Nurs 2002 Final Exam

how might older age affect GI and GU health?

-risk for nutritional deficits: poor diet, living alone, social isolation, not preparing meals, etc

-dec appetite, leading to constipation

-lots of GI effects associated with many medications

-prostate pathologies in older men that may cause obstructions

how might race/ethnicity affect GI and GU health?

-certain populations at higher risk of diseases that can affect GI/GU health

-ex: African Americans and sickle cell disease, alcoholism in Native American populations, lactose intolerance has familial predisposition

what patients are at high risk for UTIs?

-sexually active

-postmenopausal

-indwelling catheter

-diabetes

-elderly

-physical/cognitive impairment (inadequate self-care)

-women

what patients are at risk for constipation?

-bed rest, immobility, post-op

-elderly

-reduced fluid

-depressed

-CNS dysfunction

-medications (ex: opioids, anticholinergics)

what urine findings would require urgent assesment?

-blood in the urine

-cloudy/foamy urine

-foul odor

-low urine production (low GFR)

what urine is considered normal?

-straw yellow

-clear, transparent

-no sediment

-no odor

what components are included in a GI and GU health assessment?

-inspection: abdomen, urine, vomit, stool

-auscultation: listening for hyper/hypoactive/present bowel sounds

-light palpation: abdomen (overall impression), kidneys, liver, bladder

what are some lifespan considerations of the male reproductive system?

-adolescents: use tanner's stages of maturation to assess,

-older adults: dec testosterone (affect libido and sexual function), loss of muscle tone (incontinence), stool retention, dysfunction from medications, erectile dysfunction

what are some lifespan considerations for the female reproductive system?

-tanner staging for development

-pregnant women: cervical changes

-older adults: menopause, vaginal infections, UTIs, dyspareunia (genital pain before/during/after sex), diminished libido, cancers

what are lifespan considerations for the breast/axillary exam?

-pregnant women: changes in breast, lactation

-adolescents: tanner staging, gynecomastia in males

what is the role of the nurse in a nutritional assessment?

-determining adequate and appropriate caloric and nutrient intake

-accurately complete nutritional assessments

-understanding client's eating habits/nutritional intake

what are risk factors for nutritional deficit?

-surgery

-trauma

-infection

-head injury

-burns

what factors can affect nutrition and nutritional status?

-age

-biological sex

-state of health

-alcohol abuse

-medications

-nutrient supplements

-socioeconomic factors

-culture/religion

-decreased/increased food intake

what are some lifespan considerations related to a nutritional assessment?

-pregnant women: weight gain, GI changes, increase in nutritional needs to support growth (inc caloric needs)

-older adults: dec energy expenditure, difficulty chewing/swallowing, dec in peristalsis, dec thirst, social isolation, unintentional weight loss

-infant/children: rapid growth, need adequate nutrition

what are urgent assessment findings of the head/lymphatics assessment?

-"BE FAST" for stroke: balance/HA/dizziness, eye issues (blurred/loss of vision), facial drooping, arm weakness/numbness, slurred speech

-acute head injuries and neurologic changes (stabilization of head/neck, trauma assessment)

-neck pain (muscle tension/spasms, check for fever/headache)

-lymphatics (fixed, irregular, hard, or rubbery mass)

-hyperthyroidism (thyroid storm/crisis)

what are urgent assessment findings of the eye assessment?

-sudden vision loss

-eye trauma/injuries

-foreign bodies, lacerations, hyphema (blood in eye)

-acute glaucoma

what are urgent assessment findings of the ears?

-outer ear foreign object

-foul-smelling drainage

-chronically draining ears

-ear trauma; tympanic rupture

what are urgent assessment findings of the nose, sinus, mouth, and throat?

-ludwig angina: edema pushing tongue up and back (leading to airway obstruction; infection of the mouth floor)

-aspiration

-abrupt loss of smell

-bacterial sinus infection

what are the risk factors related to HEENNMT and lymphatics?

-medications/supplements

-family history

-age

-past medical history (conditions, surgeries, health, allergies, prescriptions, etc)

-environmental factors (ex: smoking/tobacco use)

what developmental considerations are important in the HEENT assessment of children?

fontanels/dec visual acuity in infants, assessing for red eye reflex in kids

what developmental considerations are important in the HEENT assessment of older adults?

-bony structures more pronounced

-skin lesions more likely

-carefully assess for possible cancers

-hypothyroidism

-eye structural changes

-vision loss

-decreased tear production

-diabetic retinopathy

-cataracts

-decreased hearing d/t age and structural changes

-inc auditory reaction time

-decreased olfactory sensory fibers, saliva production, and taste buds

-loss, discoloration, and loosening of teeth

-receding gums

-smooth/shiny tongue, fissures

what are the rights of medication administration?

-right drug**

-right reason

-right dose, route, preparation**

-right patient**

-right time**

-right assessment data

-right education

-right to refuse

-right documentation

-right response

what questions would you ask to ensure the right drug? what action would you take?

-has the patient been given this medication before?

-given the patient's symptoms and diagnosis, does it make sense for the patient to have this medication?

-determine if the patient has any known drug allergies or sensitivities

-assess the patient's other medications to detect possible contraindications

-make sure it is the right medication; packaging, labeling, and spelling of some drugs look alike—watch for visual cues on packing or in how the drug name is written

-have another person double-check medications and mathematical calculations (per policy)

what question would you ask to ensure the right reason? what action would you take?

-do the patient's condition, symptoms, and health status warrant receiving this medication?

-determine if the patient has the condition the medication is used for

what questions would you ask to ensure the right dose, route, and preparation? what action would you take?

-is the correct dose being administered?

-how is the medication administered?

-does administration require med math to calculate the dose?

-is it appropriate to administer the medication orally, intravenously, by injection, or other route?

-check the original orders to verify the route of administration

-ensure that labeling is legible and clearly understood

-follow institution medication protocols as written

what question would you ask to ensure the right patient? what action would you take?

-is this the right patient to receive this medication?

-verify the identity of the patient using at least two identifiers: name and date of birth (check wristband, ask patient to state name)

what question would you ask to ensure the right time? what action would you take?

-is this the correct time for the medication to be administered?

-check when the medication was last administered; if the drug is new, document when it is first given

what question would you ask to ensure the right assessment data? what action would you take?

-is it appropriate to administer the medication, based on the specific data collected?

-collect appropriate assessment data related to mechanism of action and/or therapeutic effect

what questions would you ask to ensure the right education? what action would you take?

-is the patient familiar with the medication?

-does the patient understand the purpose, dosing, and administration information, as well as other information specific to medication?

-assess patient's level of knowledge, provide patient education as necessary

what questions would you ask to ensure the right to refuse? what action would you take?

-has the patient verbally agreed to take the medication?

-has the patient expressed any concern with the medication?

-acknowledge the patient's right to self-determination; provide education, then verify, document, and notify the provider about the refusal as needed

what question would you ask to ensure the right documentation? what action would you take?

-has the correct documentation been completed according to facility policy?

-complete documentation according to facility policy immediately after administering any medication

-document and communicate to the appropriate health care provider any signs and symptoms indicative of any adverse effects

what question would you ask to ensure the right response? what action would you take?

-how is the patient responding to the medication?

-monitor the patient to determine the efficacy of the drug, detect and prevent complication, and evaluate and document changes in health status

-when applicable, assess the patient's laboratory values to detect changes

-provide patient education, when possible, so patient is alert to adverse effects and changes in how he or she feels

what are the principles used to safely prepare and administer oral medications?

-use crusher, cutter, etc. depending on patients needs

-follow five rights

-can be capsule, pill, tablet, extended release, elixir, suspension, or syrup

what are the principles used to safely prepare and administer parenteral medications?

-selecting correct needle/syringe

-using aseptic/sterile technique to prevent infection

-careful recapping needles

-adhering to 5 rights

what are the principles used to safely prepare and administer topical medications?

-should not share

-cleaning skin thoroughly before administration to enhance absorption

-follow specific instructions of the medication

-5 rights

what are the principles used to safely prepare and administer inhaled medications?

teaching proper use of an inhaler:

-position inhaler 1-2 inches away from mouth (without spacer) or seal lips around spacer

-breathe in slowly 3-5 seconds, hold breath 10 seconds, exhale slowly

-wait 1-2 minutes between breaths

what are the subQ and IM injection sites?

-IM: deltoid, ventrogluteal, vastus lateralis, less commonly dorsogluteal

-SubQ: outer aspect of upper arm, abdomen, anterior aspects of thigh, upper back, upper ventral/dorsogluteal area

what information is necessary to establish a medication history?

-patient's name and DOB

-prescribed medications

-over the counter medications, herbal medicines, supplements

-when medications were started, discontinued, refused, or omitted

how do behavior, cognition, and one's thought process become a part of your assessment of mental health?

-much of the mental health assessment must be inferred from answers to questions and behaviors

-use these three components to determine whether there is a need to investigate an area more in depth

when assessing for violence to self (patient) and others, what do you assess for?

-assessing patient's daily routine; include questions about adverse childhood/family events

-urgent assessment: violence, harm to self/others, risk for injury d/t psychotic states/depression/dementia/delirium

-ask safety questions first

-subjective data: statements to the nurse, overhearing pt reporting to someone else, family and friends' report

-verbal and nonverbal data

-assessing for divergent strategies, manipulation, and motivation for tactics

what are the common sx of violence victims?

easily triggered, isolation, social withdrawal, numbing/shutting down feelings, spacing out/forgetfulness

what are the risk factors that you should assess for related to mental health conditions?

-exacerbating factors of violence and mental health conditions (unchangeable factors like family hx/age/gender, changeable factors like support systems/ housing/health care access/literacy, and medical issues such as parkinson disease/cancer/HIV & AIDs/other chronic conditions)

-personal history

-psychosocial history (support network, substance abuse, spirituality)

-medications

-family hx

what are the appropriate health promotion measures for mental health/related violence?

Important patient education topics

-alterations in interest: life, motivation, energy, sleep, appetite; sexual behavior

-current stressors, coping, violence

-physical, sexual abuse; altered mood, affect

-pervasive worry, anxiety; substance use

-changes: behavior; self-harm; suicidal thoughts

-memory, concentration, problem-solving abilities

-"healthy people" health promotion goals

what are the three learning domains?

cognitive, psychomotor, affective

cognitive learning domain

storing and recalling of new knowledge in the brain

-ex: lecture, panel, discovery, written materials

psychomotor learning domain

learning a physical skill

-ex: demonstration, discovery, printed materials

affective learning domain

changing attitudes, values, and feelings

-ex: role modeling, discussion, audiovisual materials

what is the teaching-learning process?

-assess learning needs and learning readiness

-diagnose the patient's learning needs

-develop learning outcomes

-develop a teaching plan

-implement teaching plan and strategies

-evaluate learning; revise the plan if the learner outcome is not met

-document the teaching-learning process

what does TEACH stand for?

T: tune into the patient

E: edit patient information

A: act on every teaching moment

C: clarify often

H: honor the patient as a partner in the education process

what are some lifespan considerations that you need to keep in mind when teaching your patients?

-older adults: identifying learning barriers, allowing extra time, planning short teaching sessions, accommodating for sensory deficits, reducing environmental distractions

-infants/toddlers/preschoolers: learning directed towards parents

-young children learn better with the most basic facts, concrete examples, and/or demonstrations

-adolescents like a sense of independence

what is health literacy? what strategies might a nurse use to promote health literacy?

-the ability to obtain, read, understand, and act on health information

-Ask Me 3: what is my main problem, what do I need to do, why is it important for me to do this?

-plain language without medical jargon, incorporation of visual models, including "teach-back" demonstration

what is loss?

occurs when a valued person, object, or situation is changed or becomes inaccessible such that its value is diminished or removed

what are the types of loss?

-actual: loss that can be recognized by others as well as by the person sustaining the loss, such as loss of a limb or a spouse

-perceived: loss of youth, financial independence, and of a valued environment experienced by a person, but intangible to others

-physical

-maturational: experienced as a result of natural developmental processes

-situational: experienced as a result of an unpredictable event (traumatic injury, disease, death, national disaster)

-anticipatory: occurs when a person displays loss and grief behaviors for a loss that has yet to take palce

what is grief?

an internal emotional reaction to loss

what is mourning?

actions and expressions of grief, including the symbols and ceremonies that make up outward expression of grief

what is bereavement?

a state of grieving due to loss of a loved one

what are Engel's six stages of grief?

1) shock and disbelief (no, not me)

2) developing awareness (why me?)

3) restitution (rituals surrounding the loss)

4) resolving the loss (dealing with the void left by the loss)

5) idealization (exaggeration of the good qualities of the person or object, followed by acceptance of the loss)

6) outcome (dealing with loss as a common life occurrence)

what are the Kubler-Ross stages of grief?

1) denial and isolation

2) anger

3) bargaining

4) depression

5) acceptance

what is dysfunctional grief?

abnormal or distorted grief that may be either unresolved or inhibited

what are signs of impending death?

-difficulty talking or swallowing

-nausea, flatus, abdominal distention

-urinary or bowel incontinence or constipation

-loss of movement, sensation, reflexes

-decreasing body temperature with cold or clammy skin

-weak, slow, or irregular pulse

-decreased blood pressure

-noisy, irregular, or cheyne-stokes respirations

-restlessness or agitation

-cooling, mottling, and cyanosis of the extremities and dependent areas

what are Kubler-Ross' five stages of dying?

1) denial: pt denies the reality of death, represses what's discussed

2) anger: pt expresses rage and hostility (why me?)

3) bargaining: pt tries to barter for more time (put personal affairs in order, make wills, fulfill last wishes)

4) depression: pt goes through period of grief; crying, not speaking much

5) acceptance: pt feels tranquil; accepts the reality of death and is prepared to die

what are the physiologic needs of the dying patient?

physical needs

-hygiene

-pain control

-nutritional needs

what are the psychological factors of the dying patient?

-pt needs control over fear of the unknown

-pain

-separation

-leaving loved ones

-loss of dignity

-loss of control

-unfinished business

-isolation

what are the spiritual needs of the dying patient?

patient needs meaning and purpose, love and relatedness, forgiveness and hope

how does the nurse care for the family of a dying patient?

-with permission of the patient, encourage the family and significant others to participate in planning the patient's care

-be available to discuss the patient's condition with family members

-offer support and care as the family begins the grieving process; be an attentive listener, listen to family's expressions of grief, loss, and helplessness

-develop a trusting relationship

how do nurses provide postmortem care?

-care of the body

-care of the family

-discharging legal responsibilities

-death certificate issued and signed

-labeling the body

-reviewing organ donation arrangements if any

-for the family: offer solace and support, arrange for family members to view the body, provide privacy for family to grieve, attend the funeral and make a follow-up visit to the family

what is delegation?

transference of responsibility/authority to a competent individual

what are the five rights of delegation?

-right task

-right circumstances

-right person

-right direction and communication

-right supervision

what tasks may you delegate to a UAP (CNA, HHA, client care technician, surgical tech)?

tasks that are considered routine, that do not require substantial scientific knowledge/technical skill, that are considered safe for the client, and that have a predictable outcome

-taking vital signs

-measuring I & O

-client transfers

-ambulation

-postmortem care

-bathing, feeding, gastrostomy feedings

-attending to safety

-weighing

-simple dressing changes

-suctioning of chronic tracheostomies

-basic life support (CPR)

what cannot be delegated to UAPs?

-assessment

-interpreting data

-making a nursing diagnosis

-creating a nursing care plan

-evaluating care effectiveness

-care of invasive lines

-administering parenteral medications

-inserting NG tubes

-client education

-performing triage

-giving telephone advice

the RN can delegate ________ and supervise appropriately; however, the _________________ cannot be delegated.

the RN can delegate individual components of care and supervise appropriately; however, the main functions of assessment, planning, evaluation, and nursing judgement cannot be delegated.

what must the nurse do before delegating?

must assess basic care activities

-activities of daily living (ADLs) and assistive devices

-nutrition and oral hydration

-elimination

-personal hygiene

-mobility/immobility

-rest and sleep

-non-pharmacological comfort interventions

how does prioritization figure into delegation?

-prioritizing is "deciding which needs or problems require immediate action and which ones could be delayed until a later time because they are not urgent"

-if nurse has some tasks that are more of a priority for them to carry out, the nurse can delegate other tasks of less priority to the appropriate personnel

what does DAR stand for?

data, action, response