nurs 2001 midterm exam

role of the professional nurse in health assessment, and in regards to health promotion and disease prevention

to promote optimum health, a healthcare delivery system must provide medical care, but also use disease prevention and health promotion strategies

• understand risk factors

• interventions for risk factors (primary, secondary, tertiary

• healthcare services/ places to go for care

three interventions

• primary: vaccinations education

• secondary: screenings

• tertiary: chemotherapy, medications for chronic illness

what role does the nurse play in health assessment

care provider, care manager, educator, evidence-based practitioner, researcher, innovator, advocate, leader, motivator, collaborative

roles of the nurses and how they apply to different situations

ADOPIE

ADOPIE - assessment

establishes baseline for patient; review HX; physical assessment, manage data

ADOPIE - diagnosis

medical model vs nursing diagnosis

• medical model: dx and tx of disease

  • nursing model/ focus: human response to health problems; how to cope/ manage problems; NANDA - approved diagnosis

types of diagnosis

• problem focused

• risk diagnosis

• health promotion diagnosis

ADOPIE - outcome identification

measurable, realistic, patient-centered goals

ADOPIE - planning

determines resources; target nursing interventions; individualized patient care plan; documentation on individualized nursing care plan

ADOPIE - implementation

intervention; RN driven

• any tx based on clinical judgement/ knowledge

ADOPIE - evaluation

judgement of effectiveness of care

describe how nurses utilize different verbal and non-verbal modes of communication

• verbal: open-ended questions; restating clients view to show your understanding; positive-reinforcement and reassurance

• nonverbal: active listening; nodding head to show understanding; body language

components of emergency, focused and comprehensive hx

• emergency: life threatening; unstable; immediate evaluation; ABCDE

• focused: addresses patient health issues; reviews 1-2 body systems

• comprehensive: complete hx; complete head to toe

review of ROS. What patient data is placed in ROS vs health history

• review: skin; head and neck; breast and lymphatics; respiratory system; cardiac and peripheral vascular system; gastrointestinal system; genitourinary system; whole-body systems

• ROS differs from hx because it includes maternal and paternal hx of ROS as well

how do nurses use clinical judgement?

• nurses make decisions based on nursing knowledge, other knowledge, critical thinking and clinical reasoning

• use this when collecting data, making interpretations of data, developing a diagnosis; identifying appropriate actions

what are the basics and the significance of documentation practices?

• documentation should be clear, accurate, consistent and precise

• FACT acronym: guide for accurate documentation

  • F: factual

  • A: accurate

  • C: complete

  • T: timely

different systems for documentation

• source oriented: divided into specific sections; most traditional form

• problem oriented: comprehensive and organized approach among all members of interdisciplinary team

  • SOAP: subjective, objective, assessment, plan

  • PIE

• focus charting: centers on specific healthcare problems and the change in condition, client events and concerns

• charting by exception: documenting only unexpected or unusual findings

• electronic documentation

documentation ethical and legal considerations

healthcare insurance portability and accountability act (HIPPA)

• protects privacy of healthcare consumers

describe purpose and process of general survey and collecting vital signs

• to observe the patient as a whole

• important to collect vital signs to detect or monitor medical problems

  • make sure all are within regular range

examples of subjective and objective data

• subjective: symptoms; patient tells you

  • pain, sore throat, nausea

• objective: signs; visible data

  • fever, rash, vomit

primary and secondary data source

• primary: patient themselves

• secondary: chart or family member

categories of pain

• acute: short term (1 second - 6 months); varies in intensity and duration; varies in onset; protective in nature; can turn to chronic if not properly managed

• chronic: long term (>6 months); persistent pain; periods of exacerbation or remission are common

pain scales

• numeric rating scale

• visual analog scale: rating pain on the line (no #s)

• FACES: cartoon like faces ranging from smiling to crying

• PQRST: provoked, quality, region/radiation; severity; timing

• CRIES: crying, increase in O2 requirement from baseline, increase in vital signs from baseline, expression on face; sleeping

• FLACC: facial expression, leg movement, activity, crying, consolability

pharmacologic vs non-pharmacologic pain interventions

• pharmacologic: medications

• non-pharmacologic: strategies that increase effectiveness of analgesic meds

  • relaxation, meditation, massage

age considerations of pain

• infants: should be treated using environmental, pharmacological and non-pharmalogical approaches

  • can’t recognize pain so they may cry or withdrawn from painful stimuli

• toddlers: can describe and localize pain

  • express pain with crying or anger bc they may view it as a punishment

• adolescents: may view pain as weakness or lack of bravery

  • may not acknowledge pain right away

• adults: may express pain ny how they learned to express it as a child

• older adults: pain goes unacknowledged as they think it is a part of growing older

relationship of health promotion to health assessment

a needs assessment can help identify current conditions and desired services or outcomes which leads to the health promotions of the patient

infection cycle

• infectious agent: something that contains a bacterium, fungus, virus, parasite or prion

• reservoir: habitat of the infectious agent; where it lives; grows; reproduces and replicates

• portal of exit: route in which the infectious agent can leave the reservoir

  • can be any body orifice; blood or body fluids

• mode of transmission: move bacteria, fungi, viruses parasites and prions from place to place

• portal of entry: required for patient to get infection, can be any body orifice (can be the same as portal of exit)

• susceptible host: required fro infectious agent to take hold and become a reservoir for infection

stages of infection

• incubation: patient may not feel ill or have visible s/s but changes in pathology occur that may be detectable in labs

  • can last seconds, minutes, hours, days, weeks

• prodromal: patient begins having initial s/s as the infectious agent replicates

  • s/s are nonspecific such as rash, fever, poor appetite

• acute illness: s/s of specific infectious disease become obvious

  • stage where infection is considered most severe

• convalescence: patient returns to previous, or new balanced state of health

implementing standard and transmission based precautions

• standard precautions: infection prevention practices applied to all patients

  • don PPE: face shields, face masks, gloves, gown, goggles in various combos

• contact precautions: help prevent transmission of infectious agents by direct or indirect contact

  • done PPE: gown and gloves and min.

correct techniques for safety and infection

hand washing, correct PPE, client identification, electrical safety, chemical safety

patients at risk for injury

• physical: stroke, amputation, recent surgery, MS, visual impairment, chronic pain, malnutrition, weakness, unsteady gait

• cognitive: sleep disorders, impulsiveness, disorientation, dementia, depression

• environment: room clutter, poor lighting, slippery floors

morse fall risk scale

• no risk —> 0-24 —> good basic nursing care

• low risk —> 25-50 —> implement standard fall precautions

• high risk —> > or equal to 51

specific safety risk factors for each development stage

• 0-4: burn injuries; accidental poisonings/ choking; drowning; car safety

• 5-12: vehicle safety; safe participation in sports; H2O safety; internet safety; firearm safety

• 13-19: everything from 5-12 plus intimate partner violence

• 19+: risks may increase as a result of stress; alcohol consumption; smoking; workplace accidents; falls (65+)

interventions to prevent injury to patients

• emergency preparedness plans

• video monitoring

• bedside sitters

• call light within reach

• non-skid footwear

• bed in low position

• adequate lighting

• fall prevention education for px

alternatives to using restraints

• engage px in social interactions

• offer diversional activities

• de-esculate situation

• place px in room near nursing station

• encourage familial presence

• bed sitter

ABCs

airway, breathing, circulation, disability, exposure

• purpose: recognize and stabilize patients most critical issues

maslows heirarchy of needs

5 categories of needs that motivate human beings

• physiological needs

• safety needs: need for secure environment in which we can work play and live

• love needs: need to give love and receive love

• esteem needs: need to have a high self image

• self-actualization: need for achievement and mastery

safety and risk reduction framework

places priority on the situation or factor that places the patient at highest safety risk

least restrictive/ least restrictive framework

using least restrictive and least invasive method to resolve a problem while maintaining client safety

survival potential framework

doing the most good for the max # of patients at a time when health care resources are limited due to large # of injuries

• triage

  • emergent or immediate

  • urgent or delayed

  • non urgent or minimal

  • expectant

acute vs chronic

acute conditions are prioritized over chronic

urgen vs nonurgent

urgent needs are prioritized over nonurgent

unstable vs stable

unstable findings are prioritized over stable findings

functions of respiratory physiology

• following inspirations is to move O2 from areas of high to low concentration

• through inhalation, O2 is carried through trachea and flows down to left + right bronchus, to bronchioles and lands in alveoli where it is exchanged through capillaries with CO2, which is removed from respiratory after it moves from pulmonary capillaries to alveoli and flows back up trachea

function and role of cardiovascular system and transport of respiratory gases

• provides O2 to and removes waste from the tissues of the human body

• superior/ inferior vena cava return deoxygenated blood to the body

age related differences that influence the care of patients with respiratory problems

compared with adults, infants and children have higher respiratory rates, higher pulse rates, and lower blood pressure readings

factors that influence respiratory function

chronic conditions, inflammation of pleura, fluid in lungs, inflammation, smoking/ tobacco use, immunizations

describe strategies to promote adequate respiratory functioning

• teaching about pollution free environments

• promoting proper breathing

• promoting and controlling coughing

• pursed lip breathing (COPD patients)

plan, implement and evaluate nursing care related to select nursing diagnosis involving respiratory problems

everyone involved in the evaluation process needs to identify effective interventions and reasons for any failures in achieving expected outcomes

retraction locations on throax

• subcostal retractions: in drawing of abdomen just below ribcage “belly breathing”

• substernal retractions: in drawing of abdomen just below sterum - breastbone

• intercostal retractions: in drawing of skin between each rib

• suprasternal retractions: in drawing of skin in the middle of the neck above sternum “tracheal tug”

retractions

skin becomes taut around the area

apical pulse

5th intercostal space, midclavicular line

sternal notch

midline notch on manubrium

arterys/ arterioles

strong sturdy vessels with elastic fibers that allow for expansion and contraction in response to pressure changes

veins/ venules

not as tough as arteries, can relax and hold more blood when needed to decrease the workload of the heart

capillaries

connection between arterial and venous system; diameter of a single RBC

nasal cannula

used when needs are low

• 1-6 lpm; 24-44% FiO2

• flow is limited

simple mask

covers nose and mouth

• 6-12 lpm; 35-50% FiO2

  • allows: appropriate mixing of room air; CO2 to escape

venturi mask

delivers precise O2 (COPD patients)

• 4-12 lpm; 24-60% FiO2

face shield/ tent

PACU or claustrophobic patients

partial re-breather mask

simple mask with 100% O2 bag attached

• 6-10 lpm; 35-60% FiO2

• bag should inflate; holes on mask allows for CO2 to escape

non-rebreather mask

delivers highest O2 with low flow

• 6-15 lpm; 60-100% FiO2

• expired CO2 escapes and O2 does not

bad valve mask

emergency equipment

• 15 lpm; 100% FiO2

high flow nasal cannula

highest level of support

• can deliver up 10 100% FiO2

are related differences that can influence cardiac function

• size of heart

• location of heart in relations to the entire body

• heart rate + BP

factors that influence cardiac function

• hypertension

• hyperlipidemia

• smoking

• diabetes

• obesity/ sedentary lifestyle

• part history of cardiac issues

• diet

develop nursing diagnosis that correctly identifies cardiac problems that may be treated by independent nursing interventions

• decreased cardiac output

• excess fluid volume

• impaired gas exchange

strategies to promote adequate cardiac functioning

• eating healthy; control cholesterol

• get active; maintain weight

s/s: skin changes for arterial disease

pallor, dependent rubor, shiny, rust colored front of tibia

s/s: skin temp for arterial disease

cool

s/s: cap refill for arterial disease

greater than or equal to 3 seconds

s/s: pulses for arterial disease

weak or absent

s/s: edema for arterial disease

absent

s/s: ulcers and necrosis for arterial disease

develop at pressure points and on toes, scab over rapidly, may be necrosis

s/s: pain for arterial disease

may be described as sharp, stabbing or intermittent claudication

tx for arterial disease

lessens in dependent position (standing, etc.)

s/s: skin for venous disease

bluish when dependent, brown pigmentation on ankles, itching at ankles, varicose, flaky dermatitis

s/s: skin temp for venous disease

warm

s/s: cap refill for venous disease

less then 3 seconds

s/s: pulses for venous disease

strong and symmetrical

s/s: edema for venous disease

present, especially around ankles

s/s: ulcers/ necrosis for venous disease

develop slowly over ankles

s/s: pain for venous disease

aching, cramping

tx for venous disease

lessens with limbs elevated

opioid sedation scale

• s: sleep easy to arouse

  • acceptable

• 1: awake and alert

  • acceptable

• 2: slightly drowsy; easily aroused

  • acceptable

• 3: frequently drowsy; arousable; drifts offs to sleep mid convo

  • unacceptable

• 4: somnolent; minimal or no response to verbal or physical stimulation

  • unacceptable

temperature vital sign

• low grade: 99.1-100.4 F

• moderate grade: 100.6-102.2 F

• high-grade: 102.4-105.8

body loses heat through…

• conduction: loss of heat due to direct contact with a cooler surface

• convection: loss of heat due to air currents

• evaporation: loss of heat via gases from the lungs or drying of sweat due to indirect contact with, or being in close proximity to a cooler surface

• radiation: loss of heat due to indirect contact with, or being in close proximity to a cooler surface

heart rate/ pulse (bpm):

rhythmic beating of the arteries in response to the ejection of blood from the left ventricle

pulse deficit

measurement between apical pulse rate and radial pulse rate

inhalation

diaphragm contracts (flattens) —> goes down

exhalation

diaphragm relaxes —> pushes up

systolic pressure

contraction of the AV ventricles; pressure being exerted on vessel walls

• “lub”

• s1

diastolic pressure

relaxation of the ventricles; pressure within the ventricles at rest

• “dub”

• s2

pulse pressure

difference between systolic and diastolic pressures

stroke volume

how much blood comes out of the left ventricle with the squeeze of the heart

unexpected events

• near miss: checking medication before giving it to patient to make sure it is the correct prescription

• patient safety

• sentinel event: giving a medication that was not supposed to be given; causes bodily harm

RACE (fire safety)

• R: rescue anyone in immediate danger

• A: activate fire alarm and notify appropriate person

• C: confine the fire by closing doors and windows

• E: extinguish or evacuate patients and other people to safe area

contact precautions

• microorganisms: RSV, shigella, enteric diseases

• private room

• gown + gloves

droplet precautions

• microorganisms: pneumonia, scarlet fever, rubella

• private room

• mask

airborne precautions

• microorganisms: measles, varicella, TB

• private room

• N95

• negative pressure airflow exchange