N330 Exam 1

Nursing process

Assessment

Diagnosis

Planning

Implementation/ intervention

Evaluation

The nursing process is how nurses

think

identify patient problems

determine patient outcome

prioritize patient care

Maslow's Heirarchy

Self actualization

esteem and self respect

belongingness and affection

safety and security

physiological needs

Chronic disease

Non communicable disease,chronic conditions or chronic disorders that

require long term management: diabetes, cancer, hypertension

disability

Dynamic between a person's health condition and

their environment

chronic illness

the human experience of living

with a chronic disease or condition; experienced

by the individual and the family; individual's

perception and responses to the chronic disease

or condition

Models of Disability

medical model

rehabilitation model

social model

biopsychosocial model

functional model

interface model

medical model

disabled people = their disability

disability is a problem of the person

HCPs are the experts/authorities

management of disability = to cure

people with disabilities are viewed as tragic

rehabilitation model

disability = deficiency which requires a rehabilitation specialist

if disabled person failed to overcome their disability, they are perceived as having failed

social mode

disability = socially constructed + political issue resulting from social and physical barriers in the environment

removal of these barriers = removal of disability

Biopsychosocial model-

integrates medical and social models

biological, individual, social perspectives

critique: the disabling condition (takes importance over) > the experience of the person with the disability

interface model-

addresses components of health rather than consequence of disease

goals of rehabilitation

identify, reach, and maintain- physical, sensory, social levels, etc..

focus on- present abilities to facilitate independence

goal- help patient achieve optimum health

maximize- independence and prevent secondary disability

Activities of daily living (ADLs):

Self-care activities that the patient must accomplish

each day to meet personal needs including

bathing, grooming, dressing, feeding, and

Toileting.

pressure injury preventions

Position patient comfortably

Reposition every 2 hours

Clean up, don't expose skin to urine and stool

Use pillows

Interventions to prevent pressure injury:

Relieving- Relieving pressure, pressure relieving devices

Positioning- Positioning patient, reducing friction and shear

Minimizing- Minimizing irritating moisture

Improving- Improving: mobility, sensory perception, tissue perfusion

Improving- Improving nutritional status

Cellular and extracellular changes:

changes in physical appearance, like changes in

Shape and body makeup

Age related changes in hematopoietic system influences:

RBC blood production, increases

Levels of anemia.

Cardiovascular system

Decreased cardiac output,

dec. ability to respond to stress

Decrease in muscle strength

Dec. vital capacity, gas exchange diffuse capacity

respiratory system

Inc in lung residential volume,

Inc cough efficiency

integumentary system

Dec fat, muscle tone, fluid, sensory receptors,

cardiovascular disease

complains ab fatigue, inc heart rate)

(exercise, avoid smoking, good diet)

musculoskeletal system

Loss of bone density, decreased muscle strength

(dec height)

(exercise regularly)

genitourinary system

Decreased muscle contractility, bladder capacity, increased residue in urine

male genitourinary system

benign hyperplasia

female genitourinary system

relaxed perineal muscles, urethral dysfunction

nervous system

.Decreased brain volume, reduced speed in nerve conduction, and cerebral blood flow

.(slow to react, learning takes longer, faints)

.(pace education, encourage visitors, hospitalize)

acute pain

pain that results from tissue damage, abates as healing occurs, signal that Something is wrong and needs attention

chronic pain

time limited pain. Persists beyond usual time of tissue healing.

breakthrough pain

chronic pain with acute exacerbations

Barriers to pain assessment in older adults are:

dementia, cognitive impairment

And delirium.

effects of chronic/ acute pain

elevated heart rate, blood pressure and respiratory rate; they may shake or shiver,

have goose bumps and pale skin. The more intense the pain, the more visible these

signs and symptoms are

Weight loss, sleep loss, no appetite.

pain is :

subjective

defense mechanism

tissue damage

define pain:

unpleasant sensory, emotional experience with potential or actual tissue damage.

misconception of pain

If patient is sleep, they don't feel pain

Vital signs are reliable indicators of pain

Caregiver best judge of pain

Pain is normal part of aging

Anxiety makes pain worse

If a patient is distracted, they are no longer in pain.

nonpharmacologic methods for patients with pain

Relax and reposition patients

Music, herbs

Decrease sound, light and temp.

Manage acute pain

Pharmacologic: methods for pain

opioids

non-opioids

adjuvants

1 scale

(0-3) mild pain

(non-opioid: ibuprofin)

2 scale

(4-6) moderate pain

(opioids)

3 scale

(7-10) sever pain

(opioid, morphine)

component of pain assessment

OLD CARTS

Macular degeneration

age related, occurs mostly in older patients. Causes blurred vision and blindness due to thinning of the macula.

glaucoma

a group of eye conditions that damage the optic nerve. Caused by pressure. Slow vision

cataracts

cloudy area in the disk of the eye.

detached retina

Separation of the sensory retina and the RPE (retinal

pigment epithelium)

Clinical manifestations of detached retina

sensation of a shade or curtain

coming across the vision of one eye, bright flashing

lights, sudden onset of floaters

managing visual impairments

Same placements for items in the room

"Clock method" for trays

Service animals

communication

Meniere's disease

abnormal inner ear fluid balance cause by malabsorption

of the endolymphatic sac or blockage of the endolymphatic duct

Age related changes (hearing) -

Presbycusis- hearing loss increases with age,

Nursing considerations/interventions hearing impaired:

Hearing aids

Communication strategies

acute pain

chronic pain

time limited or last a lifetime

cancer

non- cancer: peripheral neuropathy, back pain

Clinical manifestations of Glaucoma

Less than or equal to 21 mmHg

headache

eye pain

blurred vision

1.symptom and signs definitions (clinical manifestations)

1. a symptom is a manifestation apparent to patient

2.a sign is a manifestation the physician perceives.

cataracts clinical manifestations

Clouded, blurred or dim vision.

Meniere's disease clinical manifestations

vertigo, nausea, vomiting, loss of hearing, ringing in the ears, headache, loss of balance, and sweating.

external otitis manifestations

pain, discharge, edema, hearing loss

acute otitis media manifestations

otalgia (ear pain), fever and hearing loss

clinical manifestations for the hearing impaired

tinnitus- ringing in ears

Risk factors of Osteoporosis

low calcium intake

gastrointestinal surgery

eating disorders

Musculoskeletal System: The Older Adult

Alterations in bone remodeling

Loss of muscle strength, size

Deterioration of muscle fibers and cell membranes

Degenerated joint cartilage

osteoporosis

causes bones to become weak and brittle — so brittle that a fall or even mild stresses such as bending over or coughing can cause a fracture.

osteoporosis prevention

eating foods that are rich in calcium and vitamin D

weight training, walking, hiking, jogging, climbing stairs, tennis, and dancing.

nursing considerations for patients who is post op hip arthroplasty

lay on non operative side with hips abducted

a structured approach to routine patient assessment, testing, medications, pain management, wound care, nutrition, activity progress, psychosocial issues, and discharge planning.

Nsg Interventions for Sprains and Strains

Contusion

strain

sprains

dislocation

Contusion

soft tissue injury produced by blunt force

(Pain, swelling, and discoloration: ecchymosis)

Strain:

Strain: Pulled muscle injury to the musculotendinous unit

Pain, edema, muscle spasm, ecchymosis, and loss of function are on a continuum graded first, second, and third degree

Sprain:

injury to ligaments and supporting muscle fiber around a joint

Joint is tender, and movement is painful, edema; disability and pain increases during the first 2 to 3 hours

Dislocation:

articular surfaces of the joint are not in contact

A traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb and loss of mobility

taking care of a patient with fractures:

Immobilization

Open fracture: cover with sterile dressing to prevent contamination

short term (care for fractures)

cast, splints

long term (care for fractures)

brace

Nsg Management of a Patient in a Brace or Cast

casts are meant to stay dry. A wet cast can lead to skin irritation or infection. Plaster casts and fiberglass casts with conventional padding aren't waterproof.

6 P's & Compartment Syndrome

pain

Poikilothermia

Pallor

Pulselessness

Paresthesia

paralysis

Poikilothermia

(i.e., takes on the ambient temperature)

skeletal traction

metal pin and wire through bone

what is a traction used for

stabilize fracture until surgery

external fixator

a surgical procedure that treats an unstable bone fracture

The Care of the Patient With Fracture of the Hip—Interventions #1

Use aseptic technique with dressing changes

Avoid or minimize use of indwelling catheters

Supporting coping

support coping with patients includes

Provide and reinforce information•

Encourage patient to express concerns•

Support coping mechanisms•

Encourage patient to participate in decision making and planning•

Consult social services or other supportive services

The Care of the Patient With Fracture of the Hip—Interventions #2

Orient patient to and stabilize the environment

Provide for patient safety

Encourage participation in self-care

Encourage coughing and deep breathing exercises

Ensure adequate hydration

Encourage ankle exercises

Patient and family teaching

TED/ SCD

Factors that Inhibit Healing of Fractures

Age >40 years

Bone loss

Cigarette smoking

Comorbidities

etc/...

Nsg Interventions after an Amputation

priority problems

resolving grief and enhance body image

achieving physical motility

priority problems

acute pain

impaired skin integrity

disturbed body image

grieving

self-care deficit

impaired physical mobility

resolving grief and enhancing body image

encourage comm and expression of feelings

create accepting, supportive atmos

provide support, listen

encourage feeling and looking at residual limb

set realistic goals

resume self-care and independence

referral to counselors and support groups

achieving physical mobility

proper positioning of limb, avoid abduction, external rotation, flexion

turn frequently, prone positioning if possible

use of assistive devices

ROM exercises

muscle strengthening exercises

preprosthetic care, proper bandaging, massage, toughening of the residual limb

John visits his general physician on Monday because he was feeling sick over the weekend. When he is called back from the waiting room, the nurse on staff takes his temperature, heart rate, and blood pressure. She then asks John a series of questions about how he's been feeling lately. The nurse notes his responses when he says he's been having difficulty breathing and has been feeling very tired. She also sees on John's medical history that he has had previous problems with his cholesterol levels and blood pressure. John also has a blood sample taken during his doctor's visit.

assessment

The nurse looks over John's symptoms and notes that his heart-rate is higher than average and his blood pressure is elevated. She also considers that he has experienced fatigue and shortness of breath before when his cholesterol levels were very high. The nurse determines that John is experiencing Hyperlipidemia, also known as having high levels of fat within the blood. John's blood tests confirm this hypothesis. The nurse is also concerned that John is at risk for heart disease.

diagnosis

John returns on Tuesday for a follow-up visit. The nurse sits down with him in a closed room and explains his cholesterol levels and high blood pressure. She suggests that John be put on medication to help lower these numbers and recommends he exercise at least twice a week. The nurse also tells John he should stay away from salty foods and eat less red meat. John agrees with the nurse, and they setup a follow-up appointment two weeks later. The nurse reminds John to call if there are any changes in his condition, or if he starts to feel worse.

planning

John is prescribed the medication and takes it as recommended. One week later, he has a day where he feels especially sick and calls the doctor's office. The nurse explains that the medication could cause nausea as a side-effect and advises John to drink Ginger-Ale and avoid any foods that generally upset his stomach. John continues taking the medication and goes to the gym four times during the two-week period. Once the two weeks has passed, he returns to the doctor's office for his follow-up appointment

implementation

When John returns, the nurse asks him a series of questions about how he's been feeling. John replies that he has been having an easier time breathing and feels significantly less tired since exercising and taking the medication. The nurse marks "Patient's Condition Improved" on his official medical records and congratulates John on his well being. She then advises him to remain on the medication for one more month and to continue his exercise.Although there are calculated steps behind the nurse's approach, her methods are extremely friendly and warming and care is taken to treat the patient like a human being. As you can see, the nursing process will feel like second nature when put into real-world practice.`

evaluation

prioritize

airway, circulation, infection

what is the most important step of maslows heirarchy

basic needs

The nurse is caring for a client who is 1 day post operative for a total hip replacement. Which is the best position in which the nurse should place the client?

A. Head elevated lying on the operative side

B. On the nonoperative side with legs abducted

C. Side-Lying with the affected leg internally rotated

D. Side-lying with the affected leg externally rotated

B

When positioning the client on the nonoperative side or supine, abduction should be maintained. All other answer choices are avoided following a total hip replacement unless specifically ordered by the provider.

The nurse is providing instructions for a client and family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions?

A. "I should sleep on my left side."

B. "I should sleep on my right side."

C. "I should sleep with my head flat."

D. "I should not wear my glasses at any time."

A

Following cataract surgery, the client should not sleep on the affected (surgical side) as this may cause edema and increased intraocular pressure.

3. The nurse is caring for an older client in a lg-term care facility. Which action contributes to encouraging autonomy in the client?

A. Planning meals

B. Decorating the room

C. Scheduling haircut appointments

D. Allowing the client to choose social activities

D.

Autonomy is all about having the ability to choose for oneself. The ability to choose their social activities is the only option that allows the client to be the decision maker.

The long term-nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note? (Select all that apply)

A. Increased heart rate

B. Decline in visual acuity

C. Decreased respiratory rate

D. Decline in long-term memory

E. Increased susceptibility to urinary tract infection

F. Increase awakening after sleep onset

B E F

Decreased visual acuity occurs as the anatomy of the eye changes with age. Heart rates decrease with age. Lung function may decrease but respiratory rate stays the same. Short-term memory may decline with age. Sleep pattern changes are consistent with increased age.

5. The nurse is providing instructions to the assistive personnel (AP) regarding care of an older adult client with hearing loss. What should the nurse tell the AP about older clients with hearing loss?

A. They are often distracted.

B. They have middle ear changes.

C. They respond to low-pitched voices.

D. They develop moist cerumen production.

C

Presbycusis refers to age related irreversible changes of the inner ear that lead to decreased hearing ability. As a result, older adults have decreased response to high-frequency sounds. Low-pitched sounds are heard more easily.

The nurse is performing an assessment ton an older adult who is having trouble sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep?

A. "I swim three ties a week."

B. "I have stopped smoking cigarettes."

C. "I drink hot chocolate before bedtime."

D. "I read for 40 minutes before bedtime."

C

Hot chocolate has caffeine in it and may lead to difficulty falling asleep or staying asleep.

The nurse is caring for a client who has had a spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding?

A. Temperature of 101.6 F (38.7c) orally

B. Complaints of discomfort during repositioning

C. Old bloody drainage outlined on the surgical dressing

D. Discomfort during coughing and deep-breathing exercises

A.

A mild temperature is normal after surgery, however, a temperature oof 101.6 should be reported to the provider. Discomfort wile moving is expected after surgery.