N330 Exam 1 Study Guide

Professional Nursing Practice and the Nursing Process, Disability and Chronic Illness, Management of the Older Adult Patient, Pain, Management of Patients with Musculoskeletal Disorders, Management of Patients with Musculoskeletal Trauma, Nutritional and Cultural Assessments, Management of Patients with Eye Disorders, and Management of Patients with Hearing and Balance Disorders.

Critical thinking

A cognitive process that utilizes thinking that is purposeful, insightful, reflective, and goal directed to develop conclusions, solutions, and alternatives

• Using general knowledge, questioning assumptions, comparing information, and recognizing relationships

Clinical reasoning

The thought processes that allow healthcare providers to arrive at a conclusion

• Applying critical thinking to this specific patient and situation by gathering and interpreting relevant clinical information

Clinical judgment

The observed outcome of critical thinking and decision making.

• An iterative process with multiple steps that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern and generate the best possible evidence-based solutions to deliver safe patient care

• Process of recognizing, interpreting, prioritizing, acting, and evaluating that uses both critical thinking and clinical reasoning to make decisions about patient care

• Critical thinking + clinical reasoning + knowledge and experience

Clinical Judgment Model

1. Recognize Cues → What matters most? (Assessment)

2. Analyze Cues → What does it mean? (Analysis)

3. Prioritize Hypotheses → Where do I start? (Analysis)

4. Generate Solutions → What can I do? (Planning)

5. Take Action → What will I do? (Implementation)

6. Evaluate Outcomes → Did it help? (Evaluation)

Maslow’s Hierarchy of Needs

1. Physiological Needs → Food, water, warmth rest

2. Safety Needs → Security and safety

3. Belongingness and Love Needs → Intimate relationships and friends

4. Esteem Needs → Prestige and feeling of accomplishment

5. Self-Actualization Needs → Achieving one’s full potential, including creative activities

SMART Goal

• S- Specific → Who, what, when, where, why?

• M- Measurable → You can’t improve what you don’t measure

• A- Achievable → Challenging but not impossible

• R- Relevant → Closely connected to the objective

• T- Timely → A completion time frame holds you accountable

*Always start with “The patient will…” (It keeps the goal patient-centered)

Clinical Judgment: Recognizing Cues/Assessment

• Recognizing normal vs. abnormal, urgent vs. non-urgent, and stable vs. unstable

• Quickly identify immediate concerns → What pieces of information are the most important?

• Notice signs and symptoms

• Gather objective and subjective data

Clinical Judgment: Analyzing Cues/Analysis

• Recognize connections between pathophysiology and patient presentation

• Begin to form your hypotheses → How do the cues you identified connect with possible client conditions?

• Identify gaps in your hypotheses → What additional information is needed? How can you obtain it?

• Make connections based on patterns and use your clinical reasoning

Clinical Judgment: Prioritize Hypotheses (Analysis)

• What explanations are most vs. least likely?

• Which explanations are the most serious/concerning?

• Rank possible explanations by priority → Consider your ABCs and Maslow’s Hierarchy of Needs

• Develop your priority Nursing Problem/Concern

Clinical Judgment: Generating Solutions/Planning

• Consider possible outcomes

• Establish SMART goals

• Consider which interventions are needed, who will enact them, and frequency of enactment

Clinical Judgment: Taking Action/Implementing

• Carry out your proposed plan (directly or indirectly)

• Request all items or assistance needed

• Administer (medications, fluids, etc.)

• Perform nursing skills (dressing change, assessment, etc.)

• Document!

• Continually assess the patient and communicate

Clinical Judgment: Evaluate Outcomes

• Determine the patient’s response to nursing interventions

• Complete an appropriate reassessment

• What data points are changing in the client’s status?

• Could other interventions have been more effective or been added to the treatment plan?

• Are there new priorities?

• Are revisions to the plan needed?

Chronic disease

A diagnosable medical condition that is treatment-focused and objective

Chronic illness

The lived experience of managing symptoms, emotions, and lifestyle changes that come with chronic disease.

• Nursing Care: Assess the whole person, ask about daily life, identify barriers and supports, promote dignity and autonomy, communicate, and educate (check for understanding and set goals)

Multiple Chronic Conditions (MCC)

Having two or more chronic health conditions:

• Increases the complexity of care

• Risk for conflicting medical advice, adverse effects of medications, unnecessary duplicative tests, and preventable hospitalizations

• Costs of care increase with the number of chronic conditions

Disability

• Physical, mental, intellectual, or sensory impairment that, in interaction with various barriers, may hinder full participation in society

• Interaction between a health condition and societal barriers

• Acceptable Language → “person with a disability” or “disabled person”

• Nursing Care Considerations: Promote autonomy, ask preferences, adapt with tools, pace your assessment, prevent complications, advocate

Ableism

• A system of beliefs and practices that devalues people with disabilities or chronic illnesses by assuming that able-bodiedness is the norm → creates discrimination, exclusion and health disparities

• Impact of Patients: delayed or missed diagnoses, psychological harm, loss of trust, decreased access to care, and poor health outcomes

Geriatrics

A field of practice that focuses on the physiology, pathology, diagnosis, and management of the disorders and diseases of older adults

Comorbidity

Having more than one illness that the same time

Activities of Daily Living (ADLs)

Personal care activities such as bathing, dressing, grooming, eating, toileting, and transferring

Instrumental Activities of Daily Living (IADLs)

Complex skills needed for independent living (Ex. shopping, cooking, housework, etc.)

Assessment of the Older Adult

• Assess functional status → Have they achieved an optimal level of functioning?

• Evaluate their self-care abilities

• Evaluate medication reconciliation and polypharmacy → What are their prescriptions? Are they taking them correctly?

• Evaluate psychosocial and support systems → Do they live alone?

• Evaluate fall risk and environmental safety

• Do a cognitive and sensory screening

• Do a physical exam

Cardiovascular and Respiratory System Nursing Considerations

• Encourage cardiovascular health → promote reasonable activity and diet management

• Monitor for hypertension → it can be one of the first signs of heart disease

• Encourage deep breathing

• Promote mobility

• Assess perfusion → especially in distal extremities

• Prevent infection

Integumentary System Nursing Considerations

• Skin in the older adult tends to be drier and has decreased perfusion

• Prevent skin breakdown

• Assess skin daily

• Maintain skin integrity

• Avoid injury

• Promote wound healing

Gastrointestinal System Nursing Considerations

• Prevent constipation → encourage hydration, fiber, and activity to promote peristalsis

• Support nutrition and digestion

• Prevent/monitor for UTIs → Catheter care is critical, clean and remove catheters ASAP

• Support continence → Promote regular toileting, pelvic floor exercises, and continence care with dignity

• Monitor renal function → What is their urine output? Kidney labs?

Musculoskeletal System Nursing Considerations

• Prevent falls

• Promote mobility and strength → emphasize weight-bearing exercise

• Support bone health → promote vitamin D and calcium, and watch for signs of osteoporosis and arthritis

• Monitor for complications

• Many older adults have bone density loss, muscle loss, joint cartilage deterioration, decreased joint flexibility, and reduced mobility

Reproductive System Nursing Considerations

• Promote comfort and sexual health

• Provide privacy and dignity

• Promote sexual health and STI prevention

• Monitor for changes and symptoms

Nervous System Nursing Considerations

• Adapt communication

• Screen for cognitive changes → Confusion is NEVER normal, acute changes in cognition should always be investigated

• Prevent and manage delirium

• Support safety and function

Delirium

• ACUTE CONFUSION → Onset is sudden (hours to days)

• Fluctuates to be better or worse over hours

• Short-term duration (days to weeks)

• Attention is severely impaired (HALLMARK SIGN)

• Awareness is reduced, patient is disoriented and confused

• Often reversible if underlying cause is treated

• Caused by acute illness, infection, medications, dehydration, or hospitalization

Dementia

• CHRONIC DECLINE → Onset is gradual (months to years)

• Progressive and steady cognitive decline

• Long-term duration

• Attention is usually intact early on

• Awareness is generally clear until late stages

• IRREVERSIBLE

• Caused by Alzheimer’s Disease, vascular damage, or Lewy body

Basic Cognitive Assessment

Alert and Oriented x4 (A/Ox4)

• Person = What is your name?

• Place = Where are you at?

• Time = What month and year is it?

• Situation = Can you tell me about what brought you in today?

Sensory System Nursing Considerations

• Assess hearing → Face the patient, reduce background noise, speak clearly and low pitched, ask about hearing aid access

• Monitor for vision changes → Ensure appropriate lighting

• Safety and function

Mental Health in the Older Adult

• Depression is common but NOT normal; often has atypical presentation

• Symptoms of depression = feelings of despair/sadness, sleep problems, no desire for socializing, loss of interest in beloved activities, irritability/grumpiness, loss of appetite and weight changes, and struggling to think clearly

• Screen using PHQ-2 or PHQ-9

• Suicide risk should ALWAYS be assessed

Ageism

• Prejudice or discrimination against individuals based on their age

• Consequences = delayed diagnoses, lower trust, reduced functional outcomes, internalized ageism

• Nursing = Avoid assumptions, encourage autonomy, identify strength and resilience in aging, and promote informed decision-making

Types of Pain

• Acute (short-term) and Chronic (long-term)

• Nociceptive → Sharp, stinging, dull, or throbbing pain; can be somatic or visceral

  • Examples of conditions = osteoarthritis, bone fractures, burns, physiological pain to brain

• Neuropathic → Burning, stabbing, numbness, tingling, hypersensitivity

  • Examples of conditions = diabetic neuropathy, HIV/AIDS, multiple sclerosis

Pain Assessment

Assess before AND after intervention; frequency depends on type of medication and its peak effect

O- Onset

L- Location

D- Duration

C- Characteristics

A- Alleviating/aggravating factors

R- Relieving factors

T- Timing

S- Severity

Assessment of the Musculoskeletal System

1. Subjective Data = Functional status (ADLs, IADLs, and general mobility), family history, occupation, medications, and use of assistive devices

2. Objective Data = Visualizing/verbalization of pain, tenderness on palpation, posture, gait, muscle strength, joint function, and neurovascular status

5 Ps of Neurovascular Assessment for Compartment Syndrome

1. Pain

2. Pallor (paleness) → is the skin pink and warm?

3. Pulse

4. Paresthesia (pins and needles sensation)

5. Paralysis

Low Back Pain

• Characterized as acute (<3 months) or chronic (>3 months)

• Causes: weak muscles, muscle strain, unstable ligaments, disc problems

• Diagnostics: X-ray, CT scan, MRI scan. U/S

• Assessment: nerve pain, gait, mobility, reflexes, motor strength, sensation, tenderness, deformity, spasm

• Nursing Care: Mobility education, body mechanics, pain management, weight-reduction

Bursitis

Inflammatory condition where fluid-filled sacs (bursae) that prevent joint friction become inflammed

Tendonitis

Inflammatory condition where muscle tendon sheaths become inflammed

Impingement Syndrome

Impaired movement of rotator cuff to shoulder; due to repetitive overhead movement

Carpool Tunnel Syndrome

Median nerve is compressed; commonly caused by repetitive hand motions

• Positive Tinel sign

• Nursing Care: NSAIDs, splint, steroid injections, assess for Tinel sign

Ganglion

Collection of gelatinous material near tendons/joints; it’s round, firm, and swollen

• Nursing Care: Aspiration, steroid injections, or excision

Dupuytren Disease

A chronic hand condition that causes the fibrous tissue beneath the skin of the palm to thicken and shorten, which can gradually pull one or more fingers into a bent position

• Usually in fourth and fifth fingers

• Risk factors: Age >50, male, Scandinavian or Celtic diabetes, gout, and smoking

Surgery Care of Upper Extremity Disorders

• Pre-Op: Thorough assessment of pain, mobility, and limitations

• Post-Op:

  • Hourly neurovascular assessment x24hrs

  • Compare limbs, pre-op and post-op findings

  • Demonstrate mobility

  • Dressing care

  • Prescribed mobility exercises/rehabilitation

  • Pain management

  • Assisting and encouraging independent ADLs

  • Elevation of limb

Hallux Vagus (Bunion)

Deformity where the great toe deviates laterally; redness, swelling, and pain may be present

Plantar fasciitis

Inflammation of foot-supporting fascia that cause acute heel pain upon walking

Onychocryptosis (Ingrown toenail)

Free edge of nail penetrates skin; risk for infection, pain, and swelling

Nursing Management of Foot Surgery

• Pre-Op: Assessment of gait, mobility, neurovascular status of the foot, and plan home care

• Post-Op:

  • Assessment of neurovascular status of foot and exposed toes every 1-2 hours x24hr

  • Compare affected foot to unaffected foot

  • Manage pain

  • Elevation of affected limb

  • Monitor and change dressings as needed

  • Follow weight-bearing advisements from the surgical team

  • Ensure proper use of assistive devices

  • Prevention of Deep Vein Thrombosis (DVT)

Osteoarthritis (OA)

Joint/cartilage problem occurring when the protective cartilage that cushions the ends of your bones wears away over time; incidence increased with age and is more common in women

• S/S = pain, stiffness, function impairment; pain is aggravated by movement and relieved by rest; crepitus

• Diagnostics = physical assessment and health history; X-ray

• Nursing Management = Exercise, OT/PT, pharmacologic therapy, non-pharmacologic methods, promotion of weight loss, maintaining optimal functional ability

Osteoporosis

A disease that weakens bones, making them fragile and much more likely to break; most commonly affects small-framed, post-menopausal women

• Precursor = Osteopenia; low bone mineral density

• Risk = Fractures

• Clinical Manifestations = Abnormal DEXA scan, fractures, height loss, stooped posture, and back pain

• Nursing Management = Fall prevention, home safety, physical and mobility assessment, pain assessment, DEXA scan, promotion of calcium and vitamin D intake, promotion of weight-bearing exercise, and medication adherance

Arthroplasty

When joint disease becomes severe, it’s a surgical procedure to restore, reconstruct, or replace a diseased, damaged, or worn-out joint with an artificial implant → Nursing priorities shift to postoperative complications, mobility, and safety

Crepitus

Any grating, crackling, popping, or grinding sound and sensation that occurs when you move a joint or when air gets trapped under the skin

Total Joint Arthroplasty

• Conditions: OA, RA, trauma, congenital deformity

• Commonly Replaced Joints: Hip, knee and finger joints

• Nursing Management:

  • Preventing and management of blood loss

  • Preventing venous thromboembolism → Use of sequential compression devices (SCDs)

  • Preventing infection

  • Pain management

Top Hip Arthroplasty

• The replacement of a severely damaged hip with an artificial joint

• Indications: OA, RA, femoral neck fracture, hip fracture

• Nursing Management:

  • Prevention of dislocation of his prosthesis

  • Maintain ABduction, neutral rotation, and limited flexion

  • Assist with position changes

  • Prevention of heel pressure injury

Osteomyelitis

• Bone infection caused by bacteria

• Risk Factors: recent bone surgery, open fracture, soft tissue infection near bone, bloodborne infection, older adults, poor nourishment, impaired immune system, chronic illness

• Causative Organisms: Staphylococcus aureus (increasingly MRSA)

• Direct inoculation = open fracture

• Contiguous infection = foot ulcer overlying bone

• Hematogenous spread = Bacteria due to endocarditis

• Nursing Care: prevent, administer antibiotics and monitor response, post-op wound care, pain control, improving mobility

Contusion

Soft tissue injury produced by blunt force → Causes pain, swelling, and ecchymosis (bruise)

Strain

Pulled muscle injury to the musculotendinous unit → Causes pain, edema, muscle spasm, ecchymosis, and loss of function

• Graded on first, second, and third degree

Sprain

Injury to ligaments and supporting muscle fiber around a joint → Joint is tender, edema, painful movement

Dislocation

Articular surfaces of the joint are not in contact → a traumatic dislocation is an emergency with pain, change in contour, axis, length of the limb, and loss of mobility

Fractures

• Complete or incomplete disruption in the continuity of a bone structure

• Clinical Manifestations: acute pain, loss of function, ecchymosis, edema, visible deformity, and shortening

• Nursing Care: assessment, immobilization, neurovascular assessment, coping

  • Open Fracture → Cover with sterile dressing (reduce risk of osteomyelitis)

Splints

Used for initial fracture management; simple injuries

Braces

Provide support, control, and prevent further injury; long-term use

Casts

Rigid external immobilizing device

• Use: immobilize a reduced fracture, correct deformity

• Risks: skin breakdown (pressure necrosis), muscle atrophy, ineffective tissue perfusion, impaired physical mobility, compartment syndrome, and compromised neurovascular function

• Nursing Care: neurovascular assessment, skin assessment, ensuring appropriate fit, patient education (exercises, cast care, and preventing complications)