Final Exam - Nursing I

Autonomy

• Ability to initiate independent nursing interventions without a provider order (e.g., cough/deep-breathing exercises postop).

• Requires staying current, competent, and skilled.

Accountability

• Being professionally and legally responsible for the quality/type of nursing care.

• Applies to independent, dependent, and interdependent nursing actions.

Responsibility

• Duties/activities you are employed to perform (found in job description).

• Includes assessments, care plans, evaluating outcomes.

• Reflects ownership of patient care.

Patient Rights Under HIPAA

• Right to consent to use/disclosure of PHI.

• Right to inspect/copy medical records.

• Right to request amendments to incorrect/incomplete info.

• Limits who can access records

Privacy vs. Confidentiality

• Privacy: Patient’s right to control personal info.

• Confidentiality: Protection of info once shared with healthcare providers

HIPAA Practical Requirements

• No patient discussions in public areas.

• Provide privacy when communicating about a patient.

• No posting patient info on room message boards.

• Share info only with those who have a right to know (involved in care).

• Violations → legal fines

Additional Patient Rights

• Notice of rights regarding care decisions.

• Grievance procedures.

• Safety and personal freedom.

• Access to medical records.

• Freedom from unnecessary restraints

Verbal Communication

• Avoid medical jargon; define medical terms simply.

• Limit acronyms/abbreviations.

• Check understanding by having patients restate information.

• Use tone, pace, and emphasis to maintain attention.

• Introduce terms clearly

Nonverbal Communication

• Facial expressions (eyes/mouth show most emotion)

• Eye contact (culture-dependent)

• Posture and positioning

• Hand gestures

• Physical appearance

• Tone of voice

• Fidgeting, sighing, yawning

Therapeutic Nonverbal Techniques

• Open, relaxed posture; sit at eye level.

• Avoid standing over the patient.

• Use appropriate eye contact and gestures.

• Move around the group rather than staying still.

• Show enthusiasm and engagement

Factors Promoting Learning

• Encourage active participation.

• Use multiple senses (visuals, discussion, role-play).

• Present material enthusiastically.

• Address symptoms (pain, nausea) before teaching.

• Use relaxation techniques to reduce anxiety

Factors Inhibiting Learning

• Anxiety, stress

• Pain or physical symptoms

• Poor emotional/physical health

• Low health literacy

• Cultural conflicts with teaching

• Lack of readiness or motivation

• Inattention

• Attitudes and values

• Education level

• Developmental stage

• Prior knowledge

• Emotional state

Timing of Teaching

• Teach when patient is alert, attentive, and receptive.

• Schedule short sessions (10–15 min); easier to tolerate and remember.

• Allow rest periods between teaching.

• Longer sessions may be needed with short hospital stays

Teaching Techniques

• Keep information simple, clear, and easy to understand.

• Use developmentally appropriate teaching aids.

• Provide clear written instructions.

• Use visuals whenever possible.

• Give examples for multistep tasks.

• Allow practice time for new skills.

• Involve family caregivers when possible

Evaluation of Learning

Teach-Back

• Ask patient to explain information in their own words.

• Use return demonstration for skills.

• Shows whether teaching was effective.

Feedback

• If successful: reinforce learning.

• If not successful: modify teaching, clarify, or reteach.

• Indicates whether objectives were met or need revision

Patient Safety: Developmental Stages Infants & Toddlers

• Leading cause of death after age 1 = injuries.

• High risk for choking, aspiration, poisoning (increased oral activity).

• Button batteries can cause severe injury/death if swallowed.

Safe Sleep

• Back to sleep; firm mattress.

• Crib free of pillows, blankets, toys.

• Avoid bed-sharing, couches, floors

Patient Safety: Developmental Stages Preschoolers

• More aware of dangers but still limited coordination.

• Risks: falls, burns, drowning (pools, bathtubs)

Chain of Infection (6 Links)

• Infectious agent – pathogen.

• Reservoir – where pathogen lives/multiplies.

• Portal of exit – how it leaves reservoir.

• Mode of transmission – how it spreads (touch = most common).

• Portal of entry – how it enters new host.

• Susceptible host – person at risk.
  Break any link → stops infection

Localized Infection

• Redness, warmth, swelling.

• Yellow/green/brown drainage.

• Pain/tenderness.

• Tightness from edema.

• Limited movement if large area.

• Tender to palpation.

• Common in wounds, mucous membranes, abscesses

Systemic Infection

• Fever, fatigue, malaise, nausea/vomiting.

• Swollen/tender lymph nodes.

• ↑ HR and ↑ RR; possible low BP.

• Changes in activity/alertness.

System-Specific

• Lungs: productive cough, purulent sputum.

• Urinary: cloudy, foul-smelling urine

Older Adult Infection Considerations

• Symptoms often atypical or delayed.

• May lack fever (reduced immune response; NSAID use).

• Increased fatigue, decreased pain sensitivity.

• Confusion, agitation, incontinence may be only signs

Reducing Disease Transmission

Hand Hygiene

• Most important infection prevention method.

PPE

• Use for splash/spray risk.

• Gloves for wound drainage.

• Mask + eye protection for splash risk.

Standard Precautions

• Use for all patients, all the time

Standard Precautions (All Patients)

• Hand hygiene after patient contact & after removing gloves.

• Wear gloves for potential contact with blood/body fluids.

• Use PPE for splash/spray risk.

• Bag contaminated linen in fluid-resistant bags.

• Clean shared equipment between patients

Contact Precautions

Used for: MRSA, VRE, multidrug-resistant organisms.
Key Points:

• Private/cohort room.

• Gloves + gown for all contact.

• Dedicated equipment; disinfect before reuse

Droplet Precautions

Used for: Influenza, pertussis, meningitis, mumps, rubella.
Key Points:

• Private/cohort room.

• Surgical mask within 3 ft of patient.

• Patient wears mask during transport

Airborne Precautions

Used for: TB, measles, chickenpox, COVID-19, SARS.
Key Points:

• Negative-pressure room; door closed.

• N95 respirator or PAPR for staff.

• Patient wears surgical mask for transport

Physiological Factors Affecting Blood Pressure: Age

• BP rises through childhood and with advancing age.

• Larger/heavier children → higher BP than smaller children.

• Optimal adult BP: <120/80 mm Hg

Physiological Factors Affecting Blood Pressure: Position Chan

• Standing: SBP decreases slightly (<10 mm Hg), DBP & pulse increase slightly.

• Orthostatic hypotension:

  • ↓SBP ≥20 mm Hg or ↓DBP ≥10 mm Hg, or ↑HR ≥20 bpm when standing.

  • Causes: dehydration, antihypertensive meds, poor vasoconstriction.

  • Assess in older adults, dizzy/syncopal patients, those on BP meds

Measurement Errors

Cuff Size & Placement

• Too small or too large cuff → inaccurate reading.

• Snug on bare upper arm; midline of bladder over brachial artery.

Arm Position

• Arm at heart level:

  • Sitting → raise/support arm at heart level.

  • Supine → pillow under arm.

• Incorrect arm position → inaccurate BP.

Inflation Errors

• Under-inflation → falsely low SBP.

• Inflate 20–30 mm Hg above estimated SBP

Atypical Presentations in Older Adults

• Classic signs of illness often absent, blunted, or atypical due to:

  • Age-related organ/system changes

  • Loss of physiological/functional reserves

  • Coexisting acute/chronic conditions

• Key point: Do not rely on fever to indicate infection.

  • Older adults may have lower core temp and decreased immune response

  • Atypical signs often appear before fever, pain, or lab changes

Myocardial Infarction (MI)

• Classic symptoms: Crushing chest pain, diaphoresis (may be absent)

• Older adults: Sudden dyspnea, anxiety, confusion

Pneumonia

• Classic symptoms: Fever, productive cough, chills (may be absent)

• Older adults:

  • Tachycardia, tachypnea

  • Confusion

  • Decreased appetite/functioning

  • Hypothermia may replace fever

  • Confusion/stupor may be only finding

Musculoskeletal System

Muscle Changes

• Muscle fibers shrink with age → strength declines.

• Decline starts in 50s; by 80s, muscle mass ≈30–40% of age 30.

• Exercise preserves muscle and bone mass.

Bone Changes

• Peak bone mass: 18–25 years.

• Bone density/mass declines from 30s (men & women).

• Osteoporosis increases fracture risk

Neurological System

Neuron Changes

• Fewer/smaller neurons → slower reflexes.

• Reduced ability to respond to multiple stimuli.

Sleep Changes

• Trouble falling/staying asleep, early awakening, excessive daytime napping.

• Due to age-related sleep-wake cycle changes

Sensory Changes

Vision (Presbyopia)

• Difficulty focusing near → far; needs more light.

• Increased glare sensitivity, smaller/slower pupils.

• Trouble adjusting bright ↔ dark; color discrimination declines (blues/greens/pastels).

Hearing (Presbycusis)

• High-pitched sounds/conversational speech harder to hear.

• Usually bilateral, more common in men.

• Check for earwax impaction before diagnosing.

Taste & Smell

• Saliva production decreases; taste buds lose sensitivity.

• Harder to differentiate salty, sweet, sour, bitter.

• Reduced smell further decreases taste

Recognition of Data Patterns

Normal Findings

• Assessment matches expected parameters for age, condition, baseline.

• Vital signs within normal range.

• Symmetrical physical features/movements.

• Appropriate cognitive and behavioral responses.

Abnormal Findings (Cues)

• Deviations from normal via observation/measurement.

• Examples: elevated temp, abnormal HR, SOB, inflamed wounds, confusion, decreased function

Clinical Inference Process

1. Cluster Related Cues

• Group related assessment findings.

• Look for patterns in signs/symptoms.

2. Validate Findings

• Confirm accuracy; avoid incorrect inferences.

• Compare with additional assessments, EHR, or team input.

• Clarify vague/unclear data.

• Example: inflamed incision → check body temperature

Clinical Inference Process

3. Gather Additional Data

• Reassess areas as needed.

• Continue data collection to confirm or refute patterns.

4. Analyze & Identify Nursing Diagnoses

• Use scientific knowledge + experience.

• Compare observed data to common patterns.

• Identify familiar clusters.

• Example: tired after exertion + rests more → possible Activity Intolerance or Fatigue

Capillary Refill

• Normal: <2 sec

• Abnormal: >2–3 sec → decreased peripheral perfusion

• Causes: ↓ cardiac output, vasoconstriction, hypovolemia, arterial occlusion

Pulse Assessment

• Absent/decreased pulse: impaired arterial blood flow

• Causes: arterial occlusion (embolus/thrombus), graft occlusion, severe PAD, vasospasm

Skin Temperature & Color

• Cool, pale, mottled extremities: indicate poor perfusion

• Cause: ↓ blood flow → ↓ oxygen delivery → vasoconstriction

Edema Assessment

• Dependent edema: sacrum, legs, feet

• Causes: gravity, ↑ capillary pressure, ↓ cardiac output, venous insufficiency, immobility

• Appearance: swollen, shiny, cool skin

Anemia-Related Findings

• Pale/pasty skin → ↓ RBC/hemoglobin → ↓ oxygen delivery

• Best assessed in: sclera, conjunctiva, buccal mucosa, nail beds, palms

HIPAA Confidentiality Requirements

Protected Health Information (PHI)

• Only healthcare team members involved in patient care can access records.

• Discuss patient info only with those directly involved.

• Never share with uninvolved staff or other patients.

Patient Rights

• Consent to use/disclose PHI

• Inspect and copy records

• Amend errors or incomplete info

• Written permission usually required to release info

HIPAA Confidentiality Requirements

Privacy Rule – “Minimum Necessary”

• Access only the specific information needed for a task

• Example: rescheduling appointment → phone number only

Practical Applications

• Avoid discussing patients in public areas (hallways, elevators, cafeteria)

• No posting patient info on message boards or in units

• Provide reasonable privacy when communicating

Maslow's Hierarchy of Needs

1. Physiological Needs (Base) - Oxygen, fluids, nutrition, body temperature, elimination, shelter, sex

2. Safety and Security - Physical and psychological safety

3. Love and Belonging - Relationships, connection, acceptance

4. Self-Esteem - Recognition, respect, confidence

5. Self-Actualization (Top) - Highest expression of individual potential, continual self-discovery

How Critical Thinking Enables Clinical Judgment

• Know the patient thoroughly

• Reflect on past experience

• Adapt to environment

• Use logical reasoning
  Outcomes:

• Sort information into patterns

• Identify problems & changes in patient condition

• Make appropriate care decisions under pressure

Clinical Judgment

• Outcome of critical thinking + decision making

• Conclusion about patient needs/health problems

• Guides action, modifying approaches, or creating solutions

Steps of the Nursing Process

1. Assessment

• Collect comprehensive info on patient, family, or community

• Gather objective & subjective data (cues)

• Sort data, recognize patterns, identify health problems

• Person-centered and ongoing

2. Analysis & Diagnosis

• Use critical thinking to identify patterns

• Make clinical judgments about health problems

• Formulate nursing diagnoses

Steps of the Nursing Process

3. Planning & Outcome Identification

• Prioritize diagnoses/problems

• Set measurable outcomes

• Choose interventions

• Use clinical judgment to generate solutions

4. Implementation

• Execute planned interventions

• Provide care based on nursing diagnoses

5. Evaluation

• Assess effectiveness of interventions

• Determine if outcomes were met

• Modify plan as needed

Nursing Diagnoses

• Clinical judgment classifying responses to illness (not medical diagnoses)

• Guides understanding of healthcare needs

• Nurses independently treat patient responses; only APNs treat medical diagnoses

• Addresses: pathophysiological, treatment-related, personal, environmental, maturational responses

Comprehensive Respiratory Assessment

Key Focus Areas

• Airway patency: open and clear

• Chest symmetry: equal bilateral expansion

• Respiratory rate, depth, character: quality & pattern

• Pulse oximetry: SpO₂ monitoring

• Breath sounds: auscultate for decreased/absent sounds

Critical Assessment Components

• Nursing history: normal & present cardiopulmonary function

• Past cardiac, circulatory, or respiratory impairments

• Methods patient uses to optimize oxygenation

• Drug, food, and other allergies

• Compare findings with expected signs for known conditions

Early Warning Signs of Respiratory Problems

Impaired Ventilation

• ↓ SpO₂

• Slowed breathing

• Reduced chest/abdominal movement

• Use of accessory muscles

• Decreased/absent breath sounds

Hypoxemia Manifestations

• Tachypnea

• Gasping

• Anxiety, restlessness, confusion

• Rapid or thready pulse

Immediate Safety Actions

• Stimulate/wake patients with poor respiratory effort or distress

• Coach deep breathing once awake

• Regular monitoring: vitals, SpO₂, capnography, or tech-assisted tools

Sputum Assessment

• Normal: trachea/throat = thin, colorless; lungs/bronchi = thick, pale yellow

• Abnormal: changes in color or consistency → possible infection; document all characteristics

Breath Sound Classification

• Normal: Bronchial, bronchovesicular, vesicular

• Abnormal (Adventitious): Crackles, wheezes, stridor, pleural friction rub

Adventitious Breath Sounds

Crackles

• Fine: small airways popping open during inspiration

• Coarse: larger airways with secretions/fluid

• Associated with: Pneumonia, pulmonary edema, atelectasis

Wheezes

• High-pitched, musical; air through narrowed/obstructed airways

• Prolonged expiration, rapid ventilation, increased effort

• Associated with: Asthma, COPD, bronchospasm, airway obstruction

Stridor

• High-pitched from large airway obstruction

• Heard during inspiration; slow ventilatory rate, large tidal volume

• Associated with: Epiglottitis, foreign body, severe upper airway swelling

Pleural Friction Rub

• Inflamed pleural surfaces rubbing during respiration

• Associated with: Pleurisy, pleural inflammation

Underlying Pathophysiology

• Increased fremitus: Vibration felt; fluid/dense tissue (pneumonia, tumor, secretions, above pleural effusion)

• Decreased/absent fremitus: Hand farther from lung or hyperinflated lung (pleural effusion, pneumothorax, atelectasis)

Positioning

• Conscious patients: Supine with head of bed elevated → maximizes thoracic expansion

• Reposition: Every 1–2 hours → full chest expansion, perfusion, prevent pressure injuries

• Early mobility: Sit in chair and ambulate as soon as ordered

Oxygen Therapy

• Administer via nasal cannula or face mask as ordered

• Helps eliminate anesthetic gases and meet increased O₂ demand

Breathing Exercises

Sustained Maximal Inspiration

• Inhale deeply → hold a few seconds → exhale → repeat and cough

Diaphragmatic/Abdominal Breathing

• Inhale slowly through nose, hold → exhale through mouth

• Place hands over lower ribs/upper abdomen to feel movement

• Frequency: 10 times/hour while awake (unless contraindicated)

Incentive Spirometry

• Provides visual feedback

• Prevents alveolar collapse

• Moves secretions to larger airways

Coughing Techniques

• Deep breaths move secretions and stimulate cough reflex

• Splint incisions with pillow/blanket

• Facilitates expectoration

Medication Absorption: Fastest → Slowest

1. Intravenous (IV)

• Immediate systemic circulation → fastest effect

• Ideal for rapid analgesia and titration

• Continuous infusions provide steady-state blood levels

2. Mucous Membranes & Respiratory Airways

• Rapid absorption due to rich blood supply

3. Intramuscular (IM)

• Faster than oral, slower than IV

• Not ideal for pain management (painful, variable absorption, risk with chronic use)

4. Subcutaneous (SubQ)

• Slower than IM, faster than oral

• Slow onset; used for continuous end-of-life analgesia

5. Oral (PO)

• Slow absorption; affected by first-pass liver metabolism

• Requires larger doses to match IV effect

• Food can alter absorption

6. Topical / Skin

• Slowest absorption due to lipid barrier of skin

Intradermal (ID)

• Needle: 25–27 gauge, 3/8–5/8 inch

• Sites: Inner forearm, upper back, upper chest

• Angle: 5–15°

• Volume: 0.01–0.1 mL

• Purpose: TB and allergy testing

Subcutaneous (SubQ)

• Needle: 25–31 gauge, 3/8–5/8 inch; insulin: 4–12.7 mm

• Sites: Abdomen (fastest absorption), outer arms, thighs, upper back, hips/buttocks

• Angle: 90° (standard), 45° for thin patients

• Volume: 0.5–1 mL (up to 2 mL)

• Key Points:

  • Rotate sites (prevent lipohypertrophy)

  • Keep injections ≥½–1 inch apart

  • Avoid exercising area immediately after injection

Intramuscular (IM)

• Needle: 18–25 gauge (22–25 typical), 1–1½ inch (adults), 5/8–1 inch (children/small adults)

• Sites & Volume:

  • Ventrogluteal: safest, up to 3 mL

  • Deltoid: small muscle, ≤1 mL (vaccines)

  • Vastus lateralis: infants, up to 5 mL

  • Dorsogluteal: avoid (risk sciatic nerve/artery injury)

• Angle: 90°

Factors That Promote Sleep

• Environment: Quiet, dark, ventilated, temperature-controlled, comfortable bed, usual bed partner, soft lighting

• Lifestyle & Routine: Consistent schedule, bedtime rituals, calming evening activities

• Nutrition: Light evening meals, adequate hydration, avoid heavy/spicy foods

Factors That Disrupt Sleep

• Environment: Noise (alarms, staff, equipment), excessive light, room too hot/cold, unfamiliar environment, restless bed partner

• Lifestyle: Shift work, late-night activities, unusual work, changed mealtime

• Nutrition: Heavy meals, caffeine, alcohol, nicotine, food allergies, rapid weight changes

• Health: Chronic pain, depression, caregiver stress

Sleep Interventions & Therapies

• Care Planning: Individualized, based on patient’s habits, home environment, lifestyle; set realistic goals

• Environmental Modifications: Minimize interruptions, control noise/light/temp, promote quiet

• Behavioral Strategies: Maintain routines, support bedtime rituals, ensure adequate sleep opportunity

Pharmacological Interventions

Multimodal Analgesia

• Combines multiple medications to reduce opioid use and side effects

• Often ordered PRN

Opioid Analgesics

• Side effects: Constipation, nausea/vomiting, respiratory depression, hypotension

• Assessment before administration: Pain level, vitals, consciousness

• Notify HCP if pain persists or patient becomes somnolent

Patient-Controlled Analgesia (PCA)

• Patient self-administers preset doses

• Routes: IV, oral, epidural, transdermal

• Benefits: Early ambulation, better pain control, higher satisfaction

Epidural Analgesia

• Opioid infusion via catheter into epidural space

• Reduced total dose, constant effect

Perineural Local Anesthesia

• Local anesthetic via catheter to surgical site

• Example: Bupivacaine liposome (Exparel) → up to 72-hour relief, reduces opioid need

Timing Considerations

• Administer before painful activities

• Monitor for complications (e.g., VTE) that analgesics may mask

Non-Pharmacological Interventions

Complementary Therapies

• Music therapy, guided imagery, relaxation, aromatherapy

Physical Interventions

• Repositioning, massage, distraction

Physical Activity Recommendations

Adults (All Ages)

• Aerobic:

  • Moderate: 150–300 min/week

  • Vigorous: 75–150 min/week

  • Or combination of both

• Strength: ≥2 days/week, all major muscle groups

Children

• ≥60 min/day of moderate-to-vigorous activity

Older Adults

• Same as adults if possible

• Add balance exercises ≥3 days/week

• Strength exercises ≥2 days/week

Nutrition Guidelines

Increase:

• Fruits & vegetables

• High-fiber foods

• Hydration: 2000–3000 mL/day

Limit:

• Sugar

• Total fat

• Sodium

Balance:

• Food intake with activity level

• Alcohol volume and pattern