NURS 2001 Reading Guides 1-6 Exam 1

wellness

an integrated method of functioning oriented toward maximizing the potential of the individual

illness

separate short or long events that may challenge a person’s desire for health

when the person who moves toward illness and premature death develops signs and symptoms of disease or disabilities

When does treatment occur?

a systematic problem-solving approach to identifying and treating human responses to actual or potential health difficulties, serves as a framework for providing individualized care not only to individuals but also to families and communities

What is the nursing process?

assessment, diagnosis, outcome, planning, implementation, and evaluation

What are the 6 steps of the nursing process?

subjective data

based on patient experiences and perceptions

objective data

measurable, observe patients general appearance; assess vital signs; listen to heart, lungs, and abdomen; and assess peripheral circulation

• is driven by patient, family, and community needs

• is based on the nursing process, evidence-based thinking, and the scientific method

• requires specific knowledge, skills, and experience

• is guided by professional standards and codes of ethics

• nurses are required ti contemplate analysis, develop alternatives and implement the best interventions

• critical thinking is essential to resolving difficulties

How do nurses use critical thinking as part of the nursing process?

based on critical thinking, includes gathering and clustering data to draw inferences and propose diagnoses or hypotheses

What is diagnostic reasoning in nursing?

• the nurse forms hypotheses, prioritizes them, generates solutions, and then takes actions.

• the goal of this process is to direct you in implementing it in a way that will improve your patient’s care

What is the clinical judgement model?

emergency and urgent assessment

involves a life-threatening or unstable situation, such as a patient who has experienced a critical traumatic injury

• use ABCDE to determine level of urgency

• A (airway), B (breathing), C (circulation), D (disability), E (exposure)

comprehensive assessment

a complete health history and physical assessment

• ex. physical similar to the one required for admission to school

focused assessment

based on patient’s health issues

• ex. patient who preesnts to the clinic w/ a cough. health history focuses on duration of cough, associated symptoms such as wheezing or shortness of breath

• life threatening issues always take priority

• nurses prioritize on different ways

• the ability to make decisions about the rank order in which nursing actions should be taken using nursing judgement

What does “priority setting” mean?

• nonmaleficence (do no harm)

• beneficence (promote good of client)

• autonomy (clients right to make decisions)

• confidentiality (respect right of client to maintain privacy)

• justice (treat everyone fairly regardless of their ability to pay for treatment

What 5 ethical principles are nurses to use w/ in their nursing practice?

physical privacy

needed to make the client feel secure, don’t expose any more of the body than required at the time so client doesn’t feel vulnerable. curtain should be pulled, drape client w/ blankets, etc.

personal

maintain confidentiality and ensure client has been identified properly

if the nurse observes suspected abuse, they are required, by law, to report it

what is mandated reporting?

examples of therapeutic communication

ask openended questions, engage in active listening, staying away from medical terms, give positive reinforcement and reassurance w/ out passing judgement or disapproval

examples of non-therapeutic communication

giving personal opinions, giving approval and disapproval, using plural pronouns like “we”, giving false reassurances

• Identify (state the team member’s name and title)

• Situation (provide the circumstances that have required the communication to occur)

• Background (provide the background data regarding the client assist the provider with familiarity)

• Assessment (provide the most recent set of vital signs or other data relevant to the communication)

• Recommendations (provide any suggestions that may be helpful to the situation)

• Read back orders (repeat the orders that are given and clarify anything that is unclear)

What is ISBARR?

• Inspection

• Auscultation

• Palpation

• Percussion

What are the 4 techniques nurses use when assessing patients and what order are they performed in?

good light source, pen light, tape measure, pulse oximeter, tongue depressor

What tools are need for Inspection technique when assessing patients?

stethoscope and doppler

What tools are need for Auscultation technique when assessing patients?

no special tools but nurse should wear gloves

What tools are need for Palpation technique when assessing patients?

• performed by advanced provider

• need hands

What tools are need for Percussion technique when assessing patients?

electronic record

electronic communication tools for documenting progress, treatments, interventions, and client responses to care

physical record

when used, be sure to maintain integrity, properly date and time each entry followed by a full signature and title act the end. if error is made, draw single line through the entry and initial it

the client

Who has the right to see a patient record?

• the client’s name, address, and phone number against the client’s medical record

• the client’s age and date of birth

• ask if the client has any illness or medical disability that could affect activities of daily living or social interactions

• their contact person (an immediate family member, partner, or friend)

What is included on biographic data?

focusing on an ill or injured client’s reason for seeking medical care

What is a “chief complaint” or “presenting problem?”

• document in chronological order the appearance of the manifestations connected with the reason for seeking care

• begin w/ first event and continue until the present time

• for each reported symptom, not the location, character of the symptom, severity of its appearance, its timing, and the setting it became noticeable

• record the client’s answer to a question about their perception of the meaning of the illness injury

How should the history of present illness (HPI) be recorded?

• after collecting data about the client’s biographic data, recognize if any of the social determinants (financial stability, education, social and communicty aspects, access to health care and neighborhood and environment) are active factors in their health status

• if any of these factors play a role in the client’s health, follow that topic of conversation

How are social determinants of health used in the Health History?

• childhood illness, injuries, chronic illness, hospitalizations, surgeries, immunizations, health maintenance examinations and screenings, allergies, current medications (medication reconciliation), and nutrition

What general topics are included in Health history?

general; specific

When taking a health history start with ______ questions, and then funnel down to more _______ questions.

• do you have a family history of thyroid or diabetes?

to evaluate the client’s overall health and identify any unexpected manifestations

What is the purpose of Review of Systems? (ROS)

will help the rest of the interview go more smoothly

how can obtaining a thorough ROS help navigate your physical assessment?

if a client indicates manifestations in a specific body system are present or if they report painful symptoms, addressing that symptom becomes your priority

In what manner should a review of systems be conducted?

musculoskeletal, neurologic, hematologic, and endocrine

What are the 4 whole body systems that should be included in the ROS?

determines the client’s ability to care for themselves when they are not experiencing an acute illness

what is the purpose of a functional assessment?

• self concept

• healthy literacy

• stress

• activity and exercise

• sleep

• spirituality

• substance abuse

What are the internal factors of a functional assessment?

• occupational health

• living environment

• relationships

• abuse

What are the external factors of a functional assessment?

• alcohol use

  • do you ever drink alcohol in the morning?

  • have you ever felt guilty about drinking alcohol?

• Tobacco/nicotine use:

  • do you vase?

  • do you or have you ever smoked or chewed tobacco?

• Recreational Drug Use:

  • What type of substances have you consumed?

  • How often do you consume these substances?

Which substance abuse products would you ask about during a functional assessment?

• be committed to preventing and managing their pain

• share pertinent info w/ them about pain and pain relief

• respect their reports of pain and respond appropriately to them'

• consult w/ the appropriate pain management experts as needed

What are the responsibilities of the healthcare team when it comes to managing client pain?

• ask for pain relief sooner rather than later

• work w/ the healthcare team to develop a pain management plan

• help the health care team evaluate their plan and the effectiveness of pain-relief interventions

• share any info or concerns they might have about taking pain meds

What are the client responsibilities regarding pain management?

• always believe the client

• the client is entitle to adequate pain relief

• pain is an urgent situation

• base interventions on the client’s pain relief goals

• use analgesics as prescribed

• work w/ other health care team members

• evaluate the effectiveness of interventions

• prevent or minimize side and adverse effects of analgesia

• educate the client and family about pain and pain management

The basic essentials for guiding pain management are:

• relaxation

  • progressive muscle relaxation

• distraction

• cutaneous stimulation

  • thermal therapies

  • massge

  • transcutaneous electrical nerve stimulation

  • acupressure

• guided imagery

• hypnosis

• biofeedback

• music therapy

• exercise

• controlling the environment

• other therapies

  • complementary therapies

What are some non pharmacological approaches to pain management?

complementary

used in addition to conventional treatment

alternative

used instead of conventional treatment

no later than 1 hour afterward

once the nurse has implemented an intervention for pain relief, when should the patient’s pain be reassessed?

nonopiods, opioids, and adjuvants

What 3 categories of meds are used to treat pain?

nonopiods

pain relieving medications that do not contain what has traditionally been called a narcotic component ex. aspirin, acetaminophen, NSAIDS

opioids

potent pharmacological analgesics once referred to as narcotics

adjuvants

medications that are primarily used to treat something other than pain, but that improve pain relief when used in combination w/ a pain medication

when it reaches a mild level

At what level should the patient notify you of pain?

• Past medical history to include previous illnesses, and state of health

• Last oral intake of liquids and food

• Events leading to illness or injury

• Allergies and type of reactions

• Symptoms or chief complaint

• Each prescribed medication, OTC medications, and herbal supplements

wHat is the PLEASE acronym?

C - have you ever felt the need to cut down on alcohol consumption?

A - Have you ever been annoyed at criticism regarding drinking?

G - Have you ever had guilty feelings related to drinking?

E - Have you ever taken a morning eye-opener?

What does the CAGE questionnaire stand for, for drinking?

pain

What is the 5 th vital sign?

acute pain

lasts 1 second up to 6 months, rapid in onset, varies intensity and duration, protective in nature

chronic pain

3 to 6 months, may be limited, intermittent, or persistent, lasts beyond the normal healing period, periods of remission or exacerbation are common

breakthrough

unpredictable episode of severe pain not controlled by current pain interventions

Legal obligation

pain management is standard care. not adhering to standards of care is a negligent act = malpractice

moral obligation

every patient has the right to pain management

clinical judgement model

represents the process of making clinical judgements

they incorporate critical thinking, clinical reasoning, and clinical judgement in order for nurses to make sound clinical decisions

What is the relationship b/t the nursing process and the clinical judgement model?

assigning a nursing activity or procedure to another person who has the training appropriate for that activity or procedure

What is delegation?

• a theory that suggests there are five categories of needs that motivate human beings. the five categories are psychological, safety, love and belonging, esteem, and self-actualization

what is Maslow’s hierarchy of needs?

a systematic method that can be utilized in any health care setting to evaluate and treat the client. ABCDE is the acronym for airway, breathing, circulation, disability, exposure

What is the ABCDE approach?

• priority is given to whatever finding poses the greatest or immediate risk to the client’s physical or psychological well-being

  • ex.  if a nurse sees a wet area on the floor, the nurse or designee should dry the floor immediately to prevent clients from slipping and injuring themselves.

Explain the safety and risk reduction framework

• interventions are selected that maintain client saefty while producing the least amount of restriction to the client; the nurse chooses interventions that are the least invasive

What is the least restrictive/least invasive priority setting framework?

priority is given to the client who has a reasonable chance of survival w/ immediate intervention. this framework is typically used in situations where resources are limited, such as with mass casualties and disaster triage

When would you use the survival potential and what are the categories w/ in it?

acute vs. chronic framework

a framework in which acute conditions are prioritized over chronic conditions

urgent vs. nonurgent framework

priority is given to the client who has urgent need over a client with a nonurgent need

Unstable vs stable framework

priority is given to the client who has an unstable condition versus the client with a stable condition

• a sequence of factors needed for an infection to occur

• how bacteria, viruses, fungi, parasites, and and prions move from place to place. these are contact, droplet, and airborne

What is the chain of infection?

infectious agent

something that contains bacteria, fungi, virus, parasite, prion

• ex. Clostridium difficile, staphylococcus aureus, flora from GI tract

reservoir

the habitat of the infectious agent, a location where it can live, grow, and reproduce itself or replicate

• ex. table, bed

portal of entry

any body orifice—for example, ears, nose, mouth, mouth, or skin—that provides a place for an infectious agent to replicate or for a toxin to act

mode of transmission

how bacteria, viruses, fungi, parasites, and prions move from place to place. these are contact, droplet, and airborne

susceptible host

required for the infectious agent to take hold and become a reservoir for infection

• client w/ suppressed immune system

portal of exit

the route by which an infectious pathogen can leave the reservoir

• wound drainage, GI tract

• age

• underlying disease HIV/AIDS

• malignancy

• transplants

• medications: immunosuppressants, anti rejection medication, antineoplastics, antimicrobials, corticosteroids, gastric suppressants

• surgical procedures

• radiation therapy

• indwelling devices: endotracheal tubes, urinary catheters, central venous catheters, arterial catheters, and implants such as pacemakers and artificial joints

What factors increase infection susceptibility?

infection prevention practices and these apply to all clients, whether or not they are known to have an infectious agent

What are standard precautions?

direct contact transmission

occurs when micro-organisms are directly moved from an infected person to another person, rather than through a contaminated object or person

indirect contact transmission

occurs when microorganisms are directly moved from the infected person to another person with having a contaminated object or person b/t these two

droplet transmission

occurs when droplets from the respiratory tract of a client travel through the air and into the mucosa of a host

airborne transmission

when small particles move into the airspace of another person

vehicle transmission

transmission of infectious agents to various individuals through a common source, such as contaminated food or water

vector-borne transmission

transmission of infectious agents through animals, such as insect or rodent

during medical asepsis

When should isolation precautions be used?

• wet hands with water, apply enough soap to cover all hand surfaces, rub hands palm to palm, right palm over dorsum w/ interlaced fingers and vice versa, palm to palm with fingers interlaced, backs of fingers to opposing palms with fingers interlocked, rotational rubbing of thumb clasped in palm and vice versa, rotational rubbing, backwards and forwards with clasped fingers of hand in palm and vice versa, rinse hands with water, dry thoroughly with a single use towel, use towel to turn off faucet, and your hands are safe

How is hand hygiene properly performed?

when hands are not visibly soiled

When would you use hand sanitizer over soap and water?

• Meant to protect the health care worker from contamination, blood, or body fluids. this equipment may include masks, eye protection, gown, gloves, and hair caps. equipment that should be put on (donned) prior to client interactions to prevent the spread of infectious organisms; can include gloves, gowns, masks, eye and face protection, and show covers.

What is the role of PPE?

• natural defense of the body when injured, when foreign substances are present or when infectious agents attack.

in simple terms, explain the inflammatory response?

redness, swelling, heat, pain, loss of function

What are the signs and symptoms of inflammation?

infections that are acquired in a health care facility

What are healthcare associated infections?

bacteria that are resistant to one or more classes of existing antimicrobials

What are multidrug-resistant organisms (MRDOs)?

proper hand washing, wearing gloves, and using contact precautions

how can nurses prevent the spread of multi drug-resistant organisms?

interventions to eliminate or decrease the presence of micro-organisms that can cause infection.

What are the principles of aseptic technique