FUNdamentals of Nursing - Exam 1

What are the most important roles of the nurse (5)

Caregiver

Advocate

Educator

Researcher

Leader

What are the 5 steps in the nursing process?

(1) Assessment

(2) Nursing Diagnosis

(3) Planning

(4) Implementation

(5) Evaluation

*** All of the above require critical thinking!

Define Assessment

Collects comprehensive data pertinent to the patient's health and/or situation.

- info medical personnel can look at

- begins the moment you walk through the door

Can the RN provide subjective information about patient?

NO! Only the patient can give subjective info.

OBJECTIVE info is what the RN sees, hears, or smells

What is the Diagnosis phase?

Analyze the assessment and make a clinical judgement related to an ACTUAL or POTENTIAL health problem.

** Nurses have to be aware of potential risks based on health problems.

** Also collaborate with other specialists to manage the problem(s)

What are the three phases of a Nursing Diagnosis?

First info → Related to → as evidence by

WHAT is the problem?

WHY is it a problem?

WHAT is the evidence of that problem?

Ex:

"Acute pain → related to surgical incision → as evidence by patient report (or as evidence by crying)"

What are the OUTCOMES IDENTIFICATION?

This is the statement of how a patient's status will change once interventions have been successfully instituted

Identify the expected outcomes when planning for the patient's individual situation.

Interventions must be measurable criterion indicating that objectives have been met.

Define the PLANNING stage of the nursing process

Develops a plan that prescribes strategies and alternatives to attain expected outcomes.

- Prioritize strategies

- Goals (statement that describes the aim if the nursing care) should be short term and long term

Describe IMPLEMENTATION of the nursing process

The actions to facilitate positive patient outcomes

What three skills are needed in order to implement goals?

Cognitive

Personal

Psychomotor

Describe the EVALUATION phase of the nursing process

This describes how well the patients needs were met (or not met).

Done through reassessment

What percentage of all communication is nonverbal?

90%

What two characteristics should nurses always exude?

CARING

COMPETENCE

How is communication used in the Assessment phase of the nursing process?

Verbal interviewing and history taking

Visual and intuitive observation of nonverbal behavior

Visual, tactile, and auditory data gathering during physical examination.

Written medical records, diagnostic tests, and literature review.

Define REFERENT

The referent motivates one person to communicate with another.

Examples of referents: sights, sounds, odors, time schedules, messages, objects, emotions, sensations, perceptions, ideas, etc.

Define SENDER in communication

The person who encodes and delivers the message.

Sender puts ideas or feelings into form that is transmitted and is responsible for accuracy and emotional tone of message content

What is the RECEIVER in the communication process?

The person who receives and decodes the message

** senders message acts as a referent for the receiver, who is responsible for attending to, translating, and responding to the message.

MESSAGE in communication process

Content of communication.... verbal, nonverbal & symbolic language.

CHANNELS in communication process

These are the means of conveying the message through visual, auditory, and tactile senses.

Facial expression = visual message

Spoken word = auditory

Touch = tactile

FEEDBACK in communication process

The message that the receiver returns. This indicates if receiver understood meaning of message. Sender can evaluate effectiveness of communication.

Explain the communication process briefly

The source has a message and encodes the message.

Message is sent through a channel

Receiver must first decode the message

Before message can be fully received

What are the 5 levels of communication in nursing?

Interpersonal

Interpersonal

Small group

Public

Transpersonal

Define Intrapersonal

a.k.a. SELF-TALK

Define Intrerpersonal

Occurs between two people or groups

- usually one on one conversation

Define Small Group Communication

Committee or a conference

Public Communication

Interaction of one person with a group of people

Transpersonal Communication

Within a person's spiritual domain

Forms of Communication

Messages conveyed verbally and nonverbally, concretely and symbolically.

Expression through: Words, movements, voice inflection, facial expression, and use of space

Elements can work in harmony to enhance a message OR conflict with one another to confuse it.

Example Forms of Communication

VOCABULARY

What is the role of the nurse?

Nurse often the interpreter of medical terminology

Example Forms of Communication

DENOTATIVE AND CONNOTATIVE

What is the role of the nurse?

Denotative is the exact meaning

Connotative is shades of the meaning

Be selective in word choice and avoid easily misinterpreted words.

Example Forms of Communication

PACING

What is the role of the nurse?

Speak slowly and enunciate clearly!

Too fast = unintended messages

Too slow = impression of hiding the truth

Example Forms of Communication

INTONATION

What is the role of the nurse?

Tone of voice... be careful

Example Forms of Communication

CLARITY & BREVITY

What is the role of the nurse?

Simple - short - to the point

& possible repeated

Example Forms of Communication

TIMING & RELEVANCE

What is the role of the nurse?

When it is appropriate to discuss issues & what is most important at that time.

What are forms of Nonverbal Communication?

Personal Appearance

Posture and gait

Facial Expression

Eye Contact

Gestures

Sounds - sighs, moans, groans...

Territoriality & Space

What are the four phases of the Helping (Nurse-Patient) Relationship?

Pre-interaction

Orientation

Working

Termination

Describe the PRE-INTERACTION phase of the Helping Relationship.

This takes place before meeting the patient:

- Review available data, history

- Talk to other caregivers who have info about patient

- Anticipate health concerns or issues that arise

- Identify a location or setting that fosters comfortable, private interaction

- Plan enough time for initial interaction

Describe the ORIENTATION phase of the Helping Relationship.

When nurse and patient first meet and get to know one another:

- Set the tone for the relationship by adopting a warm, empathetic, caring manner

- Recognize relationship is tentative

- Expect patient to test your competence and commitment

- Closely observe

- Begin to make inference and form judgements about messages and behaviors

- ASSESS PATIENT HEALTH STATUS

Describe the WORKING phase of the Helping Relationship.

When nurse and patient work together to solve problems and accomplish goals. TEACHING occurs.

- Encourage pt. to express feelings about health

- encourage pt. w/ self exploration

- Provide information

- Help pt. set goals

- Take action to meet said goals

- Use therapeutic comm

- Use appropriate self-disclosure & confrontation

Describe the TERMINATION phase of the Helping Relationship.

Ending of the relationship

- Remind pt. that termination is near

- Evaluate goal achievement with pt.

- Reminisce about relationship with pt.

- Separate from the pt. by relinquishing responsibility for care

- Achieve a smooth transition for pt. to other caregivers

Acronym used for successful communication in the workplace to promote teamwork and safety.

S - situation

B - background

A - assessment

R - Recommendation

Characteristics of communication within Caring/Working Relationships:

Professionalism - appearance, demeanor, behavior

Courtesy - hello, good-bye, knock on doors, please, thank you...

Use of Names - Always introduce yourself

Confidentiality - HIPPA

Trust - always honest!

Acceptance & Respect - Non-judgmental attitudes

Availability - "Anything else I can get you?

Socializing - don't socialize with pt. and don't socialize with colleagues where pt's can hear

What is therapeutic communication techniques?

Specific responses that encourage the expression of feeling and ideas and convey acceptance and respect.

Define the therapeutic communication technique of:

Active Listening

Being attentive to what patient is saying both verbally and nonverbally.

** Use SOLER to facilitate attentive listening

Define acronym SOLER

S - Sit facing the patient

O - Open posture

L - Lean toward the patient

E - Establish & maintain eye contact

R - Relax

Define the therapeutic communication technique of:

Sharing Observations

Observations/perceptions can help start a conversation, but need to be careful not to anger patient or make assumptions.

Define the therapeutic communication technique of:

Sharing Humor

Important but often underused resource in nursing interactions. It is a coping strategy that adds perspective and helps adjust to stress.

Define the therapeutic communication technique of:

Using Silence

Allow patient to break the silence, particularly when he/she has initiated it.

Particularly useful when people are confronted with decisions that require thought.

Define the therapeutic communication technique of:

Providing Information

To help patient understand, but do not preach

Define the therapeutic communication technique of:

Clarifying

Check that understanding is accurate

Restate an unclear message

Rephrase to clarify

Define the therapeutic communication technique of:

Focusing

Centers on key elements of concepts of message

Helpful when patient is vague or rambles

Define the therapeutic communication technique of:

Restating

or Paraphrasing

this sends feedback that lets the patient know nurse is actively involved

Define the therapeutic communication technique of:

Open-ended Questions

Asking relevant questions allows patient to fully respond

Define the therapeutic communication technique of:

Reflection

Summarizing a concise review of key aspects of interaction. Especially helpful in termination phase

Other techniques of therapeutic communication are:

Sharing empathy

Sharing hope

Use of Touch

Sharing feelings

Self-Disclosure

Confrontation (with sensitivity after trust is established)

What physical and emotional factors must a nurse assess through communication?

Developmental -

age, physiological status (pain, hunger, weakness)

Socioculture

Language

Gender

How can you communicate with non-english speaking patient?

Translator or translator phone

What are some non-theraputic communication characteristics?

Inattentive listening

use of medical jargon

Sympathy

Arguing

Being defensive

How does the nurse demonstrate caring in communication?

Become sensitive to self & others

Promote and accept expression of pos & neg feelings

Develop helping trust relationships

Instill faith & hope

Promote interpersonal teaching & learning

Provide supportive environment

Assist with gratification of human needs

Allow for spiritual expression

What are the Zones of Touch?

Social zone

Consent zone

Vulnerable zone

Intimate zone

Social zone of touch is

Hands, arms, shoulders, back

Permission not needed

Consent zone of touch is

Mouth, wrists, feet

Permission needed

Vulnerable zone of touch is

Face, neck, front of body

Special care needed

Intimate zone of touch is

Genitalia, rectum

Great sensitivity needed

Zones of Personal Space

Intimate - 0-18"

Personal - 18" - 4'

Social - 4 -12 ft

Public - > 12 ft

What is Intimate zone of personal space?

Holding crying infant

Performing physical assessment

Bathing, grooming, dressing, feeding, and toileting a patient

Changing patient dressing

What is Personal Zone of personal space?

Sitting at a patient's bedside

Taking patient history

Teaching patient

Exchanging info at shift change

What is Social Zone of personal space?

Making rounds with physician

Sitting at the head of a conference table

Teaching a class for patients with diabetes

Conducting family support

What is public zone of personal space?

Speaking at a community forum

Testifying at a legislative hearing

Lecturing to a class of students

INFECTION PHYSIOLOGY.......

SEE NOTECARDS FOR MED-SURG EXAM, PART ONE

to review vocabulary and basic understanding.

THEN... proceed in this set of flashcards for the Nursing Care of Infections

Nursing process for Infection: Assessment

Assess all risk factors:

age, nutrition, diagnostic procedures (IV, catheters), occupation, high-risk behaviors, travel history, trauma, stress

Nutritional Status

- reduction in protein impairs healing

Lab Data

- WBC count (5000-10000 norm)

- Cultures

- ESR (up to 15 for men and 20 for women)

- Iron level 60-90g/100mL

- Differentials

Chronic or serious infections/diseases/disorders

- COPD → pneumonia

- heart failure → skin breakdown

- diabetes → venous stasis ulcers

* diabetes patients at risk for chronic infections

Nursing process of Infection: Diagnosis

⊗ Disturbed body image = look bad, smell bad, etc

⊗ Risk for fall

⊗ Risk for infection = lab results (WBC 5,000-10,000/mm³), review current meds

⊗ Identify potential sites of infection = IV, catheter

⊗ Imbalanced nutrition = protein needed for healing

⊗ Acute pain

⊗ Impaired skin integrity or tissue integrity

⊗ Social isolation

Nursing process of Infection: Planning

Goals & Outcomes

Setting priorities

→ Treatment is always a priority

Collaborative care

Nursing process of Infection: Implementation

Health promotion - break chain of infection

Nutrition

Hygiene

Immunization

Adequate rest and regular exercise

Nursing process for Infection: Evaluation

Measure the success of infection prevention

Measure the patient and family adherence to discharge plans

Wound status and healing

** did your patient get better or worse? Did your patient get an infection at hospital?

Standard precautions taken with ALL patients protect health care workers from:

Blood

Body fluids (except sweat)

Excretions

Non-intact skin

** These precautions began in the 80's as a result of HIV/AIDS

It is required to wash hands with water and soap when:

Hands are visibly dirty

When soiled with blood or other body fluids

Before eating

After toileting

Exposure to spore-forming organisms (c-diff, bacillus anthracis)

Use of alcohol-based waterless antiseptic agent for routinely decontaminating hands for following situations:

Hands NOT visibly soiled

Before/after/between direct patient contact

After contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressing

When moving from contaminated to a clean body site during patient care

After contact with inanimate surfaces or objects in the patients room

Before caring for patients with sever neutropenia or other forms of immunosuppression

Before putting on sterile gloves to insert invasive devices

After removing sterile gloves

Nursing process for Infection: Implementation in Acute Care Settings

Use standard precautions

Control or eliminate infectious agents

Cleaning

Disinfection/Sterilization

Control or eliminate reservoirs

Control of portals of exit

Control of transmission

hand hygiene

Isolation & barrier protection

Protective equipment

Proper removal of PPE

Role of infection prevent & control

Prep for sterile procedures

Restorative/long-term care

What is order of preparing to enter room on isolation?

Gown

Mask or Respirator

Eye wear

Gloves

What is order of removal of protective equipment for isolation?

Gloves

Goggles

Gown

Mask

Sterile field must have what size border?

1 inch

What are the vital signs?

Pulse

Pain

Temp

BP

Respiration

Pulse Ox

When do you take vitals?

When they first enter

Appropriate intervals during stay

Just before they leave

Why must you know the baseline vitals for a patient?

Any changes in vital signs can help the nurse immensely

What are guidelines to measuring vital signs?

Must get baseline by taking when first enter

Measure correctly

Understood & interpreted

Communicated

Body Temp normal range

96.4-100.1

Body temp is affected by heat loss, what causes this?

Radiation

Conduction

Evaporation

Convection

What produces heat in the body?

Cellular Respiration

What is considered a fever?

Adult 102.2 ↑

Child 104

What is pyrexia?

FEVER

What is an Antipyretic?

Medication that brings down fever

Ex: Tylenol, NSAIDS

How is temp measured?

At the core or the surface by:

Electronic

Infrared

Digital

Disposable Chem Dot

What is pulse?

Palpable bounding of the blood flow in a peripheral artery

What are the locations for pulse?

Temporal

Carotid

Apical

Brachial

Radial

Ulnar

Femoral

Popliteal

Posterior tibia

Dorsalis pedis

What is Tachycardia

Pulse faster than 100 bpm

What is Bradycardia

Pulse slower than 60 bpm

What is Blood Pressure

Ability of the peripheral blood vessels to constrict and dilate that depends on cardiac output, PV resistance, blood volume, blood viscosity, and artery elasticity

What are the blood pressure variations?

Hypertension

Hypotension

Orthostatic hypotension

Orthostatic Hypotension

Looking for a drop in blood pressure during a rise in heart rate when person changes from lying to sitting to standing.