NURS 120 Exam 1

Stage 1: Novice

Initial stage; covers those who have no experience. Struggles

Stage 2: Advanced Beginner

Involved in enough real world problems to recognize patterns and recurrent situations. Focus on rules and guidelines, needs clinical support

Step 3: Competent

Able to prioritize tasks by drawing on past experiences. Not function w same speed or ease as proficient. Recognize patterns more quickly

Stage 4: Proficient

Understand bigger picture/ outcome. Able to respond to changing situations and modify plans

Stage 5: Expert

Extensive experience and knowledge to draw from when responding to complex situations. Self confidence and trust their intuitive sense. Knows what needs to be done

A in ADPIE

Assessing. performing a nursing assessment

D in ADPIE

Diagnosing. Making nursing diagnoses

P in ADPIE

Planning. Formulating and writing outcome statements, determining appropriate nursing interventions based on evidence (research)

I in ADPIE

Implementing care

E in ADPIE

Evaluating the outcomes and the nursing care that has been implemented. Make necessary revisions in care interventions as needed

Nursing Diagnosis

based upon the patient's response to the medical condition e.g. Anxiety, fear, disturbed sleep pattern

Medical Diagnosis

made by the physician or advanced health care practitioner that deals more with the disease, medical condition, or pathological state only a practitioner can treat

e.g. Diabetes, Tuberculosis, Amputations, Hepatitis, Chronic Kidney Disease

Case manager

Coordinates interdisciplinary services, discharge planning, and insurance coverage for clients

CNE

Provides education to staff nurses, develops orientation programs and introduces new technology

Nurse researcher

Conducts scientific studies to generate evidence for nursing practice and public findings

Nurse educator

Teaches students and mentors new nurses

Nurse manager

Leadership role responsible for a team of nurses, budgeting, scheduling, resolving conflicts, and client safety

Change agent

Recognize the need for change.

Leader

Inspires and motivates a group toward achieving a common goal/cause

LPN

Licensed practical nurse, 1 year; under RN supervision

ADN

Meet the demands of care under a nursing shortage

BSN

Professionalism, research, leadership; wider range of competencies related to research

RN

Registered nurse, ADN or BSN 2-4 years, pass NCLEX

APRN

Advanced practice registered nurse, master's degree in CRNA, CNM, CNS, or NP

MSN

Masters degree for RNs who choose to further their education and work in advanced practice

DNP

Doctor of nursing practice; clinical practice degree for advanced practice RNs in leadership roles and clinical practice

PhD in Nursing

Doctor of philosophy in nursing; research-based terminal degree focused on research and science

NCLEX

National Council Licensure Examination (NCLEX-RN & PN); used by state regulatory boards to determine entry-level safety

RN Licensure

Authorized by BONs, ensuring an individual has met predetermined qualifications to practice safely

National League for Nursing (NLN)

Nursing organization for faculty and education leaders to build a strong and diverse workforce

NLN Competence

Encourage human flourishing, demonstrate safe nursing judgment, cultivate professional identity, and sustain inquiry

Nursing Code of Ethics

Developed by the ANA; outlines rules for client privacy, nursing conduct, and behaviors to protect clients and the profession

Board of Nursing (BON)

Authority to enforce regulations and rules set by the NPA

NCSBN

National Council of State Boards of Nursing; includes state BONs and develops nurse licensure and certification exams

Nurse Practice Acts (NPA)

Current laws and regulations governing nursing practice in every state

American Nurses Association (ANA)

Founded in 1896; enhances the nursing profession by encouraging standards of practice, ethical work environments, and well-being

National Student Nurses' Association (NSNA)

Founded in 1952; provides professional development, networking, and preparation for nursing licensure

I in ISABRR

Identify. State the team member's name and title.

S in ISBARR

Situation. Provide the circumstances that have required the communication to occur.

B in ISABARR

Background. Provide the background data regarding the client to assist the provider with familiarity.

A in ISBARR

Assessment. Provide the most recent set of vital signs or other data relevant to the communication.

R in ISBARR

Recommendations. Provide any suggestions that may be helpful to the situation.

Second R in ISBARR

Read back orders. Repeat the orders that are given and clarify anything that is unclear.

Step 1 of Nursing Process

Assessment. Application of knowledge about the client's health status. Focuses on client's response to a specific health problem. Thinks critically to perform a comprehensive assessment of subjective and objective information

Step 2 of Nursing Process

Analysis. Analyze data to identify health problems/risks. Identifies patterns of trends and compares the data. Draws conclusions to direct nursing care

Step 3 of Nursing Process

Planning. Ability to make decisions and problem solve. Uses assessment to develop a plan.

Step 4 of Nursing Process

Implementation. Ability to apply nursing knowledge to implement interventions

Step 5 of Nursing Process

Evaluation. Evaluation of the client's response to the intervention and reach a judgment of whether or not the client met the goal/outcome

Primary Objective data

measurable based on facts; what a nurse can observe or notice by using the senses

Primary Subjective data

derived from the client's self-report

Secondary Subjective data

What others tell the nurse, or what the client has told others.

Secondary Objective data

Data the nurse collects from other sources (family, friends, caregivers, literature review, medical records).

Physiological needs

The most basic human needs for air, water, food, housing, sleep, and sexual activity

Safety needs

The need for a secure environment in which one can live, work, and play

Love needs

A need to give love and receive love

Self-esteem needs

A need to have a high self-image

Self-actualization

A need for achievement and mastery

A

Airway. Partial or complete

B

Breathing. Asses pt breathing status, monitor for peripheral cyanosis

C

Circulation. BP, urine output, and level of consciousness

D

Disability. Determining pt neurological status

E

Exposure. Head to toe assessment, skin check

Tracheal breath sounds

Loud intensity and high pitch; inspiration and expiration durations are equal.

Bronchial breath sounds

Loud intensity and high pitch; inspiration is shorter in duration than expiration.

Bronchovesicular breath sounds

Moderate intensity and pitch (esp on R); inspiration and expiration durations are equal.

Vesicular breath sounds

More intense/loud airflow in upper anterior lobes, softer/low pitch in other lobes; sounds like wind blowing through trees.

Expected breath sounds

Tracheal, bronchial, bronchovesicular, and vesicular breath sounds.

Unexpected breath sounds

Pleural friction rub, crackles, wheezes, rhonchi, and stridor

Pleural Friction Rub

Low-pitched, coarse, grating tone like rubbing two pieces of leather together; heard on inspiration and expiration; caused by pleural inflammation.

Crackles

Intermittent rattling, crackling, popping, or bubbling sound; fine/high or coarse/low pitched, not cleared by coughing; heard during inspiration.

Wheezes

Whistling, high-pitched musical sounds from narrowed airways; inspiratory, expiratory, or both; associated with asthma or bronchitis.

Rhonchi

Continuous low-pitched snoring sound heard during inspiration and expiration; caused by fluid, mucus, or growth in larger airways; may clear with coughing.

Stridor

High-pitched crowing sound heard without a stethoscope; upper airway obstruction caused by inflammation or foreign body; life-threatening.

Oxygenations assessments

pulse oximetry & ABG

Pulse Oximetry

Non-invasive assessment that estimates arterial hemoglobin oxygen saturation.

ABG (Arterial Blood Gas)

Directly measures partial pressure of oxygen and CO2 in blood.

Sputum Specimen Collection

Obtaining an AM sample examined by the lab; patient takes deep breaths, forces deep cough of 1-2 tsp of mucus into cup.

Chest Physiotherapy

Percussion, vibration, and postural drainage to enhance secretion clearance; good for COPD, cystic fibrosis, or pneumonia.

Incentive Spirometer

Device to promote deep breathing and provide visual feedback on inspiratory volume.

Pursed Lipped Breathing

Technique to help with breathlessness during stressful or labor-intensive activities; good for chronic lung diseases, emphysema, COPD, and pulmonary fibrosis.

Flutter Valve

Breathing therapy device that makes breathing more comfortable, easier to clear mucus, and prevents atelectasis.

Huff Coughing

Technique used to clear mucus from the lungs consisting of inhaling air and holding it.

Suctioning

Clears airway and prevents respiratory infections; performed through mouth, nose, or artificial airway.

Nasotracheal Tube

Artificial airway passed through nares and nasopharynx into trachea; suctioning performed using sterile technique.

Endotracheal Tube

Artificial airway inserted through mouth into trachea to keep airway open, protect from aspiration, and ensure ventilation.

Tracheostomy

Long-term airway management device inserted into trachea through a surgical opening; requires special suctioning equipment.

Closed Chest Drainage

Chest tube inserted into pleural/mediastinal space to allow drainage of blood, fluid, or air and restore normal intrapleural pressure.

Hypoxemia vs. Hypoxia

Hypoxemia is a limited amount of oxygen in the blood; hypoxia is a lack of oxygen on the cellular level.

Hyperventilation

Increase in rate and depth of breathing leading to decreased CO2; can cause alkalosis, weakness, dizziness, and anxiety.

Hypoventilation

Shallow breathing with low respiratory rate leading to too much CO2; can cause acidosis, anxiety, dyspnea, and confusion.

Dyspnea

Shortness of breath or difficulty breathing; signs include chest tightness, tachypnea, gasping, and wheezing.

Heart Disease Risk Factors

Diet high in sugars and processed carbs, exercise under $30\text{--}60\text{ min/day}$, smoking, stress, and environmental exposures.

Cues for Concern in Heart Disease

Shortness of breath (SOB), chest pain, and abnormal heart sounds such as $S_3$ or $S_4$.

Myocardial Ischemia

Reduced blood flow to the myocardium preventing adequate cellular oxygenation.

Myocardial Ischemia Symptoms

Angina, neck/jaw pain, fatigue, nausea, vomiting, tachycardia, arm/shoulder pain, and sweating.

Angina Pectoris

Chest discomfort caused by temporary reduction in coronary blood flow.

Angina Pectoris Symptoms

Chest squeezing/tightness, pain radiating to arms, neck, jaw, or back; diaphoresis, dizziness, fatigue, and nausea.

Myocardial Infarction

Irreversible myocardial tissue necrosis due to severe prolonged ischemia.

Myocardial Infarction Symptoms

Radiating chest pain, irregular heart rate, diaphoresis, anxiety, and lightheadedness.

Ostomy Nursing Interventions

Provide stoma care, ensure healthy pink stoma tissue, and change appliance if skin barrier seal leaks.