NURS 20020 Final Exam

Florence Nightingale

Founder of modern nursing
Introduced education to nurses
Began nursing research during the Crimean war (washing hands standard of care)
Noticed relationship between environment and health

Dorothea Dix

Established the Nurse Corps in the US Army

Clara Barton

Organized the American Red Cross

Nightingale

environmental theory (sunlight, fresh air, nutrition)

Peplau

focused on interpersonal relationship

Rogers

energy fields in the environment, holistic approach, comforted via noninvasive ways

Henderson

assist patient to gan as much independence as possible

Orem

self care theory

King

goal attainment theory

Neuman

individuals response to stress

Roy

adaptive responses lead to better health

Maslow's Hierarchy of Needs

establishes priority in nursing care

ABCs

Airway
Breathing
Circulation

CABD

Chest compression
Airway
Breathing
Defibrillation

American Nurses Association (ANA)

established nursing code of ethics (the boundary and duty of nursing practice)

American Association of Colleges of Nursing

commission of collegiate nursing education accreditation agency

QSEN

Quality and Safety Education for Nurses
establishes a culture of safety instead of a culture of blame and ensures care for the community

purpose of QSEN

to prepare nurses with the competencies necessary to continuously improve the quality and safety of the healthcare systems in which they work

QSEN competencies

Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics

Patient Centered Care

Recognize the patient as the source of control and full partner in providing compassionate and coordinated care based on the respect for patient's preferences, values, and needs

Teamwork and Collaboration

a joint action by 2 or more people, each person contributes
Joint decision making among all healthcare parties

Evidence Based Practice

Integrates best current evidence with expertise for optimal health care

Quality Improvement

Monitors outcome of Care
Continuously improve quality and safety of the health care systems
Nurses and students are part of the system that affects outcomes

Safety

Minimize harm to patient and providers through both system effectiveness and individual practice

Informatics

Use of information and technology to communicate, manage knowledge, mitigate error, and support decision making

Therapeutic Communication

Learned skill (unnatural)
Focuses on the patient and their concerns
Verbal and Nonverbal

Sender

The person who encodes the message

Communication channel

The median through which the message is sent

Receiver

The decoder- person who can understand the message

Feedback

The receiver's response to a message

Written/electronic communication

Documentation, EHR, written instructions, emails

Intrapersonal Communication

Self-talk, powerful form of communication that occurs within the individual

Interpersonal Communication

One on one interactions between the nurse and the patient, occurs face to face and is most frequently used by the nurse

Verbal Communication

Vocabulary: no medical jargon
Pacing: slow speech down so pt. can understand
Intonation: tone of voice affects the message
Clarity and Brevity: simple, few words
Timing and relevance: know when to communicate

Nonverbal Communication

Eye Contact, facial expression, posture, gait, gesture, personal appearance, sounds
Includes 5 senses
Can reveal true meaning
80% of communication

Communication Congruence

Verbal and nonverbal communication need to be consistent with one another to avoid confusion and prevent sending "mixed messages"

Intimate Zone

0-18 inches
Most nursing care performed here

Personal Zone

18 inches to 4 feet
Sitting at bedside, taking patient history, giving information

Social Zone

4 to 12 feet
Rounds with the physician

Public Zone

12ft and beyond
Community forum, lecturing

Factors influencing communication

Gender: women generally prefer more details than men
Cultural/Language: ethnic background, not all words translate
Roles and relationships: stereotyping based on occupation
Altered sensory perception: do not assume all elderly are deaf
Mental and Emotional States
Values
Environment

Nurse-client relationship phases

1. Orientation/initiating
2. Working
3. Termination

Orientation/initiating phase

Establish trust/rapport

Working phase

The patient becomes an active participant
Implementing nursing interventions to achieve patent outcomes

Termination phase

Closure of the relationship when the patient is discharged
Key component=discharge planning
Continued contact beyond professional responsibilities is unprofessional

Therapeutic Communication Skills

Conversations skills, listening skills, use of silence, therapeutic touch (noninvasive way to comfort and show you care), humor (can be over played)

Communication Techniques

Open-ended questions
Validating/clarifying
Reflective
Silence
General Leads
Direct Questions
Providing info needed to understand situation
Sharing observations

Responses to Avoid in Therapeutic Communication

False reassurance
Close ended questions
Giving advice (NO)
Sharing personal opinions
Changing the subject
Using personal terms of endearment
Asking for explanations/ Why? questions

Color Assessment

Pallor (face and mucous membranes)
Cyanosis (circumorial or nails)
Jaundice (sclera)
Erythema (sacrum, heels, greater trochanter)

Moisture Assessment

Hydration (dryness or oiliness)
Diaphoresis (perspiration)
Flaking, scaling, or crusting (more common in elderly, overuse of soap)
Dryness (dehydration, smoking, stress, sun exposure)
Excessive dryness (eczema or dermatitis)

Temperature Assessment

Dependent on the amount of blood circulating through the dermis
Best assessed through palpation
Compare symmetrical body parts
Be alert to areas of warmth and erythema (may be a stage one pressure ulcer)

Braden Scale

Sensory perception, moisture, activity, mobility, nutrition, friction and shear
Score 6-23 (high-low risk)

Texture Assessment

Smooth
Rough
Thin
Thick
Tight
Indurated
Scarred
Wrinkled

Turgor Assessment

Elasticity (edema, dehydration, age)
Pinch forearm and release
Tenting indicates dehydration

Tenting

poor skin turgor/dehydration

Vascularity Assessment

Observe/inspect for reddened, pink or pale areas
Petechiae

Petechiae

Pin point purple or red spots
May indicate blood clotting disorders, drug reactions, or liver disease
Small hemorrhages

Edema Assessment

Observe/inspect and palpate for fluid build up in tissues
May be secondary to: direct trauma or impaired venous return
More common in dependent areas

Pitting Edema

Indentation remains after 5 seconds of applied pressure

Lesion Assessment

Observe/inspect and palpate: blemishes, bruising, birthmarks, freckles, moles, keratosis, angiomas, warts, macule, papule, nodules, tumors, wheals, pustules, ulcers, cancer

Melanoma

Deadliest form of skin cancer
Begins as small, mole-like growth
Encourage patient to use ABCDE rule to assess warning signs
Educate patient to notify their healthcare provider if lesions do not heal, change in color or appearance

ABCDE

asymmetry, border, color, diameter, evolving

Hair Assessment

Observe/inspect: Color, Distribution, Quantity, Thickness, Texture, Sheen, Hirsutism (female facial hair)
Palpate: Condition, Smooth, Pliant, Texture, Thick, Thin, Brittle

Scalp Assessment

Observe/inspect: lesions, bruises, hair loss, dandruff, psoriasis, lice, ticks, ringworm
Palpate: lumps, tenderness

Nail Assessment

Observe/inspect and palpate: cleanliness, shape and contour, consistency, color, capillary refill

Capillary Refill Assessment

Press on the patient's nailbed and release
Normal capillary refill = < 3 seconds
Abnormal capillary refill = >3 seconds (peripheral vascular disease, arterial blockage, heart failure, shock)

Skin, Hair, and Nails Nursing Diagnosis

Risk for impaired skin integrity
Impaired skin Integrity
Impaired tissue integrity
Bowel Incontinence
Ineffective individual self coping
Self-mutilation
Disturbed body image

Purpose of Health Assessment

Establish a database of the patient's abilities (obtain a baseline with which to compare)
Interpret physical data and compare findings laterally and with normal
Decide on interventions based on data obtained

Primary source

Information directly from the patient

Secondary Source

Information from other than the patient (family members, old charts)

Head to Toe Assessment

Organized system for gathering physical data
Brief

Focussed Assessments

Focus on specific body systems
Very detailed
E.g. cardiovascular

Functional Assessments

Gordon's Functional Health Patterns (FHP), more holistic, assess patient spirituality, physically, emotionally, and psychologically

Assessment of Health Perception

Client's perspective of his/her health status

Assessment of Activity Exercise

Gait and balance
Decreased mobility

Assessment of Nutrition and Metabolism

Dietary habits and metabolic needs

Assessment of Elimination

Adequacy of bowel and bladder function

Assessment of Rest and Sleep

Client's normal sleep patterns

Assessment of Cognition and Perception

Client's ability to think

Assessment of Self-Perception and Self-concept

Client's feelings about self

Assessment of Roles and Relationships

Client's roles and how illness affects roles

Assessment of Coping and Stress Tolerance

How does the client cope with stressors

Assessment of Sexuality and Reproduction

Client's sexual role and satisfaction

Assessment of values and beliefs

Spiritual assessment
May focus on religious beliefs

Inspection

Physical observations of the client
General survey: overall appearance of the pt.
Side to Side
(look)

Palpation

Using the hands to feel the skin and accessible underlying organs and other tissues
(touch)

Percussion

Tapping on a surface to determine the difference in the density of the underlying structure

Auscultation

The use of a stethoscope to listen to sounds within body cavities (listen)

Order of Abdominal Assessment

Inspection, auscultation, percussion, palpation

Five Vital Signs

Temperature, pulse, respiration, blood pressure, pain

Guidelines for Vital Sign Assessment

Nurse collaborates with the physician to determine the frequency of assessment depending the patients condition
Cannot be interpreted in isolation

Temperature

Oral: 98.6 F/ 37 C
Tympanic: 99.5 F/ 37.5 C
Axillary: 97.5 F/ 36.5 C
Rectal: 99.5 F/ 37.5 C
Temporal: 98.6 F/ 37 C

Thermoregulation

Heat production- heat loss= body temperature

Neural and Vascular Temperature Regulation

Hypothalamus: senses internal temperature and signals the body to change temperature

Heat Production

Basal Metabolic Rate (BMR)
Voluntary movement
Shivering
Release hormones

Radiation

Heat radiates out

Conduction

Transfer of heat from the body to another surface (contact)

Convection

Dispersion of heat by air currents

Evaporation

Dispersion of heat through water vapors

Diaphoresis

Profuse sweating