Theory Objectives EXAM 1
Demonstrate the four assessment techniques.
(ABCT'S) Appearance: Posture/position, Body movements, Dress, Hygiene, Pupils Behavior: LOC, Facial Expression, Speech (Quality, pace, articulation, word choice), Mood/affect Cognition: Orientation, Attention span, Recent/Remote memory, Judgement Thought Process:(if what pt says makes sense) Thought content, Perceptions - Screen for Anxiety Disorder - Screen for Depression - Screen for Suicidal Thoughts
Discuss the role that critical thinking plays in providing hygiene.
- Certain patients need certain special needs in regards to hygiene. Example: Diabetes nail/foot care - To help pt adapt existing hygiene practices or develop new ones when illness, loss of function, or decreased activity tolerance impairs self-care activities - Based on knowledge, experience, ADA standards, and attitudes.
List safety and comfort measures underlying bed making procedures.
- Check for soiling and wrinkles - Hold dirty linen away from uniform, never place on floor - Never shake linen - Raise bed to comfortable height - If pt in bed, take privacy into account! - Do not bring excess linen in room
Demonstrate appropriate procedure for assessing normal respirations and counting them.
- Do not let pt know you are counting them, they may alter the regular pattern. Be inconspicuous. - Act like you are counting pulse rate - If normal rhythm, count 30 sec X2,If irregular count for a full minute
Define the legal implications of restraints.
- Has to be ordered by physician by face to face assessment every 24 hours - Physical or Chemical - All 4 side rails up is considered a restraint - Have to state type of restraint, location, specify duration, and circumstances in which it will be used - Alternatives preferred - NOT PRN - Must be removed q 2hrs - Quick release, tied to movable portion of bed, NOT SIDERAILS
Describe assessment activities designed to identify clients' physical, psychosocial, and cognitive status as it pertains to their safety.
- Identify pt perception of safety/risks - Identify potential threats to pt safety - Determine the impact of underlying illness on pt safety - Identify risks based on developmental stage and environment of pt - Determine effect of environment influence on pt safety - Medication history - Activity/exercise - Home maintenance/safety
Identify common hazards in the home.
- Inadequate lighting - Furniture placement - Floor condition - Expired food - Broken smoke detectors - Presence of lead - Throw rugs - Cords under rugs - Doorway thresholds
Discuss the impact of healthcare associated infections on the client and facility.
- Increase health care costs - Additional suffering - Extended hospital stay - Increased disability - Increased cost of antibiotics - Prolonged recovery times
Identify clients at risk for injury.
- Infants - Children - Older Adults - The ill - persons with visual, hearing, mental impairments - The illiterate - The poor
Use basic clinical reasoning to determine which pain assessment tool is appropriate for diverse clients across the lifespan.
- Infants cannot rate pain verbally, but they show it through behavioral and physiological clues (FLACC) - Children 2 years of age can report pain and point to location. - Rating scales are introduced at 4-5 years of age. The faces pain scale 0-10 how much do you hurt? - Aging adults can use alternative to pain scale called the descriptor scale: No pain, mild pain, moderate pain, severe pain
Explain the rationale for standard precautions.
- Nurses use standard precautions for all patients to protect themselves from contact with blood and other potentially infectious body fluids - Prevent/control infection transmission - HAND HYGIENE!!!
Describe how hygiene care for the older adult differs from that for the younger client.
- Older adult skin is thinner and more fragile. - Some don't like lotion after bathing. - They get cold faster - Some have dentures - Chronic conditions may exist
Identify clients most at risk for an infection.
- Older adults due to weakening immune system - Infants - Pt with diseases of the immune system - Pt with chronic diseases due to debilitation and nutritional impairment - Pt with burns - Multiple Illnesses - Nutrition/Poorly nourished (anorexia/obesity lead to impaired immunity) - Trauma (lead to sepsis) - Heath workers - Homeless - Traveling with no immunizations
Discuss factors that influence the condition of the nails and feet.
- Poor fitting shoes, Nail care, Use of a lot of nail polish removers, Moisture in shoes/socks Callus- thickened part of sole or palms made of keratotic cells Corns-Friction/pressure from loose shoes. On or between toes. Plantar Warts- lesion on sole of foot from papilloma virus Athletes foot (Tinea Pedis)- Fungal infection of foot
Discuss assessment factors when a client is in restraints.
- Proper placement - Skin integrity - Pulses - Skin temp - Color - Sensation of restrained part
Adapt hygiene care for a client who is cognitively impaired.
- Proper positioning to decrease aspiration - Suctioning for needed secretions - Always explain to pt what you are doing, even if unconscious - Use adjuncts if needed for oral care to ensure open airway, and so pt does not bite down - Inform pt when procedure is over
Conduct a comprehensive assessment of a client's total hygiene needs.
- Self-care ability - Skin assessment - Feet/Nails assessment - Oral cavity assessment - Hair/scalp assessment - Ears, eyes, nose assessment
Discuss different approaches used in maintaining a client's comfort and safety during hygiene care.
- Use a gentle approach to calm and relieve pt - Understand it can be embarrassing for pt - Encourage independence - Individualize care based on pt preference - Provide privacy - Maintain safety (rails up, call light within reach) - Maintain warmth - Gender congruent perineal care - Anticipate needs (bring clothes prepared and bedside hygiene products) - Back rubs
Identify the purpose of nursing theories.
A nursing theory conceptualizes an aspect of nursing to describe, explain, predict, or prescribe nursing care. Theories offer a perspective for assessing your patients' situations. They help you organize, analyze, and interpret data.
Develop a plan of care with a client with an infection.
ASSESSMENT Ask about risk factors (any cuts/lacerations) Any fever?Pain/Burning while urination? Cough with sputum? Have you traveled outside US in past 6 months? Current meds? Stressors? DIAGNOSIS Check labs, Review meds, Identify potential site of infection PLANNING Create goals/outcomes, Set priorities, Teamwork/Collaboration IMPLEMENTATION Health promotion, Nutrition, Hygiene, Immunizations, Acute care EVALUATION See through pt eyes. Have expectations been met? Patient outcomes: Is pt satisfied? If not, determine steps to achieve goal.
Define Health Promotion.
Activities such as routine exercise and good nutrition that help patients maintain or enhance their present level of health and reduce their risk of developing certain diseases.
Differentiate between acute and chronic illness.
Acute illness: usually reversible, has a short duration, and is often severe. The symptoms appear abruptly, are intense, and often subside after a relatively short period. Chronic illness: persists, usually longer than 6 months, is irreversible, and affects functioning in one or more systems. Pts often fluctuate b/t maximal functioning & serious health relapses that may be life threatening.
Recognize factors influencing contemporary nursing practice.
Affordable Care Act (ACA) Rising health care costs Demographic changes Medically underserved Nurses's Self-Care: Burnout, Compassion fatigue, Health Nurse Healthy Nation
Give examples of nursing interventions to prevent infection for each element of the infection chain.
An infectious agent: disinfect, sterilize A reservoir: hygiene, change dressings, cap fluid containers, linen disposal Portal of exit: hand hygiene, dry dressings, PPE, masks Mode of transmission: wash hands, clean equipment, PPE Portal of entry: good hygiene and immune system Susceptible host: intact skin, nutrition, immunization
Identify factors to assess in determining a client's sensory status.
Assessment: Persons at risk, mental status, sensory alterations history, physical assessment, health promotion habits, communication methods, use of assistive devices, social supports, environmental hazards, ability to perform self-care.
Discuss the roles and responsibilities of the nurse & how they influence the nurse's scope of practice.
Autonomy-Initiation of intervention without order) Accountability- Responsible professionally/legally for care Caregiver- Help pt maintain/regain health, manage disease/symptoms, help through healing. Advocate- Protect pts human/legal rights and provide assistance in asserting rights. Educator- Explain concepts/facts about health, describe, demonstrate, and reinforce learning. Communicator- Communicate with pt, family, community, other providers. Manager-Establish Pt centered care environment to have positive pt outcomes.
Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose.
Bathing: - Distal to proximal for venous return - Do not massage calves, may release a DVT - Pay attention to skin folds Nail/Foot care - Ask about nail polish remover use - Type of footwear - DM? PVD? Heart failure, Renal disease? Stroke? - Let fingers/toes soak for 10-20 mins. DO NOT SOAK IF DIABETIC! - If pt has circulatory problems, do not cut nails Oral care - Brush 2x day - Fluoride toothpaste - Avoid fluoride rinse if under 6 - Do not use lemon-glycerin sponges - New brush every 3 months recommended Perineal Care - At least 1 time a day, more if pt has urinary catheter - Gender congruent care - Clean least contaminated to most contamination to prevent microorganisms Eyes/Ears/Nose - Ask if wearing contacts - Wash with plain warm water, Soak crust for 2 mins - Unconscious pt need more freq eye care - Clean ears with end of moistened washcloth DO NOT USE COTTON TIP APPLICATORS - Use a washcloth, or tip of cotton applicator to assist - Change tape on nasal tubes once a day to prevent maceration
5. Describe the criteria for a profession.
Body of Knowledge Service Orientation Recognized Authority & Specialized Education Code of Ethics Professional Organization Ongoing Research & Autonomy
List nursing interventions to prevent sensory deprivation and to control sensory overload.
Constant reorientation and control of excessive stimuli become an important part of a patient's care. Be aware of pts existing sensory function and quality of stimuli in environment. Sensory deprivation: put on music, encourage conversation, open curtains, tasteful foods, etc. Sensory overload: opposite..
Describe mechanisms of infectious disease transmission.
Contact Direct: Person-to-person (fecal, oral) physical contact between source and susceptible host (e.g., touching patient feces and then touching your inner mouth or consuming contaminated food) Indirect: Personal contact of susceptible host with contaminated inanimate object (e.g., needles or sharp objects, dressings, environment) Droplet: Large particles that travel up to 3 feet during coughing, sneezing, or talking and come in contact with susceptible host Airborne: Droplet nuclei or residue or evaporated droplets suspended in air during coughing or sneezing or carried on dust particles Vehicles Contaminated items: Water, Drugs, Blood, Food Vector External mechanical transfer (flies) Internal transmission: parasitic conditions between vector and host such as: Mosquito, Louse, Flea, Tick
Explain the importance of foot care for the client with diabetes.
DM raises sugar in blood, High sugar damages nerves leading to peripheral neuropathy, Nerve damage + poor circulation= infection. These wounds take longer to heal and pt may not feel pain at all due to nerve damage.
List common hair and scalp problems and their related interventions.
Dandruff: Scaling of scalp is accompanied by itching. Shampoo regularly with medicated shampoo. Ticks: Small, gray-brown parasites burrow into the skin and suck blood. Ticks transmit several diseases to people. (Rocky Mountain spotted fever, tularemia, and Lyme disease.)Using blunt tweezers, grasp the tick as close to the head as possible and pull upward with even, steady pressure. Hold until tick pulls out, usually for about 3-4 minutes. Save tick in a plastic bag and put in the freezer if it is necessary to identify the type of tick. Pediculosis Capitis (Head Lice):Parasite resides on scalp attached to hair strands. Eggs look like oval particles, similar to dandruff. Wearing gloves, check entire scalp by using a tongue depressor or special lice comb. Use medicated shampoo for eliminating lice. Caution against the use of products containing lindane because the ingredient is toxic and known to cause adverse reactions. Manual removal is the best option when treatment has failed. Vacuum infested areas of home. Pediculosis Corporis (Body Lice) Body lice suck blood and lay eggs on clothing and furniture.Patient itches constantly. Scratches seen on skin become infected. Bathe or shower thoroughly. After skin is dried, apply recommended pediculicide lotion. After 12 to 24 hours take another bath or shower. Bag infested clothing or linen until laundered in hot water. Vacuum rooms thoroughly and throw away bag after completion. Pediculosis Pubis (Crab Lice)Parasites are in pubic hair. Shave hair off affected area. Clean as for body lice. If lice were sexually transmitted, notify partner. Hair Loss (Alopecia)Stop hair care practices that damage hair. Use of hair curlers, hair picks, tight braiding, and hot comb contributes to hair-loss condition.
Describe and document the different characteristics of pain.
Dull, sharp, stabbing, throbbing, achy, shooting, burning, numbing
Describe the steps of evidence-based practice.
EBP is a systematic, problem-solving process that facilitates achievement of best practices. 0. Cultivate a spirit of inquiry. 1. Ask a clinical question in PICOT format. 2. Search for the most relevant and best evidence. 3. Critically appraise the evidence you gather. 4. Integrate all evidence with your clinical expertise and patient preferences and values. 5. Evaluate the outcomes of practice decisions or changes using evidence. 6. Share the outcomes of EBP changes with others.
Describe how Healthy People 2020 Goals impact Americans.
Evidence based objectives for promoting health and preventing disease. Increases focus on health promotion 4 GOALS 1. Attain high quality longer life 2. Health quality and improve group health 3. Create social environments that promote good health for all 4. Promote quality of life, healthy development, and healthy behaviors amongst all life stages
Discuss the different trends in nursing.
Evidence-Based Practice: Your practice needs to be based on current evidence, not just according to your education and experiences and the policies and procedures of health care facilities. Quality and Safety Education for Nurses: QSEN encompasses six competencies: patient-centered care, teamwork, collaboration, evidence-based practice, quality improvement, and safety. Impact of Emerging Technology Genomics: Study of inheritance and how genes are passed down. Public perception of nursing Impact of Nursing on politics
Describe health promotion, wellness, and illness prevention activities across the lifespan.
Exercise Nutrition Immunizations Hand Hygiene Stress Management Cessaciation classes
Develop nursing interventions that are age specific for reducing risks of falls, fires, poisonings, and electrical hazards.
FALLS Infants/Toddlers:Window guards, Leave crib sides up at all times, keep in sight, baby gates by stairs, no walkers by stairs Preschoolers:Window guards, gates,rails of crib raised,supervise at playground. School Age:Head injuries common, use bike safety, Adolescents:Don't text drive, Older Adults: Annual vision/hearing, use of assist devices, institute toileting schedule FIRES Infants/Toddlers:knobs on the stove to prevent fires, gas release, Preschoolers: fire safety, School Age: Lock up firearms, Adolescents: fire safety and plan, Older Adults: alarms for stove tops R- RESCUE A- ACTIVATE ALARM C- CONTAIN E- EXTINGUISH POISONINGS Infants/Toddlers:Make sure toys have no lead, place toxic things out of reach, hang plants rather than on floor, child protection locks for meds, Preschoolers:Keep poisons out of reach, child locks, teach not to eat plants School Age: Educate on hazards, teach to say "no" to if offered drugs/alcohol, keep dangers out of reach, med safety lock, Adolescents: No drugs/alcohol, Older Adults: Keep track of medications ELECTRICAL HAZARDS Infants/Toddlers:Safety caps on outlets, keep hair irons out of reach, never leave baby in bath alone they may change heat settings, Preschoolers:Move electrical appliances out of reach, keep electric wires hidden, teach what "hot" means, School Age: Do not fly kite high near wires, safe cooking teaching, Adolescents: Internet safety, Older Adult: remove cords out of walk way.
Discuss conditions that place clients at risk for impaired oral mucous membranes.
Glossitis: Inflammation of tongue Gingivitis: Inflammation of gums Cheilitis: Cracked lips Halitosis: Foul breath Endentulous: Without teeth Dental Caries: Tooth decay
Describe educational programs available for registered nurses (RN) and explain how these programs affect nursing practice.
Graduate Nursing: can receive a master's degree in nursing, which is important for the roles of nurse educator and nurse administrator, and it is required for an APRN. Continuing Education: Certifications and specialization of nurse practice. Ex. ICU nurse In-Service Education: held in the institution and increases the knowledge, skills, and competencies of nurses employed by the institution. They're often focused on new technologies Ex. how to correctly use the newest safety syringes.
Discuss the influence of social, historical, political, and economic changes on nursing practice.
HISTORICAL Florence Nightingale estab. 1st nursing philosophy based on health maintenance & restoration. She developed the first program for training nurses, the Nightingale Training School for Nurses at St. Thomas' Hospital in London. She was 1st practicing nurse epidemiologist. Her statistical analyses connected poor sanitation w/cholera and dysentery. "Lady with a lamp" The Civil War stimulated the growth of nursing in the US. Clara Barton, founder of the American Red Cross, tended soldiers on the battlefields, cleansing their wounds, meeting their basic needs, and comforting them in death. Mother Bickerdyke organized ambulance services and walked abandoned battlefields at night, looking for wounded soldiers. Mary Mahoney: The first professionally trained African-American nurse. She was concerned with the effect culture had on health care, and brought forth an awareness of cultural diversity and respect for the individual, regardless of background, race, color, or religion. Lillian Wald and Mary Brewster: nursing in the community did not increase significantly until 1893, when they opened the Henry Street Settlement, which focused on the health needs of poor people who lived in tenements in New York City. 20th Century: a movement toward developing a scientific, research-based defined body of nursing knowledge and practice evolved. Army and Navy Nurse Corps established. 1st nursing professor at Columbia Teachers College. 21st Century: Nurses and nurse educators are revising nursing practice and school curricula to meet the ever-changing needs of society, including an aging population, bioterrorism, emerging infections, and disaster management. Robert Wood Johnson Partnered with IOM to create vision for nursing 2020 including: increase BSN, Double amount of nurses with Doctorate, Implement residency programs, Promote lifelong learning. SOCIAL Demographic changes, medically underserved, nurse's self-care (compassion fatigue), human rights. POLITICAL & ECONOMIC Affordable Care Act (ACA) and Rising health care costs.
Explain ways to prevent the spread of healthcare associated infections.
Hand hygiene- wash hands before and after pt contact Standard Precautions- proper PPE based on pt status and possible isolation measures Proper sanitization of equipment/pt areas
Describe measures to prevent accidents.
Health promotion Passive strategies: public health and government legislative measures Active: pt actively involved (exercise) Developmental Interventions Based on age, certain interventions exist to maintain safety Environmental Measures Eliminate environmental threats Basic Needs related to oxygen, nutrition, and temperature General Preventative Measures Adequate lighting Adequate security Hand hygiene Fall Prevention Restraints
Discuss health, morbidity, mortality, illness, disease and personal definition of health.
Health: Each individual has own definition of health. Can include physical, mental, social, and spiritual well-being. Illness: If a patient previously had a stroke, and fully recovered, they may not consider themselves ill anymore. Morbidity: the rate of disease Mortality: relative frequency of deaths Disease: alteration in body function and resulting in shortening of lifespan
Discuss ways to maintain a safe environment for clients with sensory deficits.
IN THE HOME Uneven cracked walkways Cords in walking area Loose rugs and runners Bathroom with no grab bars Unmarked water faucets No handrails on stairs Poor lighting IN THE HOSPITAL Call light in reach Iv poles on wheels and easy to move? Are machines and bags positioned so pt can rise from bed/chair easily Are bedside tables/area clutter free Maintain noise level if possible
Define the nurse's role in assessing for sensory alterations.
Identify patients who may be at risk, identify signs of impairment, use of assistive devices, and screening as needed.
Identify Assessment Alerts (abnormal findings or risks) and necessity of communicating findings to health care provider in timely manner.
If abnormal findings are not communicated, this can lead to harm to patients. Ex. Changes in Mental status, Drastic vital changes, SPO2 below 90
Discuss ways to apply evidence in practice.
If you decide that the evidence is strong and applicable to your patients and clinical situation, you begin to identify how to incorporate it into practice. Your first step is simply to apply the research in your plan of care for a patient. Use the evidence you find as a rationale for an intervention you plan to try. Evidence is integrated in a variety of ways through teaching tools, clinical practice guidelines, policies and procedures, and new assessment or documentation tools. Depending on the amount of change needed to apply evidence in practice, it becomes necessary to involve a number of staff from a given nursing unit.
Discuss conditions that place clients at risk for impaired skin integrity.
Immobilization: Inability to turn/change position increases pressure ulcer risk Bariatric Pts: Pt cannot visualize skin properly when cleaning. Excessive weight creates pressure, and increased moisture with poor perfusion Reduced sensation caused by stroke, spinal cord injury, DM, nerve damage Altered cognition from dementia, psychological disorders, delirium, can't voice skin care needs Limited protein/calorie intake and reduced hydration Impaired tissue synthesis. Skin becomes thinner and weaker. Poor healing results Excessive secretions/excretions on skin from perspiration, urine, wound damage Moisture causes bacterial growth and irritation, and skin maceration Presence of external medical devices (cast, restraint, dressing) Vascular insufficiency: Arterial blood supply inadequate, or venous return impaired. Decreased circulation to extremities. Risk for infection is HIGH.
Discuss the benefits of evidence-based practice.
Implementing evidence-based practice (EBP) helps you make effective, timely, and appropriate clinical decisions in response to the broad political, professional, and societal forces present in today's health care environment.
Identify correct procedure for measurement of weight, height, and recumbent length across the lifespan.
Infants Weight: Use balance scale Height: N/A Recumbent Length: Hold head midline, hold knees down to extend legs. Children Weight: 2-3 years use upright scale Height: Measure when 2-3 yrs. Stand flat against wall or use pole on scale. Recumbent Length: Done when child less than 2 years, hold head midline, hold knees down to extend legs. Adults Weight: Compare with last weight, Upright scale Height: Wall mounted device, No shoes Recumbent Length: Not done in adults unless there is scoliosis or deformity present
Discuss pain assessment of the pediatric client focusing on signs and symptoms of pain for all age groups
Infants cannot report pain but show FLACC, Children can report pain and point to location but cannot rate pain intensity F- FACE L-LEGS A-ACTIVITY C- CRY C-CONSOLABILITY
Provide anticipatory guidance for all ages regarding risk-taking behaviors and safety.
Infants/Toddlers/preschoolers Immunizations, Choking, Cabinet locks, Car seats, Do not leave unattended, Street safety, Door locks School Age Stranger danger, Diet, Head injury from bikes- wear helmet, Water safety, Car seat safety, Firearm safety Adolescents Care safety, Water safety, Suicide, Violence toward others, Safe sex, Internet safety, Bullying Adults Exercise/diet, alcohol /drug use, Depression, Car safety, Safe sex Older Adults Falls, Impairment, Illness, Weakness, Driving, Depression, Medication, Hot water setting
Discuss principles of infection and infection control measures.
Infections are caused by improper hygiene and by not taking proper precautions. Proper infection control measures include proper PPE, hand washing/hand hygiene, and improper cleaning of environment.
Describe the role of the nurse in protecting the rights of clients.
Informed consent: Participants receive full and complete information They can understand the information They have free choice to participate They understand how their confidentiality will be kept Confidentiality
Describe internal and external variables that impact health beliefs and practices across the lifespan.
Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors. External variables influencing a person's health beliefs and practices include family practices, psychosocial and socioeconomic factors, and cultural background.
Identify potential growth and development interruptions that may occur with problems affecting the sensory organs.
Learning difficulty Depression/Anxiety Loss of self-worth Environmental dangers Malnutrition if impaired taste/smell Impact quality of life
Discuss licensure and certification of registered nurses.
Licensure = NCLEX-RN Certification = Beyond the NCLEX-RN, can work toward certification in a specific area of nursing.
Describe the signs/symptoms of a localized infection/inflammation and those of a systemic infection/inflammation.
Localized infection (ex, a wound infection), a patient usually experiences localized symptoms such as pain, tenderness, warmth, and redness at the wound site. Systemic infection (ex. blood infection) - An infection that affects the entire body instead of just a single organ or part is systemic and can become fatal if undetected and untreated. Increased WBC, fever, increased HR, RR, nausea, vomiting, malaise, anorexia,
Identify correct placement and proper use of equipment when assessing vital signs.
Make sure BP Cuff is applied correctly and right size and do not apply on the same side as a: Fistula/shunt, Mastectomy or removal, PICC Line, IV Infusion, Trauma to that side Make sure SPO2 site: Has adequate circulation, Is dry, Has no tremors, Has no nail polish or artificial nails, Has no latex allergy.
Describe Maslow's Hierarchy of Human Need.
Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs. According to this model, certain human needs are more basic than others.
Explain the difference between medical and surgical asepsis.
Medical asepsis: Procedures used to reduce the number of microorganisms and prevent their spread EX. Hand hygiene, barrier techniques, and routine environmental cleaning. Surgical asepsis requires more stringent techniques than medical asepsis and is directed at eliminating ALL microorganisms.
Identify the normal defenses of the body against infection.
Normal Flora - Body contains microorganisms that reside on the surface/deep levels of skin, saliva, GI, and GU tracts. - Does not usually cause disease but participate in maintaining health. - Broad spectrum antibiotics disrupt balance and can lead to SUPRAINFECTION "killing good bacteria" Body System Defense Skin/Mucous Membranes- Barriers Lungs- Cilia in the respiratory tract sweep away debris GI/GU Tract- Prevents retention of bacterial contents Inflammatory Response
Discuss the purpose of nurse practice acts and standards for nursing practice.
Nurse Practice Acts: Assessment, Diagnosis, Outcomes identification, Planning, Implementation, Evaluation. PURPOSE: Describe competent level of nursing care by critical thinking model known as "The Nursing Process" Standards for Nursing Practice: Ethics (Code of Ethics), Quality of Practice, Professional Practice Evaluation, Education, Communication, Resources, Evidence-Based Practice and Research, Leadership, Environmental Health, and Collaboration. PURPOSE: Describe competent level of behavior in the professional role. Provide a method to ensure high quality care.
Define members of the interdisciplinary health care team.
Nurse, Physicians, Physician's Assistant, Physical Therapists, Occupational Therapists, Respiratory Therapists, Dietitians, Pharmacists, Social Workers, Case Managers
Describe the role of the nurse with Health Promotion.
Nurses have a vital role in health promotion. Nurses have a responsibility to foster well-being, self actualization, and personal fulfillment and to promote positive health care attitudes and behaviors. Health promotion is a central focus of healthcare delivery that has been shown to add quality years of life and decrease healthcare costs. Model healthy lifestyle behaviors and attitudes Facilitate client involvement in the assessment, implementation, and evaluation of health goals Teach clients self-care strategies to enhance fitness, improve nutrition, manage stress ▪Educate clients to be effective healthcare consumers Reinforce clients' personal and family health-promoting behaviors
Describe theory-based nursing practice.
Nursing has its own body of knowledge that is both theoretical and experiential. Theoretical knowledge stimulates thinking and creates a broad understanding of nursing science and practice. Experiential, or clinical, knowledge, often called the art of nursing, is formed from nurses' clinical experience. Both types of knowledge are needed to provide safe, comprehensive nursing care
Identify the themes in the definitions of nursing.
Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and populations. HOLISTIC CARE.
Explain the influence of nursing theory on a nurse's approach to practice.
Nursing theories help to: - Identify domain and goals of nursing, - Provide knowledge to improve nursing administration, practice, education, and research. - Guide research to expand the knowledge base of nursing. Identify research techniques and tools used to validate nursing interventions. - Develop curriculum plans for nursing education. - - Establish criteria for measuring quality of nursing care, education, and research. - Guide development of a nursing care delivery system. - Provide systematic structure and rationale for nursing activities.
Describe the characteristics of objective data that are collected in a nursing assessment.
Objective Data is anything observed or measured by the nurse ex. Vitals, LOC, Height/Weight.
List various routes of temperature measurements.
Oral, rectal, axillary, and temporal.
Develop a PICOT question.
P = Patient population of interest Identify patients by age, gender, ethnicity, and disease or health problem. I = Intervention of interest Which intervention is worthwhile to use in practice (e.g., a treatment, diagnostic test, prognostic factor)? C = Comparison of interest What is the usual standard of care or current intervention used now in practice? O = Outcome What result do you wish to achieve or observe as a result of an intervention (e.g., change in patient behavior, physical finding, or patient perception)? T = Time What amount of time is needed for an intervention to achieve an outcome (e.g., the amount of time needed to change the quality of life or patient behavior)?
Discuss health beliefs, health promotion, basic human needs, and holistic health models to understand the relationship between patients' attitudes toward health and health practices.
Patients attitudes and beliefs influence healthcare decisions. Health beliefs are based on pts perception of susceptibility, perception of seriousness of illness, and the likelihood of preventative action. Health promotion describes pt individual experiences that impact health, specific knowledge, and behavior outcomes. Holistic models attempt to make conditions that focus on optimizing level of health by alternative intervention (music, aromatherapy)
Identify the four major domains that nursing theories address.
Person is the recipient of nursing care. Health: Your challenge as a nurse is to provide the best possible care based on a patient's level of health and health care needs at the time of care delivery. Environment/situation: all possible conditions affecting patients and the settings where they go for their health care. Nursing: protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations"
List assessment findings included in the General Survey.
Physical Appearance:Age, Sexual Development, LOC, Skin, Facial Features Body Structure: Stature, Nutrition, Symmetry, Posture, Position, Body Build/ Contour, Physical Deformities Mobility: Gait, Range of Motion Behavior: Facial Expression, Mood/Affect, Speech, Dress, Personal Hygiene
Discuss the three levels of preventive care.
Primary prevention: true prevention; it precedes disease or dysfunction and is applied to patients considered physically and emotionally healthy. Is aimed at health promotion includes health education programs, immunizations, nutritional programs, and physical fitness activities. It includes all health promotion efforts and wellness education activities that focus on maintaining or improving the general health of individuals, families, and communities. Secondary prevention: individuals who are experiencing health problems or illnesses and are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention, thereby reducing severity and enabling the patient to return to a normal level of health as early as possible Tertiary prevention: when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration. Activities are directed at rehabilitation rather than diagnosis and treatment.
Discuss the methods of nursing research.
Quantitative- Involves concepts of basic and applied research ex. Precise measurement Qualitative- Conducted to gain insight by discovering meanings ex. Pts perception of illness or quality of life Based on belief that reality is based on various and differing perceptions
Discuss the care of the hospitalized client with sensory deficits.
Reassure pt and family Orient pt to surroundings Safe environment Encourage self-care/independence Support for loss and adaptation Remove hazards Help ambulating if needed Maintain healthy lifestyle *PT IS the ONLY PERSON WHO CAN TELL YOU IF SENSORY ABILITY HAS IMPROVED*
Differentiate among the processes of reception, perception, and reaction to sensory stimuli.
Reception- stimulation of a receptor such as light, touch, or sound. Perception- ability to receive sensory input & translate the data into meaningful info. Reaction- only most important stimuli will elicit a reaction.
Describe the importance of developing a culture of safety.
Reporting events Report changes in pt condition or concerns to prevent injury Responding to errors Check on pt if there is error, and report it and let providers know Sharing the learning When errors happen, share the failure to prevent it from happening again Disclosing the error Depends on policy on how to report error to family
Explain how nursing research improves nursing practice.
Research allows you to study nursing questions and problems in greater depth within the context of nursing. Nurses who do not use an evidence-based approach to practice often rely solely on personal experience or the advice of nursing experts. These nurses do not question if there is an intervention that produces better outcomes. When an intervention is not successful, nurses who do not use EBP will usually use an approach practiced by a colleague or try a different sequence of accepted measures. Improves quality, safety, patient outcomes, and nurse satisfaction while reducing costs
Define sentinel events and "never events".
Sentinel events and "never events" are CMS named events to NEVER occur in healthcare. Ex: - Air embolism - Blood incompatibility - Stage III or IV pressure ulcers - Falls/Trauma - Catheter Infections - Suicide of any patient within 72 hours of discharge. - Abduction of any patient - Discharge of an infant to the wrong family - Surgical and nonsurgical invasive procedures on the wrong patient, wrong site, or wrong procedure - Unintended retention of a foreign object in a patient after surgery or other procedure
Describe factors that influence personal hygiene practices.
Social practices, personal preferences, body image, socioeconomic status, health beliefs and motivation, cultural variables, physical condition, and developmental status.
1. Describe the socialization process of nursing, utilizing the Benner model.
Stage I: Novice (new nurse student/no experience) Stage II: Advanced beginner (some experience) Stage III: Competent Stage (2-3 yrs experience) Stage IV: Proficient Stage (More than 2-3 yrs experience) Stage V: Expert (diverse experience, can zero in on problem and focus on multiple dimensions.
Define the National Client Safety Goals and give examples.
The TJC safety goals are goals to reduce risk of medical error, improve pt safety, and address on-going problem areas in healthcare. Ex: Identify pt correctly, Improve staff communication, Use meds safely, Use alarms safely, Prevent infection, Prevent surgery mistakes, Prevent falling, Prevent bed sores.
Discuss the holistic health model of Health-Illness continuum to understand the relationship between the client's attitudes toward health and health practices.
The holistic health model of nursing attempts to create conditions that promote a patient's optimal level of health. Nurses using the nursing process consider patients to be the ultimate experts concerning their own health and respect patients' subjective experience as relevant in maintaining health or assisting in healing. In the holistic health model patients are involved in their healing process, thereby assuming some responsibility for health maintenance.
Discuss the importance of standards for public reporting of client safety events.
The importance of standards for public reporting of client safety events is to serve as a framework reporting safety information to consumers. This also leads to improved quality care.
Describe variables influencing illness behavior.
The influences of these variables and a patient's illness behavior often affect the likelihood of seeking health care, adherence to therapy, and health outcomes. Internal variables: patient perceptions of symptoms and the nature of the illness influence patient behavior. External variables: the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support.
Discuss common causes and effects of sensory alterations.
The most common types of sensory alterations are sensory deficits, sensory deprivation, and sensory overload. Presbyopia: A gradual decline in the ability of the lens to accommodate or focus on close objects. Individual is unable to see near objects clearly. Cataract: Cloudy or opaque areas in part of the lens or the entire lens that interfere with passage of light through the lens, causing problems with glare and blurred vision. Glaucoma: A slowly progressive increase in intraocular pressure that, if left untreated, causes progressive pressure against the optic nerve, resulting in peripheral visual loss, decreased visual acuity with difficulty adapting to darkness, and a halo effect around lights. Diabetic retinopathy: Pathological changes occur in the blood vessels of the retina, resulting in decreased vision or vision loss caused by hemorrhage and macular edema. Presbycusis: A common progressive hearing disorder in older adults. Cerumen accumulation: Buildup of earwax in the external auditory canal. Cerumen becomes hard and collects in the canal and causes conduction deafness. Dizziness and disequilibrium: Common condition in older adulthood, usually resulting from vestibular dysfunction. Frequently a change in position of the head precipitates an episode of vertigo or disequilibrium. Xerostomia: Decrease in salivary production that leads to thicker mucus and a dry mouth. Often interferes with the ability to eat and leads to appetite and nutritional problems. Peripheral neuropathy: Disorder of the peripheral nervous system, characterized by symptoms that include numbness and tingling of the affected area and stumbling gait.
Describe the relationship among nursing theory, the nursing process, and patient needs.
The nursing process is used in clinical settings to determine individual patient needs. Although the nursing process is central to nursing, it is not a theory. It provides a systematic process for the delivery of nursing care, not the knowledge component of the discipline. However, nurses use theory to provide direction in how to use the nursing process. For example, the theory of caring influences what nurses need to assess, how to determine patient needs, how to plan care, how to select individualized nursing interventions, and how to evaluate patient outcomes.
Define the following terms: theory, phenomenon, concepts, definitions, and assumptions.
Theory - contains a set of concepts, definitions, and assumptions or propositions that explain a phenomenon Phenomenon - the term, description, or label given to describe an idea/responses about an event, a situation, a process, a group of events, or a group of situations. Concepts - words/phrases that identify, define, and establish structure and boundaries for ideas generated about a particular phenomenon. Think of concepts as ideas and mental images. Definitions - used to communicate the meaning of the concepts of a theory. Theoretical or conceptual definitions simply define a particular concept, much like what can be found in a dictionary. Operational definitions state how concepts are measured. Assumptions - the "taken-for-granted" statements that explain the nature of the concepts, definitions, purpose, relationships, and structure of a theory. Accepted as truths and are based on values and beliefs.
Explain the function of professional nursing organization/associations.
These organizations seek to improve the standards of practice, expand nursing roles, and foster the welfare of nurses within the specialty areas, & they present educational programs and publish journals.
Discuss the events in the inflammatory response.
Vascular Response After injury, arterioles vasoconstrict Then release of histamine and other chemicals by the injured cells = vasodilation Vasodilation - Results in hyperemia, Increased blood flow in the area, Raises filtration pressure Fluid in tissue spaces (Edema) Initially serous fluid - Later: plasma proteins - albumin Proteins exert oncotic pressure that further draws fluid from blood vessels Tissue becomes edematous (swollen) Cellular Response Blood flow slows as fluid is lost and viscosity increases Neutrophils and monocytes move to site of injury *** Chemotaxis Exudate Consists of fluid and leukocytes that move from the circulation to the site of injury Nature and quantity depend on the type and severity of the injury and the tissues involved TYPES OF EXUDATE Serous- clear like plasma (blister) Sanguineous- Contains RBC (bloody drainage) Purulent- Not good! Yellow/Green opaque drainage (WBC and bacteria) Serosanguineous- mixture of serous and sanguineous. clear and bloody. Tissue repair Regeneration (like cells) Fibrous tissue formation (scar)
Discuss normal sensory changes that can occur with aging.
Vision changes Reduced visual fields Increased glare sensitivity Impaired night vision Reduced depth perception Reduced color discrimination Hearing changes Decreased hearing acuity Speech intelligibility Pitch discrimination Gustatory/Olfactory Begin around 50 Decrease in number of taste buds Decrease in sensory cells in nasal lining Reduced taste descrimination Sensitivity to odors Proprioceptive Difficult balance, spatial orientation, coordination Declining sensitivity to pain, pressure and temperature
Analyze situations which place client care at risk when health promotion is neglected.
When health promotion is neglected, pts will not be at their maximum health levels, or maintain stagnant at the same place in their health. If health promotion is not used when a patient is chronically ill, the pt condition may deteriorate or get worse.
