Core Concepts of Nursing - Exam 1 Blueprint

What Makes Nursing a Profession?

Regulation (Nurse Practice Act + Standards of Care)

Licensure (NCLEX)

Education (life-long learning process)

Professional Organization (being an active member)

Code of Ethics (from the ANA)

Board of Nursing (BON)

Standards of practice establish a minimal acceptable level of nursing practice in any setting for each level or nursing licensure or advance practice authorization

When was nursing NOT the #1 most respected job?

In 2001, firefighters were the most respected because of 9/11

Ethics

the study of conduct and character; affect judgments about what is right or wrong

ethical principles

Autonomy

Beneficence

Nonmaleficence

Justice

Fidelity

Veracity

DO NOT CHANGE

Autonomy

the right to make one's own personal decisions

Justice

fairness in care delivery and use of resources

Veracity

a commitment to tell the truth

Fidelity

fulfillment of promises

Beneficence

Action that promotes good for others, without any self-interest

Nonmasleficence

a commitment to do no harm

What about ethical principles DOES change?

interpretation and application

ethical dilemma

occurs when ethical principles and their application DIFFER

ethical decision making

involves finding a balance between science, ethics, and personal moral values

morals

a system of beliefs that is taught for deciding good and bad

- what's right or wrong for one's self

values

personal beliefs about ideas that determine standards that shape behavior

- comes from within

- professional and societal standards

self-reflection

first step in developing self-awareness

moral distress

situation where the actions taken are different from what the nurse feels is ethically correct

ANA Code of Ethics

9 provisions that serve as a basic ethical guideline for nursing

Caring

the basis of the nursing profession

- NOT an ethical principle

Kindness

an outward expression of caring

5 Auscultation Sites of the Heart

1. Aortic: 2nd ICS (right)

2. Pulmonic: 2nd ICS (left)

3. Erb's Point: 3rd ICS (left)

4. Tricuspid: 4th ICS (left)

5. Mitral: 5th ICS (left)

Erb's Point

the transition point where "lub" (S1) becomes louder than "dub" (S2)

Mitral

the apex of the heart

- point of max impulse (PMI)

- medial to the midclavicular line

S1

"lub" - first heart sound

- atrioventricular

- closure of the mitral and tricuspid valves (contraction; systole)

S2

"dub" - second heart sound

- semilunar

- closure of aortic and pulmonic valves (relaxation; diastole)

S3

ventricular gallop heard after S2

S4

strong atrial contraction, expected finding in older and athletic adults/children, use bell

murmurs

abnormal heart sounds created by increased blood volume in the heart, or impeded flow

Bruits

abnormal blowing or swishing sound of the heart; decreased blood flow

Where to Hear Bruits

1. carotid arteries

2. abdominal aorta

3. renal arteries

4. iliac arteries

5. femoral arteries

Patient Position for Listening to the Heart

1. sitting, leaning forward

2. lying supine

3. turned towards the left side (best for extra sounds)

Diaphragm of stethoscope

High-pitched sounds (lung, bowel, heart); place firmly against skin

Bell of stethoscope

low pitched sounds (extra heart sounds, murmurs); place lightly against skin

Normal BP Range

90-120 systolic

60-80 diastolic

Prehypertension BP Range

120-139 systolic

80-89 diastolic

Components of a Health Assessment

- systematic (talking precedes touching)

- critical thinking (using the data to make critical decisions

- patient's current and ongoing health status (70% of the diagnosis comes form the health history)

- risk factors (modifiable or non-modifiable)

- identify health-promoting activities

Problems Presented by the Patient

- Physical (pain, SOB, weight gain, rashes, etc)

- Social (anxiety, stress, sexual history, etc)

- Emotional (recent life-altering events, depression, mental health, etc)

- Cultural

-Environmental (occupation, home life, etc)

Four Types of Assessments

1. Initial (baseline): performed after admission to establish a baseline (K levels, vital signs, etc)

2. Problem-focused: determines the status of a specific problem; ongoing process (specific vascular checks, cranial nerve assessments, etc)

3. Emergency: during a crisis to identify life-threatening problems (ABC method for respiratory distress)

4. Ongoing Reassessment: comparison of the patient's current statue to the previous baseline data (head-to-toe, looking at trends)

Sources of Data

Primary = the CLIENT

Secondary = all other sources which does NOT COME FROM THE client (family, friends, patient record, literature, other healthcare providers)

Subjective data

anything reported by the patient

- typically SAID; presents in quotations

EX: pain, symptoms verbally expressed, family history, social history, etc

Objective data

anything that can be measured by the healthcare professional

EX: heart rate, urine output, lab reports, weight, vital signs, etc

Methods of Data Collection

1) Observation

2) Interviews

3) Examination

Observation Method of Data Collection

Using the senses to observe patient data

Vision: skin color, body language, weight gain/loss, etc

Hearing: cough, speech, wheezing, etc

Smelling: body odor, infection, melena, etc

Touch: edema, temperature, equal pulses, etc

Interviewing Method of Data Collection

A sit down conversation with the patient in an appropriate setting with an adequate amount of time

- Techniques: Standardized formats or Therapeutic techniques

- have privacy, consider having an interpreter, pull up a chair and face the patient

General Examining Sequence

1. Inspection

2. Palpate

3. Percussion

4. Auscultation

Abdomen Examining Sequence

1. Inspection

2. Auscultation

3. Percussion

4. Palpate

- Auscultation comes prior to steps 3 & 4 to ensure that the bowel sounds do not become obstructed

Maslow's Hierarchy of Needs

1. Physiological Needs: the priority concern to address first (respiratory status, cardiovascular health, GI needs such as food, fluids, and nutritional intake as well as elimination, etc.)

2. Safety and Security (preventing injuries or illnesses from occurring, establishing security and safety, building trust, etc)

3. Love and Belonging (ensure adequate support systems are maintained)

4. Self-Esteem (promoting a sense of worthiness and acceptance, etc)

5. Self-Actualization: lowest priority

Erickson's Stages of Development

- Infancy (birth to 18 months) Trust vs. Mistrust

- Early Childhood (2 to 3 years) Autonomy vs. Shame and Doubt

- Preschool (3 to 5 years) Initiative vs. Guilt

- School Age (6 to 11 years) Industry vs. Inferiority

- Adolescence (12 to 18 years) Identity vs. Role Confusion

- Young Adulthood (19 to 40 years) Intimacy vs. Isolation

- Middle Adulthood (40 to 65 years) Generativity vs. Stagnation

- Late Adulthood (65 to death) Ego Integrity vs. Despair

Validating Data Collection

checking allergies, clarifying vague statements, checking extreme abnormal findings a second time or manually

Interpreting Data Collection

using the information to determine nursing care

- includes nursing autonomy

Documentation

a part of communication; if it was not documented, it was not done

- objective

- use SBAR during handoffs

General Survey Components

information gathered upon the first encounter with the patient

- AIDET

- physical appearance, body structure, mobility, behavior, and vital signs

- always check patient ID (name, DOB, etc)

AIDET

Acknowledge

Introduce

Duration

Explain

Thank

PQRST

Provoked (what causes the pain?)

Quality (what does the pain feel like?)

Region (where is the pain?)

Severity (0-10 scale)

Timing (when did it start? is the pain consistent?)

What is the nursing action for a patient with an irregular pulse?

Count the pulses for the entire minute instead of 30 seconds

If there are no bowel sounds heard, what action should the nurse take?

Listen to each quadrant for 5 minutes

Regular Respiration Rate

12-20 breaths per minute

Regular Pulse Rate

60-100 beats per minute

- measure using radial pulse

Normal Blood Pressure Range

90-119 systolic

60-79 diastolic

Tympanic Temperature

measuring the body temp from the heat of the eardrum; range: 96.2 to 100

- for older patients, pull the ear back and up

- for children, pull the ear back and down

Temporal Temperature

measuring the body temp using the forehead; range: 98.7 to 100.5

Oral Temperature

measuring the body temp sublingually; range: 96.8 to 100.4

- wait 10-30 mins if the client has been eating, drinking, etc

- instruct patient to breathe out their nose

What temperature is considered a fever?

100.4 F

When measuring the Blood Pressure...

...ensure the cuff is the correct size, and place the cuff about 2 inches above where you palpated the brachial pulse; use the diaphragm of the stethoscope on the brachial artery

- if the cuff is too big: BP reading will be a false LOW

- if the cuff is too small: BP reading will be a false HIGH

Pulse Oximeter

attaches to the earlobe or fingertip to measure the oxygen saturation of arterial blood

- results may be skewed with nail polish or excessive movement

Before beginning any personal care delivery, what task should be completed?

an evaluation of the client's ability to participate in personal hygiene; encourage them to participate as much as they can

Types of Baths

complete baths, partial baths, and therapeutic baths

- bathe systematically from the upper extremities to the lower extremities

- long firm strokes form distal to proximal

Changing Bed Linens

- do unoccupied linen change as often as possible

- smooth wrinkles

- keep soiled linens AWAY from you

- DO NOT SHAKE linens because it spreads micro-organisms through the air

- mitered corners

Nail, Hand, and Foot Care

- Inspect the feet daily, do not apply lotion between the toes or fingers, cut nails straight across (check the facility's policy prior to cutting)

- Check nails for cracking, clubbing, and fungus

Nail and Foot Care for Patients with Diabetes Mellitus

- do not soak the feet due to the risk of infection

- do not cut the nails; file nails using a nail file

- do not apply lotions between the fingers and toes

-a qualified professional may be needed

Oral Hygiene for Unconscious Patients

- have suction set up at bedside

- use a soft-bristled brush

- use a syringe with a small amount (10mL) of water

- place patient on one side with the head turned toward you or in semi-Fowler's position

- DO NOT put your fingers in their mouth

- perform oral care every 2 hours

Denture Care

BE HELLA CAREFUL

- remove/insert the top dentures first (down and out)

- remove/insert the bottom dentures second (up and out)

- place a towel in the bottom of the sink

- use tepid water

- place the dentures in a cup with water to keep them moist

Perineal Care

always use fresh water and a new area of the washcloth to perform perineal care; cleanse from front to back

- Males: cleanse penis in a circular motion; retract foreskin to wash the tip (meatus outward) then replace the foreskin

- PAT dry

Hair Care

brush or comb hair daily with soft-bristled brush or wide-toothed comb

- use dry shampoo or no-rinse shampoo (heat activated) and shampoo cap

For Shaving:

- if patient is prone to bleeding, is on anticoagulants, or has a low platelet count, use an electric razor

- shave in the direction of the skin

- large strokes for large areas, short strokes for the chin and lips

What's the priority action to prevent falls?

complete a fall-risk assessment for each client upon admission and at regular intervals

- use the Morse Fall Scale or the Hendrich II Fall Risk Model

Other Priority Actions for Fall Prevention

1. Bed Locked

2. Bed Low

3. Call light within reach

4. Bedside table w/in reach

5. Correct number of side rails up

Which organization sets the National Patient Safety Goals?

The Joint Commission (TJC) in 2002

- developed and revised by a panel of healthcare experts

- maximum impact and usefulness for the minimum cost

QSEN 6 Core Competencies

1. Patient-centered care

2. Informatics and Technology

3. Evidence-based practice

4. Quality improvement

5. Safety

6. Teamwork and collaboration

- ensures that nurses have knowledge, skills, and attitude (KSA)

Fire Safety

All staff must know the location of exits, alarms, fire extinguishers, and oxygen shut-off valves; know the evacuation plan

- change smoke detector batteries twice a year

- use cotton material to prevent fire

- have "No Smoking" signs

RACE

fire response acronym

R = rescue and protect clients

A = activate the facility's alarm system

C = contain/confine the fire by closing doors and windows & turning off oxygen

E = extinguish the fire

PASS

acronym for fire extinguisher use

P = pull the pin

A = aim at the base of the fire

S = squeeze the handle

S = sweep the extinguisher from side to side

Why is Carbon Monoxide so dangerous?

It binds to hemoglobin and reduces oxygen; it cannot be seen, smelled, or tasted; can cause death

Food Poisoning

- most caused by bacteria

- most occurs due to unsanitary food practices

ABCDE principles

Airway: open airway?

Breathing: chest rise and fall, RR

Circulation: heartbeat, pulse, cap refill, BP, stop any bleeding

Disability: level of conciousness

Exposure: prevent hypothermia; warm blankets, fluids

CPR

sustains oxygenation and circulation to vital organs

- involves "CAB"

CAB

components of CPR

C = chest compressions

A = airway

B = breathing

What should be the temperature of the water heater in someone's home?

below 120 degrees

Standard Precautions

- proper hand hygiene

- PPE

- effective management of potentially contaminated surfaces

Restraints

protective devices used to limit physical activity of the client or a part of the body

- used to protect the patient from self-harm and to protect other patients and staff

Physical Restraints

any manual method, material, or device attached to the patient's body to limit or restrict free movement

- limb restraints

- belts

- mitts

- wheelchairs with stationary lap trays

- bed rails

Chemical Restraints

pharmacological agents administered for the purpose of controlling behavior

- sedatives (EX: Benedryl)

Unethical uses of Restraints

- convenience of staff

- punishment for the patient

- patients who are extremely physically or mentally unstable

Policies and Procedures for Using Restraints

- MUST BE PRESCRIBED AFTER A F2F ASSESSMENT

- can be applied in emergencies, but a prescription must be obtained from the provider within 1 hour

- max 24 hours

- Length of application: Adults = 4 hours; Ages 9-17 = 2 hours; under 9 = 1 hour

- Assess skin every 2 hours

- always offer food, fluids, and bathroom breaks

- pad bony prominences

- use a QUICK-RELEASE KNOT

- do not secure restraints to the bed rails

Homeopathic medicine and herbal remedies are...

...not FDA approved

Non-pharmacological Nursing Interventions

Guided Imagery, healing intention, breath work, humor, meditation, simple touch, music or art therapy, therapeutic communication, and relaxation techniques

Pain

an unpleasant sensory and emotional experience associated with actual or potential tissue damage

THE #1 PRIORITY

- based on duration and origin

pain threshold

the point at which a person feels pain

Pain tolerance

the amount of pain a patient can endure

Acute Pain

pain that lasts less than 6 months

- has a direct cause, sudden onset, and is temporary

- causes changes in physiological responses (vital signs)

- deal with the source!!!

- can lead to chronic pain if not handled

EX: breakthrough pain