Fundamentals Prep Exam 1 : Pt 1

What are the 7 caritas care processes?

1. Embracing loving-kindness and equanimity

2. Being authentically present to another person

3. Cultivating our own spiritual practices

4. Developing and sustaining loving, trusting, and caring relationships

5. Allowing for expression of positive and negative feelings

6. Creative problem solving and decision making

7. Engaging in genuine teaching learning experiences

8. Creating healing environments

9. Assisting with basic human needs

10. Opening to spiritual, mysterious, and existential dimensions

What is a nursing concept?

A fundamental idea that forms the basis of nursing practice, guiding nurses in their decision-making and actions. It represents a framework for understanding patient care, healthcare environment, and the roles and responsibilities of nurses

True or False: A nursing concept requires evidence of an actual or potential problem

True

How is evidence gathered in a nursing concept?

Gathered through recognizing cues and analysis of patient data

What do nursing concepts allow for?

Allow for organization by system or problem area, and for prioritization of problems and intervention, as well as organization of assessment data and nursing intervention

Nursing concepts or concerns may include clusters of assessment data, potential problems, and potential intervention that include what domains?

• physical, psychological, developmental, social or spiritual

• actual or potential problems

What are some examples nursing concepts?

• Neurologic system:

  • Confusion - altered mental status

  • impaired communication

  • pain

• Integumentary:

  • impaired skin integrity

• Cardiac:

  • Activity intolerance

  • Decreased cardiac output

• Pulmonary:

  • impaired oxygenation

What is the format of a nursing concept?

• Consists of a body system (cluster normal and/or abnormal data from the head-to-toe assessment here)

• A concept: what is the priority given the abnormal assessment data

• And a cause: what is the physiology behind the condition (if known)

What is a problem statement?

It combines a nursing concept + evidence of the concept + the confirmed or suspected cause of the problem

Ex: A patient who is bed-bound and has diminished strength is said to have “impaired mobility” evidenced by decreased strength and inability to get out of bed. The cause is the initial reason for bed-bound status: musculoskeletal injury, critical illness, etc

Where does the evidence required to create and assign a nursing concept primarily come from in a fundamentals course?

The head-to-toe assessment

By what two categories do nursing concepts allow a nurse to organize assessment data?

By body system or by problem area.

What is an Expected Client Outcome (ECO)?

States what the patient must do or achieve in order to correct, manage, or prevent a problem

What are SMART goals?

Goals that are:

• Specific

• Measurable

• Attainable

• Realistic

• Timed

Should smart goals be stated positively or negatively?

Positively

Ex: Would write “Pt will be free from falls” instead of “Pt will not fall”

To make a goal 'Specific' and 'Measurable,' what type of data should be provided?

Concrete assessment data (objective numbers).

Ex: Temperature less than (X); Patient will state “X”

What must a nurse consider to ensure a goal is 'Realistic' and 'Attainable'?

The patient’s condition, baseline level of function, and disease progression

What does “Time” ask in SMART goals?

Asks when will the change occur

Examples of times that could be used:

• By the end of the shift

• By discharge

• By 1200 vital signs

Why is 'no more hyperthermia' an insufficient goal statement?

It lacks timing, specificity, and a measurable metric.

How do SMART goals impact nursing interventions?

They drive specific nursing actions and medication choices that can be replicated by the care team

The acronym SMART stands for Specific, Measurable, Attainable, Realistic, and _____.

Timed

What are some interventions that can help the nurse reach their goal for the patient?

Nursing actions and pharmacologic treatment

When looking at what we can do to meet goals, what should we look to do?

Should look at specific actions: who will be doing what and when will they do it

Should be looking at what medications will be used

Should try to make goals As Specific As Possible

Ex:

• Goal: by the end of the shift, the patient will achieve a temperature less than 38 C

• Intervention: The nurse will cool the room, provide cooling blankets, ice water, and ice packets to groin and axilla

Which phase of the nursing process involves determining if patient goals were achieved?

Evaluating outcomes

When evaluating outcomes, what questions must the nurse ask?

Must ask: Did the patient meet the goal

• If patient met the goal, must ask how was this goal met

  • Ex: Patient’s temperature at 1700 was 37.8 C after administration of Tylenol, cooling blankets, and ice packs

• If the patient did not meet the goal, must ask why this goal was not met

  • Ex: Despite application of ice packs and administration of acetaminophen, patient’s temperature at 1700 was 38.2 C

What should a nurse do immediately after determining that a goal was not met?

Reevaluate the outcomes and restart the nursing process

When re-evaluating a goal, what questions should the nurse ask?

• Was the goal unrealistic?

• Was the intervention unrealistic?

• Can additional intervention be added?

What is the nursing history?

a holistic assessment gathered at the very beginning of a patient encounter designed to gather information on a patient's physical development and significant life events, while providing insight into spiritual, religious, social, or emotional factors that might influence how they present with an illness, their perception of their condition, and their personal timeline for healing

What is the goal of the nursing history?

Obtain subjective data: the client’s description of what’s happening to them in their own words

To build a complete nursing history, a nurse systematically gathers information across what key areas:

• Across the room assessment

• Nursing Health History: biographical data and demographic data

• Chief complaint

• History of present illness

• Past medical history

• Review of systems (ROS)

• Psychosocial history

What is the across the room assessment?

When the nurse notices the physical environment, noting safety for patient and nurse. Note any signs of acute pain, anxiety, or physical distress

What information is obtained when getting biographical data and demographic data?

Name, age, sex assigned at birth, gender, preferred language (Ex: AB is a 36 yo female, denies acute pain or distress)

• Noice any signs of distress, subjective and objective

What is the chief complaint (CC)?

Patient’s reason for seeking care in their own words. When documenting this, use quotation marks.

Should be phrased as, “What brought you here today?”

What is the history of present illness (HPI)?

Pinpoints details of active issue using 7 dimensions:

• Location - where is the problem?

• Quality - client description, such as dull, sharp, pounding

• Quantity - scale of 0-10, is it constant? is it intermittent?

• Timing and setting - onset, time of day?

• Aggravating factors - what makes it worse

• Alleviating factors - what makes it better? Position, activity, noise?

• Associated data - other symptoms that may be occurring

What is past medical history?

Includes patient’s general health status, as well as any childhood illness, immunizations, hospitalizations/surgeries, chronic illnesses, obstetrical history, allergies, and current home medications

How many generations should be included when documenting a family history?

3 generations, living or deceased

What is the family history?

a health history spanning typically three generations (the patient, their parents, and their grandparents) to identify hereditary risks, noting whether family members are living or deceased, their age at death, and their specific causes of death

What environments are important to assess when doing an environmental history and hazards assessment?

Home, work, community, travel: inside US and/or foreign countries

What is the importance of obtaining an environmental history?

Screening for daily hazards or exposures that could impact health, such as exposure to tobacco smoke, occupational risks (like inhaling dander or chemical particles), communal living environments (like college dorms or group homes), or recent travel to countries with higher rates of specific infectious diseases

What is a review of systems?

A collection of data about a particular system adressing expected functioning vs changes in function that directs your physical assessment

What does psychosocial history address?

Questions regarding lifestyle, community support systems, religious or spiritual practices, sleep and exercise habits, alcohol or drug use, history of grief, home safety, and thoughts of self-harm or suicide.

Which section of the history covers alcohol, caffeine, and illicit drug use?

The psychosocial history

What is objective data?

Findings that the healthcare professional can see and observe

Information that the nurse observes directly, such as slurred speech or drainage, is called _____.

objective data

Why is joint pain classified as subjective data?

Because the nurse cannot experience or see the pain and must rely on the patient's report.

What is patient education?

An ongoing, goal-driven, interactive process that provides patients with new information and is a fundamental element of a nurse’s scope of practice

What nursing concept does patient education cover?q

Knowledge deficit

What are the goals of patient education?

Health promotion, restoration of health, and adaption to permanent illness/injury

What characteristics do patients need in order to learn?

Ability, motivation (intrinsic, extrinsic) and readiness

What is intrinsic motivation?

The natural or inherent drive to seek out challenges and new horizons for personal satisfaction.

What is extrinsic motivation?

Performing a task for reasons other than simple joy, such as working toward a specific external reward.

What concept describes a patient's combined ability and willingness to accept and internalize information?

Readiness to learn

What are some factors that promote learning?

• Perceived benefit

• Enhanced health literacy

• Ongoing patient participation

• Nonjudgmental support

• Quiet, low-stimulus environment

• Repetition

What are some biological/physical barriers to patient learning?

• Sensory impairments

• Mobility impairments

• Medication influence

• Fatigue or pain

What are some psychological barriers to patient learning?

• Stress or anxiety

• Negative coping styles

• Stage of adaption to illness

• poor spiritual health

What are some cultural barriers to learning?

• Language

• Traditions or norms

• Beliefs or values

• Religion/spirituality

What are some environmental barriers to learning?

• Setting

• Resources

• Time

• Context

At what point in the patient interaction should education ideally begin?

On day one

In the assessment of learning needs, what are some important questions to consider?

• What does the patient need to know and/or want to know?

• Are there family/caregivers that need to know/want to know?

• What actions dot he patient/family need to take?

• What is the potential impact from taking action or not taking action?

• How will the patient/family best learn?

At what grade level should all written patient education materials be written?

6th grade

What materials should you provide for your client and in what kind of environment should you administer them?

Verbal, written, audio, and visual materials/methods should be provided in a distraction-free environment

What is the first step of the 'Elicit-Provide-Elicit' model?

Asking the patient what they already know or what questions they have.

What occurs during the 'Provide' phase of the Elicit-Provide-Elicit model?

The nurse shares expertise, tips, and strategies for care based on the patient's specific needs.

What is the goal of the final 'Elicit' step in the educational model?

To allow the patient to process information, ask follow-up questions, and clarify understanding.

What is the nursing process?

A scientific, clinical reasoning approach to patient care that involves:

• assessment

• planning

• implementation

• evaluation

Ideally steps go in this specific order, but this is dynamic due to individual needs

What are the four primary steps of the nursing process as listed in the general definition?

Assessment, planning, implementation, evaluation

What is the flow of clinical judgment and the nursing process?

Assessment: Notice patient cues → Analysis of cues → Plan and prioritize potential problems → Establish client outcomes/consider potential solutions → Nursing intervention → Evaluation of outcomes

What is the nursing plan of care?

A systematic way of organizing and responding to patient outcomes

• Functions to promote patient outcomes, Organizes and prioritizes care, and communicates plan to health care team

The nursing plan of care is dynamic/static and follows the nursing process and clinical judgment model (noticing, analyzing, planning, creating and evaluating outcomes)

Dynamic

What occurs in the assessment phase (recognition of cues) in the nursing process?

• Conduct a head to toe assessment, assess vital signs, and assess the environment. Notice what is normal/abnormal and what information is relevant/irrelevant

• Gather subjective and objective data to establish baseline info

• Obtain nursing history from primary and secondary sources

• Notice patterns of health and illness, risk factors, and resources for adaptation and coping

What is the purpose of the assessment

To gather data to establish baseline of information

What is subjective data?

Data based on personal feelings or interpretation of the client. This is put into quotes

What is objective data?

Data that is observable, measurable, and undistorted by personal bias. Something the nurse observes and can describe

Who is the primary source of the nursing history?

The client

Whoa are some secondary sources of nursing history?

Family, health care team members, medical records, literature review

When documenting the assessment/recognition of cues, where is this documented?

In the plan of care as a head to toe assessment

What step occurs between assessment and planning?

Analysis

What is the purpose of the analysis step?

To organize relevant information. Can determine if information points to safety risks, physiologic changes, or alterations in a body system and identify common themes or body systems affected here

When moving from analyzing to planning, what should be identified?

Any abnormal data from the physical assessment. Synthesize data to identify key concerns, including actual or potential problems, causes of problems, possible solutions, and patient education needs

What two factors are used to rank potential patient conditions when prioritizing hypotheses?

Likelihood and acuity

What occurs in the planning phase of the nursing process?

Organization of assessment data and nursing intervention. Cluster assessment data, potential problems, and potential intervention

• involves nursing concepts or concerns - systematic way of identifying patient problems

What must be provided in the planning phase to support the identification of a specific problem?

Evidence

What happens in the “establishing client outcomes” phase?

Plan for potential outcomes. Asks what outcomes do we want and how can we achieve them, and what outcomes do we not want and how can we avoid them

• Requires a specific patient goal and outcome formatted as a nursing problem statement

What is required when establishing client outcomes?

A specific patient goal and outcome, formatted as a nursing problem statement

In nursing interventions, nurses do what?

Take action. They implement the interventions that address the highest acuity problems

Asks: how can we best implement intervention, in what order should it be done, and how can we collaborate or delegate?

• note specific actions and who will be doing what, as well as specific medications

  • Ex: The nurse will cool the room, provide cooling blankets, ice water and ice packs to groin and axilla

What questions should be asked when evaluating the intervention?

Did we achieve the outcomes set in our “Generate solutions” portion?

How will we evaluate?

When wil we evaluate

What indicates need for further intervention? (would different intervention be more effective?)

Was the goal met or not"?

What evaluating outcomes, what question should be asked?

Did the patient meet the goal?

• Yes or no and describe the outcome

  • Ex: Despite application of ice packs and administration of acetaminophen, patient’s temperature at 1700 was 38.2 C

What should be done after evaluation is complete?

Restart the nursing process, regardless of if goal was met or not

• Assess the goal - was it unrealistic? was the intervention unrealistic? can additional interventions be added?

• Re-asses the patient - what changed? what additional info do we have?

What is a key component in development of critical thinking?

Reflection

What is Tanner’s (2006) clinical judgment model"?

Noticing, interpreting, responding, reflection into impact on clinical experience

What are the five main vital signs assessed?

Temperature, pulse, respirations, blood pressure, and pulse oximetry

What do vital signs indicate?

Indicate how the body is responding to a stressor

What should vital signs be compared to?

• Expected range

• Lifespan considerations

• Patient’s condition

• Previous baseline

• The overall trend

What is often considered the fifth vital sign?

Pain

The nurse obtains vital signs on their assigned patient. What phase of the nursing process is occurring?

Assessment

When should vital signs be assessed?

• On admission - establish baseline

• Before and/or after procedure, treatment, intervention or medication

• With change in client condition

• Every shift (or per unit protocol)

• At scheduled intervals as ordered

• At discharge

• Any time you feel it is necessary

• More frequently as required (subject to parameters)

What is temperature?

A measure of the body’s balance between heat lost and heat produced

What are some methods to assess temperature?

Oral (PO), Axillary (Ax), Tympanic (T), Temporal (TA), and core temp via esophageal, bladder, and rectum

What is the preferred method to assess temp?

Oral

If assessing temp under arm, will it be one degree higher or cooler than oral?

Cooler

If assessing core temp, will it be one degree higher or cooler than oral?

Higher