Final Exam

Concepts of health literacy and application to patient scenarios

Health literacy: ability to find, understand and act on health information
Populations at risk: elderly, minority, low income, chronic conditions, developmentally delayed
Strategies to help:

• use universal precautions

• use clear verbal communication

• use clear written communication

• use patient preferred speaking and written language when teaching

• promote reliable sources

• discuss medications clearly

• encourage questions

• use teach-back method

Cognitive domain

The thinking domain
Ability to make sense of and use information

Patient will describe, explain, list ways, demonstrate
Teaching methods: discussion, lecture, one-on-one instruction, audiovisual materials, printed materials, computer assisted instruction

Affective domain

The feeling domain
Includes values, beliefs, feelings, and attitudes associated with information recieved and applying that information to own health behaviors
Outcomes: positive feelings and attitudes toward changing behavior
Teaching methods: role play, simulation gaming, venn diagram, discussion (group and one-on-one), debate, values clarification exercises

Psychomotor Domain

The skill domain
Includes physical and motor skills
Patient will demonstrate skills

Teaching: demonstration, practice, return demonstration, independent projects; games

Positive learning environment for young/middle adults

• Must be practical and relevant to them

• Must see the need

• Use peer education but also able to practice in private

• Sessions under an hour

• Encourage active and independent learning

Positive learning environment for older adults

• Teach when alert and rested

• Involve in discussion

• Simple instruction/ one idea at a time

• Keep sessions short 20-30 minutes

ADPIE

• Assess: gather information about the patient

• Diagnose: Identify the patient’s problems

• Plan: Set goals of care and desired outcomes and identify appropriate nursing actions

• Implement: Perform the nursing actions identified in planning

• Evaluate: Determine if goals and expected outcomes are achieved

Clinical judgement model

• Recognize cues: identify and recognize relevant clinical data

• Analyze cues: interpret cues then organize and recognize patterns to link the patients clinical presentation to a problem

• Prioritize hypotheses: figure out what matters

• Generate solutions: Determine desired outcomes and the best solutions

• Take action: Implement nursing interventions based on your plan

• Evaluate outcomes: Compare observed outcomes to the desired/expected outcomes

Ego Defense mechanisms to stress/anxiety

• Compensation: Making up for a deficiency in one aspect of self-image by strongly emphasizing a feature

• conversion: Unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms

• denial: Avoiding emotional conflicts by refusing to consciously acknowledge anything that causes emotional pain

• displacement: Transferring emotions, ideas, wishes from a stressful situation to a less anxiety-producing substitute

• dissociation: Experiencing a subjective sense of numbing and a reduced awareness of one’s surroundings

• regression: Coping with a stressor through actions and behaviors associated with an earlier developmental period

• repression: thoughts are pushed into the subconscious as if the stress had never occured

Therapeutic communication techniques

• active listening: being attentive to what patient is saying verbally and nonverbally

• Sharing observations: Gently telling the patient what you notice about their behavior, appearance or mood

• Sharing empathy: Statements are a neutral and nonjudgmental recognition of the patients feelings

• Sharing humor: Using light, appropriate jokes or laughter

• Sharing feelings: Helping patients express emotions by making observations, acknowledging feelings

• Using silence: Allowing patients quiet time to think, feel, and respond

• Providing information: providing clear, honest information

• Clarifying: Asking questions or repeating what the patient said

• Paraphrasing: Repeating what the patient said in your own words

• Focusing: Centering conversation on key elements or concepts

• Confrontation: Gently helping the patient become aware of inconsistencies in feelings, attitudes, beliefs, and behaviors

• Summarizing: Concisely repeating the main points of what the patient said

Non-therapeutic communication

• Sharing opinions

• Generalization

• False reassurance

• Sympathy

• Use of medical jargon

SBAR

• Situation

• Background

• Assessment

• Recommendation

Maslows’s hierarchy

Self-actualization
Self-esteem
Love and belonging needs
Safety and security
Physiological needs (oxygen, fluids, shelter, sex)

Primary prevention

Aims to prevent disease or injury before it ever occurs
Examples: vaccinations, altering risky behaviors, promoting healthy behaviors

Secondary prevention

Focuses on early disease detection in those who have health problems or illness or are at risk for developing complications or worsening conditions
Examples: screenings, annual blood pressure measurements

Tertiary prevention

Manages a disease after diagnosis to slow or stop disease progression
Examples: medications, rehab services, chemo

Recommended screenings

• Breast cancer: Grade B, women aged 40-74

• STI behavioral counseling: Grade B for those who are sexually active

• Folic acid: Grade A, person who is pregnant or planning to be or sexually active

• Prostate cancer: Grade C 55-69, Grade D men older than 70

• Pancreatic cancer: Grade D, asymptomatic adults

Modifiable vs Non-modifiable risk factors of disease

Modifiable:diet, exercise, smoking
Non-modifiable: age, sex, family, and medical history

Transtheoretical model of change

• Pre contemplation: individual sees no need for change, no intention of taking action in the foreseeable future (>6 months)

• Contemplation: Individual sees need for change and has some desire, but it is not yet translated into action, intention to change in less than 6 months

• Preparation: Individual is ready to take action and changes behavior in next 30 days

• Action: Individual has changed behavior and is committed to change, behavior change occurred within 6 months

• Maintenance: Individual has sustained behavior change over time, change has lasted 6 months or more

BMI percentiles

<5%- underweight
5%-85%-Healthy weight

85%-95%- overweight
>95%- obese

Infant piaget & Erikson

Erikson: Trust vs mistrust
Piaget: Sensorimotor

Nursing care: respond to crying promptly, allow infant time to warm up, use a soothing, calming tone, talk directly to the infant, avoid loud harsh sounds and sudden movement, singing, talking, eye contact

Toddlers 12m1day-36mon

Erikson: Autonomy vs Shame and Doubt
Piaget: Preoperational
Nursing care: approach carefully, use toddlers preferred words for actions and objects, supervised play with medical devices, enjoy stories, dolls, and books, be consistent: dont smile when doing painful things, distraction with play

Preschooler 3-6y

Erikson: Initiative vs guilt
Piaget: Preoperational
Nursing care: Use play, puppets, or story telling, transitional objects or third party approach, speak honestly, allow choices as appropriate, use simple, concrete terms

School age 6-12y

Erikson: Industry vs Inferiority
Piaget: Pre-operational to concrete operations
Nursing care: Use diagrams, illustrations, books, and videos, allow honest expression of feelings, use third party stories, allow adequate time and encourage questions

Adolescents 12-18

Erikson: Identity vs role confusion

Piaget: Formal operations
Nursing care: Be honest with them, respect their need for privacy, address limits of confidentiality, use appropriate medical terminology defining words as necessary, use creativity, realize importance of peers and activities that are important to each individual

SIDS

Dies during sleep from unknown causes, often related to sleep position or unsafe sleep environment.
To prevent: babies should sleep alone, on their backs, in a safe crib

SUID

Accidental suffocation or airway obstruction resulting in death, often during sleep. Babies should sleep alone, on their backs, in a safe crib

Car seat safety

Infants- rear facing only
Toddlers/prek- forward facing with harness
School-aged- Booster seats
Older children: seat belt if 4’9 and over

Infant milestones

1 month:
reflexes present,turns head side to side, startles to loud noise, fixes gaze on object 12-24 in, gains 5-7 ounces weekly
2 months:
posterior fontanelle closes at 8 weeks, social smile
3 months:
Vocalizes, laughs, coos, opens and closes hand
4 months:
No head lag when pulled to sitting, bites and chews, first foods if formula fed, most primitive reflexes gone, rolls front to back
6 months:
babbling, rolls back to front, doubles birth weight gains 3-4oz/week, first tooth eruption, sits with assistance, first foods if breast fed
8 months:
Stranger anxiety begins, sits without assistance, transfers objects between hands
9 months:
waves bye bye, has object permance
10 months:
pulls to stand and cruises
12 months:
loses babinski reflex, 3-5 words, follows simple verbal commands, neat pincer grasp, walks a few steps, birth weight triples, switch to cow’s milk, some cause/effect understanding

Puberty in females

Thelarche: appearance of breast buds age 9-13 ½ yrs
Adrenarche: Growth of pubic hair on mons pubis 2-6 months after thelarche
Menarche: Appearance of menstruation 2 years after thelarche

Puberty in males

Testicular enlargement, thinning, reddening, and increased looseness of scrotum age 9 ½ to 14 yrs
Penile enlargement, pubic hair, voice changes, facial hair growth

Delayed puberty

Females: no thelarche by age 12
Males: No increase in testicular size by age 14

Stalled puberty

Puberty was started but not completed within 4 years of the first signs of development

Precocious puberty

S/S include development of the following before age 8 in girls and age 9 in boys
Girls S/S: breast growth and first period
Boys S/S: enlarged testicles and penis, facial hair, deepening voice

Adolescents illnesses

PHQ9-A: depression and suicide
GAD7: anxiety
ACES: childhood trauma
HEADSSS: social history like drugs, sexuality, eating, education
EAT26: eat disorders

Young adult piaget vs erikson

Erikson: Intimacy vs Isolation
Piaget: formal operations
Nursing care: Allow partners to be present if wanted

Middle adult piaget vs erikson

Erikson: Generativity vs Stagnation/self-absorption
Piaget: Formal operations
Nursing care: help patient acknowledge contributions to younger generations

Older adult erikson vs piaget

Erikson: Integrity vs despair
Piaget: Formal operations
Nursing care: Assist patient to reflect on meaningful relationships and life contributions; encourage sharing of advice and wisdom

Negative health effects of smoking

Cancer, respiratory disease, cardiovascular disease, reproductive effects, diabetes, cataracts

The 5 A’s of tobacco cessation

Ask: ask about use
Assess: Assess readiness to make a quit attempt
Advise: Advise the patient to quit
Assist: Assist with preparing to quit
Arrange: Arrange follow-up support

Successful tobacco treatment plans

Brief interventions of 3 minutes
More than 8 sessions doubles chances
Clinician support more than one

Precautions for c-diff

Contact precautions
Must wash hands with soap and water
bleach wipes are used for equipment

Types of precautions

Contact precautions: PPE required includes gloves and gowns
Droplet precautions: PPE required includes gown, gloves, and mask
Airborne precautions: PPE required includes gown, gloves, and N95 respirator mask

Vaccine precautions vs contraindications

Vaccine precautions:
- MMR: recent blood transfusion
- MMRV: family history of seizures
- Varicella: antiviral drugs 24 hours prior to vaccine, use of asprin
- Influenza: history of gillian barre syndrome
- Rotavirus: chronic GI disease, spina bifida
- Anaphylactic egg allergy: give immunization in office or hospital
Contraindications:
patient can never have a specific vaccine, due to serious reaction to vaccine

Live vaccines

Weakened form of the whole germ that causes a disease
Ex: MMR, flu mist, rotavirus, varicella

Vaccines

DTAp (Whooping cough): transmission contact or respiratory droplet
Tetanus: bacterial infections through wounds
HiB: Respiratory droplet, bacterial
Hep A & B: viral infection through fecal/oral/contact
HPV: bacterial through sexual contact
Influenza: Respiratory droplet
Covid-19: airborne/respiratory droplet
MMR: Respiratory droplet
Meningococcal: respiratory droplet
Rotavirus: fecal-oral
Varicella: Airborne contact
Herpes zoster (Shingles): primary respiratory droplet/contact

Receptive (Wernicke’s) vs Expressive (broca’s) aphasia

Receptive (Wernicke’s) aphasia is a language disorder where individuals have difficulty understanding spoken or written language

Expressive (Broca’s) aphasia involves difficulty in speech production, where individuals can understand language but struggle to form sentences.

Delirium vs Dementia

Delirium is onset and reversible
Dementia is grandual onset and usually irreversible.

Sensory overload

Reception of multiple stimuli at once
Treat by reducing background noise and environmental distractions.

Sensory deprivation

Inadequate quality or quantity of stimulation
Treat by providing stimuli for short periods of time throughout the day

Preload vs Afterload

Preload: volume of blood in ventricles at end of diastole (end diastolic pressure), amount of stretch of ventricles at the end of diastole, or before contraction
Afterload: Resistance left ventricle must overcome to circulate blood, pressure with which the ventricles must push against to get blood to lungs/body

Heart failure causes

F: faulty heart valves
A: Arrhythmias
I: Infarction
L: lineage
U: uncontrolled hypertension
R: recreational drug use
E: Evaders (viruses or infections)
left sided: DROWNING
D: difficulty breathing, R: rales, O: orthopnea, W: weakness, N: nocturnal dyspnea, I: increased HR, N: nagging cough, G: gaining weight
right-sided: SWELLING
S: swelling of legs, hands, liver, abdomen, W: weight gain, E: edema, L: large neck veins, L: lethargic, I: irregular heart rate, N: nocturia, G: girth of abdomen increased

Pursed lip breathing

Deep inspiration and prolonged expiration (longer than inhilation phase), used to prevent alveolar collapse, used in COPD patients to control shortness of breath and anxiety during panic episodes, promotes the removal of co2

Oxygenation delivery devices

Nasal canula: 24-40%, 1-6L/min
Simple face mask: 35-50%, 5-8L/min
Non-rebreather: 60-80%, 10L/min
Venturi mask: 24-60% depends

Ejection fraction

A measurement of the percentage of blood leaving the heart each time it contracts, indicating the heart's pumping efficiency.

COLDERR

Character, onset, location, duration, exacerbation, relief, radiation

Tolerance, physical dependence, addiction for pain management

Tolerance: Occurs after repeated exposure to an opioid analgesic in the long term
Physical: Occurs after repeated exposure to an opioid analgesic, with withdrawal symptoms if the drug is abruptly withdrawn, not a sign of addiction
Addiction: Drug-seeking behavior, overwhelming involvement with obtaining and using a drug for a high

Nociceptive pain

Damage to tissues
Visceral pain: injuries/damage to your internal organs
Symptoms: pressure, aching, squeezing, cramping

Neuropathic pain

Damage to or dysfunction of your nervous system
Described as burning, freezing, numbness, tingling, shooting, stabbing, electric shocks

Acute pain

Short history of onset and does not last longer than days or weeks, intensity is variable, and typically resolves once the underlying cause is treated.

Chronic pain

Long history with often poorly-defined onset; duration unknown, intensity is variable, depression and irritability is prominent feature

Labs for kidney function

Color: Clear/amber yellow
pH: 4.6-8.0
Specific gravity: 1.010-1.025
Leukocytes: 0-4 or negative
Ketones, protein, bilirubin, glucose, RBC’s, nitrites- negative

BUN/creatinine

BUN: 10-20mg/dl
Creatinine: 0.5-1.1 for females 0.6-1.2 for males

UTI

Causes: HARD TO VOID
H: hormone changes A: antibiotics R: renal stones D: diabetes T: toiletries O: obstruction V: vesicoureteral reflux O: overextended bladder I: indwelling catheters, invasive procedures, intercourse D: decreased immune system

Pyelonephritis

An infection of the kidney, commonly caused by bacteria ascending from the bladder. Symptoms may include fever, flank pain, and urinary changes.

Urinary catheter nursing care

Make sure there are no twists or kinks
Keep urine collection bag below the level of the bladderMake sure bag doesn’t drag or pull
Check for inflammation or signs of infection
Clean area around catheter twice a day with soap and water
Do not apply powder or lotion

Hyponatremia

Normal range for sodium is 135-145
Hypo is less than 135
Hypovolemic- vomiting, diarrhea, diuretics, burns, sweating, laxatives
Hypervolemic- CHF, kidney failure, liver failure, IV saline infusion
S/S: SALT LOSS
S: seizures A: abdominal cramping L: lethargic T: trouble concentrating L: loss of urine/appetite O: orthostatic hypotension S: spasms of muscles S: Shallow breathing
Treatments: oral intake of sodium, monitor neuro, restrict fluids

Hypernatremia

Greater than 145
Causes: dehydration, sweating, diarrhea, diabetes inspidus
S/S: FRIED
F: fever R: restlessness I: increased fluid retention E: edema D: decreased urine output/dry skin & mouth
Treatments: push PO fluids, restrict sodium diet, monitor neuro and oral cavity

Hypokalemia

Potassium normal range: 3.5-5.0
Low: less than 3.5
Causes: fluid loss from NG suction, vomiting, diarrhea, wound drainage, sweating, or drugs such as laxatives and diuretics
S/S: 7 L’s
L1: lethargy L2: low BP/HR L3: limp muscles L4: lots of urine L5: lethal cardiac L6: low/shallow respirations L7: leg cramps
Treatments: PO or IV potassium NEVER PUSH, avoid lasix and thiazides, encourage potassium rich foods, monitor cardiac and tele

Hyperkalemia

Greater than 5.0
Causes: Renal failure, excessive potassium, ACE inhibitors, NSAIDS
S/S: MURDER
M: muscle weakness U: loss of urine R: respiratory failure D: decreased cardiac contractility E: early signs of muscle spasms/twitching R: rhythm changes
Treatments: Kayexlate, Lasix, glucose/insulin, dialysis, monitor cardiac, respiratory, neuromuscular

Hypomagnesmia

Normal range for magnesium: 1.3-2.1
Hypo: less than 1.3
Causes: hypokalemia, alcohol dependence, malabsorption
S/S: TWITCHING
T: trousseau W: weak respirations I: irritability T: torsades de pointes C: cardiac changes H: hypertension I: involuntary movements N: nausea G: GI issues
Treatments: IV magnesium, monitor cardiac, telemetry

Hypermagnesmia

Greater than 2.1
Causes: Overcorrection of hypomagnesmia
S/S: LETHARGIC
L: lethargy E: EKG T: tendon reflexes absent H: hypotension A: Arrythmias R: respiratory arrest I: impaired breathing C: cardiac arrest
Treatment: Discontinue magnesium intake, monitor cardiac and respiratory

Hypophosphatemia

Normal phosphate levels: 3.0-4.5
Hypo: less than 3.0
Causes: Antacids, hyperparathyroidism, malabsorption, alcoholism, hypercalcemia, bone cancer
S/S: breathing problems, neuro changes, decreased cardiac output
Treatment: PO/IV phosphate, monitor cardiac, respiratory, MSK, calcium levels

Hypocalcemia

Normal range for calcium levels: 9.0-10.5
Hypo: less than 9.0
Causes: hypoparathyroidism, alcoholism, bulimia, pancreatitis, renal issues
S/S: CRAMPS
C: Cvozeks sign positive R: reflexes hyperactive A: arrhythmias M: muscle spasms P: positive trosseau’s sign S: seizures
Treatments: PO/IV calcium, calcium intake, monitor phosphate levels, cardiac and respiratory

Hypercalcemia

Greater than 10.5
Causes: hyperparathyroidism, glucorticoids, endocrine, and kidney disorders
S/S: WEAK
W: weak muscles E: EKG changes A: Absent reflexes K: kidney stone formation
Treatments: avoid calcium intake, calcium reabsorption inhibitors, dialysis

Isotonic/hypotonic/hypertonic fluids

Isotonic: same concentration as blood
Hypotonic: solutions are less concentrated than blood
Hypertonic: solutions are more concentrated than blood

0.9% normal saline and lactated ringers

0.9% saline: give for fluid volume deficit, replace large sodium losses
lactated ringers: give for correct dehydration, sodium depletion, and replace GI tract fluid losses

Enema procedure

Fill bag and tubing with warm solution
Clamp tubing
Lubricate tip
Instruct patient to breath slowly and insert tip toward the umbilicus about 3-4 in
Hold tubing in rectum throughout procedure and place bag height 12in from anus
Open clamp slowly

Healthy stoma

Should be pink, red, and moist with no signs of irritation or necrosis.

Occult blood test

A diagnostic test used to detect hidden blood in stool or other samples, often used for screening conditions like colorectal cancer.

Normal stool characteristics

Type 2-4
Lower= constipation
Higher=diarrhea
Patients should have frequency of 3 times a day to one every other day

Collect a stool sample

Wear clean gloves
Collect a stool specimen with sterile tongue blade and put it directly in a leak-proof container with a tight fitting lid
Send to lab

Suppository

small round/cone shaped object that can be placed rectally/vaginally
Will be broken down by the body
Given for constipation, prior to enemas

Affects of bowel pattern

Personal habits- routine matters, if in a new environment, routine changes too
Age: Older adults are at risk for elimination alterations
Diet: fiber flushes fat and waste
Physical activity: promotes peristalsis, encourages ambulation early after surgery
Medications: Opioids slow peristalsis, antibiotics create diarrhea, NSAIDS and aspirin create a risk for upper GI bleeding, Iron creates black stool, constipation and abdominal cramping
Pain: can create avoidance of bowel movements due to discomfort or fear of pain.

Paralytic ileus

A condition where the intestine does not function properly, leading to a lack of movement in the digestive tract. This can result in blockage, abdominal pain, and inability to pass stool or gas.
Treatment: place NGT and suction, encourage early mobilization, assess and monitor bowel sounds, monitor bowel and ability to pass flatus

Unusual Stool Appearnaces

Ribbon-like: this indicates obstruction
Dark, tarry stool: may suggest gastrointestinal bleeding
Bright red: may indicate hemorrhoids or lower GI bleeding.

Colon cancer causing risks

>45 years of age
Hereditary
High intake of animal fats and low in fiber
Lifestyle: obesity, smoking, sedentary, alcohol intake
Diabetes type II

Hemorrhoids

Dilated engorged veins in the lining of the rectum, external or internal
Causes: straining/constipation, pregnancy, heart failure, chronic liver disease
Thrombosis causes severe pain and needs to be excised
Mild cases treated with topical steroid, restoration of healthy bowel elimination

Sim’s position

A position where the patient lies on their left side with the right knee and thigh drawn up, used for rectal examinations and procedures.

Ileostomy vs colostomy

Both surgical procedures creating an opening in the abdomen for waste elimination, but differ in the part of the intestine used; ileostomy is from the ileum (small intestine) and colostomy is from the colon (large intestine).

Clear liquid vs full liquid diet

Clear:

• Short term diet with clear liquids that supply fluid and calories w/out residue

• Leaves little residue in the GI tract

• Often used with acute illness, before and after surgery

• Includes coffee, tea, clear juices, gelatin and clear broth

Full:

• Transition between clear liquid and a soft or regular diet

• Includes milk, strained and creamed soups, grits, creamed cereal and fruit/vegetable juices

• Scrambled eggs because of their high water content

Nutritional problems

Indigestion

• Nausea, vomiting, diarrhea

• Anorexia

• Dysphagia

• NPO

Digestion

• Bowel diseases such as IBD, celiac, cystic fibrosis, lactose intolerance

Metabolism

• Liver diseases/infection/trauma/fever/burns/major illness = metabolism increase

• Older adults= decrease metabolism or constipation

Common screening tools for nutritional assessment

Mini nutritional assessment

Labs for nutritional status

Albumin: chronic protein depletion

• Normal: 3.5-5.0

Prealbumin: acute problems of nutrition

• Normal: 15-36

Hemoglobin: low levels can make it difficult for the body to perform essential gas exchange functions

• Male: 14-18

• Female: 12-16

Cholesterol: used by the body to make vitamin D, hormones, and substances that aid in digestion

• Total cholesterol: less than 200mg/dL

• HDL (good): >40mg/dL for men >50mg/dL in women; >60 risk for heart disease

• LDL (bad): less than 100mg/dL

• Triglycerides: less than 150mg/dL

Dysphagia

Difficulty swallowing
At risk: older adults, stroke history, trauma to head, foreign body, strictures
Complications: aspiration, pneumonia, dehydration, decreased nutritional status, and weight loss
Interventions: positioning in semi/high fowlers, chin tuck, double swallowing, check for pocketing, oral hygiene, liquid orders

Intake and output

Intake: oral, tube feedings, IV fluids, total parenteral nutrition & lipids, blood products, dialysis fluids
Output: urine, liquid stools, drainage from drains or chest tubes, emesis

Advancing the diet

Gradual progression of dietary intake or therapeutic diet
Promoting appetite
Assisting patients with oral feeding
Teaching may be needed

Stages of grief