skin/Risk Assessment:* - At least EVERY 8 or 12 hours (every shift) - Use valid tool: Braden Tool - Refine for factors as: Fragile skin, Existing pressure injury of any stage, Impairments in blood flow, Pain in body areas exposed to pressure *Skin Care:* - Use pH balanced skin cleansers - Clean skin promptly after episodes of incontinence - Use skin moisturizers on dry skin - Avoid positioning on an area of erythema, pressure injury *Nutrition:* - Valid & reliable risk of malnutrition screening tool (mini nutritional assessment) - Refer to nutritionist/registered dietitian if screen positive for malnutrition - Be present and assist at mealtimes - Encourage fluids, balance diet - If needed, provide nutritional supplement between meals and with medications *Reposition & Mobilization:* - Turn, reposition if at risk for pressure injury - Frequency is based on support surface, skin tolerance to pressure and individual preferences (consider longer intervals at night for uninterrupted sleep); hourly for immobile - Turn into a 30o side lying position (lateral), palpate sacrum to be sure off bed (polyurethane foam dressing) - Avoid pressure points (including heels to be off bed) - Use breathable incontinence pads *Education:* - Instruct with teach back about PI injury - Instruct with patient, family, significant others or care provider engagement with using and applying risk reduction interventions.

How would you know a nursing diagnosis is a nursing diagnosis? (Hint: What is not considered a nursing diagnosis?)

- A Medical diagnosis (Type 1 Diabetes) - A Medical pathology (Hypoglycemia) - Diagnostic tests, treatments, equipment (FBS, insulin therapy, insulin pump) - Therapeutic patient need (needs to learn the relation among diet, exercise and insulin) - Therapeutic nursing goals (to develop therapeutic diabetes self-care behaviors) - A single sign or symptom (after successfully administering own insulin for 3 days, patient tells nurse, "you give me my shot today" - An invalidated nursing inference (the above incident leads to the nursing inference: noncompliance related to depression

Describe a Focused Assessment (compared to an initial one)

- A focused assessment is when the nurse gathers data about a specific problem that has already been identified. - A focused assessment may be done during the initial assessment if the patient's health problems surface, but it is routinely part of ongoing data collection. - Gather information about the problem by asking the patient the 8 critical characteristics. - Another purpose of the focused assessment is to identify new or overlooked problems.

In the third step of data interpretation and analysis, describe the STRENGTHS which include the patient and family/significant others.

- A patient appears to meet a standard or norm, the nurse concludes that the patient has a strength contributing to level of wellness. - However, it is important to identify strengths so the nurse can counsel the patient on using them in times of illness. - Many people take their strengths for granted and may not know how to use them effectively when responding to illness. - Strengths may include healthy physiologic functioning, emotional health, cognitive abilities, coping skills, interpersonal strengths, and spiritual strengths. Resources such as the presence of support people, adequate finances, and a healthy environment contribute to strengths.

The challenges of living with chronic conditions include the need to accomplish the following:

- Alleviate and manage symptoms - Psychologically adjust to and physically accommodate resulting disability - Prevent and manage crises and complications - Carry out regimens as prescribed - Validate individual self-worth and family functioning - Manage threats to identity - Normalize personal and family life as much as possible - Live with altered time, social isolation, and loneliness - Establish networks of support and resources that can enhance quality of life - Return to a satisfactory way of life after an acute debilitating episode (e.g., another myocardial infarction or stroke) or reactivation of a chronic condition - Die with dignity and comfort

What does using clinical reasoning during assessment involve?

- Assessing systematically and comprehensively - Detecting bias and determining the credibility of information sources - Distinguishing normal from abnormal findings and identifying the risks for abnormal findings - Making judgments about the significance of data, distinguishing relevant from irrelevant - Identifying assumptions and inconsistencies, checking accuracy and reliability, and recognizing missing information

What is the purpose of a care plan?

- Directs the efforts of the nursing team working with the patient to meet his or her health goals. - Ensures the nursing team delivers efficient, holistic, goal-oriented, person-centered care to patients.

What are the main risk factors for the development of pressure injuries?

- Immobility - Nutrition and hydration - Skin moisture - Mental status - Age

Describe common problems related to data collection & examples of each.

- Inappropriate organization of the database (using wrong tool to collect data; failure to plan to type of data to collect) - Omission of pertinent data (not following up on observed cues during the interview) - Inclusion of irrelevant or duplicate data (failure to identify the purpose of the data collection), erroneous or misinterpreted data (failure to validate data collected during the interview) - Failure to establish rapport and partnership with the patient (use of inappropriate communication techniques or knowing what information you want; failure to complete interviewing task before entering the patient room) - Recording an interpretation of data rather than observed behavior (nurse jumps to hasty conclusions with deficient validation) - Failure to update the database (low priority attached to ongoing data collection).

What are the different types of wounds and how are each of them caused?

- Incision: Cutting or sharp instrument; wound edges in close approximation and aligned. - Contusion: Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma. - Abrasion: Friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded. - Laceration: Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue. - Puncture: Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental. - Penetrating: Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues. - Avulsion: Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures. - Chemical: Toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis. - Thermal: High or low temperatures; cellular necrosis as a possible result. - Irradiation: Ultraviolet light or radiation exposure. - Pressure Ulcers: Compromised circulation secondary to pressure or pressure combined with friction. - Venous Ulcers: Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction. - Arterial Ulcers: Injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis. - Diabetic Ulcers: Injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure.

What will promote wound healing?

- Intact skin is the first line of defense - Surgical asepsis is used for wound care - The body responds systemically to trauma - Adequate blood supply is essential for effective healing - Maintaining a wound is free of foreign materials to promote healing - Extent of damage and person's state of health affects wound healing - Proper nutrition enhances the wound healing process (protein, carbs, fats, water, zinc & Vitamins C, K, A)

What is objective data and when is it collected?

- Objective data is the data collected by the nurse through observation. It is measurable data that can be seen, heard, or felt by someone other than the person experiencing them. - AKA the "signs." For example: elevated temperature, skin moisture, vomiting. - It is phrased how the nurse would document it. - It is collected during the physical assessment.

Look over these examples of well written nursing interventions.

- Offer patient 60-mL water or juice (prefers orange or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL. - Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. - Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake.

Be able to recognize examples of Check-backs.

- One member of the team calls out, "BP is falling, 80/48 down from 90/60." Another team member verifies and validates receipt of the information by saying, "Got it; BP is falling and at 80/48, down from 90/60." The original sender of the information completes the loop by saying, "Correct." - One member of the team says "can you walk 33-1 to the bathroom, it's been 5 minutes since she put on her call light requesting help?" The other team member responds with "you need me to walk 33-1 to the bathroom now because it's been 5 minutes since she requested help." "Yes, that would help me meet the patient's request."

List the 3 different ways a Nursing Diagnosis can be written.

- One-part statements: (nursing diagnosis label) = HEALTH PROMOTION - Two-part statements: (nursing diagnosis label-patient's problem) and relate to... (the cause/etiology or contributing factors) = RISK - Three-part statements: (patient's problem (diagnosis label), related to... (its cause (etiology) and AEB (the problem's defining characteristics)) = PROBLEM FOCUSED

Describe the different ways an inference may be validated / What criteria are used to determine data validity?

- Physical examination, using the proper equipment and procedure (you may need to have an expert confirm your findings) - Using what the patient said and objective data - Clarifying statements ("You said this is not a problem, but I sense you may still be worried.") - Sharing your inferences with other respected members of the team and seeking consensus - Checking your findings with research reports, textbooks, or journals - Comparing cues to your knowledge base of normal function When it is clear data are correct, the nurse is ready to analyze the data and formulate nursing diagnoses/problems

What are the key elements of a well-written care plan?

- Represents nursing's four aims: promoting health, preventing disease and illness, promoting recovery, and facilitating coping with altered functioning. - Prepared by the nurse who best knows the patient. - Created (recorded) on the day the patient presents for treatment and care. - Is responsive to the individual characteristics, values and needs of the patient; is culturally appropriate. - Clearly identifies: 1. The nursing assistance the patient needs 2. Nursing's collaborative responsibilities for fulfilling the medical and interdisciplinary care plan 3. Clearly specifies nursing diagnoses/problems, patient outcomes, nursing interventions, and evaluative strategies - Directs nurse's assessment priorities, caregiving behaviors, and teaching, counseling, and advocacy behaviors - Is based on scientific principles; incorporates nursing research findings - Meets the patient's needs (physiologic, developmental, psychosocial, and spiritual) - Is updated to reflect changes in the patient's status and related needs for nursing care - Addresses the discharge needs of the patient (and family) - Provides for as much patient (and family) participation as possible - Is compatible with the medical care plan and that of the interdisciplinary team (when appropriate) - Creates a record that can be used for evaluation, research, reimbursement, and legal purposes

What is subjective data and when is it collected?

- Subjective data is the information that the patient reports. It is only perceived by the affected person. - AKA the "symptoms." For example: ◦pain experience, feeling dizzy, feeling anxious - It is collected during the health history by what the patient says.

Using inspection and palpation, what findings related to the wound would be assessed?

- Surrounding skin (inspection and palpation) - Pain - Wound Appearance - Location - Size (length, width, depth) - Color of wound - Drainage color and amount (sanguineous, sero-sanguinous, serous, or purulent) - Temperature (palpation) - Odor - Wound closures - Type of dressing - Inspection for sight and smell - Palpation for appearance, drainage (type, amount, consistency), and pain - Sutures, drains or tubes, and manifestation of complications - Approximated edges?

What is a nursing diagnosis?

- The interpretation and analysis of patient data to identify actual or potential patient strengths, health problems or issues (an ill-defined problem) that nursing intervention can prevent or resolve - The nursing diagnosis may change from day to day as the patient's responses to health and illness change. - Each nursing diagnosis provides the basis for selecting nursing interventions that will facilitate the achievement of patient outcomes (valued by the patient).

When is data validated?

- When there is a discrepancy between what the person is saying and what the nurse is observing. - When the data lack objectivity, suspicions are not objective *Whenever any data discrepancy or conflict exists, the nurse must investigate further, gathering focused information to support, confirm, or negate the suspicions (in short, get more data).*

What are the different steps of the nursing process?

1. *Assessing* the patient to determine the need for nursing care. 2. Determine *Nursing Diagnoses* for actual and potential health problems. 3. Identify expected *Outcomes* and *Plan Care* 4. *Implement* the care 5. *Evaluate* the results of care

Describe the 4 Standards of Effective Communication.

1. Complete: - Communication includes all relevant (important) information while avoiding unnecessary details that may lead to confusion. - Leave enough time for patient questions, and answer questions completely. 2. Clear: - Use information that is plainly understood (layman's terminology with patients and their families). - Use common or standard terminology when communicating with members of the team. 3. Brief: - Communicate in a concise manner 4. Timely: - Be dependable about offering and requesting information. - Avoid delays in relaying information that could compromise a patient's situation. - Note times of observations and interventions in the patient's record. - Update patients and families frequently. - Verify authenticity, which requires checking that the information received was the intended message of the sender. - Validate or acknowledge information

What are the two important considerations a nurse must make when they begin to prepare in collecting data.

1. Establish the Assessment Priorities 2. Systematically structure how the data collection occurs

What are the 4 common errors to avoid when writing an outcome statement?

1. Expressing the patient outcome as a nursing intervention: - Incorrect: Offer Mr. Myer 60-mL fluid every 2 hours while awake. - Correct: Mr. Myer will drink 60-mL fluid every 2 hours while awake, beginning 2/24/21. 2. Using verbs that are not observable and measurable: - Incorrect: Mrs. Gaston will know how to bathe her newborn. - Correct: After attending the infant care class, Mrs. Gaston will correctly demonstrate the procedure for bathing her newborn. 3. Including more than one patient behavior/manifestation in outcomes: - Incorrect: Patient will list dangers of smoking and stop smoking. - Correct: 1) By next meeting, 3/11/21, the patient will identify three dangers of smoking 2) By next meeting, 3/11/21, the patient will describe a plan he is willing to try to stop smoking. [goals 1 & 2 are examples of short-term outcomes] 3) By 6/20/21, the patient will report that he no longer smokes. [this is an example of a long-term outcome] 4. Writing outcomes that are so vague that other nurses are unsure of the goal for nursing care: - Incorrect: "Patient will cope better. - Correct: 1) After teaching, 10/20/21, the patient will describe two new coping strategies he is willing to try 2) After teaching, 10/20/21, the patient will demonstrate decreased incidence of previously observed ineffective coping behaviors (chain smoking, withdrawal behavior, heavy alcohol consumption).

Identify Challenges to Communication.

1. Language barriers: - Non-English speaking patients/staff pose particular challenges. 2. Distractions: - Emergencies can take your attention away from the current task at hand. - TVs going, noises down the hallway, etc. 3. Physical proximity: - Too far away = Can't hear the person - Too close = can't pay attention because you're thinking about backing up 4. Personalities: - Sometimes it is difficult to communicate with particular individuals. 5. Workload: - During heavy workload times, all of the necessary details may not be communicated, or they may be communicated but not verified. 6. Varying communication styles: - Health care workers have historically been trained with different communication styles. 7. Conflict: - Disagreements may disrupt the flow of information between communicating individuals. 8. Lack of verification of information: - Verify and acknowledge information exchanged. 9. Shift change: - Transitions in care are the most significant time when communication breakdowns occur. - One of the biggest times where sentinel events happen with patients

What guides a nurse in making those rankings? In other words, what are the 3 guides you can use when prioritizing/ranking the list of nursing diagnosis?

1. Maslow's Hierarchy of Human Needs (basic needs of the patient must be met before the patient can focus on higher ones): - Physiologic needs - Safety needs - Love and belonging needs - Self-esteem needs - Self-actualization needs 2. Patient Preference (being thoughtful and patient-centered) - First meet the needs that the patient thinks are most important, so long as this order of priority determined by patient does not interfere with other vital therapies. 3. Anticipation of Future Problems - Nurses must tap their knowledge base to consider the potential effects of different nursing actions. - Assigning low priority to a diagnosis that the patient wants to ignore but can result in harmful future consequences for the patient might be nursing negligence.

What are the 4 steps involved in interpreting and analyzing assessment data to make the best determination of a nursing diagnosis? Note: The next set of questions after this one asks you to explain each step further.

1. Recognizing significant data (comparing data to standards) 2. Recognizing patterns or clusters 3. Identifying strengths and problems and potential complications 4. Reaching conclusions

What are the 2 components of an evaluation statement?

1. The decision about how well the outcome was met 2. The patient data or behaviors that support this decision

What are the 6 major categories for impaired tissue integrity?

1. Trauma/injury 2. Loss of perfusion 3. Immunological reaction 4. Infections/infestations 5. Thermal/radiation 6. Lesions

What is a data cluster?

A grouping of patient data or cues that point to the existence of a health problem.

What is the definition of "wound"?

A wound is a break or disruption in the normal integrity of the skin and tissues. Wounds occur when skin is no longer able to function as a barrier and the protective function is impaired.

Define expected outcome.

An expected conclusion to a patient health problem or patient's health expectation with specific measurable criteria; the results achieved.

Describe the different sources from which a nurse collects data: Assessment Technology.

Assessment technology includes collecting data from technologies/devices requiring continuous monitoring such as cardiac, respiratory, vital signs.

What would be the focus of a cognitive, psychomotor, affective, clinical, functional and quality of life based outcome?

Cognitive Outcomes: - Describe increases in patient knowledge or intellectual behaviors (e.g., "Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge." Psychomotor Outcomes: - Describe the patient's achievement of new skills (e.g., "By 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer." Affective Outcomes: - Describe changes in patient values, beliefs, and attitudes (e.g., "By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer." Clinical: - Describe the expected status of health issues at certain points in time, after treatment is complete; addresses whether the problems are resolved or to what degree improved. Functional: - Describe the person's ability to function in relation to the desired usual activities. Quality of Life: - Focus on key factors that affect someone's ability to enjoy life and achieve personal goals.

How does communication affect team processes and outcomes?

Communication (a lifeline of the team) affects team process and team outcomes by influencing how the team functions and as well as the flow of the mechanism of teamwork resulting with an impact on patient safety by increasing the risk of error. Communication facilitates the development of shared mental models, adaptability, mutual trust, and patient safety.

In the third step of data interpretation and analysis, describe how potential COMPLICATIONS are identified.

Complications Patient May Have or Experience: - Patients may experience many complications related to their diagnoses, medications or treatment regimens, or invasive diagnostic studies - The role of the nurse is early detection and prevention of complications through identification of abnormal (significant cues) data sets. - To understand the potential for complications, the nurse must be familiar with the potential complications associated with the patient's diagnoses, diagnostics, and treatment, and if you report all abnormal data.

Describe the differences between Cues and Inferences as they relate to the assessment portion of the Nursing Process.

Cues: - Subjective and objective data to help identify that something may be wrong. - Ex: "The patient does not respond when I speak to him on his left side." Inferences: - Judgments reached about cues - Ex: The patient's hearing may be impaired on his left side. - Inferences must be validated for accuracy and can be performed during data collection or at the end of the data-gathering process. - Ex: Until you check the patient's hearing, you cannot be sure that your inference is correct.

In the third step of data interpretation and analysis, describe how patient PROBLEMS are determined.

Determining Problem Areas Patient is Likely to HAVE: - When a person who does not meet a certain health standard or norm probably has a limitation in that area and may benefit from professional care. - For example: A person with a long history of constipation probably needs care to help overcome this problem. However, the nurse decides whether the data represents a nursing diagnosis or a collaborative problem, or whether the data should be reported to the health care provider because they might lead to a medical diagnosis. Determining Problems the Patient is Likely to EXPERIENCE: - When data analyzed predicts a potential health problem. - The prediction has implications for future nursing care. - For example: A nurse notes that a patient has signs of a wound infection, but laboratory test results show that the patient's white blood cell count has not increased, as is usual when such an infection is present. The nurse concludes that the body apparently is not building up normal defenses to combat the infection. The nurse then predicts the problems this patient is likely to encounter, such as a longer-than-normal healing period. Potential nursing diagnoses alert other caregivers to problems the patient may experience if certain trends in the patient's condition continue unreversed. This prediction has implications for nursing care, such as the need for measures related to the patient's diet, fluid intake, urine output, and mobility.

How do direct and indirect care interventions differ?

Direct Care: - A treatment performed through interaction with the patient(s) - Includes physiologic (physical contact) and psychological (supportive and counseling) nursing actions. Indirect Care: - A treatment performed away from the patient but on behalf of a patient; aimed to manage the patient care environment, collaborate with the interdisciplinary team, and support the effectiveness of direct care interventions.

Differentiate between the terms disability, chronic disease & chronic illness.

Disability: - Restriction or lack of ability to perform an activity in a normal manner; the consequences of impairment in terms of a person's functional performance and activity. -Disability represents impairment at the level of the person (e.g., bathing, dressing, communication, walking, grooming, doing schoolwork, working at a job). Chronic Disease: - Medical or health problem with associated symptoms or disabilities that require long-term management. - Also referred to as noncommunicable disease, chronic condition, or chronic disorder. Chronic Illness: - The experience of living with a chronic disease or condition; the person's perception of the experience and the person's and others' responses to the chronic disease or condition (a person's lived experience with the condition).

How should the physical assessment portion of the focused exam be conducted?

During the Physical Assessment: - Clinical nurses must be organized to complete meaningful physical assessment on all assigned patients within the first hour of the nursing shift. - Requires the nurse to assess each patient quickly and efficiently, incorporating assessments directed at basic bodily functions as well as assessment based on individual patient priorities. - Nurses should use clinical judgment to adapt this generic assessment to the individual circumstances of an individual patient and to monitor for changes that might require further intervention. - This prioritized general assessment may also identify specific findings to follow-up on later (focused) and used to gather pertinent data to provide a basis for prioritizing nursing care.

What are the components of a nursing intervention statement?

Each nursing intervention statement should include: - Verb: Action to be performed - Subject: Who is to do it - Descriptive phrase: How, when, where, how often, how long, or how much - Date - Signature (optional based agency policy) Interventions must be comprehensive specifying: - What observations (assessments) need to be made and how often? - What nursing interventions need to be done and when they must be done? - What teaching, counseling, and advocacy needs do patients have?

Be able to recognize examples of missed communication opportunities.

Examples: - Unavailable or underutilized status board - Inconsistencies in the utilization of automated systems - Poor documentation - not timed, nonspecific, illegible, and incomplete - Failure to seek input from the patient

What part of the nursing diagnosis is an expected outcome derived from?

Expected outcomes/goals are derived from the problem statement (label) of the nursing diagnosis.

Describe the different sources from which a nurse collects data: Family and Significant Others.

Family and significant others or in some cases caregivers (making sure you have patient's permission) can be very helpful in supplying information. Remember the patient is always part of the conversation when information is being supplied by someone other than the patient.

If given an evaluative statement, can you determine if it meets criteria?

Here are some examples to review. Note that each example contains the two required components: - 1/21/20—Outcome met. Patient reports 1 week of no tobacco use. C. Taylor, RN - 1/21/20—Outcome partially met. Patient reports decreasing tobacco use from one pack per day to 4 to 6 cigarettes per day. Continue to implement and monitor plan. C. Taylor, RN - 1/21/20—Outcome not met. Patient reports no change in tobacco use. Revision: Reexplore patient's commitment to try tobacco-use control strategies and adequacy of personal support systems to eliminate tobacco use. C. Taylor, RN

What are the 3 rankings when a nurse is prioritizing a list of nursing diagnoses?

High-Priority Diagnoses: - Pose the greatest threat to the patient's health and well-being -> Needs to be done now. Medium-Priority Diagnoses - Not life threatening. Low-Priority Diagnoses: - Not specifically related to the current level of health or well-being Note: What if the patient's preference is the low one rather than the high one? Have to discuss with the patient that if we don't address the high priority diagnosis first, it could cause this or that.

How might assessment data be organized? (hint: models of organizing or clustering data).

Holistic Focused Models: 1. Maslow's Human Needs - Physiologic (survival) - Safety and Security - Love and Belonging - Self Esteem - Self-Actualization 2. Gordon's Functional Health Patterns: - Health Perception/Health Management - Nutritional-Metabolic - Elimination - Activity/Exercise - Cognitive-Perceptual - Sleep/Rest - Self-Perception/Self-Concept - Role/Relationship - Sexuality/Reproductive - Coping/Stress Tolerance - Value Belief 3. Human Response Patterns (unitary person) - Exchanging - Communicating - Relating - Valuing - Choosing - Moving - Perceiving - Knowing - Feeling Medically Focused Model: 1. Body Systems - Neurologic - Cardiovascular - Respiratory - Gastrointestinal - Musculoskeletal - Genitourinary - Psychosocial

Describe the difference impaired tissue integrity vs impaired skin integrity.

Impaired Tissue Integrity: - Includes varying levels of damage to one or more of those groups of cells - Superficial, partial -thickness of epidermis to deep or full-thickness injury of dermis and deeper tissues Impaired Skin Integrity: - Damage focused to the epidermal and dermal layers of epithelial tissue - Disruption of underlying tissues is associated with deep damage to skin integrity

For these items below, think about how these factors contribute to the progression of chronic illness and then what would be prevention strategies the help slow the progression of the chronic illness or ward off the development of a chronic illness. - Hypertension (high blood pressure) - Tobacco use (any form of tobacco use) and exposure to secondhand smoke - Overweight or obesity (high BMI) - Lack of physical activity -Excessive alcohol use - Consumption of diets low in fruits and vegetables - Consumption of food high in sodium and saturated fats

Interventions According to Risk Factors: Tobacco: - Reduce affordability of tobacco and electronic nicotine delivery systems (ENDS) including e-cigarettes, e-pens, e-pipes, e-hookah, and e-cigars by increasing their costs. - Legally mandate smoke-free environments in all indoor workplaces, public places, and public transport. - Disseminate warnings about dangers of tobacco, tobacco smoke, and ENDS through mass media campaigns and ban all forms of tobacco advertising, promotion, and sponsorship. Harmful Use of Alcohol: - Reduce affordability of alcohol by increasing its costs. - Limit availability of alcohol - Ban all forms of alcohol advertising and promotions. Diet and Physical Activity: - Promote reduction of dietary salt intake and replacement of trans fats with unsaturated fats. - Implement public awareness programs on diet and physical activity. - Promote and protect breast-feeding (reduces risk of obesity later in life). Cardiovascular Disease and Diabetes: - Promote glycemic control for diabetes and control of hypertension using medication therapy. - Counsel individuals who have had a heart attack or stroke and those people at high risk of a fatal and nonfatal cardiovascular event in the next 10 years. - Initiate acetylsalicylic acid (aspirin) use for acute myocardial infarction. Cancer: - Promote hepatitis B immunization to prevent liver cancer. - Promote screening, immunization with the HPV vaccine, and early treatment of precancerous lesion to prevent cervical cancer.

What component of the nursing diagnosis are nursing interventions derived?

Interventions are developed on information that relates to the cause (etiology) of the problem, the factors that are maintaining the unhealthy state or response (contributing to or cause).

Describe the different parts of SBAR which help to improve a team's communication,

Introduction: people involved in handoff identify themselves, their roles and their jobs. S = Situation -> What is going on with the patient? - Complaint, diagnosis, treatment plan, patient's wants and needs B = Background - > What is the clinical background or context? - Vital signs, mental and code status, list of medications and lab results A = Assessment -> What do I think the problem is? - Current provider (nurse's) assessment of the situation R = Recommendation -> What would I recommend/request? - Identify pending lab results and what needs to be done over the next few hours and OTHER recommendation for care. Question and Answers: opportunity for questions and answers; person's involved including patient and patient (family if permitted to receive information)

What does lack of communication lead to the failure of?

Lack of communication leads to the: - Failure of sharing information with the team - Failure of requesting information from others - Failure of directing information to specific team members - Failure of including patients and their families in communication involving their care.

What does the Initial Comprehensive Nursing Assessment enable the nurse to do?

Make a judgment about a person's health status, ability to manage his or her own need for self-care, and the need for nursing care. Plan and deliver thoughtful, person-centered nursing care: - Draws on the person's strengths - Promotes optimum functioning, independence, and well-being Refer the patient to a provider or other health care professional, if indicated.

How do nurse initiated, physician/provider initiated and collaborative interventions differ from each other?

Nurse Initiated Interventions: - Autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes. - Nurse-initiated interventions do not require a health care provider's (or other team member's) order and are suggested by the cause (etiology) of nursing diagnosis. - When selecting nursing interventions, the nurse specifically addresses factors that cause or contribute to the patient's problems. - According to Alfaro-LeFevre (2014, pp. 142-143), nurse-initiated interventions are actions performed by the nurse to: 1. Monitor patient health status and response to treatment 2. Reduce risks 3. Resolve, prevent, or manage a problem 4. Promote independence with activities of daily living 5. Promote optimum sense of physical, psychological, and spiritual well-being 6. Give patients the information they need to make informed decisions and be independent Physician/Provider Initiated Interventions: - Initiated by a physician in response to a medical diagnosis but is carried out by a nurse in response to a doctor's order. - The physician and nurse are legally responsible for these interventions, and nurses are expected to be knowledgeable about how to execute these interventions safely and effectively. - Nurses who question the appropriateness of physician-initiated interventions are legally responsible to seek clarification of the order with responsible parties. Under no circumstances should a nurse implement a questionable intervention, even at the urging of a physician or other professional. Collaborative Interventions: - Treatments initiated by other providers such as pharmacists, respiratory therapists, or physician assistants but carried carry out by the nurse.

What are the suggested components with their purpose in a nursing student care plan?

Nursing diagnoses: - Each with subjective & objective data, patient strengths/limitations. Expected Outcomes: - One for each nursing diagnoses Nursing Interventions: - Nursing orders Scientific Rationale: - To support the nursing intervention Evaluation: - Was the outcome met, partially med or unmet with evidence within evaluative statement.

What guidelines are used in the selection of a nursing diagnosis?

Nursing interventions should be: - Valued, whenever possible, by the patient and family - Appropriate in terms of the nursing diagnosis and related patient outcomes, safe, and efficient - Consistent with research findings and standards of care - Realistic in terms of the abilities, time, and resources available to the nurse and patient - Compatible with the patient's values, beliefs, and cultural and psychosocial background - Compatible with other planned therapies

What makes a data cluster different from a pattern of data?

Once clusters are defined, the nurse examines data for patterns within each cluster. Once you have organized your data into clusters, you begin to look for and test your initial impressions about patterns of human functioning: - Alfaro (2014) recommends testing your first impressions to decide what's relevant, making tentative decisions about what the data suggest, and focusing your assessment to gain more in-depth information to better understand the patient's situation. - She stresses the importance of trying to learn why the pattern came to be, emphasizing that there is usually more than one contributing factor because health problems are complex

Describe the different sources from which a nurse collects data: Other Health Care Professionals.

Other health care professionals (other nurses, providers, social work, and others on the care team) can provide information regarding health habits, patterns, and responses to illness as each member of the team has a different circumstance and purpose when interacting with the patient.

How is first intention healing different from second and third intention wound healing?

Primary/First Intention: - No or minimal tissue loss (surgical incision) and scarring - Wound edges approximated (skin edges are tight together) - Heals rapidly - Post-op sterile dressing covering Secondary/Second Intention: - Loss of Tissue -> Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. - Wound edges CANNOT be approximated - Open wound requiring more tissue replacement - Longer healing time (from base of wound to surface- granulation) -> Granulation process (development of new tissue during repair) is visible as the wound heals, the wound bed becomes smaller and shallower. This type of healing is typically what occurs with some pressure injury wounds or when someone experiences an abrasion/scrape. - More extensive scarring - Susceptible to infection (If a wound that is healing by primary intention becomes infected, it will heal by secondary intention) Tertiary/Third Intention (delayed primary closure): - Widely separated - Wound left open several days to allow edema or infection to resolve and fluid to drain and then are closed. - Usually have poor circulation in area of wound - Dressing - packed with moist gauze - Results in a deeper and wider scar due to the extent of connective tissue required for healing

Describe the differences between the 3 types of Nursing Diagnoses: Problem-Focused, Risk & Health Promotion

Problem-focused Nursing Diagnosis: - A clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, group, or community. - The problem is existing - Four components: label, definition, defining characteristics, and related factor. Risk Nursing Diagnosis: - A clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes. - The problem does not exist yet but prevention is needed - Two components: label and related to factors Health Promotion Nursing Diagnosis: - A clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. - These responses are expressed by a readiness to enhance specific health behaviors, and can be used in any health state. - Health promotion responses may exist in an individual, family, group, or community.

What is the purpose of the evaluation step in the nursing process?

Purpose: - To allow the patient's achievement of expected outcomes to direct future nurse-patient interactions. Evaluating nursing care involves interpreting and analyzing evaluation data -> Factors are identified by the nurse that contribute to the patient's ability to achieve expected outcomes and when not achieved, modifies the care plan.

Be able to recognize examples of SBAR.

RN calling provider regarding patient's elevated temperature, breathing difficulties, and deteriorating condition: S—"Jeff's temperature this evening shot up to 103°F, and his respirations are labored; RR of 40, HR of 95 BPM, and O2 Sat of 82% on room air. He is pale and drooling." B—"Jeff was transferred 2 days ago from the state home for children with respiratory difficulties. Jeff is a 9-year-old with a genetic disease that includes severe intellectual disability." A—"I am concerned about Jeff's deteriorating condition." R—"Another nurse is staying with Jeff, offering O2 and positioning and suctioning, but I need you to come to the bedside and assess this patient." RN calling team manager regarding home hospice patient's inadequate pain management: S—"Ms. Tadesse is grimacing and moaning—she appears uncomfortable." B—"She is in end-stage breast cancer and her family has been told that death is imminent—expected sometime this week." A—"Her daughter has been administering the PRN morphine sulfate as ordered, but it no longer seems to be keeping her mother comfortable." R—"Should we have the palliative care provider reevaluate Ms. Tadesse's analgesics and recommend a better pain management regimen?" RN calling provider about inadequate social support services for a patient scheduled for a discharge from a hospital rehab unit to home: S—"Mr. Ames is scheduled for discharge today. His wife appeared to "take him home" and arrived via taxi. She is a frail, 89-year-old woman who seems overwhelmed by the care she will need to provide in the home. She states that there are no families or friends capable of helping her care for her husband." B—"Mr. Ames has spent the last week in a hospital rehabilitation unit following a right-sided total knee replacement. He weighs 320 lb. He has signed the discharge papers. There is no home care follow-up ordered." A—"I am concerned about the Ameses because Mr. Ames still needs help ambulating. Prior to his surgery, Mr. Ames, who is 75 years old, was the primary caretaker for the couple. Without good home care services, I am concerned about their ability to manage." R—"Should we invite the social worker and the case manager to reevaluate this family prior to his discharge and set up visiting nurses to assist?"

Describe the components/elements that may be a part of a focused assessment.

Starts with a health history, the collection of subjective information that provides information about the patient's health status. Physical assessment is a collection of objective data that provides information about changes in the patient's body systems.

How would you define each component of an outcome statement?

Subject: - The patient or some part of the patient. Verb: - The action the patient will perform. Conditions: - The specific circumstance(s) in or by which the outcome is to be achieved. Not every outcome specifies conditions. Performance Criteria - The expected patient behavior or other manifestation described in observable, measurable terms. Target Time: - When the patient is expected to be able to achieve the outcome. - The target time or time criterion may be a realistic, actual date or other statement indicating time (e.g., "before discharge," "after viewing film," or "whenever observed")

Which of the assessments provides the nurse comprehensive baseline data?

The INITIAL assessment provides the nurse with comprehensive baseline data.

What is the main purpose of a nursing diagnosis?

The Nursing Diagnosis is a pivotal point for the following reasons: 1. The purpose of diagnosis is to clarify the exact nature of the problems and risks that must be addressed to achieve the overall expected outcomes of care. - If you do not completely understand the problems and what factors are contributing to them, how do you know what to do about them? - If you don't pay attention to risks, how are you going to prevent problems? 2.The conclusions you make during this phase affect the entire care plan. - If your conclusions are correct, your plan is likely to be on target. - If they are not—for example, if you are operating on assumptions rather than sound reasoning that is based on evidence—your plan is likely to be flawed, maybe even dangerous.

In the first step of data interpretation and analysis, describe how you recognize data as significant and be able to recognize different examples.

The nurse must be familiar with comparative standards or "norms". - A standard, or a norm, is an accepted rule, measure, pattern, or model to which data can be compared in the same class or category. Standards or norms can be used to identify "significant cues" when assessment findings are: 1. Changes in a patient's usual health patterns that are unexplained by expected norms for growth and development. - Example: An infant who took to breastfeeding easily as a newborn suddenly stops sucking when put to the breast and begins to lose weight. 2. Deviation from an appropriate population norm. Example: A first-year college student begins to accelerate her exercise habits dramatically and starts inducing vomiting after binge eating. She rapidly loses weight. 3. Behavior that is nonproductive in the whole-person context. - Example: A college student breaks up with her boyfriend and begins to believe that she is "unfit" for any other relationship, withdrawing from her friends and social activities. 4. Behavior that indicates a developmental lag or evolving dysfunctional pattern. - Example: A 16-year-old single mother with a 6-month-old infant continues to "party hard" with her friends, hangs out at the mall, and shows no interest in caring for her son, who is repeatedly left with concerned family members.

In the fourth & final step of data interpretation and analysis, describe the 4 basic conclusions that the nurse could reach.

The nurse reaches one of four basic conclusions after interpreting and analyzing the patient data. Different nursing responses result from each conclusion: No Problem: - No nursing response is indicated. - Reinforce the patient's health habits and patterns. - Initiate health promotion activities to prevent disease or illness or to promote a higher level of wellness. - Wellness diagnosis might be indicated. Possible Problem: - Collect more data to confirm or disprove a suspected problem. Actual or Potential Nursing Diagnosis or Problem or Issue: - Begin planning, implementing, and evaluating care designed to prevent, reduce, or resolve the problem. - If unable to treat the problem because the patient denies the problem and refuses treatment, make sure that the patient understands the possible outcomes of this stance. Clinical Problem Other Than Nursing Diagnosis: - Consult with the appropriate health care professional and work collaboratively on the problem. - Refer to medical or other services, as indicated. *It is important to partner with patients, they want to play a leading role in identifying and treating their health problems.*

How is comprehensive baseline data used by the nurse?

The nurse uses comprehensive baseline data to: - Establish priorities for ongoing focused assessments - Create a reference baseline for future comparison - Make a judgment about a person's health status, ability to manage his or her own need for self-care, and the need for nursing care. - Plan and deliver thoughtful, person-centered nursing care -> Draws on the person's strengths & Promotes optimum functioning, independence, and well-being - Refer the patient to a provider or other health care professional, if indicated.

Describe the different sources from which a nurse collects data: The Patient Record

The patient record provides information supplied by members of the health care team. In some instances, it may be helpful to review patient record information prior to your interview so that you don't repeat asking for information, instead approach as clarifying the information you read. Information in the patient record is not a primary source but a secondary source of information - the interpretation of data the person recording the information has about the patient.

Describe the different sources from which a nurse collects data: The Patient.

The patient should ALWAYS be CONSIDERED the PRIMARY and BEST SOURCE of information. However, when mental capacity (cognitive impairment) or limited communication capacity enter the picture, the nurse must be creative in collecting data. This might include asking questions for interpretation at the patient health literacy or cognitive capacity, finding the best means for communication or including family and significant others in the data collection interview for subjective information.

What is the purpose of nursing interventions?

The purpose is to identify nursing interventions that most likely lead to the achievement of outcomes and meeting patient's individual needs.

What is the primary purpose of the Outcome Identification and Planning step of the nursing process?

To design a plan of care with and for the patient that, once implemented, results in the prevention, reduction, or resolution of patient health problems and the attainment of the patient's health expectations, as identified in the patient outcomes.

What is the purpose of validating data during data collection? If data is not validated, how might that influence how care is provided?

To keep data as free from error, bias, and misinterpretation as possible. Invalid information can lead to inappropriate nursing care and in some cases omitted care than may be required.

One critical result of effective communication is a shared understanding between the sender and receiver(s) of the information conveyed. What are two considerations in communication?

Two considerations in communication are whom you are communication with and how you are communicating information: 1. Whom you are communicating with (the audience) will influence how information is conveyed. - Example: an information exchange with a lab technician may differ from an exchange with a physician. 2. How you communicate includes two models: verbal and nonverbal. - Verbal: See standards for effective communication - Nonverbal: In healthcare most is written, but nonverbal influences.

What verbs should and shouldn't be used in an outcome statement?

Verbs HELPFUL in writing measurable outcomes include: - Define - Verbalize - Describe - List - Select - Apply - Explain - Identify - Design - Prepare - Choose - Demonstrate. Verbs to AVOID (action not observable): - Know - Understand - Learn - Become aware

What criteria is used to determine that interventions are well written?

Well-Written Nursing Interventions accomplish the following: - Assist the patient to meet specific outcomes that are related directly to one outcome. - Clearly, concisely describe the nursing action to be performed (i.e., answer the questions who, what, where, when, and how). - Use only accepted abbreviations. - Refer the nurse to procedure manual or other literature for steps of routine, lengthy procedures. - Are dated when written and when the care plan is reviewed. - Are signed by the nurse prescribing the order or intervention.