NURS 200_Final Exam Study Guide copy (complete) Xavier University.

NURS 200 Final Exam Review 1. Know hand hygiene pg. 612 (no matter how old always use hand hygiene) • #1 way to prevent infection, always use hand hygiene before patient contract (no matter the age) 2. Know standard precautions pg. 619 (for AIDS use standard precuations) • Used in the care of all hospitalized individuals regardless of diagnosis or possible infection status • These precautions apply to: blood, all body fluids, excretions, secretions, nonintact (broken) skin, mucous membranes • Equipment: gloves, mask, gown • SP includes: hand hygiene, use of PPE, safe injection practices, safe handling of potentially contaminated equipment, cough etiquette • Examples: HIV, Leukemia 3. Know airborne precautions #3 on pg. 619 • Used for clients known to have or suspected of having serious illnesses transmitted by airborne droplets smaller than 5 microns • Wear an N95 respirator mask when entering the room of a client who is known to have or suspected of having primary TB. • Examples: TB, Varicella, Measles 4. Know how to remove a face mask #11 on pg. 623 • Remove the mask at the doorway to the client’s room. If using a respirator mask, remove it after leaving the room and closing the door • If using a mask with strings, first untie the lower strings of the mask (this prevents the top part of the mask from falling onto the chest) • Untie the top strings and while holding the ties securely, remove the mask from the face. If side loops are present, lift the side loops up and away from the ears and face. Do not touch the front of the mask (the front of the mask through which the nurse has been breathing is contaminated) • Discard a disposable mask in the waste container • Perform proper hand hygiene 5. Know the information on hypertension on pg. 500-501 (not an immediate intervention, the answer is to schedule appointment to see the doctor) • Screening guidelines: screen for cardiac disease=if not normal, evaluate BP • Hypertension cannot be diagnosed unless an elevated BP is found when measured twice at different times. A single elevated BP reading indicates the need for reassessment i. It is usually asymptomatic and is often a contributing factor to myocardial infarctions (heart attacks) • Primary hypertension: elevated BP of unknown cause • Secondary hypertension: an elevated BP of known cause • Factors associated with hypertension: thickening of the arterial walls, inelasticity of arteries • Lifestyle factors: smoking, obesity, heavy alcohol consumption, lack of physical exercise, high blood cholesterol levels, stress 6. Know table 29-4 on pg. 501 priority risk factor (know the numbers of hypertension) • Normal: 120 mmHg systolic and 80 mmHg diastolic • Prehypertensive: 120-139 mmHg systolic or 80-89 mmHg diastolic • Hypertension stage 1: 140-159 mmHg systolic or 90-99 mmHg diastolic • Hypertension Stage 2: 160 mmHg systolic or 100 mmHg diastolic 7. Know how age and temperature are related on pg. 479 #1 Age (know that factors that affect body temp is age) • Infants are greatly influenced by the temperature of the environment and must be protected from extreme changes • Children’s temperatures vary more than those of adults do until puberty • Many older people, particularly those over 75 years, are at risk of hypothermia (temperatures below 36 degrees Celsius or 96.8 degrees Fahrenheit) i. For a variety of reasons such as: inadequate diet, loss of subcutaneous fat, lack of activity, reduced thermoregulatory efficiency ii. Older adults are also particularly sensitive to extremes in the environmental temperature due to decreased thermoregulatory controls 8. What tasks can be delegated to a UAP? • Never assessment, education, teaching, medication • Pick the answer that does not have the above mentioned 9. Know hearing aids, skill 33-7 #1 on pg. 705 (help them be as independent as possible) • Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate • Always give freedom to patient and encourage as much independence as possible 10. Know partial bed bath pg. 675 (what to do for partial bed bath and who gets a partial bed bath) • Also known as “abbreviated bath” • Only the parts of the client’s body that might cause discomfort or odor, if neglected, are washed: the face, hands, axillae, perineal area, and back i. Omitted from the bath: arms, chest, abdomen, legs, and feet ii. The nurse provides this care for dependent clients and assists self-sufficient clients confined to bed by washing their backs iii. Some ambulatory clients prefer to take a partial bath at the sink. The nurse can assist them by washing their backs • Used for patients who are dependent clients, and self-sufficient clients who are confined to the bed 11. Know practice guidelines for bed making on pg. 709 (used linens do not go on the ground) • Wear gloves while handling a client’s used bed linen. Linens and equipment that have been soiled with secretions and excretions harbor microorganisms that can be transmitted to others directly or by the nurse’s hands or uniform. Wash hands after removing gloves • Hold soiled linen away from uniform • Linen for one client is never placed on another client’s bed • Place soiled linen directly in a portable linen hamper or tucked into a pillow case at the end of the bed before it is gathered up for disposal • Do not shake soiled linen in the air because shanking can disseminate secretions and excretions and the microorganisms they contain • When stripping and making a bed, conserve time and energy by stripping and making up one side as much as possible before working on the other side • To avoid unnecessary trips to the linen supply area, gather all linen before starting to strip a bed 12. Know client teaching related to skin rashes on pg. 684 (read options very carefully) • Keep the area clean by washing it with a mild soap. Rinse the skin well and pat it dry • To relieve itching, try a tepid bath or soak. Some over the counter preparations such as Caladryl lotion may help but should be used with full knowledge of the product • Avoid scratching the rash to prevent inflammation, infection, and further skin lesions • Choose clothing carefully. Too much can cause perspiration and aggravate a rash • Keep site dry and do not rub, provide extra care and take time with rash site 13. Know attentive listening book 26-1 “E” on pg. 420 (the answer is maintaining eye contact) • Maintain good eye contact. In north American culture, mutual eye contact, preferably at the same level, recognizes the other person and denotes willingness to maintain communication. Eye contact neither glares at nor stares down another but is natural. In other cultures, too much eye contact especially with someone in a position of authority is out of order. 14. Know table 26-1 on pg. 420, using silence (being silent allows the patient to collect their thoughts and feelings and put them into words) • Accepting pauses or silences that may extend for several seconds or minutes without interjecting any verbal response • Examples: sitting quietly (or walking with the client) and waiting attentively until the client is able to put thoughts and feelings into words • Helps patient gather thoughts 15. Know stereotyping in Table 26-2 on pg. 422 • Offering generalized and oversimplified beliefs about groups of people that are based on experiences too limited to be valid. These responses categorize clients and negate their uniqueness as individuals • Examples i. “Two-year-olds are brats” ii. “Women are complainers” iii. “Men don’t cry” iv. “Most people don’t have any pain after this type of surgery” 16. Table 26-1 on pg. 421 seeking clarification perception checking and seeking consensual validation (this will be a scenario that you will have to choose the seeking clarification comment form the scenario) • Seeking clarification i. A method of making the client’s broad overall meaning of the message more understandable. It is used when paraphrasing is more difficult or when the communication is rambling or garbled. To clarify the message, the nurse can restate the basic message or confess confusion and ask the client to repeat or restate the message. Nurses can also clarify their own message with statements ii. Examples: 1. “I’m puzzled” 2. “Would you please say that again?” 3. “I meant this rather than that” 4. I’m not sure I understand that” • Perception checking or seeking consensual validation i. A method similar to clarifying that verifies the meaning of specific words rather than the overall meaning of a message ii. Examples: 1. Client: “My husband never gives me any presents.” 2. Nurse: “You mean he has never given you a present for your birthday or Christmas?” 3. Client: “Well- not never. He does get me something for my birthday and Christmas, but he never thinks of giving me anything at any other time” 4. Nurse: “how dare he…..” • Both are used to elicit more information from the client 17. Know open-ended questions pg. 420 Table 26-1 (knowing the type of technique, using silence and opened ended questions, and what technique is being used either using silence or the open ended questions) • Asking broad questions that lead or invite the client to explore (elaborate, clarify, describe, compare, or illustrate) thoughts or feelings. Open-ended questions specify only the topic to be discussed and invite answers that are longer than one or two words • Examples: i. “I’d like to hear more about that” ii. “Tell me more” iii. “How have you been feeling lately?” iv. “What is your opinion?” v. “What brought you to the hospital?” 18. Know Ensuing confidentiality of computer records on pg. 222 (never ever share your password with anyone) • The Security Rule of HIPAA became mandatory in 2005, this rule governs the security of electronic PHI (protected health information), ways to ensure the confidentiality and security of computerized records: i. A personal password is required to enter and sign off computer filed. Do not share this password with anyone including other health team members ii. After logging on, never leave a computer terminal unattended iii. Do not leave client information displayed on the monitor where others may see it iv. Shred all unneeded computer-generated worksheets v. Know the facilities policy and procedure for correcting an entry error vi. Follow agency procedures for documenting sensitive material such as a diagnosis of AIDS vii. Information technology (IT) personnel must install a firewall to protect the server from unauthorized access. 19. Know SBAR Box 15-6 on pg. 238 (know that R stands for) • S: Situation i. State your name, unit, and client name ii. Briefly state the problem • B: Background i. State client admission diagnosis and date of admission ii. State pertinent medical history iii. Provide brief summary of treatment to date iv. Code status (if appropriate) • A: Assessment i. Vital signs ii. Pain scale iii. Is there a change from prior assessments? • R: Recommendation i. State what you would like to see done or specify that the care provider needs to come and assess the client ii. Ask if health care provider wants to order any tests or medications iii. Ask health care provider if she or he wants to be notified for any reason iv. Ask, if no improvement, when you should call again 20. Know heart failure on pg. 1297 (left sided heart failure is failure of the lungs –respiratory system) • May develop if the heart is unable to keep up with the body’s need for oxygen and nutrients to the tissues. Heart failure usually occurs because of MI but it may also result from chronic overwork of the heart such as in clients with uncontrolled hypertension or extensive arteriosclerosis. If left-sided heart failure the vessels of the pulmonary system become congested or engorged with blood. This may cause fluid to escape into the alveoli and interfere with gash exchange, a condition known as pulmonary edema • S/S i. Pulmonary congestion: adventitious lung sounds ii. SOB iii. Dyspnea on exertion (DOE) iv. S3 heart sound v. Increased respiratory rate vi. Nocturia vii. Orthopnea viii. Distended neck veins • Gender and Race disparities: African Americans experience symptoms of heart failure (HF) earlier possibly because of the higher rate of uncontrolled hypertension. African Americans have higher BMI than Caucasians due to their views on body size (larger the body the more it is valued positively) 21. Know assessing the heart #6 on pg. 564 (mitral value) • S1: heart loudest in mitral area (5th intercostal space, Left mid-clavicular line) • Assessment i. Auscultate the heart in all four anatomic sites: aortic, pulmonic, tricuspid, and apical (mitral) ii. Auscultation need to be limited to these areas; however, the nurse may need to move the stethoscope to find the most audible sounds for each client 1. Eliminate all sources of room noise (heart sounds are of low intensity and other noise hinders the nurse’s ability to hear them) 2. Keep the client in a supine position with head elevated 15-45 degrees 3. Use both the diaphragm and the bell to listen to all areas 4. In every area of auscultation, distinguish both S1 and S2 sounds 5. When auscultating, concentrate on one particular sound at a time in each area; the first heart sound followed by systole and then the second heart sound then diastole. Systole and diastole are normally silent intervals 6. Later reexamine the heart while the client is in the upright sitting position (certain sounds are more audible in certain positions) iii. Normal Findings 1. S1: usually heart at all sites, usually louder at apical (mitral) area 2. S2: usually hear at all sites, usually louder at base of heart 3. Systole: silent interval; slightly shorter duration than diastole at normal heart rate (60-90 BPM) 4. Diastole: silent interval: slightly longer duration than systole at normal heart rates 5. S3 in children and young adults 6. S4 in many older adults iv. Deviations from normal 1. Increased or decreased intensity 2. Varying intensity with different beats 3. Increased intensity at aortic area 4. Increased intensity at pulmonic area 5. Sharp-sounding ejection clicks 6. S3 in older adults 7. S4 may be a sign of hypertension 22. Know impaired tissue perfusion physical assessment on pg. 1298 (know the bullet points) • Atherosclerosis is the most common cause of impaired blood flow to organs and tissues. As vessels narrow and become obstructed, distal tissues receive less blood, oxygen, and nutrients i. Any artery in the body may be affected by atherosclerosis however the effects are most associated with coronary arteries, vessels supplying blood to the brain and arteries in peripheral tissues ii. Partial obstruction of coronary arteries causes myocardial ischemia often resulting in angina pecotris; if the obstruction is complete a heart attack (MI) occurs. iii. Partial obstruction of cerebral vessels may cause a TIA; if the obstruction is complete, a stroke occurs. iv. Peripheral vascular disease leads to ischemia of distal tissues such as legs and feet 1. Gangrene and amputation may result • Ischemia: lack of blood supply due to obstructed circulation • S/S of impaired peripheral arterial circulation in the legs and feet i. Decreased peripheral pulses ii. Pain or paresthesia iii. Pale skin color (pallor) iv. Cool extremities v. Decreased hair distribution • Risk factors for peripheral atherosclerosis i. Smoking ii. Obesity iii. Hypertension iv. Diabetes • On the venous side i. Incompetent valves may allow blood to pool in veins causing edema and decreasing venous return to the heart. Veins can also become inflamed, reducing blood flow and increasing the risk of thrombus (clot) formation ii. Thrombi can break free and become emboli which can occlude blood supply to the capillaries. 23. Know a priority assessment if someone has numbness in their fingers or toes pg. 1299 (check circulation and pulse r/t peripheral circulation) • Check pulses and circulation • Examine the cardiovascular system i. BP in both arms (should be within 10mmHg of each other) ii. Palpate peripheral pulses for strength and equality iii. Apical pulse auscultated for rate, rhythm, and quality of the heart iv. Assess skin for color, temperature, hair distribution v. Clients with extensive peripheral vascular disease may have cool feet with weak pulses, and shiny, hairless shins and feet; Pitting edema of feet and ankles may be noted with clients with heart failure vi. Interview: past or current cardiovascular problems & Medical history, lifestyle habits (smoking, drinking, recreational drug use) 24. What would a patient be at risk for if they would be receiving fluids and not eating? (fluid retention and imbalance) • Fluid retention and imbalances 25. Know that a least invasive task that does not require an assessment can be delegated to a UAP (assisting with pt meals / feeling) • Sitting patient up in bed, ambulating with patient 26. Skin fold measurements on pg. 1146 (must be months to years) • Anthropometric measurement • Months years rather than days  weeks • Changes in anthropometric measurements occur slowly and reflect chronic rather than acute changes in nutritional status. They are used to monitory client’s progress for months to years. Ideally, initial and subsequent measurements need to be taken by the same clinician. Measurements obtained need to be interpreted with caution. Fluctuations in hydration status that often occur during illness can influence the accuracy of results. Normal standards often do not account for normal changes in body composition such as those that occur with aging 27. What is a priority of the nurse if a patient is not tolerating a tube feeding? (the patient has a tube and suction and their stomach hurts, so check the equipment to make sure it is working properly) • Stop feeding and check the machine for malfunctions 28. Know Lifespan considerations bullet 6 on pg. 528 (check skin turgor on sternum and clavicle for older adults) • Due to the normal loss of peripheral skin turgor in older adults, assess for hydration by checking skin turgor over the sternum or clavicle 29. Know table 30-8 on pg. 557 (know crackles) • Crackles: fine, short, interrupted crackling sounds; alveolar rales are high pitched. Sound can be simulated by rolling a lock of hair near the ear. Best heard on inspiration but can be heard on both inspiration and expiration. May not be cleared by coughing • Cause: air passing through fluid or mucus in any air passage • Location: most commonly heard in the bases of the lower lung lobes 30. What class of medications could decrease respiratory rate (answer is a narcotic do not pick digoxin) • Narcotics: opioids: pain medication 31. Know what to teach a patient about the use of an incentive spirometer pg. 1254 (explain the purpose of the activity/ therapy) • AKA sustained maximal inspiration devices (SMIs): measure the flow of air inhaled through the mouthpiece and are used to: i. Improve pulmonary ventilation ii. Counteract the effects of anesthesia or hypoventilation iii. Loosen respiratory secretions iv. Facilitate respiratory gaseous exchange v. Expand collapsed alveoli 32. Know venturi mask pg. 1261 • Delivers oxygen concentrations varying from 24% to 40% or 50% at liter flows of 4 to 10 L/min • The Venturi mask has wide-bore tubing and color-coded jet adapters that correspond to a precise oxygen concentration and liter flow. i. For example, in some cases, a blue adapter delivers a 24% concentration of oxygen at 4L/min and a green adapter delivers a 35% concentration of oxygen at 8L/min. However, colors and concentrations may vary ii. The nurse must find a mask of appropriate size. Limitations of masks include difficulty in achieving a proper fit and poor tolerance by some clients who may complain of feeling hot or “smoldering” 33. Know how to perform nasopharyngeal suctioning #8 on pg. 1270 (its going to ask you how long can you suction, the answer is 15 seconds) • Apply your finger to the suction control port to start suction and gently rotate the catheter (gentle rotation of the catheter ensures that all surfaces are reached and prevents trauma to any one area of the respiratory mucosa due to prolonged suction) • Apply suction for 5-10 seconds while slowly withdrawing the catheter, then remove your finger from the control and remove the catheter (intermittent suction reduces the occurrence of trauma or irritation to the trachea and nasopharynx) • A suction attempt should last only 10-15 seconds (should not exceed 15 seconds) during this time, the catheter is inserted, the suction applied and discontinued, and the catheter removed. 34. Know the steps on inserting an oropharyngeal airway pg. 1265 #3 bullet point (know bullet points 3-7) • Hold the lubricated airway by the outer flange, with the distal end pointing up or curved upward 35. Know the lifespan considerations on pg. 102: Assessing older adults’ section (asks about ADL’s since ADL’s are self care the answer is how well they perform self care) • Assessing the functional levels of older adults on an ongoing basis will provide guidelines for detecting needs for special care, resources, and services. It helps to determine their level of independence and changes as they occur. The two most common assessments are to evaluate the following activities of daily living and instrumental activities of daily living i. Activities of daily living: bathing, dressing, toileting, transferring, continence, feeding ii. Instrumental activities of daily living: ability to use the telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility for own medication, ability to handle finances • Help the patient be as independent as possible • ADLs= self-care 36. Know the musculoskeletal assessment on pg. 514 and what would not be normal (older patients have brand new symptoms) • Normal: bilateral strength of pulses however in older adults this gets weaker due to decreased perfusion. Osteoarthritis is also considered normal in older adults • Abnormal findings: make sure to document, report, and address abnormalities as found. • Purposes of physical assessment i. To obtain a baseline data about client’s functional abilities ii. To supplement, confirm or refute data obtained in the nursing history iii. To obtain data that will help establish nursing diagnoses and plans of care iv. To evaluate the physiological outcomes of health care and thus the progress of a client’s health problem v. To make clinical judgements about client’s health status vi. To identify areas for health promotion and disease prevention 37. Know expressive aphasia pg. 581 • Any defects in or loss of the power to express oneself by speech, writing, or signs, or to comprehend spoken or written language due to disease or injury of the cerebral cortex is called aphasia. • Categories of aphasia i. Sensory or receptive aphasia: the loss of the ability to comprehend written or spoken words 1. Auditory (acoustic) aphasia a. Lost ability to understand the symbolic content associated with sounds 2. Visual aphasia a. Lost ability to understand printed or written words • Pick out patient that displays expressive aphasia i. Motor or expressive aphasia involves loss of the power to express oneself by writing, making signs, of speaking. Clients may find that even though they can recall words, they have lost the ability to combine speech sounds into words 38. Know the home care considerations on pg. 1055 (2 questions) (the things that will help them stay safe the most) (the things that will cause the most harm to them) • When making a home visit assess carefully for safety issues concerning ambulation. Counsel the client and family about inadequate lighting, unfastened rugs, slippery floors, and loose objects on the floors • Check the surroundings for adequate supports such as railings and grab bars • Recommend that nonskid strips be placed on outside steps and inside stairs that are not carpeted • Ask to see the shoes the client intends to wear while ambulating. They should be in good repair and should support the foot 39. Know the home care considerations related to applying restraints on pg. 665 (know bullet point 2 for restraints) • Restraints may be necessary for clients in wheelchairs or in the home. Safety guidelines apply in all cases. Assess the knowledge and skill of all caregivers in the use of restraints and educate as indicated i. Use means other than restraints as much as possible, and stay with the client ii. Pad bony prominences, such as wrists and ankles, if needed before applying a restraint over them iii. Tie restraints with knots that will not tighten when pulled and to parts of the wheelchair that do not move and release quickly in case of emergency iv. Assess restrained limbs for signs of impaired blood circulation v. Always stay with a client whose restraint is temporarily removed 40. Know that it is important for a patient to do as much as they can for themselves, nurses should promote independence 41. Know how to teach a patient about using a walker pg. 1056 (walker first then patient) • Walkers are mechanical devices for ambulatory clients who need more support than a cane provides and lack the strength and balance required for crutches. • The walker requires partial strength in both canes and wrists, strong elbow extensors and strong shoulder depressors. The client also needs the ability to bear at least partial weight on both legs • The nurse needs to adjust the height of a client’s walker so that the hand bar is just below the client’s waist and the client’s elbows are slightly flexed (this position helps the client assume a more normal stance • A walker that is too low causes the client to stoop; one that is too high makes the client stretch and reach • When maximum support is required i. Move the walker ahead about 6 in while your body weight is borne by both legs ii. Then move the right foot up to the walker while your body weight is borne by the left leg and both arms iii. Next move the left foot up to the right foot while your body weight is borne by the right leg and both arms • If one leg is weaker than the other i. Move the walker and the weak leg ahead together about 6 inches while your weight is born by the stronger leg ii. Then move the stronger leg ahead while your weight is borne by the affected leg and both arms 42. Know how to use crutches pg. (upper body specifically the arms) • Crutches may be a temporary need for some clients and a permanent one for others • They should enable a client to ambulate independently • The most frequently used kind of crutches are the underarm crutch or axillary crutch with hand bars. • All crutches require suction tips which help to prevent slipping on a floor surface • In crutch walking, the client’s weight is borne by the muscles of the shoulder and the upper extremities. Before beginning crutch walking, exercises that strengthen the upper arms and hands are recommended 43. Know passive range of motion pg. 1050 (answer going to have the word joint in it) • Another person moves each of the client’s joints through its complete range of movement, maximally stretching all muscle groups within each plane over each joint. • Because the client does not contract the muscles, passive ROM exercises are of no value in maintaining muscle strength but useful in maintaining joint flexibility • Passive ROM exercises should be performed only when the client is unable to accomplish the movements actively • Passive ROM exercises should be accomplished for each movement of the arms, legs, and neck that the client is unable to achieve actively • Should be accomplished to the point of slight resistance but not beyond and never to the point of discomfort • The movements should be systematic, and the same sequence should be followed during each exercise session, exercises should be repeated at the clients tolerance from 3 to 5 times and repeated twice daily • Most effective in supine position 44. Know how to perform log rolling #6 select all that apply (3 total) pg. 1042 (bullet points) • Document all relevant information • Record: i. Time and change of position moved from and position moved to ii. Any signs of pressure areas iii. Use of support devices iv. Ability of client to assist in moving and turning v. Response of the client to moving and turning (anxiety, discomfort, dizziness) 45. Know what to do before moving a patient in bed. Safety!! #4 pg. 1047 (lock wheels and lower the bed before • Position the equipment appropriately i. Lower the bed to its lowest position so that the client’s feet will rest flat on the floor, lock the wheels of the bed ii. Place the wheelchair parallel to the bed and as close to the bed a possible. Put the wheelchair on the side of the bed that allows the client to move toward his or her stronger side. Lock the wheels of the wheelchair and raise the footplate 46. Know the table 11-1 on pg. 158 assessing (3 questions related to this table) (focus on assessing and evaluation, why would you assess and evaluate because its part of the nursing process) • Assessing: collecting, organizing, validating, and documenting client data i. Purpose: to establish a database about the clients response to health concerns or illness and the ability to manage health care needs ii. Activities: establish a database: 1. Obtain a nursing health history 2. Conduct a physical assessment 3. Review client records 4. Review nursing literature 5. Consult support person's 6. Consult health professionals 7. Update data as needed, organize data, validate data, communicate/document data 47. Why do nurses perform physical assessments? Pg. 167 Examining section (establish a baseline) • To get a baseline of patient condition • The physical examination or physical assessment is a systematic data collection method that uses observation to detect health problems. To conduct the examination, the nurse uses techniques of inspection, auscultation, palpation, and percussion • Steps of physical assessment i. Record a general impression about the client’s overall appearance and health status: age, body size, mental and nutritional status, speech and behavior ii. Vitals, height, weight iii. Head-to-toe assessment (focus on area of concern) 48. Know the nursing process introduction paragraph on pg. 155 and the scope of nursing on pg. 13-14 (the roll of nurses is promoting wellbeing and giving emotional support) • Introduction paragraph i. The nursing process is a systematic, rational method of planning and providing individualized nursing care. Its purposes are to identify a client’s health status and actual or potential health care problems or needs, to establish plans to meet the identified needs and to deliver specific nursing interventions to meet those needs. The client may be an individual, a family, a community, or a group 1. Hall originated the term “nursing process” in 1955 and Johnson (1959), Orlando (1961) and Wiedenbach (1963) were among the first to use it to refer to a series of phases describing the practice of nursing. Since then, various nurses have described the process of nursing and organized the phases in different ways. • Scope of Nursing i. Nurses provide care for three types of clients: individuals, families, and communities. Theoretical frameworks applicable to these client types as well as assessments of individual, family, and community health are discussed in Ch 7 and 24. ii. Nursing practice involves four areas: promoting health and wellness, preventing illness, restoring health, and caring for the dying 1. Promoting health and wellness a. When health is defined broadly as actualization of human potential, it has been called wellness. Nurses promote wellness in clients who are both healthy and ill. This may involve individual and community activities to enhance healthy lifestyles, such as improving nutrition and physical fitness, preventing drug and alcohol misuse, restricting smoking, and preventing accidents and injury in the home and workplace 2. Preventing illness a. The goal of illness prevention programs is to maintain optimal health by preventing disease. Nursing activities that prevent illness include immunizations, prenatal, and infant care, and prevention of sexually transmitted infections 3. Resorting health a. Focuses on the ill client and extends from early detection of disease through helping the client during the recovery period. Nursing activities include the following i. Providing direct care to the ill person, such as administering medications, baths, and specific procedures and treatments ii. Performing diagnostic and assessment procedures such as measuring BP, and examining feces for occult blood iii. Consulting with other health care professionals about client problems iv. Teaching clients about recovery activities such as exercise that will accelerate recovery after a stroke v. Rehabilitating clients to their optimal functional level following physical or mental illness, injury, or chemical addiction 4. Caring for the dying a. This area of nursing practice involves comforting and caring for people of all ages who are dying. It includes helping clients live as comfortable as possible until death and helping support person's cope with death. Nurses carrying out these activities work in homes, hospitals, and extended care facilities. Some agencies called hospices are specifically designed for this purpose. 49. Know the type of assessments in table 11-3 on pg. 161 (focus on emergency) • Emergency assessment i. Time performed 1. During any physiological or psychological crisis of the client ii. Purpose 1. To identify life-threatening problems, to identify new or overlooked problems iii. Example 1. Rapid assessment of an individual’s airway, breathing status, circulation, during a cardiac arrest. Assessment of suicidal tendencies or potential for violence 50. Know types of data on pg. 160-161 (objective and subjective data) • Subjective i. Referred to as symptoms or covert data ii. Includes the client’s sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation 1. Only apparent to the person affected and can be described or verified by that person 2. Examples: Itching, pain, and feelings of worry • Objective i. Also referred to as signs or overt data ii. Detectable by an observer or can be measured or tested against an accepted standard iii. They can be seen, heart, felt, or smelled and are obtained by observation or physical examination iv. Examples: discoloration of skin, BP measurement • During the physical examination, the nurse obtains objective data to validate subjective data and to complete the assessment phase of the nursing process • Constant data i. Information that does not change over time such as race or blood type • Variable data i. Can change quickly, frequently, or rarely such as BP measurements, level of pain, age 51. Know the characteristics of the nursing diagnosis bullet #5 on pg. 184 (focus on pattern behavior over time) • Base diagnosis on patterns that is on behavior over time rather than on an isolated incident i. For example, even though Margaret O’Brian is concerned today about needing to leave her children with her in-laws, it is likely that this concern will be resolved without intervention by the next day. Therefore, the admitting nurse should not diagnose Interrupted Family Process but rather, Risk or Interrupted Family Process 52. What would be an appropriate nursing diagnosis R/T BMI? BMI is on pg. 1131 (focus on nutrition imbalance and underweight) • BMI Ranges i. Normal: 18.5-24.9 ii. Overweight: 25.0-29.9 iii. Obesity I: 30-34.9 iv. Obesity II: 35.0-39.9 v. Obesity III: 40.0 53. When writing short-term goals what outcomes are most realistic or achievable? (know the outcomes are realistic and achiiveable include the patient in something they can do, write goeals together) • Includes patient in the process of creating goals, education, go over goals, be in the patient’s capability to achieve goals 54. What is a primary goal when caring for a patient who has an infectious disease? (prevent spreading to others) • To prevent spread of infections • Teach patients how to prevent the spread of infectious diseases 55. Know what needs to be in outcomes/goals pg. 198-199 (2 questions) (pick out what is missing from a written goal) (choose which goal is written correctly) (smart goals) • Purpose of goals/desired outcomes i. Provide direction for planning nursing interventions ii. Serve as criteria for evaluating client progress iii. Enable the client and nurse to determine when the problem has been resolved iv. Help motivate the client and nurse by providing a sense of achievement • Components of goal/desired outcome statements i. Subject ii. Verb: refers to the specific action the client is to perform iii. Conditions or modifiers: to explain the circumstances under which the behavior is to be performed. They explain what, where, when, how iv. Criterion of desired performance: indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior • Guidelines for writing goals/desired outcomes i. Write goals and outcomes in terms of client responses not nursing activities. Beginning each goal statement with “the client will” may help focus the goal on client behaviors and responses ii. Avoid using statements that start with “enable, facilitate, allow, let, permit” or similar verbs, these verbs indicate what the nurse hopes to accomplish not what the client will do iii. Be sure that desired outcomes are realistic for the client’s capabilities, limitations, and designated time span iv. Ensure that the goals and desired outcomes are compatible with the therapies of other professions v. Make sure each goal is derived from only one nursing diagnosis vi. Use observable, measurable terms for outcomes vii. Make sure client considers the goals/ desired outcomes important and values them. 56. Know the introduction paragraph on pg. 208 R/T evaluation within the nursing process (know that is evaluated based patient outcomes) • The nursing process is action oriented, client centered, and outcome directed. After developing a plan of care based on the assessing and diagnosing phases, the nurse implements the interventions and evaluates the desired outcomes. On the basis of this evaluation, the plan of care is either continued, modified, or terminated. As in all phases of the nursing process, clients and support person's are encouraged to participate as much as possible. 57. What would be an appropriate nursing diagnosis for whooping cough? (ineffective airway clearance) • Ineffective airway clearance 58. What is a patient at risk for after hip surgery? (fall risk) • Falls 59. Know the readiness of a patient to learn on pg. 441 factors affecting learning (2 questions) (appropriate time when pt should be educated) (Pt readiness for education) • Readiness i. Readiness to learn is the demonstration of behaviors or cues that reflect the learner’s motivation to learn at a specific time. Readiness reflects not only the desire or willingness to learn, but also the ability to learn at a specific time. For example, a client may want to learn self-care during a dressing change, but if the client experiences pain or discomfort he or she may not be able to learn. The nurse can provide pain medication to make the client more comfortable and more able to learn. The nurse’s role is often to encourage the development of readiness 60. Know the learning domains pg. 440 (2 questions) (definition questions) • Cognitive domain i. The “thinking” domain, includes six intellectual abilities and thinking processes beginning with knowing, comprehending, and applying to analysis, synthesis, and evaluation • Affective domain i. AKA “feeling” domain deals with personal issues such as attitudes, beliefs, behaviors, and emotions • Psychomotor domal i. AKA “skill” domain includes fine and gross motor abilities such as giving an injection 61. Know the lifespan considerations on pg. 446 select all that apply (3) (know older adults in lifespan considerations use different techniques for older alduts) • For older adults to be motivated to learn, the material must be practical and have meaning for them individually, especially if the information is new to them • Health promotion is a priority need and should include: i. Exercise ii. Nutrition iii. Safety habits iv. Having regular health checkups v. Understanding medications • Set achievable goals: involve the client and family in doing this • If developing written materials: i. Use large print ii. Use buff-colored paper or white paper that has a matt finish iii. Present the information at the sixth to eighth grade reading level • Increase time for teaching and allow for rest periods because processing of information is slower in older adults i. Verbal presentation of material should be well organized ii. Ensure that there is minimal distraction • Repeat information if necessary • Use return demonstrations • Determine where clients obtain most of the health information (newspapers, tv, magazines) • Use examples that clients can relate to in their daily lives • Be aware of sensory deficits: hearing and vision • Use the setting with which the individual is most comfortable: either a group or one-on-one setting 62. Know what promotes self-care behaviors pg. 454 (promoting self care behaviors know last bullet point on 454) • Learning is more effective when the learners discover the content for themselves. Ways to increase learning include stimulation motivation and self-direction • For example: i. By providing specific, realistic, achievable outcomes ii. By giving feedback iii. By helping the learner derive satisfaction form learning • The nurse may also encourage self-directed independent learning by encouraging the client to explore sources of information required. If certain activities do not assist the learner to attain outcomes, these need to be reassessed • Explanation alone may not be enough to teach client, actually doing the action is more effective 63. Know dietary data on pg. 1147 (promote healthy diet) • Dietary data includes the client’s usual eating patterns and habits, food preferences, allergies, intolerances: frequency, types, and quantities of foods consumed; and social, economic, ethnic, or religious factors influencing nutrition i. Factors may include living and eating companions, ability to perchance and prepare food, availability of refrigeration and cooking facilities, income, and effect of religion and ethnicity on food choices • Four methods for collecting dietary data are a 24-hour food recall, a food frequency record, a food diary, and a diet history i. 24-hour food recall 1. The nurse asks the client to recall all of the food and beverages the client consumes during a typical 24-hour period when at home. The data obtained are then generally evaluated according to the food guide to judge overall adequacy ii. Food frequency record 1. A check list that indicates how often general food groups or specific foods are eaten. Frequency may be categorized as time/day, times/week, times/month, or frequently, seldom, never. 2. Provides information about the types of foods eaten but not the quantities. 3. When specific foods or nutrients are suspected of being deficient or excessive, the health care professional may use a selective food frequency that focuses on, for example, fat, fruit, vegetable, or fiber intake iii. Food diary 1. Detailed record of measured amounts (portion sizes) of all food and fluids a client consumes during a specified period usually 3-7 days. iv. Diet History 1. Comprehensive time-consuming assessment of a client’s food intake that involves an extensive interview by a nutritionist or dietitian. Includes characteristic of foods usually eaten and the frequency and amount of food consumed. It may include a 24-hour recall, a food frequency record, and a food diary. Medical and psychosocial factors are also assessed to evaluate their impact on nutritional requirements, food habits, and choices 2. Data obtained are analyzed by a computer and translated into caloric and nutrient intake. Results are compared with the DRIs appropriate for the client’s age, sex, and condition. 64. If a nurse was teaching at a health fair and was education on poison control, what age group should she focus on? (the younger the better) • Children: the younger the better 65. Know assessing body temperature on pg. 481-482: Axillary temperature (know its axillary and leave it there for 1 minute) • The axilla is often the preferred site for measuring temperature in newborns because it is accessible and safe. Axillary temperatures are lower than rectal temperatures. • Advantages: safe and noninvasive • Disadvantages: the thermometer may need to be left in place a long time to obtain an accurate measurement 66. Know section on assessing on Pg. 159 and on table 11-2 (baseline and history and why are they there) • Assessing critical thinking activities i. Making reliable observations ii. Distinguishing important from unimportant data iii. Distinguishing relevant form irrelevant data iv. Validating data v. Organizing data vi. Categorizing data according to a framework vii. Recognizing assumptions viii. Identifying gaps in the data • Assessing i. The systematic and continuous collection, organization, validation, and documentation of data 1. In effect, assessing is a continuous process carried out during all phases of the nursing process 2. The four different types of assessments are: a. the initial nursing assessment b. problem-focused assessment c. emergency assessment d. time lapsed assessment ii. Nursing assessments focus on a client’s responses to a health problem. 1. It should include the clients perceived needs, health problems, related experience, health practices, values and lifestyles 2. To be most useful, data collected should be relevant to particular health problem iii. Each client should have an initial nursing assessment consisting of a history and physical examination performed and documented within 24 hours of admission as an impatient. iv. RN is responsible for care and must assess and develop the clients plan of care 1. Responsible for the collection of comprehensive data” physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual assessments v. The nursing assessment also involves the elicitation of client’s own perspectives on their condition: identifying barriers to communications, recognizing the impact of the nurses own attitudes, values, and beliefs on the assessment process; including family dynamics in assessment and increased emphasis on protection of privacy of data 67. Know how to pick out a reliable/measurable statement pg. 197 (will have a number in it because that will be most reliable and measurable) • Must have the most information and be measurable 68. Know that for outcomes to be effective, the patient should be part of the planning and teaching pans (pt should be part of planning and teaching)