N500 Assessment #2 Study Guide try 2

Active listening

the nurse considers both the client’s verbal and nonverbal messages to understand the true meaning of the exchange. requires each participant to focus on the speaker, rather than planning what the listener will say next.

Stress incontinence

coughing, sneezing, laughing, or physical activity that increases pressure on the bladder

Urge incontinence

strong urge to urinate, but leaking occurs before getting to the toilet

Reflex incontinence

urinary leakage as a result of nerve damage

Overflow incontinence

incomplete bladder emptying which results in the bladder overfilling when full

Functional incontinence

physical inability to reach the toilet in time

Use of Interpreters

is mandated for any health care facility that receives federal funding (Medicare or Medicaid reimbursement). In person or on the phone. Cannot be translated into one phone if not HIPAA compliant. No one can do this unless certified

Therapeutic communication techniques

builds trust and encourages open communication.

Forms of therapeutic communication techniques

motivational interviewing, active listening, asking open ended questions, giving recognition, restating/summarizing, reflecting

Motivational interviewing

nurse empowers pt to make positive changes, mnemonic OARS

OARS

open ended questions, affirmations, reflective listening, summarizing

Active listening

considers clients verbal and nonverbal message, focus on speaker not how to respond

Communication styles

Verbal (what is said), nonverbal (body language) , electronic, written, passive, assertive, aggressive, passive aggressive

Passive Communication

does not act or openly express discomfort.

Assertive Communication

displays confidence or self assurance. most effective because they communicate clearly and honestly.

Aggressive Communication

Hostile or forceful, developed a pattern of expression that is verbally, and sometimes physically, abusive, using “you” statements.

Passive Aggressive Communication

finds indirect ways to protest or express unhappiness with a situation.

Barriers to communication

languages, culture, speech or hearing impairments, developmental or cognitive disorders, medication effects, effects of recreational drugs, distress, environmental factors

Approaches to client behavior confronting, repeat, cultural preferences

Use interpreters or visual aids when necessary. Practice patience and allow extra time for communication. Adjust your approach based on the patient’s needs. Be mindful of non verbal cues such as facial expressions and gestures. Ensure a quiet and comfortable environment for communication.

Health promotion strategies

primary prevention, holistic health, health promotion

Primary Prevention

The act of intervening before negative health effects occur. focuses on decreasing the risk for development of medical conditions by changing behaviors or minimizing exposures. Vaccines, changing risky behaviors such as tobacco use, and banning harmful substances are all examples of primary prevention.

Holistic Health

may include spirituality, mental health or mindfulness, physical, or environmental aspects, depending on what the individual’s choices is done through specific actions taken by an individual resulting in wellness.

Health Promotion

process of enabling people to increase control over and improve their health.

Health Education

Learning experiences that are designed to improve the health of an individual or community through increased knowledge or by influencing attitudes

Benefits of exercise

cardio, bone density, joint and mobility, weight and metabolic regulations, mental and emotional well being

Cardiovascular and Endurance Support

It enhances cardiac efficiency, though endurance can be specifically limited by clinical disorders like diabetes, anemia, and heart failure.

Bone Density Maintenance

Performing weight bearing exercises—specifically utilizing an elliptical trainer or regular walking—directly prevents or manages the risk of osteoporosis by maintaining bone density. (Note: ATI explicitly highlights that seated rowing or water aerobics are less effective for this specific benefit)

Joint and Mobility Management

For clients with conditions like rheumatoid arthritis, regular walking and stretching maintain joint range of motion, reduce pain, and preserve mobility.

Weight and Metabolic Regulation

It helps maintain a healthy weight and aids in managing chronic conditions such as type 2 diabetes by stabilizing glycemic control and improving physical tolerance.

Mental and Emotional Well being

It acts as a primary tool for stress reduction, tension relief, and lifting mood.

Modifiable

behaviors and exposures that can raise or lower a person’s risk and measures that can be taken to reduce that risk. Can be changed

Nonmodifiable

conditions that increase the risk of developing a disease. Cannot be changed

Nonmodifiable factors examples

genetics, ethnicity/race, age, and family health history.

Health Promotion

process of enhancing people’s influence over and improvement of their health.

Disease Prevention

primary and secondary (early detection) preventive measures aimed at reducing the burden of disease and associated risk factors

Watson patient centered care

I. Tell me about your health. 2. What's it like to be in your situation? 3. How do you perceive yourself? 4. What are your health priorities? 5. How do you envision your life? 6. What is the meaning of healing for you? 7. What is the most important thing I can do for you? 8. What is the most important thing you need right now?

Swanson patient centered care

1. Maintaining belief, 2. Knowing, 3. Being with, 4. Doing for, 5. Enabling

Steps of nursing process

assessment, analysis, planning, implementation, evaluation

Assessment

Assess the objective and subjective data that pertains to the client.

Analysis

Determine the client's problems.

Planning

Create a plan to address client problems.

Implementation

Take action to provide care as outlined in planning.

Evaluation

Evaluate the effectiveness of the interventions provided and document the client’s response.

Objective Data

Data that can be observed by the nurse through the senses, measurable, based on facts and what the nurse can observe or notice by using the senses—seeing (inspection), hearing (auscultation), smelling, and touching (palpation).

Subjective Data

based upon the client's feelings, perception and assumptions. derived from the client’s self

Examples of subjective data

the client’s self report of pain and the client’s reason for seeking care.

Subjective indicators of pain

Pain scale score, along with quantity and quality of pain.

Objective indicators of pain

Grimacing, guarding, crying.

Types of urinary incontinence

Bedwetting, stress, urge, reflex, overflow, functional

Anuria

The absence of urine production or an output of less than 100 mL over 24 hours. indicates acute renal failure or severe obstruction.

Oliguria

Scanty or decreased urine output or less than 400 mL over 24 hours (or less than 30 mL/hour for adults).

Polyuria

An excessive volume of urine output (diuresis), often exceeding 2.5 to 3 liters per day. This is commonly seen in patients with unmanaged diabetes mellitus or those taking diuretics.

Dysuria

Painful, uncomfortable, or burning urination (UTI).

Nocturia

Awakening multiple times at night to urinate, disrupting sleep. aging, pregnancy, heart failure, or prostatic hyperplasia.

Hematuria

The presence of blood in the urine, which can make the urine appear pink, red, or rust

Pyuria

The presence of pus (white blood cells) in the urine, giving it a cloudy or turbid appearance. active infection.

Glucosuria (or Glycosuria)

The presence of glucose/sugar in the urine, an abnormal finding typically caused by high blood sugar levels overriding the kidneys' reabsorption limits.

Proteinuria (or Albuminuria)

The presence of abnormal amounts of protein in the urine, often an early indicator of kidney damage or glomerulonephritis

Turbid / Cloudy Urine

presence of bacteria, white blood cells, sperm, or microscopic crystals.

Amber / Dark Urine concentrated urine

typically indicating dehydration or elevated bilirubin levels.

Specific Gravity

A lab metric measuring urine concentration. ATI tests normal ranges between 1.005 and 1.030. A high specific gravity indicates concentrated urine (dehydration), while a low specific gravity indicates dilute urine (overhydration or diabetes insipidus).

Straining to have a BM

Constipation, As the body ages, increased instances of constipation may occur, requiring increased straining to evacuate the bowel, a decrease in expected frequency.

Bowel Training Programs

control of their elimination schedule. Clients may be incontinent for a variety of reasons, including spinal cord injury, multiple sclerosis, surgery, laxative abuse, childbirth, or other emotional problems.

Interventions to treat constipation

eating a high fiber diet, staying well hydrated, engaging in regular exercise, scheduled toileting/bowel training, and, when needed, using stool softening medications to draw water into the bowel to help stool move or stimulant medications to help the bowels contract.

Healthful sleep habits

Avoid stimulants, such as caffeine, alcohol, and nicotine at least four to six hours before bedtime. Remove unnecessary light and noise. Establish a bedtime routine, such as taking a warm shower or bath. Keep the room dark, quiet, and at a comfortable, cold temperature. Go to bed only when tired. If you don't sleep in 20 minutes, go to another room and read or listen to music. Turn the clock away from view. Go to bed and wake up at the same time each day. Keep naps short and before 3 p.m. Complete exercise at least three hours before going to bed. Remove work items and televisions from the bedroom when possible. The bedroom should be for sleep and sexual activity only.

Sleep disorders

insomnia, apnea, hypoapnea, obstructive sleep apnea, narcolepsy, hypersomnia, restless leg syndrome

Insomnia

an ongoing inability to sleep despite having the opportunity to do so.

Apnea

a condition in which there is an absence of inspiratory airflow for a minimum of 10 seconds.

Hypopnea

associated with a decrease in oxygen saturation and lasts 10 seconds or longer.

Obstructive sleep apnea (OSA)

related to the recurrent episodes of upper airway collapse and obstruction while sleeping combined with waking from sleep.

Narcolepsy

a chronic sleep condition characterized by sudden sleepiness and sudden periods of sleep.

Hypersomnia

a disorder of excessive daytime fatigue without improvement after more sleep.

Restless leg syndrome (RLS) also called Willis Ekbom disease

an uncontrollable urge to move the legs during sleep.

Sleep Wake Homeostasis

Assists the body to remember to sleep after a given time, regulates the level of sleep according to the amount of sleep deprivation a client is experiencing, affected by factors such as the lighting in a room, medications, caffeine, foods, sleep environment, and stress.

Stage 1 sleep

The wake stage/lightest stage of sleep. Consists predominantly of alpha and beta electrical brain waves. Alpha waves are electrical brain waves in the frequency range of 8 to 12 hertz. Beta waves are electrical brain waves in the frequency range of 12 to 30 hertz. When a person becomes drowsy and closes their eyes, the alpha waves dominate over the beta waves. Breathing is normal, and skeletal muscle tone is present. Can last from 1 to 5 minutes and is approx. 5% of total sleep cycle.

Stage 2 sleep

Deeper sleep. Consists of sleep spindles or K complex electrical waveforms that trigger the superior temporal gyri, anterior cingulate, insular cortices, and the thalamus. Client becomes challenging to awaken. Heart rate and body temperature decrease. First sleep cycle lasts approx. 25 minutes; however, it becomes progressively longer with each successive sleep cycle. Consumes approx. 50% of a total sleep cycle. Number of cycles increase with aging.

Stage 3 sleep

Deepest sleep. Consists of delta electrical brain waves, which are slower frequency, higher amplitude signals. If awoken in stage three, clients may have mental cloudiness for 30 to 60 minutes. During this stage, immune system strengthens, and the muscles, tissues, and bones repair and regenerate. Number of cycles decline with aging. Can last up to 40 minutes.

Stage 4 sleep

Includes REM, the dreaming stage. Looks like an awake cycle on an EEG; however, the skeletal muscles remain atonic (loss of muscle tone). Client's breathing is irregular and erratic, and their heart rate may be elevated. Typically begins 90 minutes after falling asleep. Initial cycle lasts 10 minutes and will become longer as the night progresses. Can last up to 1 hour.

Digestion process

act of the body breaking down food into simple substances that are absorbed by the body as nutrients or eliminated by the body as waste. involves the esophagus, stomach, liver, gallbladder, pancreas, small intestine, large intestine, rectum, and anus.

Esophagus

Muscles in the esophagus propel food down to the stomach

Stomach

Holds and digests food using acids and enzymes

Liver

Filters toxins from the blood and produces bile that breaks down carbohydrates, proteins, and fats

Gallbladder

Stores the bile produced by the liver and releases it when needed

Pancreas

Produces insulin that helps with the metabolism of sugar

Small intestine

Breaks down food and absorbs most of the nutrients

Large intestine

Removes water and electrolytes from food particles for the body’s use while turning the rest into feces

Rectum

Temporary storage area for feces

Anus

Expels feces

Therapeutic diets

clear liquid, full liquid, pureed, mechanical soft, regular, low residue, low fiber, high fiber,

Clear Liquid

Broth, Bouillon, Coffee, Tea, Carbonated beverages, Clear fruit juices, Gelatin, Popsicles

Full Liquid

Clear liquids, Smooth textured dairy products, Custards, Refined cooked cereals, Vegetable juice, All fruit juices

Pureed

Full liquids, Scrambled eggs, Mashed potatoes and gravy, Pureed meats, vegetables, and fruits

Mechanical Soft

Pureed, Ground or finely diced meats, Flaked fish, Cottage cheese, Cheese, Rice, Potatoes, Pancakes, Light breads, Cooked vegetables, Cooked or canned fruits, Bananas, Soups, Peanut butter

Regular

No restrictions unless specified.

Soft/Low Residue/ Low fiber

easily digested foods Pastas, Casseroles, Moist, tender meats, Canned, cooked fruits and vegetables, Desserts without nuts or coconut

High Fiber

Fresh, uncooked fruits, Steamed vegetables, Bran, Cornmeal, Dried fruits

For clients who have dysphagia

nectar, honey, or spoon thickened

Nectar consistency

Thicker than water but can be sipped through a straw, and includes nectar, vegetable juice, cream soups

Honey consistency

Can be eaten with a spoon but does not hold its shape and includes honey, tomato sauce, and yogurt

Spoon

thickened consistency