Exam 1: Theoretical Foundation in Nursing Practice

What is ADPIE

Assessment

Diagnosis

Plan

Implementation

Evaluation

What is Health Promotion

process of enabling people to increase control over and to improve their health (WHO)

What are the levels of Prevention

Primary: Prevents initial occurrence of disease. Education in schools, organizations, health, and exercise. Health promotion and disease prevention.

example: getting tetanus and diptheria immunization every 10 years

Secondary: focuses on early detection of disease, limiting severity. Screenings to control outbreaks

Tertiary: having the said illness or disease. More proactive to not make it chronic or doing recovery

What is Delegation Guidelines?

CPTDS

Right Circumstance

Right Patient

Right Task

Right direction and communication

Right Supervision and Evaluation

What is Safety?

-assigns priority to a factor of situation posing the greatest: safety risk and greatest risk to physical or psychological well-being of the client

-assess for external or internal factors

-sources of safety issues: client, nurse, provider (external) Abnormal lab values and vital signs (internal)

-ABC with safety and risk reduction

What is prioritization?

asking yourself questions on who to see first? Whos more at risk first? vs someone that is getting discharged you would really see last.

Maslow Hierarchy of Needs

Physiological - basic survival needs (e.g., oxygen, water, food and shelter)

Safety & security - safe and comfortable this includes psychological security (e.g., safe from falls due to treatment) employment, resources, health, property

Love & Belonging - love and affection, this can come from family members, friends or co-workers. Intimacy, sense of connection

Esteem & Self-Esteem - to feel good about themselves. (e.g., body imagine, pride in achievements, passing this exam)

Self-Actualization

Healthy People Goals

promote health and disease nationally through a collaborative effort among local governments, professional organizations and individual participation

Healthy People: Leading health indicators

-access to healthcare services

-clinical preventive services

-environmental quality

-injury and violence

-maternal, infant and child health

-mental health

-nutrition, physical activity and obesity

-oral health

-reproductive and sexual health

-social determinants

-substance Abuse

-tobacco

Healthy People: Healthy Disparities

-individuals who are:

-poor

-elderly

are of an ethnic miniority or economically disadvantaged

Integumentary System: Skin Breakdown

-move patient every two hours to prevent skin breakdown that may lead to pressure ulcers

Integumentary System: Bony Prominences

-pad elbows, heel of foot, and neck to prevent a start or pressure ulcers

Integumentary System: Skin Care/Bathing

for bathing client for complete bed bath: start with the eyes, no soap just warm water. Go inner canthus to outer.

What is Contact precaution?

-Pathogen is spread by direct contact

-Sources of infection: draining wounds, secretions, supplies

-Precautions include possible private room, clean gown, gloves, disposal of contaminated items, double bag linen and mark.

-Infections include VRE, MRSA, C. difficile, wound infections, herpes simplex, eye infections, skin infections (lice, impetigo, scabies, chickenpox (varicella), cutaneous diphtheria)

What is Airborne Precautions?

<5 microns smaller droplets through air

-remain airborne for longer periods

-isolation and negative airflow room 6-12 exchanges per hour

-Use of: N95 every time a health care worker enters & gloves (for bodily fluids, yellow sputum)

-mask must be FITTED

examples: Pulmonary TB, measles

What is Droplet Precautions?

-used when disease is transmitted by large droplets expelled into the air 3-6 feet from patient

-what to use? surgical mask, proper hand hygiene, goggles and regular masks

examples- mycoplasma pneumonia

What is contact precautions?

-direct contact refers to the care of handling of contaminated body fluids

-indirect care = contaminated instrument or hands of a healthcare worker

-use of gloves and gowns

-Private room but no negative airflow room

examples:

-VRE, MRSA, C. Difficile, salmonella wound infections and herpes simplex

What is Standard precaution?

-applied to ALL patients in ALL healthcare settings

-used with blood, blood products, body fluids, secretions, excretions (except sweat), non-intact skin and mucous membranes.

-includes infection prevention to all patients; hand hygiene; use of gloes, gown, mask and face shield; respiratory hygiene/cough etiquette and safe injection

-disinfection hands immediately after removing gloves. You cant assume that the integrity of each glove has not been infected or breached. That no powder or residue remains on hands.

What are the stages of infection?

Incubation: interval between the pathogen entering the body and the presentation of the first finding

Prodromal stage: interval from the onset of general findings to more distinct findings; during this time, the pathogen multiplies.

Illness stage: interval when findings specific to the infection occurs.

Convalescence: interval when acute findings disappear, total recovery taking days to months

What is Primary infection?

the first infection that occurs in a patient (need more info)

What is secondary infection?

an infection that follows a primary infection, especially in immunocompromised patients

What is Latent Infection?

cause no symptoms for long periods of time, even decades; examples are Tuberculosis and HIV

What is systemic Infection?

occur when pathogens invade the blood or lymph and spread throughout the body

What is portal of entry infection?

Eyes, nares, mouth, vagina, cuts, scrapes, wounds, surgical sites, IV or drainage tube sites, bite from vector (need more info)

What are the Ethic Principles?

Autonomy

The right to make one's own personal decisions, even when those decisions might not be in that persona's own best interest.

·

Beneficence

The quality of doing and producing good, obligation to act in best interest of the client regardless of the self interest of the health provider.

· Non-maleficence

Do no harm or minimize risk to reach beneficial outcomes for client

· Veracity

Duty to tell the truth

· Justice

Fairness in care delivery and use of resources

· Fidelity

Keeping of promises; remaining true to the professional promises made to provide quality/ competent care to patients and oath to profession

What values indicate an infection?

WBC >10,000 & ESR >20

BMI Scale

underweight <18.5 kg/m2

Normal 18.5-24.9 kg/m2

Overweight 25-29.9 kgm2

Obese >30 kg/m2

Calculations to find BMI

BMI = (Weights (lbs) / Height (inches)^2) x 703

Considerations for Pulse

-rate

-rhythm

-strength

-quality

use finger pads. If irregular, must perform a pulse deficit

Blood Pressure

Expected <120-80mmHg

Prehypertension: 120-139/80-89

Stage 1: 140-159/90-99

Stage 2: >160/>100

-HTN w/ 3 separate visits over weeks

Hypotension <90

Respirations

Rate: 12-20 breaths per minute

if irregular must count for 1 full minute

What type of prevention is used for someone with that has a room with air exhause directly to the outdoor environment?

Airborne precautions.

They will need:

-private room with negative pressure airflow exchange 6-12/hour

-fitted N95 with respiratory protection for caregivers and visitors

A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. which of the following infection-control actions should the nurse use while caring?

1) contact precautions

2) airborne precautions

3)droplet precautions

4) protective environment

Droplet precaution

What should you do for active pulmonary TB?

-close door

-mask

-throw sharps away

-wash hands

-because active TB is only suspended in the air, you do not need to use gloves

What should you do if you come across patient in contact precautions? importantly with C.Diff?

must use chlorhexidine to wash hands if the client is immunosuppressed.

contact precaution for pts with infectious diarrhea

A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? SATA

Irrigating clients abdominal wound and suctioning a client's new trach tube

rationale: protective eye equipment is used for any splashing. dont need it for providing hygiene care for someone who is HIV positive or emptying a urinary drainage bag for someone who has pneumonia

do not need: sterile gown, goggles, an N95 respirator

why would you use an alcohol-based gel?

-is use takes less time than washing with soap and water

Why would you use a face shield when irrigate a patients open wound?

A face shield protects the face, mouth, nose and eyes from any potential splashes of blood or other body fluids. Irrigating a wound certainly has the potential for splashing irrigating fluid containing blood, body fluids, and tissue particles onto your face

Which product can affect the permeability of gloves?

-petroleum-based hand lotion

rationale: the use of petroleum-based hand lotions or creams can impair the integrity of latex gloves, weakening them and increasing their permeability.

-water-based hand lotion do not afect the gloves.

You are caring for a patient diagnosed with mycoplasmal pneumonia. Droplet precautions have been instituted, so you must

1) wear a respirator

2) protect your eyes

3) use an air filter

4) wear shoe covers

2) protect your eyes. droplet transmission >5 large particle droplets .

-happens due to coughing, sneezing, or talking and during procedures such as a suctioning and bronchoscopy

1) wear a respirator usually for airborne precautions like TB

3) use an air filter airborne precautions use this for the room to remove it

4) wear shoe covers are not meant for transmission-based precautions

What type of precaution would you use for someone with Hepatitis B?

Standard Precaution. Hep B transmitted via bloodborne pathogens found in blood and other body fluids. Not transmitted skin-skin contact and virus is not airborne

XL or XR

extended release

TD

Time delay

TR

time release

SR

sustained release

SA

sustained action

LA

long acting

CRT

controlled release tablet

CR

controlled release

CD

controlled dose

AC

before meals

PC

after meals

PRN

as neeed

STAT

immediately

PO

by mouth

SL

sublingually

ID

intradermal

IM

intramuscular

IV

itravenous

TID

Three times a day

QID

four times a day

BID

twice daily

Which is considered a primary care service?

1)Providing wound care

2)Administering childhood immunizations

3)Providing drug rehabilitation

4)Outpatient hernia repair

Answer 2: Primary care services focus on health promotion and disease prevention; administering childhood immunizations is one such service.

1 Wound care is an example of a tertiary care service.

3 Drug rehabilitation is an example of a tertiary care service.

4 Outpatient hernia repair surgery is an example of a secondary care service.

Which are examples of a health-promotion activity? Select all that apply.

1)Helping a client develop a plan for a low-fat, low-cholesterol diet

2)Disinfecting an abraded knee after a child falls off a bicycle

3)Administering a tetanus vaccination after an injury from a car accident

4)Distributing educational brochures about the benefits of exercise

5)Administering a measles, mumps, rubella (MMR) immunization to a toddler at 15 months of age

ans 1, 4, 5

2. This is incorrect. Disinfecting an abraded knee is a treatment/intervention for an injury.

3. This is incorrect. Administering a vaccination is a disease-prevention and treatment activity.

Which is an example of theoretical knowledge?

1) A nurse uses sterile technique to catheterize a patient.

2) Room air has an oxygen concentration of 21%.

3) Glucose monitoring machines should be calibrated daily.

4) An irregular apical heart rate should be compared with the radial pulse.

ANS: 2 Theoretical knowledge consists of research findings, facts, principles, and theories. The oxygen concentration of room air is a scientific fact.

1 This is an example of practical knowledge—what to do and how to do it.

3 This is an example of practical knowledge—what to do and how to do it.

4 This is an example of practical knowledge—what to do and how to do it.

what is self-knowledge?

knowing your cultural, religious beliefs

Which is the most important reason for nurses to be critical thinkers?

1) Nurses need to follow policies and procedures.

2) Nurses work with other healthcare team members.

3) Nurses care for clients who have multiple health problems.

4) Nurses have to be flexible and work variable schedules.

ANS 3 Critical thinking is essential for client care, particularly when the care is complex, involving numerous health issues.

1 Following policies and procedures does not necessarily require critical thinking, and working with others or being flexible and working different schedules do not necessarily require critical thinking.

2 Following policies and procedures does not necessarily require critical thinking, and working with others or being flexible and working different schedules do not necessarily require critical thinking.

4 Following policies and procedures does not necessarily require critical thinking, and working with others or being flexible and working different schedules do not necessarily require critical thinking.

What do critical thinking and the nursing process have in common?

1)They are both linear processes used to guide one's thinking.

2)They are both thinking methods used to solve a problem.

3)They both use specific steps to solve a problem.

4) They both use similar steps to solve a problem.

ANS 2: Critical thinking and the nursing process are ways of thinking that can be used in problem solving (although critical thinking can be used beyond problem-solving applications).

1 Neither method of thinking is linear.

3 The nursing process has specific steps; critical thinking does not.

4 The nursing process has specific steps; critical thinking does not.

The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. The nurse ensured the nursing assistive personnel changed the patient’s position every 2 hours. In the evaluation phase of the nursing process, which would the nurse do first?

1)Determine whether she has gathered enough assessment data.

2)Judge whether the interventions achieved the stated outcomes.

3)Follow up to verify that care for the nursing diagnosis was given.

4)Decide whether the nursing diagnosis was accurate for the patient’s condition.

ANS: 2 The evaluation phase judges whether the interventions were effective in achieving the desired outcomes and helped to alleviate the nursing diagnosis. This must be done before examining the nursing process steps and revising the care plan.

1 The nurse would not implement this action first in the evaluation phase of the nursing process.

3 The nurse would not implement this action first in the evaluation phase of the nursing process.

4The nurse would not implement this action first in the evaluation phase of the nursing process.

In caring for a patient with comorbidities, the nurse draws upon her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. Which best describes these activities?

1) Full-spectrum nursing

2) Critical thinking

3) Nursing process

4) Nursing knowledge

ANS: 1 Full-spectrum nursing involves the use of critical thinking, nursing knowledge, nursing process, and patient situation.

During an assessment of a newly admitted client the nurse measures blood pressure, abdominal circumference, and pulse rate. Which critical-thinking skill is the nurse using?

1) Recognizing gaps in one's own knowledge

2) Recognizing the need for more information

3) Objectively gathering information on a problem or issue

4) Evaluating the credibility and usefulness of sources of information

ANS: 3 Obtaining data that can be verified by someone else is considered objective data.

1 Obtaining client assessment data is not recognizing gaps in one's own knowledge.

2 If more information were needed about any particular data, the nurse would focus on that body system.

4 Evaluating the credibility and usefulness of sources of information applies to research studies.

The staff development instructor prepares an in-service presentation on full-spectrum nursing for new graduate nurses. Which statement should the instructor emphasize as being the key point about this delivery approach?

1) It encourages collaboration when planning care.

2) It is a unique blend of thinking, doing, and caring.

3) It focuses on assessment as the cornerstone of care.

4) It relies on client responses to guide interventions.

ANS: 2 Full-spectrum nursing is a unique blend of thinking, doing, and caring. TDC

A father brings his toddler to the clinic for well-child care. Which would be most important for the nurse to assess?

1) How successful the child is with potty training

2) How the child acts when you enter the room

3) Whether the child is using eating utensils

4) Whether the home is child-proofed

ANS: 4 Safety is the highest priority at this age because the child has increased dexterity, mobility, and determination and is becoming more independent.

1 Potty training is typically accomplished between 18 months and 3 years of age but is not a safety concern.

2It would be normal for a child at this age to be afraid of strangers.

3 The child should be using utensils for most foods, but again it is not a safety concern.

A homeless patient is admitted with an infected leg wound. According to Maslow's hierarchy of needs, which nursing intervention meets a basic physiological need?

1)Providing the patient with a dinner tray

2) Administering antibiotics as prescribed

3) Irrigating a wound with normal saline solution

4) Encouraging the patient to express his feelings

ANS: 1 According to Abraham Maslow and his hierarchy of needs, basic physiological needs, such as food, should be addressed first.

2 After the patient's basic needs are met, the nurse can administer antibiotics as prescribed (safety needs).

3 After the patient's basic needs are met, the nurse can provide wound care (safety needs).

4 After the patient's basic needs are met, the nurse can encourage the patient to express his feelings (love and belonging or self-actualization, depending on what feelings he expresses).

What precaution, when you deal with soiled linens? What do you do?

linen that has been soiled with body fluids must be handled, transported, and processed in a manner that prevents the contamination of other people or objects. The above action would have contaminated the floor and added to the potential for transmitting infectious microorganisms.

What is the use of a bath blanket?

When you shower an elderly patient that is in complete bed bath. This prevents embarasment and discomfort.

Why would you not discuss education to the patient during bathing?

you would not want to point out deficiencies while also trying to maintain a trusting relationship. Might lead to hostility or defensiveness.

While washing the patient's face, you note the presence of cerumen in his left ear canal. You...

A. use a cotton-tipped applicator to remove the cerumen from the canal.

B.use a damp cloth or gentle irrigation to loosen debris from the canal.

C.continue the bath because cerumen in the ear canal is an expected finding.

B - CORRECT

Yes. You have selected the correct response. Gentle wiping or irrigation can effectively remove cerumen without causing injury.

A - INCORRECT

No. This is not the correct choice. Using a cotton-tipped applicator might push cerumen deeper into the ear canal and possibly injure the ear tissues.

C - INCORRECT

No. This is not the correct choice. If cerumen becomes impacted, it can cause hearing loss and predispose the ear canal to infection.