NMNC 1110- Exam 2

Noticing (CJMM)

• initial stage

• involves recognizing deviations from expected patterns or situations.

• Nurses use their knowledge, experience, and context to identify relevant cues in patient care scenarios.

Interpreting (CJMM)

• analyze and make sense of the information they've noticed.

• They use reasoning patterns, including both analytical thinking and intuition, to understand the situation's significance.

Responding (CJMM)

• Based on their interpretation, nurses determine appropriate actions and interventions.

• involves deciding how to address the patient's needs effectively.

Reflecting (CJMM)

• crucial stage

• occurs both during (reflection-in-action) and after (reflection-on-action) patient care.

• evaluate nurse actions, patient outcomes, and overall experience,

• using insights gained to inform future clinical judgments.

Active listening (therapeutic communication)

nurse fully focuses, responds to, and remembers what the patient is saying both verbally and non-verbally,

open-ended questions (therapeutic communication)

encourages patients to provide detailed, expansive responses

“how”, “what”, or “tell me about it”

restating (therapeutic communication)

active listening strategy; nurse repeats key words or phrases the pt has just spoken

• helps understand the patient’s message

• use sparingly

clarifying (therapeutic communication)

part of active listening; used in nursing to ensure accurate understanding of a pt’s message

summarizing (therapeutic communication)

concise review of the key aspects of the interaction to bring a sense of satisfaction and closure

silence (therapeutic communication)

provides time for the pt to put thoughts or feelings into words, regain composure or continue talking.

empathy (therapeutic communication)

helps patient know that feelings are understood and accepted

Giving advice (barriers)

nurse imposes own opinion and solutions on the pt, implies the patient can’t make their own decisions

minimizing feelings (barriers)

minimizing feelings is an ineffective communication technique where a nurse downplays or dismisses a pt’s emotions

jargon (barriers)

refers to specialized terminology or technical language used within a specific profession or group

• misunderstanding if used with patients

• can cause anxiety or confusion

changing the subject (barriers)

nurse takes the initiative for the interaction away from the pt, , usually due to the nurse’s discomfort

1000 mL= ? L

1 L

1 cm = ? mm

10 mm

1 m = ? cm

100 cm

5 mL = ? tsp

1 tsp

15 mL= ? TBS

1 TBS

30 mL = ? oz

1 oz

1 cup= ? mL

240 mL

1 mg = ? mcg

1000 mcg

1 g = ? mg

1000 mg

1 kg = ? g

1000 g

1 kg = ? lbs

2.2 lbs

1 lb = ? oz

16 oz

1 L = ? kg (weight)

1

1 g = ? mL (volume)

1

gait belt

assistive device used in nursing to safely support and guide patients during ambulation or transfers.

lift equipment

• Transfer mats: Smooth, low-friction surfaces to assist with lateral transfers

• Slings: Fabric supports used with mechanical lifts for various patient positions

• Mechanical lifts:

  • Floor-based lifts: Mobile units for transferring patients between surfaces

  • Ceiling-mounted lifts: Overhead systems for vertical and lateral patient movement

Proper body mechanics

1. Alignment: Maintain proper posture with the spine in a neutral position

2. Balance: Keep a wide base of support with feet shoulder-width apart

3. Leverage: Use larger muscle groups and keep loads close to the body

4. Movement: Use smooth, controlled motions rather than jerky movements

5. Ergonomics: Adjust the environment to fit your needs when possible

Preventing injuries

• Bend at the knees and hips, not the waist

• Avoid twisting; instead, pivot with your feet

• Push rather than pull when moving objects

• Use mechanical aids when available

• Work at the appropriate height to avoid strain

canes

assistive devices used for ambulation that can relieve up to 40% of the weight normally borne by a lower limb

• Held in the hand opposite the involved extremity

• Less supportive than walkers or crutches, but more maneuverable in small spaces

• Suitable for patients who need minimal assistance with balance

walkers

assistive devices designed to provide stability and support for patients with lower extremity weakness or balance issues.

• Patients should not lean over or walk behind the walker

• Avoid use on stairs

• Wheeled walkers may roll forward when weight is applied

crutches

assistive devices used by individuals who cannot bear weight on one or both legs due to injury or disability.

• Axillary crutches: Most common, with padded top fitting under the axilla

• Forearm crutches: Metal band around forearm with handgrip

benefits of active ROM

• Maintains muscle strength and tone

• Improves circulation

• Enhances joint mobility

• Promotes independence in movement

• Helps prevent muscle atrophy

benefits of passive ROM

• Maintains joint flexibility

• Prevents contractures and deformities

• Stimulates circulation

• Reduces risk of pressure ulcers

• Can be performed when patient is unable to move independently

performing difference b/t active and passive

• Active ROM: Patient performs exercises independently

• Passive ROM: Caregiver moves patient's joints

patient involvement difference b/t active and passive

• Active ROM: Requires patient's voluntary muscle contraction

• Passive ROM: Patient remains relaxed; no active muscle engagement

muscle strength difference b/t active and passive

• Active ROM: Helps maintain or improve muscle strength

• Passive ROM: Does not directly strengthen muscles

application difference b/t active and passive

• Active ROM: Used when patients can move voluntarily

• Passive ROM: Used for unconscious, paralyzed, or very weak patients

risk of injury difference b/t active and passive

• Active ROM: Lower risk if performed correctly

• Passive ROM: Higher risk; caregiver must be careful not to overextend joints

energy expenditure difference b/t active and passive

• Active ROM: Requires more energy from the patient

• Passive ROM: Less demanding for the patient

risk factors for pressure injuries

1. Impaired mobility

2. Poor nutrition

3. Incontinence

4. Excessive moisture

5. Impaired sensation

6. Cognitive impairment

7. Advanced age

8. Poor perfusion or oxygenation

9. Friction and shear forces

10. Prolonged surgery

11. Certain medical conditions

prevention strategies for pressure injuries

1. Regular risk assessment using tools like the Braden Scale

2. Frequent repositioning (every 2 hours for bedridden patients)

3. Use of pressure-redistributing surfaces (mattresses, cushions)

4. Proper skin care and moisture management

5. Nutritional support

6. Patient and caregiver education

7. Minimizing shear during transfers and repositioning

8. Regular skin inspections, especially over bony prominences

9. Management of incontinence

10. Elevation of heels off the bed surface

11. Use of protective dressings on high-risk areas

12. Maintaining adequate hydration

13. Perioperative risk assessment and interventions

types of medication errors

1. Wrong medication

2. Incorrect dosage

3. Wrong route of administration

4. Wrong time of administration

5. Missed doses

6. Extra doses

7. Incorrect patient

8. Prescription errors

9. Transcription errors

10. Preparation errors

prevention strategies for medication errors:

1. Implement the "Five Rights" of medication administration:

   • Right patient

   • Right medication

   • Right dose

   • Right route

   • Right time

2. Use barcode medication administration systems

3. Utilize computerized physician order entry (CPOE) systems

4. Double-check high-risk medications with another nurse

5. Minimize distractions during medication preparation and administration

6. Ensure clear and complete medication orders

7. Maintain up-to-date medication knowledge

8. Report near-misses and actual errors to improve system safety

9. Educate patients about their medications

10. Perform regular medication reconciliation

11. Use standardized medication administration practices

12. Implement a non-punitive reporting system for medication errors

13. Provide ongoing education and training for healthcare providers

non-punitive incident reporting

• crucial component of culture of safety

• increased reporting rates

• better id of safety issues

• improved pt care and outcomes