PCC Final Exam Blueprint

Describe each part of the nursing process and how it relates to nursing.

*Assessment* - we assess our patients to determine the problem *Diagnosis* - we must diagnose the problem in order to treat the problem *Plan* - we must form a plan to provide patient care *Implementation* - nurses must know what they can do to help a patient and what the provider must order - putting the plan into action - treatment *Evaluation* - nurses must be able to asses whether or not a treatment is working. -a systematic problem - solving process that guides all nursing actions purpose is to help nurses provide goal directed, client centered care scientific holistic - creative

Apply the nursing process to patients with bowel elimination problems.

*ADPIE* *bowel assessment*: -history: --GI diagnoses, surgeries, meds --usual bowel pattern (frequency) --characteristics of stool (form, color) --aids in elimination (food, fluid, laxatives, enemas) --change in bowel patterns -physical examination: --abdominal assessment (inspection, auscultation, percussion (normally not done), & palpation) --inspection of stool (characteristic, color) --rectal exam (done by *AP*) example = constipation *assess*: what type of stool, what color is the stool? how many times is the patient having a BM/day? *diagnosis*: client is constipated (NANDA-I diagnosis) as related to narcotic use (etiology) as evidenced by no BM in 3 days, abdominal pain, and abdominal distention (S/S). *plan*: The patient will have a BM by the end of the shift *intervention*: -increase patients fluid intake -administer laxatives/enema -increase patients mobility -educate patient to not avoid urge to defecate *evaluation*: did the patient have a BM?

List important nursing organizations.

*American Nurses Association (ANA)* -National professional organization. -Originally, the ANA focused on establishing standards of nursing to promote high-quality care and work toward licensure as a means of ensuring adherence to the standards. The ANA continues to update its standards. Representatives are elected from the local branches of the state organizations to bring their concerns to the national level. As such, they track healthcare legislation, serve as liaisons with national government representatives to inform them of how current and proposed legislation will affect nursing, and develop and sponsor legislation that will have a positive effect on nursing and on client care. The ANA publishes educational materials on nursing news, issues, and standards. The official publication is The American Nurse. *National League for Nursing (NLN)* -Establishes and maintains a universal standard of education -Sets standards for all types of nursing education programs, studies the nursing workforce, lobbies and participates with other major healthcare organizations to set policy for the nursing workforce, aids faculty development, funds research on nursing education, and publishes the journal Nursing Education Perspectives. *International Council of Nurses (ICN)* -Federation of national nursing organizations -Aims to ensure quality nursing care for all, supports global health policies that advance nursing and improve worldwide health, and strives to improve working conditions for nurses throughout the world. *National Student Nurses' Association (NSNA)* -Represents nursing students in the United States. It is the student counterpart of the ANA. Like the ANA, this association comprises elected volunteers who advocate on behalf of student nurses. The NSNA sponsors yearly conventions to address the concerns of nursing students. Local chapters are usually organized at individual schools. The NSNA also publishes Image, a journal dedicated to nursing student issues. *Sigma Theta Tau International (STTI)* -National Honor Society for Nursing. Membership includes the clinical, education, and nursing research communities and senior level baccalaureate and graduate programs. The goal of this organization is to foster nursing scholarship, leadership, service, and research to improve health worldwide. The official publication of STTI is the Journal of Nursing Scholarship. *Specialty* -Clinical, group identity, or value-specific. Numerous specialty organizations have developed around clinical specialties, group identification, or similarly held values. Here are some examples: Clinical specialty: Association of periOperative Registered Nurses (AORN), Academy of Medical-Surgical Nursing (AMSN), Emergency Nurses Association (ENA) Group identification: National Association of Hispanic Nurses (NAHN), American Assembly for Men in Nursing (AAMN), The American Association of Nurse Attorneys (TAANA), National American Arab Nurses Association (NAANA) Similar values: Nurses Christian Fellowship (NCF), Nursing Ethics Network (NEN)

Identify nursing interventions that break the chain of infection.

*Aseptic technique*: reduces exposure to pathogens, use PPE when needed - medical asepsis and sterile technique *Skin integrity*: very important natural barrier against infection (bacteria, pathogens) *Stress reduction*: stress causes the immune system to function slower *Immune system function*: collaborative care, healthy diet, sleep, activity, and lifestyle choices *Decrease the amount of time invasive medical device is in the body*: indwelling catheters, IV's, etc. *Proper hand hygiene*: perform hand hygiene before and after dealing with a patient (either washing with soap and water or using hand sanitizer) *Carefully handle laundry*: keep dirty linens away from your clothes, do not shake any dirty linens as this could cause pathogens to become airborne *Proper client placement and assignment*: do not assign a client on protective isolation to a nurse that also has extremely infectious patients - do not put a client in the same room with TB with a client who has a UTI but not TB. *Proper cleaning of equipment*: prevents the spread of pathogens from one client to another

Discuss specific diets as they relate to disease processes.

*Calorie restricted*: for those requiring weight reduction. *Sodium restricted*: for clients with hypertension, Mèniéres disease, or fluid balance problems. *Fat restricted*: for clients with elevated cholesterol or triglyceride levels; may also be prescribed for general weight loss. *Renal*: to manage electrolytes and fluid for clients with renal insufficiency. *Diabetic*: to manage calories and carbohydrate intake for clients with diabetes mellitus. *Protein controlled*: to manage liver and kidney disease. *Ketogenic*: to treat difficult to control epileptic seizures in children - effective for weight loss, insulin control, and may have a role in treating cancer and neurologic disorders (ex: migraines, Alzheimers). *Antigen avoidance*: for clients allergic to or intolerant of certain foods (ex: gluten-free for clients with celiac disease) - low FODMAP (fermentable, oligosaccharides, disaccharides, monosaccharides, and polyoils): this type of dietary meal plan may be used to ease digestive symptoms (pain, bloating, diarrhea) related to irritable bowel syndrome (IBS) or other GI disorders. *Calorie protein push*: used when there is a need to heal wounds, maintain or increase weight, or promote growth. If the client cannot consume enough kcal by adding fats and proteins to the regular diet, high calorie, high protein supplements may be used.

Review nutrition.

*Carbohydrates*: chief source of energy in the body - includes simple sugars, starches, and cellulose which convert into glucose. *Fats*: most common concentrated form of energy - carriers for the fat-soluble vitamins A, D, E, & K. *Proteins*: when broken down, contain 20 amino acids - necessary for growth and development - used for tissue repair and maintenance and a source of energy. *Vitamins*: organic food substances that are essential for growth, functioning of body processes and maintenance. *Minerals*: inorganic substances essentail to metabolic processes. *Water*: necessary for survival - is involved in every process of the body. *BMI*: -Underweight: <18.5 -Normal: 18.5-24.9 -Overweight: 25-29.9 -Class I obesity: 30-34.9 -Class II obesity: 35-39.9 -Class III obesity: 40+ *Normal values*: -Blood glucose: <70-100 mg/dL -Serum albumin: 3.4-4.8 g/dL -Creatine: female: 0.5-1 mg/dL; male: 0.6-1.2 mg/dL -Hemoglobin: female: 11.7-15.5 mg/dL; male: 13.2-17.3 mg/dL; older female: 11.7-16.1 mg/dL; older male: 12.7-17.4 mg/dL -Blood Urea Nitrogen (BUN): children: 5-18 mg/dL; 14 to adult: 8-21 mg/dL; older adult >90 years: 10-31 mg/dL *Diets modified by consistency*: -Clear liquids: short term - provides fluids to prevent dehydration and supplies some simple carbohydrates to help meet energy needs (water, tea, coffee, broth, clear juice (apple, grape, cranberry), popsicles, carbonated beverages, gelatin) - if required for more than 3 days, commercial clear liquid supplements are usually prescribed. -Full liquids: short term - contains all liquids included in the clear liquids diet plus any foods that are liquid at room temperature (soups, milk, shakes, puddings, custards, juices, some hot cereals, and yogurt) - if needed for a longer time a dietician should be consulted (high-calorie, high-protein supplements are often added). -Mechanical soft: the diet of choice for those with chewing difficulties resulting from missing teeth, jaw problems, or extensive fatigue (add to the full liquid diet: soft vegetables and fruits, chopped/ground/shredded meat, breads, pastries, eggs, and cheese - offers a full range of nutrients but is often low in fiber (constipation is a risk) - many foods can be added to this diet by cooking them extensively or blending/grinding them to alter their texture. -Pureed: a pureed diet is a blended diet - some food may or may not be included. - water is often added to the food when it is blended to give it the texture and consistency that it can be scooped onto serving plates.

Compare and contrast clinical judgment, clinical reasoning, and critical thinking.

*Clinical judgement*: encompasses critical thinking and clinical reasoning - promotes safe patient care decisions and outcomes by making unbiased, educated, and safe decisions *Clinical reasoning*: the mental process used when analyzing a clinical situation to make decisions about patient care *Critical thinking*: an objective way of thinking that searches for the truth, open to alternative ideas, allows for people to reflect on their thought process.

Describe additional precautions that must be taken when there is concern about contact, droplet, or airborne disease.

*Contact*: utilized standard precautions in addition to secondary precautions - tier 2 precaution - used when contact with bodily fluids (blood, drainage, mucous, etc.) can lead to the transmission of the infection (ex: MRSA). *Droplet*: utilized standard precautions in addition to secondary precautions - tier 2 precaution - used with pathogens spread via moist, large droplets (patients who are sneezing, coughing, talking). *Airborne*: utilizes standard precautions in addition to secondary precautions - tier 2 precaution - spread through air currents, PPE and N-95 are needed - ex: pulmonary TB, small pox - ventilation systems, fanning sheets, and sweeping the floor can facilitate the spread of airborne pathogens.

Describe a process for evaluating patient health status (outcomes) after interventions.

*End plan of care*: goal was met. *Revise plan of care*: goal was only partially met. *Continue plan of care*: goal was not met.

Assess and intervene to promote patient safety.

*General interventions related to safety*: Specific nursing activities are designed to monitor and manipulate the physical environment to promote safety. -The following general activities provide an overview of your role in safe, effective nursing care (Thinking, Doing, Caring) in all types of settings and circumstances: --Assess and continually monitor the safety needs of patients, based on their level of physical and cognitive function and past history of behavior. --Provide client education to foster informed decisions, promote involvement in care, and facilitate post-discharge health. --Evaluate and use techniques/processes to avoid medical/nursing errors in the delivery of client care. --Remove hazards from the environment or modify the environment to minimize hazards and risk. --Use technology to deliver safe effective care. --Establish mutual goals with clients and teach clients about specific safety measures. --If an accident or injury occurs in the healthcare setting, file an incident report according to agency policy. --Urge patients to be active members of the healthcare team. *HOME SAFETY PROMOTION*: -Preventing poisoning -Preventing carbon monoxide poisoning -Preventing home fires -Preventing scalds and burns -Preventing falls -Preventing firearm injuries -Preventing suffocation -Knowing how to perform choking rescue -Preventing drowning -Preventing take-home toxins *SELF-CARE SAFETY*: -Motor vehicle safety -Food safety -Fighting vector-borne pathogens -Reducing pollution -Weather hazard safety measures *HEALTHCARE SAFETY PROMOTION*: -Preventing falls -Reducing electrical hazards -Responding to fires -Preventing the need for restraints -Responding to mercury spills -Keeping equipment safe -Reducing alarm fatigue -Coping with violence

Identify risk factors and interventions to prevent patient falls.

*RISK FACTORS*: *Environmental factors*: -Slippery floors and bathtubs -Lack of grab bars -Low toilet seats -High beds *Health issues*: -Poor vision -Hypotension (low blood pressure) -A history of falls -Dizziness, pain -Alcohol use -Cognitive impairment -Polypharmacy -Arthritis -Gait or balance deficits -Age greater than 80 years *INTERVENTIONS*: -Nonskid shoes. -Tidy clothes. -Proper lighting. -Grab bars/rails. -No scatter rugs. -Fall risk assessment. -Environmental safety. -Clean dry floors. -Client education.

Explain nursing measures to promote adequate oxygenation.

*IS*: encourages patients to take deep breaths - beneficial for preventing pneumonia in bed ridden post-op patients - hold breathe after inhale to keep lungs inflated - track how far they can blow the ball up each time to track whether or not they are improving - is able to be delegated to LPN or CNA. *Postural drainage (PD)/chest physiotherapy (CP)*: usually done by a respiratory therapist not an RN - PD = gravity - CP = percussion and vibration after 10-15 minutes of PD. *Pursed lip breathing*: slows expiration and is great for COPD exacerbation - breathe in through nose and out through pursed lips. *Supplemental oxygen*: nasal cannula: most common - face mask = used if oxygenation is worse - non-rebreather mask - most efficient, 100% oxygen. *Suctioning*: remove secretions and maintain latency - yankauer: oral cavity - upper airway: oral or nasal pharyngeal suctioning - lower airway: tracheal suctioning. *Artificial airways*: oropharyngeal, nasopharyngeal, endotracheal, tracheostomy. *Nebulizer*: aerosolized medication that opens airways - usually takes about 5 minutes breathing in and out - can be mouthpiece or mask. *Chest tube*: surgically places into pleural space - remove air or fluid (treats pneumothorax) - complex assessment of drainage and respiratory status.

Describe the three phases of wound healing.

*Inflammatory*: aka cleansing - 1-5 days, hemostasis (platelets slow bleeding and clotting mechanism forms blood clots) and inflammation (phagocytosis forms scab); *Proliferative*: 5-21 days - fibroblasts arrive at wound and begin to form collagen (provides extra strength to hold wound closed); *Maturation*: 2-3 weeks to 3-6 months - begins in week 2 or 3 and continues after wound is closed forming scar tissue for the next 3-6 months.

Describe the Clinical Judgment Measurement Model (CJMM).

*Layer 4*: context - ID the individual and the environment factors that can impact the nurse's reasoning/cognitive processes *Layer 3*: recognize patterns, understand connections, examine pathophysiological processes, organize data and relate it back to the client's problems *Layer 2*: forming, refining, prioritizing and evaluation the hypothesis to achieve the desired outcome (refined scientific, theoretical, and practical knowledge base) *Layer 1:* comprises the outcome (clinical judgement) *Layer 0*: includes the clinical decisions made by the nurse to address the clients needs.

Differentiate between the various oxygenation devices regarding their uses, FiO2, and liters/minute settings.

*Nasal cannula*: most common, least amount of oxygen delivery (1L/min.=24%; 2L/min.=28%; 3L/min.=32%; 4L/min=36%; 5L/min.=40%; 6L/min.=44% Fio2) *Simple face mask*: clear, flexible mask that covers the nose and mouth and delivers oxygen flow into the mask (5-10L/min.=40-60% Fio2) - requires at least 5L/min. to prevent accumulation and rebreathing of CO2 within the mask *Partial rebreather mask*: uses the reservoir bag to capture some exhaled gas for rebreathing (6-15L/min.=50-90% Fio2) - maintain at flow rate high enough to prevent reservoir bag from collapsing during inhalation - encourage patients to take slow, deep breaths *Nonrebreather mask*: a type of reservoir bag mask; a valve keeps exhaled air from entering the reservoir bag (6-15L/min.=70-100% Fio2) ONLY MASK THAT DOES 100% O2 DELIVERY - maintain a flow rate high enough that the bag is at least 1/3-1/2 full during inhalation *Venturi mask*: a cone-shaped adapter that serves as a mixing valve to control the amount of O2 and room air that flows through the mask (24-50% Fio2) - used for COPD/chronic lung disease patients *Face tent*: a large, open plastic mask that fits under the chin (it is open at the top and secured around the head with an elastic band) (8-12L/min.=30-55% Fio2) - less reliable than a face mask for precise Fio2 levels - patients who feel claustrophobic in a face mask can usually tolerate a face tent *Tracheostomy collar*: a small, cup-shaped device that fits over the tracheostomy opening and is held in place with elastic straps around the neck (4-10L/min=24-100% Fio2) - it is possible to deliver high Fio2 and high humidity - water can condense in the tubing and accidentally drain into the trachea so watch for water accumulation (there is a water trap that can be placed to prevent this) *T-piece*: T-shaped plastic piece; the bottom of the T fits directly and tightly onto the tracheostomy tube, (4-10L/min.24-100% Fio2) - O2 and humidity are inhaled through one side of the T and exhaled through the other side, if this dislodges it can cause an airway emergency.

Explain how each of the steps (assessment, diagnosis, planning, interventions, and evaluation) are related to each of the other steps of the nursing process.

*None of the nursing process can be delegated!!!* -The nursing process is a continuous loop. We assess, we diagnose, we make a plan of care, we implement our plan of care, then we evaluate if it is working. If it is not, we must start over or revise, if it is then we continue while continuing to reassess to make sure the patient continues improving.

Describe the information contained in a patient care plan, differentiate between nursing diagnoses, expected outcomes, interventions, and evaluation.

*Nursing diagnosis*: diagnosis part of the nursing process: analyzing the cues to form a hypothesis - NANDA diagnosis: what is the problem? - etiology: what is the cause of the problem? - symptoms: what are the defining characteristics of the problem? (My nursing diagnosis is __________ as related to ______________ and as evidenced by ______________). *Expected outcomes*: statements of measurable action for the patient within a specific time frame that are responsive to nursing interventions (SMART goals). *Interventions*: the treatment (prescribed medication, AROM or PROM, ambulation, etc.). *Evaluation*: did the treatment work? Do we need to re-evaluate and come up with a different plan?

Describe the differences between parental and enteral nutrition.

*Parenteral nutrition*: delivery of nutrition intravenously through a large central vein - used when the patient cannot tolerate enteral nutrition - total parenteral nutrition (TPN): need a central line; peripheral parenteral nutrition (PPN): short term until enteral feeds can be resumed - with this type of intervention patient is at higher risk for infection. *Enteral nutrition*: indicated when a patient cannot tolerate or will not take an adequate oral diet - nasogastric (NG) tube: nose, nasopharynx, esophagus, stomach; nasojenunal (NJ) tube: extends into the duodenum or jejunum - longer tubes are used when upper GI is dysfunctional - gastrostomy (GT) tubes & jujunostomy (JT) tubes are surgically placed, used for long-term treatment.

Define patient centered care and healthcare settings.

*Provide client-centered care*: -Respect clients' differences, values, preferences, and expressed needs. -Relieve pain and suffering. -Coordinate continuous care. -Communicate and provide client education. -Focus on health promotion and illness prevention. *Provide goal-directed, client-centered care*: -Establish mutual goals with clients. -Show respect for client values, religious beliefs, needs, and preferences. -Implement interventions to promote client comfort, promote health, prevent illness, or transition to a peaceful death. -Provide client education to foster informed decisions and involvement in care and to facilitate postdischarge health.

Explain how to provide an SBAR report.

*S*ituation: -"my name is ________ and I am calling from ____________. I am calling about _________________. I have just assessed the patient and I am concerned about ___________________. The patients vital signs are ____________." *B*ackground: -state pertinent background information related to the situation -this may include: --diagnosis --medications --allergies --labs --code status --interventions --etc. *A*ssessment: -what is your assessment of the situation? -state what you think the problem is -state if the patient is unstable or appears to be declining in status *R*ecommendation: -if you have a specific request related to the problem you are reporting, state the request -remember to read back all verbal and telephone orders -request a read back when reporting critical test results

Describe nursing interventions to manage, stage and prevent pressure injuries.

*Stage 1*: unbalanceable redness - skin is still intact *Stage 2*: broken dermis and epidermis *Stage 3:* affects dermis, epidermis, and subcutaneous tissue *Stage 4*: through all three layers of tissue and down to muscle or bone. PREVENTION: *TURN PATIENT AT LEAST EVERY 2 HOURS!!!*

Differentiate among the sources of assessment data: subjective, objective, primary, secondary sources.

*Subjective*: what the patient says - not actually seen by the healthcare provider (dizziness, fatigue, etc.) *Objective*: what is observed by the healthcare provider (vitals, LOC, wounds, skin coloration, etc.) *Primary*: coming directly from the source (the patient), most reliable *Secondary*: coming from a different source such as a family member, significant other, medical chart, or friend.

Discuss common elimination problems including urinary tract infection, urinary retention, and urinary incontinence.

*UTI*: infection somewhere in the urinary tract - 4 types: catheter associated (CAUDI), infection in the kidneys (pyelonephritis), infection in the bladder (cystitis), and an infection in the urethra (urethritis) - common - primarily caused by E. coli - caused by: catheterization, retention, and poor peri care - signs/symptoms: dysuria (painful/difficult urination), hematuria (presence of blood in the urine), polyuria (excessive urination), urgency, fever, chills, cloudy urine, foul smelling urine - treatments/preventions: antibiotics, increased fluids, and avoiding catheters. In older adults look for confusion and restlessness. *Urinary retention*: unable to completely empty bladder - causes: obstruction (prostate), medications - signs and symptoms: pressure, pain, frequency, urgency, small or no output - treatment: insert catheter (possible straight cath to lessen risk of UTI), use heat/warm water, crude's maneuver (manual pressure over bladder), medications like cholinergic or alpha-blockers. *Urinary incontinence*: cannot control urination - 3 types: stress (increased pressure, ex: jumping, coughing, sneezing), urge (overactive bladder), overflow (bladder is too full which pushes out small amounts of urine) - causes: age (not normal part of aging), obesity, stroke, cognitive status, decreased mobility, history of diabetes mellitus - signs and symptoms: bladder spasms, back pain, fever, urgency - treatments/prevention: bladder training, Kegel exercises, anticholinergics, surgery

Utilize the patient chart to provide safe and effective care.

*admission documents*: -nursing admission assessment -baseline data from which to monitor change discharge planning information/needs -admission database -chief complaint/reason for admission -physical assessment -vital signs -allergies -current medication -ADL status client support system and contact information *Kardex*: -demographic data -medical diagnoses -allergies -diet/activity orders -safety precautions -intravenous therapy orders -ordered treatments (wound care, physical therapy), surgery, laboratory, and tests -summary of medications ordered -isolation orders -DNR (do not resuscitate) orders *flow sheets*: -record routine aspects of care (hygiene, turning) -document assessments; usually organized according to body systems -track client response to care (wound care, pain, intravenous fluids) -graphic records: used to record vital signs -I&O (intake and output) record *MAR*: -comprehensive list of all ordered medications --allergies -documents -scheduled/routine --PRN (as needed) ---Ex. Pain medications --STAT (give immediately) --omitted doses ---additional explanation may be required for non-routine or omitted medications. *discharge summary*: -time of departure and method of transportation -name and relationship of person(s) accompanying -condition at discharge -teaching conducted and handouts/informational matter provided to client -discharge instructions (including medications, treatments, or activity) -follow-up appointments or referrals given -most standardized in EHR *tips for documentation*: -discharge planning begins on admission -document immediately after you administer medication, NEVER before -drug allergies are always noted on MAR -dosage range prescriptions are NO longer allowed in electronic MAR system -report ALL errors --*INCIDENT REPORTS NEVER GO IN THE PATIENT CHART* -report changes in older client's condition to the primary care provider as well as the family

Demonstrate techniques to overcome communication barriers.

*barriers*: -asking too many questions -fire-hosing information -asking why -changing the subject inappropriately -failing to probe -expressing approval or disapproval -offering advice -providing false reassurance -stereotyping -using patronizing language (elderspeak) -language barrier *ways to overcome these barriers*: -professional interpreter -assess the patients situation, is it a good time and place to interact with the patient -be clear, concise, and use language you know the patient will understand -communicate one thing at a time, no listing off things like rapid fire -respect when a patient does not want to communicate - do not push -ask for clarification if you do not understand something -answer all of the patients questions and ask them to reiterate what you told them to make sure they understood -avoid terms such as "sweetie" or "honey" or "darling"

Correctly calculate drug dosages, including conversion among the metric, apothecary, and household measurement systems and working with units and milliequivalents.

*basic conversions*: 1 oz = 30 mL 1 tsp = 5 mL 3 tsp = 1 tbsp 1 tbsp = 15 mL 1 pt = 500 mL 1 qt = 1 L 1 qt = 1000 mL 1 L = 1000 mL 2 pt = 1 L 1 kg = 1000 g 1 g = 1000 mg 1 mg = 1000 mcg 1 gr = 60 mg 1 cc = 1 mL 1 mL = 15 gtt 1 tsp = 60 gtt *temperature*: c = (f - 32) / 1.8 f = (c x 1.8) + 32 *weight*: 1 kg = 2.2 lbs 16 oz = 1 lb

Discuss factors that influence pain.

*emotions*: fear, frustration, anger, helplessness, and loneliness *previous pain experience*: often patients who have had numerous painful experiences are more anxious about the prospect of experiencing pain and more sensitive to pain *developmental stage*: the behavior people exhibit when they have pain is strongly influenced by their stage of development *sociocultural factors*: beliefs about the value of expressing pain or minimizing it are often tied to personal experiences and background. -when caring for individual clients look for patterns of behavior (some may find comfort from crying or moaning in pain; others may value silence and a brave face in the presence of pain) *communication skills and cognitive impairments*: some may be unable to report pain due to cognitive impairments, often their discomfort is available in nonverbal cues such as grimacing, rapid blinking, withdrawn, labored breathing, altered gait, or decreased activity

Document nursing care in accordance with professional standards.

*chart on right patient* -double check to make sure you are in the correct patients chart *be timely* -document asap *correct terminology, grammar, & spelling* -avoid abbreviations when possible *be factual* -avoid conjecture *know military clock* -no : -1200 = 12pm; 2400 = 12am; 1400=2pm; 0200 = 2am *sign all documents* types of documentation: *source oriented documentation*: -disciplines charted separately -variety of sections (e.g., admission, H&P, diagnostic, graphic, nurses' notes, progress notes, lab, rehab, DC plan, etc.) -data scattered; may lead to fragmentation *problem oriented documentation*: -organized around client problems -four components: --database --problem list --plan of care --progress notes -allows greater collaboration *narrative charting*: -use with source or problem-oriented system -chronological story of care -tracks client's changing status -can be lengthy and disorganized *PIE charting*: -*P*roblem -*I*nterventions -*E*valuation -used only in problem-oriented charting -established ongoing plan of care *SOAP(IER) charting*: -*S*ubjective data --what the patient says -*O*bjective data --what you observe --vitals (breath sounds, HR, BP, etc.) -*A*ssessment --conclusions drawn from subjective and objective data -*P*lan --short term and long term goals and strategies -*(I)*ntervention --actions performed to achieve desired outcomes -*(E)*valuation --analysis of the effectiveness of the interventions -*(R)*evision --changes in the original plan *focus charting*: -highlights clients concerns, problems, or strengths in three columns: 1. time and date 2. focus or problem being addressed 3. charting in a DAR (data, action, response) format *charting by exception*: -chart only significant findings/exceptions to norms -drop-down boxes and checklists -caution using check boxes -know what "normal" is -do not just follow previous shift -if not normal: document specifically what was observed *FACT documentation*: -*F*low sheets --individualize specific services -*A*ssessment --baseline data -*C*oncise --progress notes -*T*imely

Identify and give examples of Bloom's three learning domains.

*cognitive*: storage and recall of information -example: facts about a disease -encompasses 6 levels of behavior: --memorization --recall --comprehension and analysis --synthesis --application --evaluation -strategies and tools that support this type of thinking are: --lectures --reading materials --panel discussions --audiovisual materials --web-based or mobile application information *psychomotor*: "hands on" skill - requires thinking and doing -example: self-administration of insulin -requires the client to accept and value the skill as well as know about the skill -strategies and tools used that support this type of thinking are: --demonstration and return demonstration --simulation mannequins --audiovisual materials --journaling and self-reflection --printed materials *affective*: changing feelings, beliefs, attitudes, and values -strategies and tools used that support this type of thinking are: --role modeling --group discussion --role playing --storytelling --mentoring --one-on-one teaching and discussion --audiovisual materials --interactive applications --digital and printed materials

Discuss cultural considerations that impact health care delivery.

*communication*: -*verbal* and *non-verbal* -if there is a *communication barrier* then an interpreter is needed -*non-verbal communication* is important to because different things have different meanings in different cultures --what therapeutic touch means in that culture, it may not be accepted --next eye contact, in some cultures avoiding eye contact is a sign of respect --what do your gestures and body language mean in that culture? *personal space*: -personal space varies -intimate: <18 in. -personal: 18 in-4 ft. -social: 4 ft.-12 ft. -public: >12 ft. *time orientation*: -present or future oriented -how do they feel about showing up on time for an appointment? -how do they feel about being late? -what are their religious or ethnic holidays related to time orientation? *social organization*: -family units and broader groups -who is in charge? -who is the head of household? -who is the decision maker? *environmental control*: -perception of pain, exercise, and diet *biological variations*: -enzymatic and genetic, drug metabolism *religion and philosophy*: -acceptable healthcare, blood transfusions *politics, law*: -government policies, limits for NP's *economy*: -public funding, medicare *education*: -knowledge, expectations of care

Communicate patient information in a clear and effective manner to other health team members.

*components of a MR*: -face sheet -graphics -flow sheet -progress notes -H&P -consults -operative report -orders -MAR -lab -diagnostics *methods of reporting*: -face-to-face meetings -walking rounds -telephone conversations -messengers -written messages -audio-taped messages --not the preferred method! -computer messages *CUBAN*: -for all reports follow these guidelines --*C*onfidential --*U*ninterrupted --*B*reif --*A*ccurate --*N*amed nurse *SBAR*: -situation -background -assessment -recommendation *hand off reporting*: -demographics --age, sex, date of admission, diagnosis, date of surgery -relevant medical history -current treatments & patient's response --IV fluids, dressings, O2, breathing treatments, drains/tubes -pending labs, procedures -current status --significant assessment findings --significant occurrences over last 24 hours -plan of care --patient's progress --priority areas to focus -concerns *transfer reports*: -your contact information -client demographics, diagnoses, reason for transfer -family contact information -summary of care -current status --medications --treatments --tubes in the client -presence of wounds or open areas of the skin -special directives, code status, preferred intensity of care, or isolation required -always ask if the receiver has any questions

Explain nursing management of patients with alternations in elimination including diarrhea and constipation.

*constipation*: -decrease in frequency of BMs or hard or difficult to pass stools -based on normal bowel pattern, can be from 3x a day to every 3 days -*causes*: --drug induced: calcium, calcium channel blockers, iron, narcotics, anticholinergics, laxative abuse --neurological dysfunction: SCI, Parkinson's, MS --metabolic dysfunction: hypothyroidism, hypercalcemia --bowel disease: IBS, obstruction --lifestyle: ignoring urge, low fiber, dehydration, inactivity -*complications*: --hemorrhoids (enlarged veins - internal and external) --fecal impaction (oozing stool) --diverticulosis (pouches that occur in the intestine) --obstruction -*management*: --if obstruction is suspected: ---x-ray or other diagnostic tests ---at risk for paralytic ileus --lifestyle changes: ---increase fiber and fluids ---do not delay defecation ---avoid laxative use --laxatives or enemas --digital "disimpaction" -*bowel retraining program*: --include patient in planning --increase fiber slowly --increase water intake to 8oz/day --establish a daily time to defecate --positioning (high-fowlers) --provide privacy --a stool softener may be needed --modify plan based on client needs *diarrhea*: -increase in frequency, volume, or looseness of stools -*causes*: --laxatives --adverse drug effect --infection: viral, bacterial, parasitic, C-diff --mal-absorption: celiac disease, enzyme deficiency -GI disease: IBS -inflammatory bowel disease: --ulcerative colitis, Crohn's disease --dumping syndrome -*management*: LISTEN FOR BOWEL SOUNDS BEFORE DOING ANYTHING - IF THERE ARE NO BOWEL SOUNDS YOU DO NOT WANT TO DO SOMETHING TO SLOW THE GI TRACT DOWN EVEN MORE!!!!! --collect stool specimen: as ordered - such as C&S, O&P, C. diff toxin, WBC, FOBT --correct underlying etiology --fluid/electrolyte replacement: get orders to replace fluids or electrolytes (PO or IV) --medications: antibiotics for bacterial infection (C. diff), anti-motility meds (loperamide - Imodium; diphenoxylate/atropine - lomotil) --diet & fluids: clear liquids or BRAT diet, avoid spicy or high fat foods, avoid unwashed raw fruits and vegetables --assess skin integrity: always risk of skin breakdown (excoriation from diarrhea) --patient education: on management and prevention - routine hand washing, foods to avoid, probiotic while taking antibiotic *fecal impaction*: -blockage of rectum with hard stool -may ooze around -need order for rectal exam -can soften with mineral oil enema -digital disimpaction -caution: rectal trauma and vasovagal -may follow with enema

Define key concepts related to cultural competency.

*cultural competency*: an ongoing process that consists of the attitudes, knowledge, and skills necessary for providing quality care to diverse populations -healthcare providers continuously strive to achieve the availability and ability to effectively work within the cultural context of the client *verbal/non-verbal* cultural considerations: -touch? -eye contact? -how should you address the patient? *ASKED* Model: cultural competency is a process not an end point *A*wareness: check yourself at the door - assess your own biases in an open and honest manner *S*kills: your ability to conduct a cultural assessment with sensitivity *K*nowledge: do you have the appropriate knowledge/information about cultural worldviews? *E*ncounters: it takes practice to become competent - is touch allowed, how should you refer to the patient, and can you make eye contact? *D*esire: you must want to be culturally competent *ETHNIC* Tool: *E*xplanation: -why do you believe you have this problem/illness? *T*reatment: -what medication, home remedies, or other treatments have you tried for this illness? -is there anything you eat, drink, do, or avoid on a daily basis to stay healthy? -what kind of treatment are you seeking today? *H*ealers: -have you sought help/advice/treatment from others (alternate healers, folk healers, friends, etc), who are not doctors for help regarding your illnesses? *N*egotiate: -try to find mutual options that benefit both you and your patient and goes along with their beliefs, rather than contradicting them *I*ntervention: -determine an intervention with your patient that may include alternate treatments, spirituality, healers, and other cultural practices (ex: food eaten/avoided, when sick or in general) *C*ollaboration: -collaborate with patient, family, other members of the healthcare team, healers, and community resources as needed

Differentiate between health promotion, health, and health protection.

*health promotion*: -helps individuals develop a state of physical, spiritual, and mental well-being -activities are useful for all individuals because they encourage optimal function -motivated by the desire to increase well-being -related to *individual* lifestyle choices *health*: state of complete physical, mental, and social well-being; not just absence of disease -theories: --jean watson: high overall functioning; a state of mind --betty neuman: continuum of energy --myers, sweeney, and witmer: integration of mind, body, spirit; those with disease can be "healthy" *health protection*: motivated by the desire to prevent illness -40 year old beginning to exercise to improve strength and endurance

Conduct a learning assessment.

*intended audience*: -who are you teaching? -what is the client's age, occupation, developmental level, and cultural affiliation? -will you be teaching a person or a group? *learning needs*: -what is the client's medical (or other) problem? -what behavioral changes are needed? -what self-care knowledge and skills does the client need? *knowledge level*: determine what the client already knows so that you can reinforce knowledge or adapt the teaching plan to the client's learning needs. ask questions such as: -what do you think caused your health problem? -what are your concerns about it? -how has the problem affected your usual activities? -what are your concerns about treatment (tests, surgery, etc.)? *health beliefs and practices*: ask the client to give a general description of their health. ask: -what do you usually do to stay healthy? -what problems do you think you are at risk for? -what lifestyle changes would you be willing to make in order to improve your health? *physical readiness*: -check ability to concentrate, manual dexterity skills, and pain level. *emotional readiness*: -find out whether the client is experiencing anxiety or emotional distress that will interfere with the learning process. ask the client whether they would like a family member or friend to be present during the learning. *ability to learn*: -what are the client's cognitive and psychomotor developmental abilities? -how does the client learn best (e.g., by memorization or recall, or by problem-solving or applying information)? -how well does the client recall previously presented material? *health literacy level*: -does the client have the ability to understand basic health information and services needed to make appropriate healthcare decisions? -can the client read and write? -do the client and healthcare provider speak the same language? *neurosensory factors*: -what is the client's ability to feel, see, hear, and grasp? -does the client have a medical condition that causes neurosensory compromise? *learning styles*: -ask the person: how do you prefer to learn new things? --for example, do you prefer to read about them, talk about them, watch a DVD, be shown how to do it, listen to the teacher, or use a computer? -do you like to read? -where do you get information about your health—from the Internet, books, magazines, your family, your healthcare provider? -do you learn best alone or with other people?

Define loss, grief, mourning, bereavement, death, stages of dying, end-of-life care, hospice care, and palliative care.

*loss*: -*actual loss*: includes the death of a loved one (or relationship), theft, deterioration, destruction, and natural disaster. the loss can be identified by others, not just by the person experiencing it (e.g., hair loss during chemotherapy). -*perceived loss*: is internal; it is identified only by the person experiencing it (e.g., a woman with a sexually transmitted infection may perceive loss of her purity). -*physical loss*: includes 1) injuries (e.g., limb amputation), 2) organ removal (e.g., hysterectomy), and 3) loss of function (e.g., paralysis). -*psychological (internal) loss*: are commonly seen in the areas of sexuality, control, fairness, meaning, and trust. loss of youth, limbs, body disfigurement, or body functions can negatively impact one's perception of self. the effect is loss of hope, faith, or dreams. -*external loss*: are actual losses of objects with sentimental or monetary value (e.g., jewelry, a home). -*environmental loss*: involves a change in the familiar, even if the change is perceived as positive (e.g., moving to a new home, getting a new job, and going to college). -*loss of significant relationships*: includes, but is not limited to, actual loss of spouses, siblings, family members, or significant others through death, divorce, or separation. *grief*: physical, psychological, and spiritual responses to a loss -*uncomplicated grief*: normal response to loss -*dysfunctional/complicated grief*: prolonged acute grief characterized by intensity of emotion and length of time --chronic grief: begins as normal and continues longterm with little resolution of feelings and inability to rejoin normal life --masked grief: occurs when the person is grieving but expressing their grief through other behaviors (drinking, arguing, working, etc) --delayed grief: grief that is put off until a later time ("i'll think about it later, right now I need to take care of my children") -*disenfranchised grief*: this is when the loss is not socially supported (ex: suicide, abortion) -*anticipatory grief*: grief is experienced before the actual loss occurs (a wife caring for her husband with a terminal illness grieved the man her husband used to be) *bereavement*: mourning and adjustment time following a loss *death*: end of the life of a person or organism -*higher-brain death*: irreversible cessation of all higher brain functions (cognitive functioning, consciousness, memory, reasoning) -*uniform commission in 1978*: irreversible cessation of all functioning of the brain, including the brainstem -*uniform determination of death act of 1981*: irreversible cessation of circulatory and respiratory functionings *stages of dying*: the early stage, the middle stage, and the last stage. these are marked by various changes in responsiveness and functioning. *end-of-life care*: refers to health care provided in the time leading up to a person's death. *hospice care*: is based on two key premises: 1) the quality of life is as important as the length of life 2) those who are terminally ill should be allowed to face death with dignity and surrounded by the comfort of their homes and families. -thus, hospice providers consider helping family members an essential part of their role. *palliative care*: is aggressively planned, holistic comfort care. general issues for most end-of-life care patients include: -supporting families and caregivers -ensuring continuity of care -ensuring respect for persons -ensuring informed decision making -attending to emotional and spiritual concerns -supporting function and survival duration -managing symptoms (e.g., pain, dyspnea, depression)

Identify unsuccessful adaptation measures and their associated risk factors.

*maladaptive*: -unhealthy style, temporary fix -some individuals choose unhealthy ways to cope, such as: --overeating --drinking alcohol excessively --smoking --excess sleeping --avoidance behavior --working too much --etc. unsuccessful adaptation can lead to: -*stress-induced organ response*: people who use maladaptive adaptation techniques put more stress on the body --cardiovascular system: decreased CO, oxygen depletion, and fatigue --endocrine system: diabetes, hyper/hypothyroidism, prenatal effects --immune system: autoimmune illnesses, suppression of the immune system --GI system: bowel inflammation, gastric hyperactivity, etc. --MSK system: muscle tension and pain, tension HA and temporomandibular joint pain --respiratory system: increased RR, hyperventilation, exacerbation of existing asthma, hay fever, and allergies -*somatoform disorders*: the presence of physical symptoms with no organic cause --hypochondriasis: the idea that they are or will become extremely ill --somatatization: anxiety and emotional turmoil are expressed in physical symptoms: pain that frequently changes location, loss of function, depression --pain disorder: emotional pain that manifests physically --malingering: conscious effort to use the patient's symptoms to escape unpleasant situations or gain something -*psychological disorders*: anxiety disorders, clinical depression, PTSD, etc. can cause: --crisis: exists when: 1. something happens that causes a drastic shift in the persons routine and they perceive it as a threat to self; 2. the persons usual coping methods are ineffective which results in high levels of anxiety --burnout: persons cannot cope effectively with the physical and emotional demands of their relationships, workplace, etc.

Discuss various factors affecting learning.

*motivation*: desire from within, created by an idea physical need, emotion, or some other force -greatest when clients recognize the need for learning, believe it is possible to improve their health, and are interested in the information they are being given *readiness to learn*: demonstration of behaviors that indicate the learner is both motivated and able to learn at a specific time -physical condition: physical factors (pain, strength, coordination, energy, senses, mobility) and intact cognition contribute to a patients willingness to learn -emotions: severe anxiety, stress, or emotional pain interfere with the ability to learn - learning itself can cause anxiety - a mild level of anxiety can enhance learning by providing motivation *timing*: clients retain information better when they have an opportunity to use it soon after it is presented - for some concepts the client may need more time to learn and apply the information *active involvement*: learning is more efficient when the client is actively involved in the planning and learning activities -learners retain 10% of what they read and 90% of what they speak and do *feedback given*: positive feedback encourages learners and boosts morale when it comes to taking difficult content or devoting the time and effort needed to get the most out of the educational process *reputation*: the client is more likely to retain information and incorporate it into their life if the content is repeated -each time the learner hears the information the more likely the information is being retained *learning environment*: an ideal learning environment is private, quiet, physically and psychologically comfortable, and free from distractions *scheduling of the session*: plan for uninterrupted time to allow you to adequately assess and understand the client -teaching time does not need to be long just uninterrupted -based on the clients condition (fatigue, pain, attention span, etc.) shorter learning times may be more beneficial *amount and complexity of content*: the more complex or detailed the content, the more difficult it is for most people to learn and retain -the greater the change, the greater the challenge for both the client and teacher *nurse/client communication*: avoid barriers to communication (i.e., pain, anxiety, fatigue, illness, hunger, dysfunctional relationships, language differences, vision and hearing impairment, cultural factors, and various environmental issues (noise and distraction)) *special populations*: adaptations made will depend on the type of special need, therefore, if you are not familiar with the clients condition, you must acquire theoretical knowledge of it -include a family member, caregiver, or other significant person in teaching to reinforce the learning and act as a safety net for implementing the information *developmental age*: an understanding of intellectual development will help to gear teaching strategies to something the client will understand *culture*: cultural sensitivity involves respect for the clients identity and needs, regardless of who they are, where they are from, how they speak, how old they are, what religion they practice or not, whether disabled or not, how much wealth or poverty they experience, how much they weigh, how socially popular they are, or any other aspect that can lead to unjust treatment *health literacy*: ability to understand basic health information and services needed to make appropriate healthcare decisions -health illiteracy is when the language spoken is not the patients preferred language -reading literacy is another significant barrier interfering with the communication between patients and healthcare providers

Describe the different types pharmacological and nonpharmacological pain relief measures.

*non-pharmacological* *cutaneous stimulation* -*transcutaneous electrical nerve stimulation* (TENS): --is a battery-powered device about the size of a pager that is worn externally --TENS units consist of electrode pads, connecting wire, and the stimulator --the pads are directly applied to the painful area --once activated, the unit stimulates a-delta sensory fibers --a TENS unit can be worn intermittently or for long periods of time, depending on the patient's pain -*percutaneous electrical nerve stimulation* (PENS): --combines a TENS unit with percutaneously placed (through the skin) needle probes to stimulate peripheral sensory nerves --PENS is effective in short-term management of acute and chronic pain --PENS therapy in some patients promotes physical activity, increases the sense of well-being, reduces the use of non-opioid medication, and improves sleep -*spinal cord stimulator* (SCS): --chronic neurological pain may be treated by a surgically implanted SCS --the SCS produces a tingly sensation that interferes with the perception of pain -*acupuncture*: --application of extremely fine needles to specific sites in the body to relieve pain --it is believed to stimulate the endogenous analgesia system -*acupressure*: --this stimulates specific sites in the body, using fingertips to provide firm, gentle pressure over the various pressure points --this process may have a calming effect through the release of endorphins --patients can be readily taught key points to stimulate so they can self-administer acupressure at any time -*massage*: --by providing cutaneous stimulation and relaxing the muscles, massage helps to reduce pain --effleurage, or the use of slow, long, guiding strokes, is used for obstetrical patients during labor and as back rubs for postsurgical patients --massage requires little effort from the patient and may improve sleep -*use of heat and cold*: --the application of cold causes vasoconstriction and can help prevent swelling and bleeding --heat promotes circulation, which speeds healing --use caution with these methods, however, because the skin may be injured by extremes of either hot or cold -*contralateral stimulation*: --this is stimulating the skin in an area opposite to the painful site --stimulation may be in the form of scratching, rubbing, or applying heat or cold --this intervention is especially helpful if the affected area is painful to touch, under bandages, or in a cast *oral sucrose*: -sucrose by mouth, alone or in combination with other analgesic measures, can be effective for pain control in newborns exposed to mild or moderately painful procedures *immobilization*: -immobilizing a painful body part (e.g., with splints) may offer some relief --it is particularly helpful with arthritic joints *cognitive-behavioral interventions*: -*distraction* is a method of drawing the patient's attention away from the pain and focusing on something other than the pain. it is based on the belief that the brain can process only so much information at one time. when distraction works, the patient has only a peripheral awareness of pain. -*sequential muscle relaxation*: for this, the person sits comfortably and tenses a group of muscles for 15 sec and then relaxes the muscle while breathing out. after a brief rest, this sequence is repeated using another set of muscles. -*guided imagery* uses auditory and imaginary processes to affect emotions and help calm and relax. acute and chronic pain, physical and psychological, may respond to guided imagery; however, it is more effective for chronic pain. -*diaphragmatic breathing*: patients can be taught to use the diaphragm (large, dome-shaped muscle at the base of the lungs that is the most efficient muscle of breathing) to intentionally take slow, even breaths when inhaling and exhaling at the rate of five to eight breaths per minute. the technique invokes relaxation and improves tissue oxygenation for managing pain and promoting comfort. -*hypnosis* involves the induction of a deeply relaxed state. once the person is in this state, the hypnotist offers therapeutic suggestions to provide relief of symptoms. for example, the hypnotist may suggest to a patient with arthritis that the pain can be turned down, like the volume of a radio. -*therapeutic touch* focuses on the use of the hands to direct energy fields surrounding the body. although research studies on its effect are not consistent, some patients become relaxed and require less pain medication after a session of therapeutic touch. -*humor* has positive effects on a patient's physical and emotional health. for most people, laughter is positive and indicates mental well-being. humor may boost the immune system as well. -*expressive writing* can help reduce chronic pain. some recommend structured writing sessions in which the patient describes stressful events for a specified period of time over consecutive days. this type of therapy is best when done in conjunction with a knowledgeable practitioner to provide direction and support. -*animal-assisted therapy*: animals (typically dogs) trained to be obedient, calm, and comforting, provide therapeutic benefit to people with chronic pain (e.g., fibromyalgia) and other health problems (e.g., cancer). patients' serum cortisol (stress hormone) levels decrease when they are exposed to therapy animals. *pharmacological*: *non-opioid analgesics* -*NSAIDs*: include aspirin, ibuprofen, and several others. NSAIDs act primarily in the peripheral tissues by interfering with the production of prostaglandins. prostaglandins sensitize pain receptors and are involved with inflammation. main side effect gastric irritation/bleeding -*acetaminophen* has very little anti-inflammatory effect. Instead it has analgesic and fever-reducing properties. it has fewer side effects and is probably the safest of the non-opioids. it does not affect platelet function, rarely causes GI problems, and can be used in patients who are allergic to aspirin or other NSAIDs. main side effect is hepatoxicity/liver damage and is dangerous for those who consume an excessive amount of alcohol and those who have liver damage *adjuvant analgesics* reduce the amount of opioid the patient requires. drugs in this category include anticonvulsants, antidepressants, local anesthetics, topical agents, psychostimulants, muscle relaxants, neuroleptics, corticosteroids, and others. *opioid analgesics*: opioids are natural and synthetic compounds that relieve pain, although they vary in potency. to some degree, opioids work by finding pain receptor sites to bind with and block the pain impulse. opiate receptors include mu, delta, kappa, and sigma receptors; however, mu receptors are most effective in relieving pain. *client-controlled analgesia pumps* (PCA pump): are an effective and safe way to deliver opioids by IV, epidural, or subcutaneous routes. they provide excellent pain relief and give the patient a sense of control over the pain. the system consists of a programmable infusion pump, a syringe (or bag), IV tubing, and a button that the patient presses to self-administer a dose. the success of the pump depends on programming a dose that can be administered frequently enough to manage the patient's pain effectively. rarely, providers order a low continuous rate of infusion (basal rate) that can be supplemented with patient-demand doses.

Define the steps to safely administer the following medication types: oral/sublingual/inhaled, optic/ophthalmic, topical/dermal, rectal/vaginal, and injectables.

*oral*: -drug swallowed and *absorbed from the stomach or small intestines* (GI tract) -however they circulate through the liver before reaching systemic circulation -many oral medications can be almost completely inactivated in this way --this inactivation is known as the first-pass effect -for this reason, oral medications are formulated with a higher concentration of the drug than are parenteral medications *sublingual*: -(a variation of transmucosal administration) the drug is held *under the tongue* and is absorbed across the sublingual mucous membrane -if this medication is chewed or swallowed it will not work *inhaled*: -a device (nebulizer, face mask) breaks the drug into finely dispersed particles, which are breathed into the respiratory passages. -some drugs are intended for local effects in the respiratory passages; other (anesthetic gases) are for systemic effects, especially in the brain -*nebulizers*: --atomizers: large droplets --aerosol sprayers: suspend the droplets in a gas, O2 --ultrasonic (handheld) nebulizer: mixes small volume of medication with normal saline, forces air and as a fine mist that can be inhaled deep into the lungs, and MDI: delivers measured dose of nebulized drug -*MDI* (metered-dose inhaler): --use spacer for kids or those who have difficulty getting the full dose --hold the inhaler to the mouth press down on the canister --have the patient breath in deeply for 2-3 seconds, hold their breath for 10 seconds and then slowly breath out through their nose or pursed lips --rinse mouth out after administration --if more than one pump is needed wait about a minute between pumps -*DPI* (dry powder inhaler): activated by a pump rather than by inhalation *otic*: -only sterile if the tympanic membrane is ruptured -medication is dedicated to one patient only -do not let dropper touch ear as this can contaminate the medication -for adults pull the pinna up and back -for kids pull the pinna down and back -solutions, drugs dissolved in a liquid carrier OR ointments *ophthalmic*: -solutions, drugs dissolved in a liquid carrier OR ointments -sterile procedure -pull down bottom eyelid and place medication into middle of lower conjunctival sac -for drops: have patient gently close their eyes for a few seconds -for ointment: have patient blink gently to distribute medication -do not touch the tip of the container to the eye to prevent damage to the patients eye and contamination of the medication -clean eyelids gently before and after the procedure starting from the inner eye and moving outward *topical/dermal*: -the drug acts locally or is absorbed directly through skin --lotions, creams, ointments --transdermal patches --eye and ear --nasal --vaginal --rectal *vaginal/rectal*: -suppositories or enemas , drugs mixed with a glycerin-gelatin or cocoa butter base and shaped for insertion into the body, they dissolve gradually at body temp OR foams, jellies, liquids (douches), creams, tablets, suppositories *injectables*: -important things to consider when administering this type of medication: --route of the injection: subcutaneous (SQ) or intramuscular (IM) --size & developmental stage --possible injection sites --solution type & volume --label all syringes you prepare with what it contains!!! *intradermal* (ID): -medications are given into the dermis, or the layer of the skin located beneath the skin surface -the intradermal route is commonly used for allergy or tuberculosis (TB) testing -most nurses use the patient's non-dominant arm for TB screening and the dominant arm, chest, or upper back for all other tests. -*administering ID injections*: --injection into the dermis layer just beneath the skin's surface --only very small amounts of medication usually *0.1 mL* --uses small *1 mL syringe*, fine gauge *26-28 G* needle --insert at *5-15º angle* --example: Tuberculin syringe or allergy testing --*sites*: forearms - upper chest and upper back *subcutaneous* (SQ): -given into the subcutaneous tissue -absorption is slower than through the intramuscular route because subcutaneous tissue does not have as rich a blood supply as muscle -however, speed of absorption varies with the subcutaneous site selected. --sites on the abdomen and arms offer *fastest* absorption --those on the thigh and upper buttocks, the *slowest* absorption -medication is absorbed more *evenly* from the abdomen than from the thighs and buttocks because it is less affected by activity -*administering SQ injections*: -*0.5 mL - 3 mL* syringe -*25 G or less* needle -*3/8-5/8 inches* in length -maximum injection amount = *1 mL* -*45º- 90º* angle -*sites* include: back of the upper arm, abdomen, upper back, lower back and top of the thighs *SQ injection of insulin*: -must prepare (draw up) injection in the presence of another nurse -insulin must ALWAYS be dual verified by another nurse -insulin syringe in units, 26-30 G needle -injection is given at a 45º or 90º angle -make sure meal tray is at bedside before injecting insulin *intramuscular* (IM): -injected into the muscle tissue -medications are absorbed faster than subcutaneous medications because of the rich blood supply in the muscles -muscles can also tolerate more fluid—you can give as much as 3 or 4 mL of liquid in the large vastus lateralis and ventrogluteal muscles -the smaller the muscle, the less fluid it can tolerate *administering IM injections*: -*1, 3, or 5 mL syringe* -*21-23 G*, *1 - 1 ½ inch* needle -maximum injection amount *1 -3 mL* depending on site chosen -must use *Z track method* -sites: --*deltoid*: ---2 fingerbreadths below the acromion process in the middle third of the muscle ---maximum injection is *1 mL* ---Z track method --*vastus lateralis*: ---between greater trochanter and the lateral femoral condyle ---injection site is the middle third of the muscle ---maximum injection is *3 mL* ---use Z track method --*ventrogluteal*: ---place your palm on the greater trochanter and thumb towards the groin avoiding the anterior superior iliac spine and iliac crest inject in the muscle ---maximum amount is *3 mL* ---use Z track method *intravenous* (IV): -medications are given through a catheter or cannula inserted into a vein. -the onset of medication action takes place within seconds, so IV administration is especially useful in emergencies. -however, because an *IV drug begins to act immediately, there is no way for you to stop its action* if an adverse reaction occurs (unless there is a known antidote)

Describe methods for evaluating teaching and learning outcomes.

*oral*: -questions / interviews / questionnaires / checklists allow clients to evaluate their own progress. you may obtain more information by talking with the client; however, you may obtain more honest responses from anonymous written evaluations. *direct observation*: -of client performance are descriptive notes that you make of the learner's performance. They will help you in providing feedback either to reinforce accurate learning or to correct misinformation. *client reports and client records of performance and results*: -you can evaluate the data and give feedback. provide criteria and clear expectations to help the client document. *tests and written exercises* -can be used in a formal learning setting to measure retention and progress toward meeting cognitive objectives. -this method requires the learner to have adequate literacy skills.

Classify pain according to origin, cause, duration, and quality.

*origin*: -*cutaneous/superficial*: arises in the skin or subcutaneous tissue --examples: touching a hot object, paper cut --even though the injury is superficial it may cause significant short-term pain -*deep somatic*: originates in the ligaments, tendons, nerves, blood vessels, and bones --localized and described as achy and tender --examples: fracture, sprain, arthritis, bone cancer -*visceral*: caused by the stimulation of deep internal pain receptors --most commonly experienced in the abdominal cavity, cranium, or thorax --not well localized and described as tight, pressure, or crampy pain --the description of the quality and extent of the pain often serves as a strong clue to the cause --examples: menstrual cramps, labor pain, GI infections, bowel disorders, organ cancers -*radiating*: starts at the origin but extends to other locations --examples: sore throat radiates to the ears and head; heartburn radiates outward from the sternum to include the whole thorax -*referred*: occurs in an area that is distant from the original site --example: pain from a heart attack may be experienced down the left arm, through the back, or into the jaw -*phantom*: perceived to originate from an area that has been surgically removed --patients with amputated limbs may still perceive that the limb exists and experience burning, itching, and deep pain -*psychogenic*: believed to arise from the mind --the patient perceives pain despite the fact that no physical cause can be identified --can be just as severe as pain from a physical cause *cause*: -*nociceptive*: when pain receptors (nociceptors) respond to stimuli that are potentially damaging --results from noxious thermal, chemical, or mechanical stimuli --may result from surgery, injury, or inflammation -*neuropathic*: complex and often chronic pain that arises when injury to one or more nerves results in the repeated transmission of pain signals even in the absence of painful stimuli --may result from: poorly controlled diabetes, stroke, tumor, alcoholism, amputation, or viral infections (HIV/AIDS, shingles) *duration*: -*acute*: short duration and generally, rapid in onset --varies in intensity and may last *up to 6 months* --most frequently associated with injury or surgery --protective and indicates potential or actual tissue damage --pain typically disappears after healing has occurred -*chronic*: long duration --*6 months or longer* --often interferes with daily activities --clients may experience periods of remission and exacerbation --usually viewed as insignificant and may lead to withdrawal, anger, depression, frustration, and dependence -*intractable*: both chronic and highly resistant to relief --should be approached with multiple methods of pain relief *description*: -*quality*: sharp, dull, aching, throbbing, stabbing, burning, ripping, searing, tingling, etc. -*periodicity*: episodic, intermittent, or constant -*intensity*: mild, distracting, moderate, severe, intolerable, etc.

Explain health promotion models utilizing the 4 stages of change.

*pender's health promotion model* (HPM): -three groups of variables that affect health promotion: --1) individual characteristics and experiences --2) behavior-specific cognitions and affect --3) behavioral outcome -based on seven assumptions that reflect both nursing and behavioral science perspectives *wheel of wellness*: -if one of the spokes is weak, the whole wheel is weak -the "spokes" of the health wheel represent the dimensions of health: --emotional --intellectual --physical --spiritual --social/family --occupational -the level of wellness progresses from the center to the outer part of the wheel -the center represents the least amount of wellness, and the outer part represents optimal wellness -if one area of an individual's life is not functioning at optimal level, life will not be as fulfilling as it could be *transtheoretical model of change*: -in this model, change occurs in four stages: --precontemplation: there is no intention to change behavior in the foreseeable future, because patients are unaware or underaware of their problems; they do not yet contemplate change --*contemplation*: involves the decision-making process --*preparation*: individuals are intending to take action in the next month and are reporting some small behavioral changes ("baby steps'') --*action*: the implementation of the plan --*maintenance*: allows the changed behavior to be reinforced --termination: completes the maintenance - persons who enter into the termination stage have changed the behavior and are not in danger of relapse -ideally, the stages would progress in this order, realistically, a person may progress and regress in any of the stages -stages 1 and 6 precede and follow the steps of change; change occurs in *4 steps (2-5)*

Identify physiological and psychological responses to stress.

*physiological*: -*general adaptation syndrome* (GAS): --*alarm stage*: fight or flight... sympathetic NS, increase hormones from hypothalamus (CRH), posterior pituitary (endorphins, ADH), anterior pituitary (ACTH), adrenal cortex (cortisol, aldosterone), adrenal medulla (E and NE) --*resistance*: adaptation, parasympathetic balances the sympathetic activity, hormone levels return to normal --*recovery or exhaustion*: adaptation leads to recovery; exhaustion occurs when alarm reaction recurs until energy is depleted, the person cannot adapt and dies -*local adaptation syndrome*: --*reflex pain*: immediately and unconsciously withdraw from the source of pain --*inflammatory*: local reaction to cell injury; regardless of the injuring agent (stressor), its mechanisms are the same, and they produce the classic symptoms of inflammation: pain, heat, swelling, redness, and loss of function ---vascular response: BV at the site constrict to control bleeding, release histamine, kinin, and WBCs move into the area ---cellular: phagocytes migrate and engulf bacteria, other foreign material, and damages cells and destroy them ---exudate formation: fluid and WBCs that move from the circulation to the site of injury are exudate. all depends on severity of injury and tissues involved ---healing: replacement of tissue by regeneration (identical or similar cells, NOT all cells can do this: central NS neurons and cardiac muscle cells) OR repair (scar tissue replaces original tissue, most injuries) *do not confuse inflammation with infection*. -inflammation is a mechanism for eliminating invading pathogens; therefore, you always see inflammation where there is infection. -however, inflammation is stimulated by trauma as well as pathogens (swelling of a sprained ankle); thus, it can occur when there is no infection. *psychological*: -*cognitive*: difficulty concentrating, daydreaming, forgetfulness -*emotional*: anxiety, fear, anger and depression (anger is often a first protective response against anxiety) -*behavioral*: outbursts, nightmares, illnesses, change in eating habits

Discuss the differences between race, ethnicity, and culture.

*race*: -unlike ethnicity -*strictly related to biology* -groupings based on biologic similarities *ethnicity*: -similar to culture -refers to *groups sharing common social and cultural heritage* -passed down through generations -way of categorizing people based off of shared characteristics -never assume a patients ethnicity, always ask "what is your ethnicity?" -ethnic groups: --characteristics in common --physical, race, ancestry, religion *culture*: -a *learned*, pattern behavior response acquired over time -includes *beliefs, attitudes, values, customs, art, taboos, and ways of life* -*primarily learned and passed on by families and social organizations* -guides decision making -impacts worldview -facilitates self worth and identity -*characteristics*: --beliefs provide *identity* and sense of belonging --consist of common beliefs and practices --exist at many levels (material - art, dress; non-material - customs, language, practices) --learned and taught --dynamic and adaptive to environment --complex --diverse --all-encompassing -culture is *individualized* -every person has a culture -culture is dynamic (it changes) -*nurses culture*: personal beliefs and nursing's professional values

Describe the nurse's role in health promotion activities.

*role modeling*: teaching by example, demonstrating the behaviors and attitudes to be learned -provide inspiration and strategies for health promotion -ex: a woman who is morbidly obese joins a weight loss group led by a woman who has lost nearly 100 pounds, she admires this woman and chooses her as a role model *individual counseling*: face-to-face may be helpful when client is attempting a large lifestyle change -customize and map out the steps required to meet the clients goals -may include writing a contract detailing the clients expected behaviors -print out the contract and have the client sign it to reinforce their commitment -suggest the client post the plan in a frequently seen area to act as a constant reminder *health education*: focus on self-care strategies, caregiver concerns, or how to be an effective healthcare consumer -self-care programs typically cover nutrition, exercise, stress management, or disease prevention -programs may consist of lectures, printed material, billboards, or posters *supporting lifestyle choices*: clients may need support to make the changes needed -provide support during counseling sessions or interactions -help client identify available support and resources within the community, or from friends, family, coworkers, etc.

Identify different concepts in teaching and learning.

*social learning theory*: -explains the characteristics of the learner. -self-efficacy is a major concept in social learning theory. --it refers to a client's perceived ability to successfully perform a task. *behavioral learning theory*: -characterized by explicit identification of information to be taught and immediate reward for correct responses. -it has its roots in psychology and the belief that the environment influences behavior and, in fact, is the essential factor in determining human action. *cognitive theory*: -sees learning as a complex cognitive (mental) activity. -learning is an intellectual or thinking process in which the learner structures and processes information. -cognitive theory also recognizes the importance of developmental stage and social, emotional, and affective influences on learning. *humanism theory*: -focuses equally on the learner's affective (emotional), cognitive (intellectual), and attitudinal qualities. -it emphasizes the learner's active participation and responsibility in the learning process. -learning is thought of as self-motivated, self-initiated, and self-evaluated, and its purpose is self-development and achievement of the learner's full potential.

Define vocabulary associated with stress including: stress, coping, adaptation, distress.

*stress*: a state of mental or emotional strain or tension resulting from adverse or very demanding circumstances *coping*: conscious strategies used to reduce unpleasant emotions *adaptation*: healthy choices and a support system which helps to directly reduce the negative effects of stress -example: change in lifestyle, problem solving *distress*: type of stress that threatens health

Explain the nurse's role in medication safety and error prevention processes.

*three checks*: -before you pour -after preparation -at bedside -if the patient questions one of the medications do not administer it, call the provider to verify -if you are unsure about an order, do not administer the medication, call the provider to verify -if you are unsure if something can be cut or crushed call the pharmacy to verify ALWAYS DOCUMENT THE MEDICATIONS GIVEN SO THAT THERE IS NO MISUNDERSTANDING BETWEEN NURSES *six+ rights of medication administration*: -right patient -right dose -right drug -right time -right route -right documentation +right reason +right to know +right to refuse

Discuss verbal and nonverbal ways to assess pain.

*verbal*: -obtain a complete pain history (ex: OLD CARTS) -pain scale: --visual analog scale (VAS) --numeric rating scale (NRS) --simple descriptor scale (mild, moderate, severe) --wong-baker faces pain rating scale *nonverbal*: -facial expression, posture, and body positioning: lowering the brow, wincing, clenching jaw, closing eyelids, guarding, tense. -changes in vital signs: generally only lasts a short time. continuous, severe pain may elevate the vital signs again from time to time, but they rarely remain elevated. *normal vital signs do not mean the patient is pain free* -patients may be in pain even if they don't "act like" they are: patients who use laughter, distraction, or sleep to cope with pain are often undertreated. *to assess pain accurately, you must ask your patients and believe them* -use an interpreter if the patient speaks a different language: ask the interpreter to explain the patient that it is important to manage pain and that you will be using a pain scale to assess their pain regularly. have the patient translate and write out the explanation and directions for the pain scale so that you can refer to the directions when assessing the patient. patients can point to a number or a face on a pain scale when no interpreter is present -some patients feel that they are being "bad" or "weak" if they express pain: withdraw or stoic, it is important that you establish a trusting relationship with your patients. convey your concern and acknowledge the persons pain. if the patient trusts you they will feel free to verbalize thoughts and feelings -remember to assess for depression: depression is often overlooked in a patient who is in pain

Discuss therapeutic nursing communication techniques (verbal and non-verbal).

*verbal*: -use appropriate vocabulary: --try to avoid healthcare jargon --use medical terms only when you know the listener will understand them -denotative and connotative meaning: --use terms that are clear, concise and not open for interpretation -pacing: --do not talk too fast (do not rush) or too slow -intonation: --tone of voice --pitch --volume -clarity and brevity: --keep it concise and to the point, do not ramble -timing: --quiet environment --willingness to talk --are there others in the room --interaction must allow ample time for response -relevance: --what do they need to talk about --what questions do they have --communication is most effective when both parties find the discussion to be important -credibility: --open and honest with patients --only provide information where you are certain of the facts -humor: --use humor with caution --never direct humor at the patient, disease process, or healthcare team *non-verbal*: -body language --is your body language appropriate? --are you standoffish? -facial expressions --do you have a RBF? --do not roll your eyes --do not look annoyed when your patient is asking questions -posture & gait -personal appearance --are you disheveled? -gestures --make sure any gestures used are appropriate and cannot be misinterpreted -touch --is touch appropriate in this situation --avoid if patient is angry or mentally unstable

Describe physiological changes that affect breathing and oxygenation status.

-*"Senile" Emphysema"*: dilation of the alveoli, enlargement of airspaces, decrease in exchange surface area and loss of supporting tissue for peripheral airways. -Changes resulting in decreased static elastic recoil of the lung and increased residual volume and functional residual capacity. -Compliance of the chest wall diminishes, thereby increasing work of breathing when compared with younger subjects. -Respiratory muscle strength also decreases with aging.

Describe the physiological changes that occur during death.

-*1 to 3 months prior to death*: the dying person begins to withdraw from the world and people. sleep increases; it becomes difficult for the body to digest food, especially meats; and appetite and food intake decrease. liquids are preferred. anorexia may be protective. the resulting ketosis can diminish pain and increase the person's sense of well-being. -*1 to 2 weeks prior to death*: a host of physical changes indicate the body is beginning to lose its ability to maintain itself. -*days to hours prior to death*: often a surge of energy brings mental clarity and a desire to eat and talk with family members. however, as death approaches, patients tend to become dehydrated and have difficulty swallowing, which results in decreased blood volume. in the final hours of life, many patients become restless and agitated. this response may be caused by medications, liver failure, cerebral hypoxia, renal failure, stool impaction, distended bladder, increased pain, or unresolved emotional or spiritual issues. near to the time of death, some people unexpectedly become more coherent and energized for a time. others become less communicative, quiet, and withdrawn. fatigue is common. *moments prior to death*: the dying person does not respond to touch or sound and cannot be awakened. typically, there is a short series of long-spaced breaths before breathing ceases entirely and the heart stops beating. *Kubler-Ross Stages*: 1. *Denial*: not necessarily negative, it gives them time to prepare psychologically to what is happening -ex: "not me, this cannot be happening to me" 2. *Anger*: the persons response to feeling that the situation is unfair - they may take their anger out on their loved ones or those who can not fight back (nurse, provider) -ex: "why me?"; "I am a good person, why is this happening to me?" 3. *Bargaining*: usually this is a bargaining with a higher power (God) -ex: "if only I could live to see my grandsons graduation/birth of my grandson" 4. *Depression*: withdrawn sadness, this is a response to the current loss and any future losses 5. *Acceptance*: not wanting the death/loss but coming to terms with it and ceasing to fight it - the person may seem devoid of feelings in this stage

Identify developmental factors that influence oxygenation status.

-*Infants and toddlers*: upper respiratory infections (URIs), nasal congestion -*School-aged children and adolescents*: exposed to respiratory infections and secondhand smoke; plus danger of starting cigarette smoking -*Young to middle-aged adults*: exposed to cardiopulmonary factors, unhealthy diet, lack of exercise, stress, cigarette smoking, illegal substances; over-the-counter (OTC) and prescription drugs not used as intended -*Older adults*: calcification of valves, SA node, and costal cartilages; osteoporosis; atherosclerosis; enlarged alveoli, trachea, and bronchi

Prioritize patient safety needs.

-*Safety is a basic human need*, second only to survival needs such as oxygen, nutrition, and fluids. -As a nurse, you will be fundamentally concerned with the safety of your clients. -You must also be concerned with your own safety and the safety of other care providers. -Many accidental injuries can be prevented by being aware of hazards and taking reasonable precautions. -According to the CDC, *accidents, or unintentional injuries, are the third leading cause of deaths in the United States*. An estimated 170,000 people die each year as a result of accidents. Expressed another way, one person dies from an accident every 5 minutes. *Poisoning is now listed as the number one cause of unintentional death, followed by motor vehicle accidents, falls, drowning, and fires*.

Describes nursing management of stress, including appropriate coping measures.

-*alter the stressor*: in some situations, a person takes actions to remove or change the stressor. -*adapt to the stressor*: adapting involves changing one's thoughts or behaviors related to the stressor. -*avoid the stressor*: you may find that being with a certain person is stressful for you, even though you have tried many times to change the dynamics of the relationship. In that case, it may be best to minimize or end your relationship with the person. this method could be maladaptive in some situations. -successful adaptation allows for normal growth and development and effective responses to changes and challenges in daily life. the outcome depends on the balance between the strength of the stressors and the effectiveness of the person's coping methods. --exercise, meditation, visualization, acupuncture, chiropractor, journaling, music, etc. personal factors that influence adaptation: -*perception of the stressor*: realistic or exaggerated (example: 2 patients with similar coping skills both have a mastectomy; one thinks: "yes, I am losing part of my body but I am more than just my breasts"; the other thinks: "I will be so ugly, I feel like I am less of a person now") -*overall health status*: stressors to their health (new diagnosis of HTN) may actually cause a healthy person to make adaptive behaviors. however, with someone who is older and tired from other health problems (RA, HF, etc.) they may be too overwhelmed and exhausted to take any action -*support system*: a good support system can help a person adapt to stress and solve problems -*hardiness*: people who thrive despite overwhelming stressors. this includes 3 key attitudes: --commitment: seek being involved with ongoing events instead of feeling isolated --control: allows them to struggle and try to influence the outcomes instead of being passive and feeling hopeless --challenge: allows them to perceive stressful situations as opportunities for learning -*other personal factors*: age, developmental level, & life experiences all influence stress responses. those who are very old or very young may not have the physiological or psychological reserves to adapt to stressors

Identify types of stressors.

-*distress* threatens health. -*eustress* (literally "good stress") is protective. -*external*: external to the person - death to a family member, a hurricane, or excessive heat in the room -*internal*: internal to the person - diseases, anxiety, nervous anticipation, negative self-talk -*developmental*: those stressors that can be predicted to occur at various stages of a person's life. in a sense, developmental stressors may be easier to cope with because they are expected and the person has some time to prepare for them. -*situational stressors* are unpredictable. they can occur at any life stage and can affect infants, children, and adults equally. -*time stressors* can lead to angst over the lack of opportunity to tend to all the things that you have to do. common examples of time stressors include worrying about managing multiple demands or rushing to avoid being late for work or an appointment. -*anticipatory stressors* are those that you experience concerning the future. sometimes this stress can be focused on a specific event, such as an upcoming exam or clinical day. anticipatory stress can also be undefined, such as a vague sense of concern about the future or a feeling that something will go wrong. -*physiological*: those stressors that affect body structure or function. --*chemical*: poison, medications, tobacco --*physical or mechanical*: trauma, cold, joint overuse --*nutritional*: vitamin deficiency, high-fat diet --*biological*: viruses, bacteria --*genetic*: inborn errors of metabolism --*lifestyle*: obesity, sedentary lifestyle -*psychological*: external stressors that arise from work, family dynamics, living situation, social relationships, and other aspects of our daily lives.

Describe the importance of interprofessional education in providing quality patient care.

-individuals with differing perspectives in healthcare offer unique ideas and talents to help improve patient care 1. empowers team members 2. closes communication gaps 3. enables comprehensive patient care 4. minimizes readmission rates 5. promotes team mentality 6. promotes patient-centered care

Define the steps of the nursing process and features common to each phase.

ADPIE *Assessment*: recognizing cues *Diagnosis*: putting together what the cues mean *Plan*: methods used to potentially fix the problem (2 types: independent - the nurse does themselves; dependent (collaborative) provider ordered) *Implementation*: taking the plan and putting it into action *Evaluation*: is the plan working?

Plan nursing care for patients with mobility issues.

-IS use -TED or SCD use -Turn every 2 hours -ROM exercises (AROM or PROM) -Assisted ambulation - if it can be tolerated

Discuss medical nutrition therapy.

-Promotes prevention, diagnosis, and management of nutritional changes in patients linked to chronic diseases. -Enteral, oral, tube feeding, parenteral.

Describe the nurse's role in infection prevention.

-Protect patients and staff from infection. -Follow proper protocols depending on the patients case. *Standard* all patients *Contact* transmission through direct or indirect contact *Airborne* <5mm picked up through the air (air currents) *Droplet* >5mm sneezing, coughing, etc. *Protective isolation* protecting the patient from the staff and visitors (severely weakened immune system)

Use standard precautions to prevent transmission of infection through blood and body fluids.

-Tier 1 precaution -applied to all patients "infectious" or not -perform hand hygiene before and after -PPE: gloves, gown, mask, face shield (if splash is expected), and safe injection practices -cough etiquette

Demonstrate interventions used to enhance wound healing to prevent complications.

-Turn patient *every 2 hours* minimum. -*Pressure injury monitoring*: is the wound getting worse or better? bigger or smaller? is there drainage? what does it look like? -*Managing moisture* (incontinence, bathing, barrier creams, lotion and massage, linens, etc.). -*Wound dressings*: provide a moist wound healing environment through the use of the proper dressings (hydrating = hydrocolloid or foam to reduce wound size) negative pressure = create vacuum, silver = barrier to bacteria, transparent = clear film, seal to help create negative pressure within the wound. -*Wound debridement*: debride necrotic tissue and cleanse the wound to remove debris. -*Nutritional substrates essential to the healing process*: calories, protein, fluid, vitamin A, vitamin C, and zinc. -*Rule of 30 degrees* HOB at </=30 degrees - this prevents patient from sliding down in bed and prevents sheering/friction injuries. -*Support surfaces* speciality mattresses, pillows to position the patient (keeping heels off the bed).

Implement safe patient handling techniques when transferring or mobilizing patients.

-Use a wide base of support (feet spread apart). -Minimize bending and twisting. These movements increase the stress on the back. Instead, face the object or person, and bend at the hips or squat. -Squat to lift heavy objects from the floor. (Squatting lowers your center of gravity.) Push against the strong hip and thigh muscles to raise yourself to a standing position. Avoid bending at the waist. -Use the muscles in your legs as the power for lifting. Bend your knees, keep your back straight, and lift smoothly. Repeat the same movements for setting the object down. -Keep objects close to your body when you lift, move, or carry them. The closer an object is to the center of gravity, the greater the stability and the less strain on the back. -Use both hands and arms when you lift, move, or carry heavy objects. -Do not stand on tiptoes to reach an object. If you must use a ladder or stepstool to reach for an object, make sure it is stable and adequate to position your body close to the object. -Push, slide, or pull heavy objects whenever possible rather than lifting. -Maintain a good grip on the patient or object you are moving before attempting to move it. -When possible, keep your elbows bent when you carry an object. -Work with smooth and even movements. Avoid sudden or jerky motions.

Describe methods to promote safety when moving and transferring patients.

-Use proper transferring method. -Do not use broken/damaged equipment -Use proper body mechanics: --Use a *wide base of support* (feet spread apart). --Minimize bending and twisting. These movements increase the stress on the back. Instead, face the object or person, and *bend at the hips or squat*. --Squat to lift heavy objects from the floor. (Squatting lowers your center of gravity.) Push against the strong hip and thigh muscles to raise yourself to a standing position. *Avoid bending at the waist*. --Use the muscles in your legs as the power for lifting. *Bend your knees, keep your back straight, and lift smoothly*. Repeat the same movements for setting the object down. --*Keep objects close to your body when you lift, move, or carry them*. The closer an object is to the center of gravity, the greater the stability and the less strain on the back. --Use both hands and arms when you lift, move, or carry heavy objects. --Do not stand on tiptoes to reach an object. If you must use a ladder or stepstool to reach for an object, make sure it is stable and adequate to position your body close to the object. --Push, slide, or pull heavy objects whenever possible rather than lifting. --Maintain a good grip on the patient or object you are moving before attempting to move it. --When possible, *keep your elbows bent* when you carry an object. --Work with *smooth and even movements*. Avoid sudden or jerky motions.

Analyze factors that contribute to urinary incontinence.

-age (NEVER A NORMAL PART OF AGING) -diabetes mellitus -obesity -stroke -cognitive impairment -decreased mobility -gender (women are more likely to have stress incontinence) -smoking

Discuss strategies to complete an assessment of cultural preferences.

-ask open-ended questions -allow patient time to answer questions -listen respectfully -listen without bias -remain non-judgmental --be mindful of your non-verbal communication

Develop tactics for working with patients of different cultures or ways of learning.

-ask open-ended questions to develop the best plan to teach -be supportive -be respectful -check yourself at the door -be culturally sensitive

Explain nursing management of care for patients with an ostomy.

-bowel or bladder diversion -*stoma*: part of the intestine that is exposed --should be beefy red color --black stoma = necrotic --stoma with irritated skin - could lead to skin breakdown - needs to be treated --pale stoma = problem with circulation -*ileostomy* - ilium - small intestine - going to bypass the large intestine - right upper quadrant - loose, continuous stool - biggest concern = skin breakdown due to the liquid drainage - another concern is risk for fluid and electrolyte imbalance -*colostomy* - location determines consistency of drainage - the closer the colostomy is to the ascending colon the more liquid and continuous the drainage will be - the closer to the rectum the more solid the drainage --ascending colostomy: right side of the abdomen --descending colostomy: left side of the abdomen --double barrel colostomy: transverse colon (upper) --sigmoid colostomy: lower left quadrant -purposes: --colitis --cancer --diverticulitis --trauma -can be temporary or permanent -placement planned with WOCN -ostomy care: --review history --assess stoma --assess output --assess peri-stomal skin --assess patient education needs (involve patient in care, consult with WOCN, diet education) --assess psychosocial issues (return to normal activities, body image, sexuality, ostomy support groups) --types of appliances (one piece, two piece) --fit to stoma --skin barrier --empty when bag is 1/3 full

Identify risk factors for urinary tract infections.

-catheters (CAUDI) -urinary retention -poor peri care -gender (women have a shorter urethra) -sexual activity -uncontrolled diabetes -dehydration -contraceptive use -kidney stones

Explain methods to help patients and colleagues cope with death.

-counseling -support groups -surround yourself with friends and family -talk through feelings of grief -take time for yourself

Discuss components of a cultural assessment.

-cultural background -rituals and customs -communication patterns/norms -nutritional practices -family relationships -decision making on consent for treatment -beliefs & perceptions relating to health, illness, & treatment -self-care v. being cared for -individual time keeping beliefs and practices -boundaries related to privacy -views of hospitals, nurses, doctors, & other healers -issues affecting delivery of care -both formal and informal education

Explain methods of nursing care that decreases patients' risk of urinary tract infections.

-education -avoid catheterization -good peri care -clean the catheter very well (if one is needed) -encourage patients to increase fluid intake

Identify nursing interventions for patients and families at end-of-life.

-emotional support: support family through stages of grief -encourage discussions of previous loss -include significant others in discussions and decisions, as appropriate -therapeutic play: encourage children to express their feelings -active listening: listen to expressions of grief -support group: identify sources of community support -crisis intervention -spiritual support

Discuss elements of the communication process.

-empathy -respect -genuineness -concreteness -confrontation

Describe nursing management of nutritional status for health promotion.

-feeding tubes -proper nutrition -documentation of food intake -proper vitamins -medication administration

Identify the objectives of Healthy People 2030.

-four broad goals for the U.S. population set by the Healthy People 2020 initiative: --*attain* high-quality, longer lives free of preventable disease, disability, injury, and premature death --*achieve* health equity, eliminate disparities, and improve the health of all groups --*create* social and physical environments that promote good health for all --*promote* quality of life, healthy development, and healthy behaviors for all life stages

Identify barriers to learning.

-illness, fatigue, other physical conditions -anxiety, personal stress -low literacy; low health literacy -environment not conducive to learning -lack of time to learn -overwhelming amount of behavioral change needed -overwhelming complexity of the condition or treatment to be learned -lack of support and ongoing positive reinforcement -lack of motivation, willingness to take responsibility -language barrier -teaching not suited to learning preferences and style -provider uses jargon and technical terms -does not perceive need for the information taught

Competently and safely manage the care of patient receiving enemas.

-installation of the solution into the rectum -requires healthcare provider order -patient is in left lateral sims position -purposes: --bowel prep --severe constipation --medication administration --diagnostic -types of enemas: --cleansing enema: ---soap suds ---tap water (hypotonic) --hypertonic: ---sodium/phospate enema (fleets enema) --retention enema: ---mineral oil enema --medicated enema: ---neomycin - antibiotic ---kayexalate - for patients with a high potassium level - lowers potassium level -risks of enemas: --fluid/electrolyte imbalances --rectal trauma --vasovagal reaction

Explain nursing techniques to address cultural barriers relating to patient care.

-is the practice good or bad? -how does the practice effect the patients care? *practice is efficacious-helpful*: -help patient preserve -encourage family to brings in food appropriate for their diet *practice is neutral-neither helpful nor harmful*: -do not interfere with practices -ex: fasting, prayers *effects of the practice are unknown*: -do not encourage or discourage until you obtain more information *practice is dysfunctional*: -discourage harmful practices -support client to modify behaviors and to adopt new, beneficial health behaviors -respect clients values and beliefs *barriers include*: -lack of knowledge -emotional responses -ethnocentrism -cultural stereotypes -prejudice -discrimination -racism -sexism -language barrier -street talk, slang, jargon -healthcare jargon

Categorize health promotion activities according to level.

-motivated by the desire to avoid illness -*primary*: prevent/slow onset of disease --eating healthy foods, exercising, wearing sunscreen, obeying seat belt laws, and immunizations -*secondary*: detect and treat illnesses in early stages --breast self-examination, testicular exams, regular physical examinations, blood pressure and diabetes screenings, and tuberculosis skin tests -*tertiary*: stop disease progression; return to pre-illness state --rehabilitation is the main intervention during this level -*individual level*: teaching a client how to modify personal dietary intake -*group level*: classes offered at the local hospital, prenatal education programs, and worksite programs -*community level*: a billboard that presents the dangers of smoking, health blogs on the internet, and health fairs

Identify nursing techniques to assess for complications related to the respiratory system.

-physical examination -diagnostic testing -sputum samples -skin testing -pulse oximetry -capnography -spirometry -ABGs -PO2, PCO2 -peak flow monitoring

Identify patients at risk for immobility.

-poor vision -cognitive impairment -history of falling -low tolerance for activity

Describe the nursing preparation for diagnostic tests for GI tract.

-prepare patient for the test -function as an assistant -provide aftercare -verify order -use standard precautions -use appropriate container -have patient defecate into bedpan, BSC, or hat -send specimen to the lab *FOBT*: hemoccult -follow hospital policy - do you send it to the lab? -collect stool and smear on card -apply reagent -*blue* = positive -high rates of false + or false - -*false negatives*: --vitamin C -*false positives*: --red meat, fish, certain fruits and vegetables --aspirin --iron --anticoagulants --menstruation --hemorrhoids *colonoscopy*: -sign an informed consent form -clear liquid then NPO diet -bowel prep (make sure lower GI tract is clear) -conscious sedation -post-procedure --recover from anesthesia --assess for bleeding or perforation *upper GI series* (radiography): -oral barium contrast -NPO -involves fluoroscopy -pictures will follow barium as it moves through the bowel (x-ray) -post-test: --laxative to eliminate barium --drink lots of fluids to help eliminate the barium *abdominal CT with contrast*: -assess if the test requires contrast, if it does check to see if patient is allergic to iodine, if they are, they cannot get this test -NPO -oral contrast -IV contrast --iodine allergy? --risk for renal failure --hold metformin for >48 hours -involves X-ray

Discuss the factors that affect skin integrity.

-pressure -friction -shear injuries -moisture (i.e. incontinence) -*immobility* -poor nutrition -dehydration -*decreased sensation* -edema -fever -infection -age

Complete documentation of teaching and patient's learning.

-use a standardized form -document formal and informal teaching -describe the response of the learners -when possible put copies of the educational materials in the chart -update the teaching plan

Develop teaching plans for patients.

-when you are making a teaching plan, you can use this list to ensure that you consider each of the five "rights" of teaching: *right time*: -is the client ready, free of pain and anxiety, and motivated? -have you and the client developed a trusting relationship? -have you set aside sufficient time for the teaching session? *right context*: is the environment quiet, free of distractions, and private? -is the environment soothing or stimulating, depending on the desired effect? *right goal*: -is the client actively involved in planning the learning objectives? -are you and your client both committed to reaching mutually set goals of learning that achieve the desired behavioral changes? -are family or friends included in planning so that they can help follow through on behavioral changes? -are the learning objectives realistic and valued by the client; do they reflect the client's lifestyle? *right content*: -is the content appropriate for the client's needs? -is it new information or reinforcement of information that has already been provided? -is the content presented at the client's level? -does the content relate to the client's life experiences or is it otherwise relevant to the learner? *right method*: -do the teaching strategies fit the learning style of the client? -do the strategies fit the client's learning ability? -are the teaching strategies varied? components of a teaching plan: *teaching strategies*: method used to present the information -written -demonstration and return demonstration -one-to-one instruction -mentoring *content*: the information needed to reach the intended goal -can include facts, skill, emotions *scheduling and sequencing*: how to organize and sequence information -present simple before complex information -present nonthreatening topics before controversial ones -when extensive content is involved it is best to schedule a teaching session ahead of time *instructional material*: format of the information, reading level, and preferred language

Outline the steps of safe medication administration including the rights of medication administration.

1. right patient 2. right drug 3. right time 4. right route 5. right dose 6. right documentation +7. right reason +8. right to know +9. right to refuse

Describe the educational requirements for current nursing practice.

Graduate from an accredited nursing program and pass the NCLEX-RN. Five levels of education for entry into practice: *Diploma*: Hospital-based programs, modeled after the Nightingale Schools of Nursing apprenticeship style of learning. The typical program lasts 3 years and focuses on clinical experience in direct client care. Since the 1960s, the number of diploma programs has steadily decreased to less than 10% of registered nursing programs. *ADN*: This type of program, conceptualized by Mildred Montag, emerged during the nursing shortage following World War II. Most associate degree (AD) programs are offered in community colleges. Although the nursing component typically lasts 2 years, students are required to take numerous other courses in liberal arts and the sciences. ADN nurses are prepared to provide direct client care. *BSN*: The course of study in pre-licensure Bachelor of Science in Nursing (BSN) programs lasts at least 8 semesters. Graduates are prepared to assume administrative responsibilities, address complex clinical situations, oversee and provide direct client care, work in community care, apply research findings, and enter graduate education. The Institute of Medicine (2011) established a goal to increase the proportion of baccalaureate-prepared nurses to 80% by 2020. The American Association of Colleges of Nursing (AACN) recognizes the baccalaureate degree as the minimum education for professional-level nursing practice (2019). However, the AACN acknowledges support of licensure at the ADN level. *RN to BSN*: Nurse who has an associate degree enrolls in a program of study that leads to a BSN degree. The length of time required to complete the BSN varies according to the program and the number of credits each student can transfer. *Master's*: Prepare RNs to function in a more independent and autonomous role, such as nurse practitioner, clinical specialist, nurse educator, nursing informatics, or nursing administrator. It typically takes 2 years to complete the master's degree. --*Direct entry master's degree program*: The typical student in these programs has a baccalaureate degree in another field and has entered nursing as a second career. Programs usually are completed in 3 years of full-time study, with the first year devoted to basic nursing content. At the completion, the student is eligible to take the licensing exam and is awarded a master's degree in nursing. *Doctorate*: --*Doctor of Nursing Practice (DNP)*: A practice degree. --*Doctor of Nursing Science (DSN/DNSc)*: A degree with a focus on research and practice. --*Doctor of Philosophy (PhD)*: A degree focused on scholarly research and knowledge generation. --*Direct entry doctoral degree*: Designed for second degree students who seek an accelerated path to the doctorate degree.Most unusual pathway into nursing.

Explain the many roles of the nurse, including the role of how to use evidence-based practice.

Roles: *Direct care provider*: addressing the physical, emotional, social, and spiritual needs of the client. (i.e. listening to lung sounds, giving medications, client teaching). *Communicator*: using interpersonal and therapeutic communication skills to address the needs of the client, to facilitate communication in the healthcare team, and to advise the community about health promotion and disease prevention. (i.e. counseling a client, discussing staffing needs at a unit meeting, providing HIV education at a local school). *Client/family educator*: assessing and diagnosing the teaching needs of the client, group, family, or community. Once the diagnosis is made, nurses plan how to meet these needs, implement the teaching plan, and evaluate its effectiveness. (i.e. postoperative teaching, prenatal education for siblings, community classes on nutrition). *Client advocate*: supporting clients' right to make healthcare decisions when they are able to voice their opinions and protecting clients from harm when they are unable to make decisions. (i.e. helping a client explain to his family that he does not want to have further chemo). *Counselor*: using therapeutic communication skills to advise clients about health-related issues. (i.e. counseling a client on weight-loss strategies). *Change agent*: advocating for change on an individual, group, family, community, or societal level that enhances health. The nurse may use counseling, communication, and educator skills to accomplish this change. (i.e. working to improve the nutritional quality of the lunch program at a school). *Leader*: inspiring others by setting an example of positive health, assertive communication, and willingness to improve.(i.e. Florence Nightingale). *Manager*: coordinating and managing the activities of all members of the team. (i.e. charge nurse (assigns clients to staff nurses)). *Case manager*: coordinating the care delivered to a client (i.e. coordinator of services for clients with TB). *Research consumer*: applying evidence based practice to provide the most appropriate care, to identify clinical problems that warrant research, and to protect the rights of research subjects. (i.e. reading journal articles, attending continuing education; seeking additional education). *Evidence-based practice*: True evidence-based practice requires that after discovering and critiquing the best available evidence, nursing expertise must be applied to see how the recommended interventions fit into the practice setting and whether they are compatible with patient preferences. Research is more than just an exercise that nurses engage in to earn master's and doctoral degrees. The ultimate reason for conducting research is to establish an evidence-based practice or to gain greater understanding of a phenomenon. This means that nurses in practice have a responsibility for finding and using the credible, scientific research that others do. You must have reasons for what you do. Research can provide those reasons.

Describe holistic care at end-of-life.

holistic care is about caring for the whole person - providing for your: -*physical*: mobility, oxygenation, safety, nutrition, fluids, elimination, personal hygiene, and control of pain and symptoms (nausea, vomiting) -*mental*: everyone involved with the patient should know exactly what the patient and the family have been told. most patients want to know their prognosis as soon as possible so that they can put personal affairs in order, share their feelings with family members, and come to terms with their life and death -*spiritual*: the person may be looking for forgiveness and/or acceptance or be reaching out to feel connected. ways to address this need include empathetic listening, contacting pastoral care or clergy if the patient asks for this service, special rituals, praying with the patient, music, meditation, or special readings -*social*: some cultures may emphasize keeping emotions more subdued and limiting expressions of grief to private settings, whereas others gauge the value of the deceased by the amount of crying -palliative care is holistic comfort care -hospice care is holistic care of dying clients

Describe the role of teaching in professional nursing.

the purpose of teaching and learning is to provide information that will empower clients and families to: 1) perform self-care 2) make informed decisions about their healthcare options. -like other interventions, you can use teaching to promote wellness, prevent or limit illness, restore health, adapt to changes in body function, and facilitate coping with stress, illness, and loss