MDC1 Exam 1: Key Terms & Definitions for ATI latest updated version with 100% accuracy

Wellness

involves the ability to adapt emotionally and physically to a changing state of health and environment.

Illness

is an altered level of function in response to a disease process.

Disease

is a condition that results in the physiological alteration in the composition of the body.

Modifiable

Can be changed, such as smoking, nutrition, access to health education, sexual practices and exercise

Non-modifiable

Cannot be changed, such as sex, age, developmental level, and genetic traits

Able to perform activities of daily living

Physical aspects of Health and wellness

Adapts to stress; expresses and identifies emotions

Emotional aspects of Health and wellness

interacts successfully with others

Social aspects of Health and wellness

Effectively learns and disseminates information

Intellectual aspects of Health and Wellness

Adopts a belief that provides meaning to life

Spiritual aspects of Health and Wellness

Balances occupational activities with leisure time

Occupational aspects of Health and Wellness

Creates measures to improve standards of living and quality of life

Environmental aspects of health and wellness

Crime vs. safety, poverty vs. prosperity, peace vs. social unrest, and presence vs. absence of support from social networks.

Social external environment

Access to health care, sanitation, availability of clean water, and geographic location

Physical external environment

The internal environment

includes cumulative life experiences, cultural and spiritual beliefs, age, developmental stage, gender, emotional factors and perception of physical functioning.

Desired outcomes

are to obtain and maintain optimal state of wellness and function through access to and use of health promotion, wellness and illness prevention strategies.

Health education and positive action (stress management, smoking cessation, weight loss, immunizations, seeking health care.

How to achieve health and wellness?

Illness-Wellness Continuum

assessment tool used to measure the level of wellness to premature death.

Runs from optimal wellness to severe illness, with the center being the persons normal state of health.

How is the Illness-wellness continuum used?

Illness (2)

is the impairment of a client's physical, social, emotional, spiritual, developmental, or intellectual functioning. It encompasses the effects of a disease on a client.

*Degree of physical changes as a result of a disease process.

*Perceptions by self and others of the illness, which can be influenced by various reliable and unreliable sources of information

*Cultural values and beliefs

*Denial or fear of illness

*social demands, time constraints, economic resources, and health care access.

Response to illness can be influenced by

*Physical assessment

*evaluating health perceptions

*identifying risks to health/wellness

*identifying access to health care

Health/Wellness assessment includes

*Perceptions of illness; awareness of the severity of the illness

*Confidence in the provider

*Belief in the prescribed therapy (past experience influence trust, religious/cultural beliefs different)

*Availability of support systems

*Family role & Function

*Financial restrictions (medication cost, appointment costs)

Obstacles to compliance and adherence to health/wellness plan

Nursing care

Evaluate the health needs of a client and create strategies to meet those needs

*Provide resources to strengthen coping abilities

*Identify and encourage use of support systems during times of illness and stress.

*Identify obstacles to health and wellness and create strategies to reduce these obstacles.

Identify ways to reduce health risks and improve compliance.

*Develop health education methods to improve health awareness and reduce health risks.

Nursing interventions for health and wellness include

In order, but overlapping

*Assessment/data collection

*Analysis/data collection

*planning

*implementation

*evaluation

5 steps of the nursing process framework

Methods of data collection

include observation, interviews with clients and families, medical history, comprehensive or focused physical examination, diagnostic and laboratory reports, collaboration with other members of the health care team.

nurses must ask clients appropriate questions, listen carefully to responses, and have excellent head-to-toe physical assessment skills. Nurses also must employ clinical judgement and critical thinking in accurately recognizing when to collect assessment data. They also must recognize the need to collect assessment data prior to interventions.

How to collect data effectively?

They feel, see, hear, and smell objective data through observation or physical assessment of the client. The nurse validates, interprets, and clusters data during the collection

Nurses observe and measure objective data (findings) during a physical examination by

Assessment/data collection

involves the systematic collection of information about clients' present health statuses to identify needs and additional data to collect based on findings. Nurses can collect data during and initial assessment (baseline data), focused assessment, and ongoing assessment.

during a nursing history. they include clients' feelings, perceptions, and descriptions of health status. Clients are the only ones who can describe and verify their own manifestations.

When is subjective data obtained and what does it include?

*recognize patterns or trends

*Compare the data with expected standards or reference ranges.

*Arrive at conclusions to guide nursing care.

Analysis/data collection requires nurses to look at the data and...

priorities and optimal outcomes of care they can readily measure and evaluate, which direct nursing interventions that promote, maintain or restore health.

When planning client care, nurses must establish

comprehensive, ongoing, and discharge

3 types of care planning a nurse does

Comprehensive (Initial)

plan of care based on comprehensive assessments the nurse completed (like an admission)

Ongoing planning

during the provision of care, new information and evaluating responses to care, cause the nurse to modify and individualize the initial plan of care

Discharge planning

is a process of anticipating and planning for clients' needs after discharge. To be effective, this planning should be started during admission.

Maslow's Hierarchy of Needs

A tool to set priorities when identifying the preferential order of problems would be

the observable criterion that will determine success or failure of the goal.

Goals identify optimal status, whereas outcomes identify

*client-centered

*Singular

*observable

*measurable

*time-limited

*mutually agreeable

*reasonable

Goals/outcomes must be

Physiological, safety and security, love and belonging, self-esteem and self-actualization

5 levels (base to top) of Maslow's Hierarchy of needs

Nurses perform or delegate the interventions and are accountable for them. An example is repositioning a client at least every 2 hr to prevent skin breakdown.

Nurse-initiated/independent interventions

Interventions nurses initiate as a result of a provider's prescription (written, standing or verbal) or the facility's protocol (blood administration procedures).

Provider-initiated/dependent interventions

interventions nurses carry out in collaboration with other health care team professionals (ensuring that a client receives and eats their evening snack).

Collaborative inventions

Therapeutic interventions

also include measures nurses take to minimize risk

Nurse uses all of the data and assessments to execute the plan of care.

Implementation stage of the nursing process

evidence-based rationale

What do nurses use for the selection and implementation of all therapeutic interventions?

*nurse evaluates the client responses

*nurses use the data to determine whether or not to change the plan of care.

*nurses evaluate the effectiveness of the care plan.

Evaluation stage of the nursing process

quick judgements that lead to single-focused solutions.

Critical thinking discourages

Lifelong learning and the ability to acquire relevant experiences that can be reflected on continuously to improve nursing judgment

critical thinking requires

knowledge, experience, critical thinking competencies, attitudes and intellectual and professional standards

Components of critical thinking include

1. Did I use language appropriate for the client?

2. Did I communicate the message clear to the provider?

A nurse should ask what about the language used during the communication process

intuition

An inner sensing that facts do not currently support something is called

*Nurse trusts the experts and thinks concretely based on the rules

*Basic critical thinking results from limited nursing knowledge and experience, as well as inadequate critical thinking experience.

Basic critical thinking level means

*Nurse begins to express autonomy by analyzing and examining data to determine the best alternative.

*Results from an increase in nursing knowledge, experience, intuition, and more flexible attitudes

Complex critical thinking level is

*Nurse expects to make choices without help from others and fully assumes the responsibility for those choices

*results from an expert level knowledge, experience, developed intuition, and reflective, flexible attitudes.

Commitment critical thinking level is

*Basic nursing education

*Use of evidence-based practice

*continuing education courses

*Advanced degrees and certifications

Knowledge; information that's specific to nursing and comes from:

*Demonstrates an understanding of clinical situations

*recognizes and analyzes cues for relevance.

*incorporates experience into intuition.

Experience: Decision-making ability derived from opportunities to observe, sense, and interact with clients, followed by active reflection. A nurse:

*Observe

*use correct techniques for collecting data

*differentiate between relevant and irrelevant data, and between important and unimportant data.

*organize, categorize, and validate data

interpret assessment data and draw a conclusion.

Critical thinking skills for assessment/data collection

*identify clusters and cues

*detect inferences

*recognize and actual or potential problem or risk

*avoid making judgements

Critical thinking skills for analysis/data collection

*Identify goals and outcomes for client care

*set priorities

*determine appropriate strategies and interventions for inclusion on a client's plan of care or teaching plan.

*take knowledge and apply it to more than one situation

*create outcome criteria

*Theorize

*Consider the consequences of implementation.

Critical thinking skills for planning

*Use knowledge base

*Use appropriate skills & teaching strategies

*test theories

*Delegate and supervise nursing care

*Communicate appropriately in response to a situation

Critical thinking skills for implementation

*Determine accuracy of theories

*evaluate outcomes bases on specific criteria

*determine understanding of teaching.

Critical thinking skills for evaluation

scientific method

problem solving

decision making

diagnostic reasoning and inference

clinical decision making; collaboration

Cognitive processes a nurse uses to make nursing judgements include

feels sure of abilities

Confidence attitude

Analyzes ideas for logical reasoning

independence attitude

is objective, nonjudgemental

Fairness attitude

Adheres to standards of practice

Responsibility attitude

Takes calculated chances in finding better solutions to problems

Risk-taking attitude

Develops a systematic approach to thinking

Discipline attitude

continues to work at a problem until there's a resolution

Perserverance attitude

Uses imagination to find solutions to unique client problems

creativity attitude

Requires more information about clients and problems

curiosity attitude

Practices truthfully and ethically

Integrity attitude

Acknowledges weaknesses

Humility attitude

ensure the thorough application of critical thinking

Intellectual standards for comparing care

*nursing judgement based on ethical criteria

*Evaluation that relies on evidence-based practice

*Demonstration of professional responsibility

*Promotes maximal level of nursing care

Professional standards for comparing care

Asepsis

is the absence of illness-producing micro-organisms. Hand Hygiene is the primary behavior.

Medical asepsis or "clean technique"

refers to the use of precise practices to reduce the number, growth and spread of micro-organisms

Surgical asepsis or "sterile technique"

refers to the use of precise practices to eliminate all micro-organisms from an object or area and prevent contamination

Soap

running water

friction

3 essential components of handwashing are

*before/after client contact

*after removing gloves

When must hand hygiene be performed with either alcohol based product or soap/water?

*visibly soiled

*before eating

*after the restroom

When must hands be washed with soap/water?

masks, gloves, gowns and protective eyewear are all used to help control the contact and spread of micro-organisms to staff and clients.

Protective clothing examples

*Do not place items on the floor

*Do not shake linens

*clean the least soiled areas first

*use plastic bags for moist and soiled items

*use biohazard containers for laboratory specimens

*Pour liquids in the avoiding spattering.

How to avoid micro-organisms from the physical environment?

*Prolonged exposure to airborne micro-organisms can make sterile items non-sterile

*Only sterile items can be in a sterile field

*Microbes can move by gravity from non-sterile item to a sterile item

*Any sterile, non-waterproof wrapper that comes in contact with moisture becomes non-sterile

Practices to maintain a sterile field

*avoid coughing, sneezing and talking directly over the field

*everyone avoid sudden movements, and touching things

Airborne threats to sterile field

*1 in border considered "not sterile", anything that touches is not sterile

*touch sterile materials with only sterile gloves

*any object below the waste is not sterile

*any object above the chest is not sterile

*sterile can touch sterile, but non-sterile contaminates everything

Rules for the actual sterile field

*do not reach across or above sterile file

*do not turn your back on a sterile field

*Hold items to add to the field at a minimum of 6 inches above it

Sterile filed etiquette

*Keep all surfaces dry

*discard any sterile packages that are torn, punctured or wet

Sterile field - moisture is bad

*Clean area, above waist level to set up

*check all packages for dry, intact and not expired

*make sure appropriate waste receptacle is nearby

equipment for a sterile field (set up/check)

*Perform hand hygiene

*Package in the center for workspace, top flap opening away from you

*Open the top flap - with the arm away from field

*Open the side flaps - right hand for right, left hand for left

*Grasp the last flap and open towards the body

Sterile field procedure

*Open the package without touching the product next to the sterile field, packages used last should be placed furtherst away

*Add them by holding the package 6 inches above the field, pulling the wrapper and letting it fall in the field.

Need more sterile packages in your field?

*remove cap (face up on non-sterile surface)

*Hold bottle with label toward palm

*pour small amount first into receptacle

*Pour solution onto the dressing or site without touching the bottle to the site

*expire after 24 hours or opening or recapping (or right way, check policy)

Sterile solution handling

*don gloves after set up

*Open wrapper, only touch outside of wrapper

*Use non-dominant hand to pick up the cuff of the dominant hand and slide the hand inside as your raise the glove.

*repeat using opposite hands

*adjust fingers after both gloved

*sterile gloves can only touch sterile gloves

Sterile glove procedure

are a framework for obtaining information about clients' physical, developmental, emotional, intellectual, social, and spiritual dimensions.

Standardized format - interviewing techniques

for health assessment foster communication and create an environment that promotes an optimal health assessment/data collection experience.

Therapeutic techniques- interviewing techniques

Shows the client they have your undivided attention

Active listening does what

encourage clients to tell their story in their own way. Use terminology clients understand

open-ended questions are used to do what

Question clients about specific details in greater depth or direct them toward relevant parts of their history.

Clarifying questions