Core Concepts of Nursing - Exam 1 2024

What Makes Nursing a Profession?

Regulation (Nurse Practice Act + Standards of Care)

Licensure (NCLEX)

Education (life-long learning process)

Professional Organization (ANA, AACN, NLN)

Code of Ethics (from the ANA)

What does ANA, AACN, and NLN mean

American Nurse Association (ANA)

American Association of Colleges of Nursing (AACN)

National League for Nursing (NLN)

7 Professional Nursing Behaviors

1. Appearance

2. Accountability (ability to answer to ones own actions)

3. Advocacy (support of clients health, wellness, safety, and personal rights including privacy)

4. Competence

5. Collaboration

6. Compassion

7. Integrity

Caring Interventions

Attitude - most important caring intervention

Compassion - 2nd caring intervention

Ethics

the study of conduct and character

- affect judgments about what is right/wrong; good/bad

Ethical Principles

Autonomy

Justice

Veracity

Fidelity

Beneficence

Nonmaleficence

DO NOT CHANGE (ABSOLUTE)

Autonomy

the right to make ones own personal decisions

Justice

fairness in care delivery and use of resources

Veracity

a commitment to tell the truth

Fidelity

fulfillment of promises

Beneficence

Action that promotes good for others, without any self-interest

Nonmaleficence

a commitment to do no harm

What about ethical principles DOES change?

interpretation and application

Ethical Decision Making

involves finding a balance between science, ethics, and personal moral values

Ex: vaccinations

ethical dilemma

occurs when ethical principles and their application DIFFER

self-reflection

first step in developing self-awareness

Self-Awareness

- first/most important step when facing an ethical dilemma

- deep understanding of what is important to you (developed over time)

ANA Code of Ethics

9 provisions that serve as a basic ethical guideline for nursing

Kindness

an outward expression of caring

5 Auscultation Sites of the Heart

1. Aortic: 2nd ICS (right)

2. Pulmonic: 2nd ICS (left)

3. Erb's Point: 3rd ICS (left)

4. Tricuspid: 4th ICS (left)

5. Mitral: 5th ICS (left)

Erb's Point

the transition point where "lub" (S1) becomes louder than "dub" (S2)

Mitral

the apex of the heart

- point of max impulse (PMI)(Apical Pulse)

- medial to the midclavicular line

S1

"lub" - first heart sound

- closure of the mitral and tricuspid valves (contraction; systole)

S2

"dub" - second heart sound

- closure of aortic and pulmonic valves (relaxation; diastole)

murmurs

abnormal heart sounds created by increased blood volume in the heart

Bruits

abnormal blowing or swishing sound of the heart; decreased blood flow

- listen with bell of stethoscope

Patient Position for Listening to the Heart

1. sitting, leaning forward, mouth open

2. lying supine

3. turned towards the left side (best for extra sounds)

Diaphragm of stethoscope

High-pitched sounds (lung, bowel, heart); place firmly against skin

Bell of stethoscope

low pitched sounds (extra heart sounds, murmurs); place lightly against skin

Normal BP Range

90-120 systolic

60-80 diastolic

General Survey of Patient

information gathered upon the *first encounter* with the patient

collect data for:

1. Physical Appearance (age, sex, race, color of skin)

2. Body Structure (height, weight, nutritional status)

3. Mobility (motor activity, ROM)

4. Behavior (facial expression, speech)

5. Vital Signs

Neurological Survey

Speech (clear/coherent)

Communication

Hearing

Level Of Consciousness (LOC)

Oriented x 3 (Person, place, time)

Components of a Health Assessment

1. systematic (head to toe make it flow)

2. critical thinking (using the data to make critical decisions)

3. patient's current and ongoing health status (70% of the diagnosis comes from the health history)

4. risk factors (modifiable or non-modifiable) modifiable=diet, exercise, smoking (can change) non modifiable = age, gender, race

5. identify health-promoting activities - (exercise)

Problems Presented by the Patient

1. Physical (pain, weight gain, rashes, etc)

2. Social (tobacco use, drug use, financial stress)

3. Emotional (recent life-altering events, depression, mental health, etc)

4. Cultural (language barriers, racial)

5. Environmental (occupation, home life, etc)

Four Types of Assessments

1. Initial (baseline): performed after admission to establish a baseline (head to toe assessment, vital signs)

2. Problem-focused: determines the status of a specific problem; ongoing process (pt. comes in w a sprained ankle, your gonna focus on the ankle)

3. Emergency: during a crisis to identify life-threatening problems (ABC method for respiratory distress)

4. Ongoing Reassessment: comparison of the patient's current status to the previous baseline data (head-to-toe every 4 hr or whatever the hospitals policy time is)

Sources of Data

Primary = the CLIENT

Secondary = all other sources which does NOT COME FROM the client (family, friends, patient record, literature, other healthcare providers)

Subjective Data

symptoms (anything reported by the patient)

- typically SAID; so will be in quotations

EX: pain, symptoms verbally expressed, family history, social history, etc

Objective data

things that the nurse observes

EX: heart rate, lab reports, weight, vital signs, etc

Methods of Data Collection

1) Observing

2) Interviewing

3) Examining

Observing (method of data collection)

Using the senses to observe patient data

Vision: skin color, body language, weight gain/loss, etc

Hearing: heart, lung, bowel sounds

Smelling: body odor, CDIFF

Touch: temperature (skin warm or dry?)

Interviewing (method of data collection)

- Techniques: Standardized formats or Therapeutic techniques

- have privacy, consider having an interpreter, pull up a chair and face the patient

General Examining Sequence

1. Inspect (look)

2. Palpate (touch)

3. Percuss (tap) w pads of fingers

4. Auscultate (listen)

Abdomen Examining Sequence

1. Inspect

2. Auscultate

3. Percuss

4. Palpate

- Auscultation comes prior to steps 3 & 4 to ensure that the bowel sounds do not become obstructed

Data Collection and Interpretation

organize, validate, interpret

Organize Data Collection (Maslow's Hierarchy of Needs)

1. Physiological Needs: the priority concern to address first (respiratory status, food)

2. Safety and Security 3. Love and Belonging

4. Self-Esteem

5. Self-Actualization: lowest priority

Validating Data Collection

checking allergies, clarifying vague statements, checking extreme abnormal findings a second time or manually

Interpreting Data Collection

using the information to determine nursing care

- includes nursing autonomy

Documentation

a part of communication; if it was not documented, it was not done

- objective

- use SBAR during handoffs

Guidelines for older adults

Allow more time for responses

AIDET

Acknowledge

Introduce

Duration

Explain

Thank

PQRST

Provoked (what causes the pain?)

Quality (what does the pain feel like?)

Region (where is the pain?)

Severity (0-10 scale)

Timing (when did it start? is the pain consistent?)

What is the nursing action for a patient with an irregular pulse?

Count the pulses for the entire minute instead of 30 seconds

If there are no bowel sounds heard, what action should the nurse take?

Listen to each quadrant for 5 minutes

Regular Respiration Rate

12-20 breaths per minute

Regular Pulse Rate

60-100 beats per minute

- measure using radial pulse

Normal Blood Pressure Range

less than 120 systolic

less than 80 diastolic

elevated blood pressure

120-129 systolic and less than 80-89 diastolic

Stage 1 hypertension

130-139 systolic

80-89 diastolic

Stage 2 hypertension

greater than or equal to 140/90

Hypotension

Systolic less than 90

Tympanic Temperature

eardrum

- for older patients, pull the ear up and back

- for children, pull the ear down and back -may read as lower

Temporal Temperature

measuring the body temp using the forehead; higher than oral and axillary

Oral Temperature

measuring the body temp sublingually;

- 95.0° - 100.3°

- wait 10-30 mins if the client has been eating, drinking, etc

- instruct patient to breathe out their nose, if they breathe through their mouth don't take

What temperature is considered a fever?

100.4 F

false high BP

- cuff too narrow

- unsupported arm

- insufficient rest before assessment

- deflating cuff too slowly

- assessing after smoking

false low BP

- cuff too wide

- deflating cuff too quickly

- arm above heart level

Before beginning any personal care delivery, what task should be completed?

an evaluation of the client's ability to participate in personal hygiene; encourage them to participate as much as they can

Types of Baths

complete baths, partial baths, and therapeutic baths

- bathe systematically from the upper extremities to the lower extremities

- long firm strokes form distal to proximal

Changing Bed Linens

- do unoccupied linen change as often as possible

- smooth wrinkles

- keep soiled linens AWAY from you

- DO NOT SHAKE linens because it spreads micro-organisms through the air

- mitered corners

Nail, Hand, and Foot Care

- Inspect the feet daily, do not apply lotion between the toes or fingers, cut nails straight across (check the facility's policy prior to cutting)

- Check nails for cracking, clubbing, and fungus

Nail and Foot Care for Patients with Diabetes Mellitus

- do not soak the feet due to the risk of infection

- do not cut the nails; file nails using a nail file

- do not apply lotions between the fingers and toes

-a qualified professional may be needed

Oral Hygiene for Unconscious Patients

- have suction set up at bedside

- use a soft-bristled brush & mouth swabs

- use a syringe with a small amount (10mL) of water

- place patient on one side with the head turned toward you or in semi-Fowler's position

- DO NOT put your fingers in their mouth

- perform oral care every 2 hours

Denture Care

- remove/insert the top dentures first (down and out)

- remove/insert the bottom dentures second (up and out)

- place a towel in the bottom of the sink

- use tepid water

- place the dentures in a cup with water to keep them moist

Perineal Care

always use fresh water and a new area of the washcloth to perform perineal care; cleanse from front to back

- Males: cleanse penis in a circular motion; retract foreskin to wash the tip (meatus outward) then replace the foreskin

- PAT dry

Hair Care

brush or comb hair daily with soft-bristled brush or wide-toothed comb

- use dry shampoo or no-rinse shampoo (heat activated) and shampoo cap

For Shaving:

- if patient is prone to bleeding, is on anticoagulants, or has a low platelet count, use an electric razor

- shave in the direction of the skin

- large strokes for large areas, short strokes for the chin and lips

Common Safety Concerns

1. Falls

2. Adverse Drug events

3. Healthcare Associated Infections (Priority Action: Hand Hygiene)

4. Restraints

5. Wrong-Site Surgery

6. Latex exposure

What's the priority action to prevent falls?

complete a fall-risk assessment for each client upon admission and at regular intervals

Room Exit Safety to Prevent FALLS

1. Bed in Lowest position

2. Appropriate # of side rails raised

3. Locked wheel

4. Bedside table w/in reach

5. Call light within easy reach (make sure they know how to use)

Which organization sets the National Patient Safety Goals?

The Joint Commission (TJC) in 2002

QSEN 6 Core Competencies

1. Patient-centered care

2. Informatics and Technology

3. Evidence-based practice

4. Quality improvement

5. Safety

6. Teamwork and collaboration

- ensures that nurses have knowledge, skills, and attitude (KSA)

Fire Safety

All staff must know the location of exits, alarms, fire extinguishers, and oxygen shut-off valves; know the evacuation plan

- change smoke detector batteries twice a year

- use cotton material to prevent fire

- have "No Smoking" signs

RACE

fire response acronym

R = rescue and protect/evacuate clients

A = activate the alarm system

C = contain/confine the fire by closing doors and windows

E = extinguish the fire

PASS

acronym for fire extinguisher use

P = pull the pin

A = aim at the base of the fire

S = squeeze the handle

S = sweep the extinguisher from side to side

Why is Carbon Monoxide so dangerous?

It binds to hemoglobin and reduces oxygen; it cannot be seen, smelled, or tasted; can cause death

Food Poisoning

- most caused by bacteria

- most occurs due to unsanitary food practices

ABCDE principles

Airway: open airway?

Breathing: chest rise and fall, RR

Circulation: heartbeat, pulse, cap refill, BP, stop any bleeding

Disability: level of conciousness

Exposure: prevent hypothermia; warm blankets, fluids

CPR

sustains oxygenation and circulation to vital organs

- involves "CAB"

CAB

components of CPR

C = chest compressions

A = airway

B = breathing

What should be the temperature of the water heater in someone's home?

below 120 degrees

Standard Precautions

- proper hand hygiene

- PPE

- effective management of potentially contaminated surfaces

Restraints

protective devices used to limit physical activity of the client or a part of the body

- used to protect the patient from self-harm and to protect other patients and staff

- physical, chemical, seclusion

Physical Restraints

any manual method attached to the patient's body to limit or restrict free movement

- limb restraints

- belts

- mitts

- wheelchairs with stationary lap trays

- bed rails

Need to tie to a non movable thing Ex: bed head-frame

Chemical Restraints

pharmacological agents administered for the purpose of controlling behavior

- sedatives (EX: Benedryl)

Unethical uses of Restraints

- convenience of staff

- punishment for the patient

- clients who are physically/mentally unstable

Policies and Procedures for Using Restraints

- MUST BE PRESCRIBED AFTER A F2F ASSESSMENT

- can be applied in emergencies, but a prescription must be obtained from the provider within 1 hour

- max 24 hours

- Length of application: Adults = 4 hours; Ages 9-17 = 2 hours; under 9 = 1 hour

- Assess skin every 2 hours

- always offer food, fluids, and bathroom breaks

- pad bony prominences

- use a *QUICK-RELEASE KNOT*

- do not secure restraints to the bed rails

Homeopathic medicine and herbal remedies are...

...not FDA approved

Pain

an unpleasant sensory and emotional experience associated with actual or potential tissue damage

THE #1 PRIORITY

- based on duration and origin

pain threshold

the point at which a person feels pain

Pain tolerance

the amount of pain a patient can endure

Acute Pain

pain that lasts less than 6 months

- has a direct cause, SUDDEN ONSET, and is temporary

- fight or flight

- causes changes in physiological responses (vital signs)

- can lead to chronic pain if not handled

EX: breakthrough pain