NU 211 Foundations Final

Stages of Illness

1. Develop sickness- the illness has begun

2. Assuming sick role- illness symptoms are present

3. Contacting medical provider- gets validation and explanation for illness.

4. Assuming dependent client role- getting treatment for illness.

5. Recovery- resumes independence and returns to normal role.

Wellness-Illness continuum

-Affected by biological factors, nutrition, physical activity, sleep and rest, meaningful work, life's choices, family relationships, culture, religion/spirituality, environmental factors, finances.

-Acute illness: goal is to treat and cure illness.

Chronic illness: goal is to keep patient at the most healthy state they can be.

Health prevention

Primary: prevent/slow onset of disease

Secondary: detect and treat illness

Tertiary: stop disease progression and return to pre-illness state

Kurt Kerwin Stages of change

1. Unfreezing: discuss and educate about change.

2. Implementation of change

3. Integration

4. Refreeze: getting feedback about change.

Stages of change model

1. Precontemplation: thinking about a potential change.

2. Contemplating: thinking of a plan

3. Preparing: plan is made and person has made a final decision.

4. Action: achieving goal

5. Maintenance: maintaining goal

6. Terminating: change is frozen, can permanently maintain change.

Elements of malpractice

Having a duty --> breach duty of care --> breach caused harm

HIPPA

Confidentiality needs to be maintained

Patient self-determination

Patient making their own decisions about their plan of care, including advanced directive and DPOA (durable power of attorney)

Mandatory reporting laws

Must report suspected abuse of vulnerable populations

Good Samaritan laws

Voluntarily providing competent care and stopping if patient refuses.

Assault

Threats to harm someone

Battery

physical violence

False imprisonment

restraints

Libel

Written defamation

Slander

Verbal defemation

Negligence

failed to do something which causes harm

Malpractice

doing something wrong that harms the patient

ANA just culture

not blaming one specific person, but blaming the system. Promotes education and improvement of the system.

Autonomy

Patient self-determination

Nonmaleficence

Duty to do no harm

Fidelity

Keeps promises

Justice

treats everyone equally

Beneficence

Duty to do good

Veracity

telling the truth

Types of leadership

1. Authoritarian: autocratic, directive, controlling.

2. Laissez-faire: followers are the majority control.

3. Democratic: shares the planning, decision making, and responsibility.

4. Transformational: sense of mission that goes beyond good interpersonal relationships.

Types of Power

-Referent: knowledge is power.

-Positional

-Coercion

-Reward

-Empowerment

MORAL to help make decisions

M- massage/examine dilemma

O- outline

R- resolve

A- act and apply

L- look back

Nursing Process (ADPPIE)

1. Assessment

2. Diagnosis

3. Planning outcomes

4. Planning interventions

5. Implementation

6. Evaluation

Objective data

Data collected that is measurable and seen by the nurse (ex. temp, BP)

Subjective data

Data collected that is stated by the patient (ex. pain, physical sensations).

Race

based on biological standards

Ethnicity

Members share a common social and cultural heritage

Acculturation

characteristics of that culture through a learning process, complete when the newcomer is fully merged into the dominant cultural group.

Assimilation

New members learn and take on the essential values, beliefs, and behaviors of the dominant culture.

Stereotype

widely held but oversimplified beliefs that have no basis in fact

Religion

ordered system of beliefs regarding the cause, nature, and purpose of the universe

ISBAR

1. Introduction/Identify

2. Situation

3. Background

4. Assessment

5. Recommendation

Types of Precautions

-Standard: applies to all patients (gloves + handwashing)

-Contact: MRSA, C. Diff, Norovirus (gloves, gown)

-Droplet: Influenza (mask, gloves)

-Airborne: TB, measles, chicken pox. (N95 mask, gown, gloves, negative pressure room)

Stages of infection

1. Incubation

2. Prodrome

3. Illness

4. Decline

5. Convalescence

Sentinel event

A serious, unexpected occurrence in healthcare that results in death, permanent harm, and severe temporary harm.

Culture of safety

Team work, good communication, transparency, accountability

Intradermal injection

Needles size: 25-28 gauge

Needle length: 1/4" - 5/8"

SQ injection

Needle size: 25-27 gauge

Needle length: 3/8" - 5/8"

IM injection

Needle size: 21-25 gauge

Needle length: 1" - 1.5"

6 rights of medication administration

1. Right med

2. Right patient

3. Right dose

4. Right route

5. Right time

6. Right documentation

Normal urine output

30 mL/hr

Older adult urinary system

Kidneys shrink, functions decrease, nephrons decrease, loss of bladder elasticity and muscle tone, prostate enlargement in men

Ileostomy

Stoma is part of ileum, bypasses large intestine, stool liquid and continous.

Colostomy

Stoma is part of colon, more formed stool than ileostomy (how formed stool is depends on location of colostomy)

Constipation management

Increase high fiber foods, fluid intake, increase activity, provide privacy, help to a comfortable position, allow uninterrupted time, and offer laxatives if these don't work.

Diarrhea management

Monitor stool (amount, color, consistency), monitor fluid imbalance and intake and output, monitor perineal area, proper diet teaching (clear liquids, bananas, rice, apple, toast, avoid dairy, fruits, veggies, caffeine)

PCA Pump

Pt education: Only patient can press button! (not nurse or family)

-Narcan/ Naloxone for opioid overdose

Wound drainage

-Serous: clean, watery, straw colored.

-Sanguineous: bloody/red

-Serosanguineous: mix of bloody and straw colored

-Purulent: yellow, contains pus, infection -->CULTURE

-Purosanguineous: Contains pus and blood

Evisceration

total separation of the surgical site where organs protrude out

Dehiscence

rupture of one or more layers of skin in surgical site, includes inflammatory phase

Infection

Swelling, redness, heat, pain, fever, foul smelling purulent drainage, change of color

Fistula

Abnormal passage connecting 2 body cavities or cavity and skin

Pressure ulcer stages

1. Red, localized

2. Breaking of skin

3. See adipose tissue, possible necrosis

4. See bone/tendon

Stages of wound healing

1. Inflammatory: bleeding and clotting, inflammation present.

2. Proliferative/granulation: granulation fills wound, wound beefy red, fibroblasts/collagen present.

3. Epitheliazation: collagen breaks down and scar forms

Signs of adequate oxygen

Instant cap refill, no cyanosis, good pulses.

Oxygen: nasal cannula

1-6 ml

Oxygen: Face mask

5-10 ml

Partial rebreather

10-15 ml

Nonrebreather

10-15 ml (make sure to have bag open/filled with O2!)

Venti mask

2-15 ml, used for COPD

Poor heart perfusion symptoms

pain, fatigue, dyspnea, poor pulses, edema, ulcers, decreased temp and cold extremities, absence of hair on limbs

Normal BP

<120/80 mmHg

HTN crisis

>140/90

Symptoms of HTN crisis: visual changes, HA, high BP

Treatment for MI?

MONA - morphine, oxygen, nitro, aspirin

Hypovolemia

-Loss of blood volume due to loss of fluid and electrolytes

-SxS: dehydration, dry skin and mucous membranes, poor skin turgor, decreased urine output and BP, high HR, increased temp.

Hypervolemia

-Too much blood volume due to excessive retention of Na and water.

-SxS: increased BP, bounding pulse, pale/cool skin, edema, ascites, crackles.

5 mL = ? tsp

5 mL = 1 tsp

15 ml = ? tbsp

15 mL = 1 tbsp

1000 mg = ? g

1000 mg = 1 g

1000 mcg = ? mg

1000 mcg = 1 mg

IV calculations for pump

ml/hr

IV calculations for drip system

gtts/min