Critical thinking- Application of knowledge and experience. To identify patient problems and to direct clinical judgments and action. That results in positive patient outcomes.

Clinical reasoning- Ability to focus and filter clinical data to recognize what is most and least important so the nurse can identify whether an actual problem is present.

Logical thinking- Rely on evidence-based practices, critical thinking, and problem-solving skills.

Intuition- A hunch, the ability to understand something immediately.

Clinical analysis- Process of carefully examining and evaluating information, data, and situations to make informed decisions and judgments in patient care.

Trial and error - Refer to a problem-solving approach where nurses try different interventions or strategies to address a patient's needs or symptoms.

Scientific method- Approach used to gather evidence, Analyze data, and make informed decisions in patient care.

Judgment- Ability to make sound decisions based on a thorough assessment of a patient's condition and the available evidence.

Assertive communication- Ability to express ideas and concerns clearly while respecting the thoughts of others.

ISBAR- Communication tool- Handoffs, shift changes, conditions.

I - Introduction: Introduce yourself and your role.

S- Situation: Clearly state the current situation or problem.

B- Background: Provide relevant background information about the patient.

A - Assessment: Share vour assessment of the patient's condition.

R- Recommendation: Make recommendations for the next steps or actions to be taken.

Hopeless- not a term used to describe patients or situations.

Nurses strive to provide care with empathy and compassion and focus on promoting the well-being of their patients.

Communication techniques SOLER-

S - Encourages the listener to sit

O- Remind the nurse to maintain an open stance or posture.

L- Suggests that the listener leaned toward speaker and open stance.

E- Refers to maintaining eye contact without staring.

R- Remind the nurse to relax.

Chapters 5 - 10 - Nursing process

Nursing process- This is the foundation of professional nursing practice. It is the framework within which nurses provide care to patients in an organized and effective manner.

Thinking like a nurse is facilitated by nurses using the nursing process to develop individualized patient care plans

Assessment phase- Assessment is the organized and ongoing appraisal of a patient's well-being. It involves collecting data from a variety of sources that are needed to care for patients.

A - Assessment - Known as a holistic approach to patient care.It can be collected from a variety of sources: patients, family, friends, communities, health care professional medical records, and lab results. Patient's feelings or comments about how they feel.

Data collection

• Primary data

• Patient interview

• Secondary data

• Subiective data

• Symptoms

• Health History

• Obiective data

• Signs, physical examination, lab results, diagnostic test results.

• Recognize cues.

D- Diagnose - Focus on one problem at a time when writing

NANDA.

NANDA - Standardized Terms and codes for patient problems or life processes expressed as a nursing diagnosis.

• Analyze data/cues Implementation.

• Cluster-related data

• Identify nursing diagnosis

• List supporting data

• Etiology

• SIS

P- Planning

• Prioritize hypothesis and nursing diagnosis

• Generate personalized care plans

• STGs (Short term goals)

• LTGs (Long term goals)

Outcome identification

NOC - Nursing Outcomes classification

I- Implementation - Consists of forming a task (Repositioning, monitoring, administrating meds, teaching patients and families) and documentation of each intervention.

• Taking action.

• Interventions

• Independent

• Dependent

• Collaborative care

• Direct

• Indirect

• Documentation

NIC - Nursing interventions classification

Care plans

• Clinical pathways

• Protocols

• Standing orders

E- Evaluation - focuses on patient and patient response to nursing interventions and outcome attainment.

Care plan evaluation.

• Patient/group goal/outcome attainment?

• Continue?

• Revise/adapt?

• Discontinue?

Medical records formats

• PIE - Problem, Intervention, Evaluation

• APIE - Assessment, Problem, Intervention, and Evaluation

• SOAP- Subjective data, Objective data, Assessment, Plan

• SOAPIER- Subjective data, Objective data, Assessment, Plan, Intervention, Evaluation, Revisions to plan.

• DAR- data, action, response

• CBE- Charting By Exception- is documentation that records only abnormal or significant data.

Flow sheets- Within EHR (Electronic Health Records) may be used to document routine care and observations that are

Recorded on a regular basis, such as vital signs, meds, and 1 & 0 measurements. Can be collected as graph and are permanent

Medical records.

Maslow's Hierarchy

Level of needs data

Physiological: basic

circulation, 02 levels, Nutrition, survival needs

temperature, warmth, elimination, shelter,

Example of

Airway Patency, Breathing,

Food intake, body

Sexuality, infection, and pain

level.

Safety & security:

drug side effects)

Need to be safe knowledge of routines & Procedures, & comfortable.

isolation, and dependence needs

Physical safety (Falls and

Physiological security

Bedtime rituals, fear of

Love and belonging:

provides information From family.

Need for love & affection strength, and support systems.

Compassion of care

And significant others,

Self-esteem: needs to (Injury, surgery, puberty) Changes feel good about oneself. in abilities.

Similar to vessel.

Change in body image

And the concept of pride

Self-actualization: Need to autonomy, motivation problem-solving fulfill maximum potential

provide and accept help, the feeling need for growth and change desired roles

Goal attainment,

Abilities. Ability to

of accomplishment

Terms to know:

• Papule - Solid, raised lesions with distinct borders.
(Example wart, psoriasis, actinic keratosis Variety of shapes: Domed, flat-topped., unciliated. Often associated with secondary features: Crusts or scales. Size < 0.5cm, > 0.5 cm Papule- referred as plague.

• Cyst - Encapsulated fluid-filled or semi-solid mass.
  Extends into the dermis or subcutaneous tissue.

• Abscess- confined. Pocket of puss that collects in tissue, organs, or spaces in between the body.

• Nodule - Raised solid mass with defined borders. (Example lipomas, squamous Cell cancers) Extends in the Dermas or beyond. Deeper and more solid than a papule size 0.5-2cm.

• Pustule- Similar to vesicle (For example, Impetigo, acne)
  Circumscribed, evaluated lesion containing pus instead of clear fluid. Most commonly infected

• Vesicle/Bula - Circumscribed, raised lesion. Filled with serious (Clear fluid) size <0.5cm. Vesicles >0.5cm:
  Referred as Bullae. (Example chicken pox (Varicella), Poison Ivy, second-degree burns, blisters)

• Friction rubs - Where: Interior lateral thorax causes inflammation, plural surfaces rubbing together during respiration due to pneumonia or pleuritis. Low-pitched, grating, or creaking sound heard during inspiration or expiration and not clear by coughing.

• Crackles- Where: Right and left lung bases cause: sudden opening of small airways and alveoli collapsed by exudate fluid, heard in patients with cystic fibrosis, asthma, COPD, bronchitis, and pulmonary edema from left-sided heart failure.

• Brief crackles- popping sound heard when a blocked airway suddenly opens, more common during. Inspiration is often described as fine, medium, and course.

• Fine crackles- soft, high-pitched, and very brief sounds during late inspiration and not cleared by coughing.

• Medium crackles- lower-pitched, moist sound, best heard at the inspiratory midpoint.

• Coarse crackles- Loud, Effervescent sounds heard best during inspiration and not relieved after coughing.

• Wheezing- where all lung fields cause high-velocity air flow through severely constricted or obstructed Airways due to asthma, foreign objects, bronchiolitis, or emphysema.

• Rhonchi- Where over the trachea and bronchiole but can be referred to all lung fields. Cause: increased secretions in large Airways due to pneumonia, increased airway

• Turbulence from Mucus, or muscle spasms. Low-pitched, snoring sounds are heard either during inspiration or expiration and usually cleared with coughing, lower in pitch, then wheezing with a sonorous quality.

• ERBs point- 5th Point of oscillation, located in 3rd intercostal space, close to this sternum.

• Tricuspid area- between right atrium and right ventricle.
  Lower-left sternal border.

• Aortic area- begins at the left ventricle, second right intercostal space

• Pulmonic area- slightly left of the Aortic valve, second left intercostal space.

• Auscultating - technique or listening to sounds made by body organs or systems such as the heart, blood vessels, lungs, and Abdominal cavity, With and without the assistance of a stethoscope.

• Palpating- using touch to assess body organs and skin texture, temperature, moisture, turgor, tension due to fluid content, tenderness, and thickness.

• Percussing- involves tapping the patient's skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures.

• Inspecting- involves the use of vision and smell to closely examine physical characteristics of a whole person and individual body systems.

What areas of the body do you perform in assessment in a particular order? Head to toe

1. Head and neck

2. Chest and lungs

3. Heart and cardiovascular system

4. Abdomen

5. Extremities, (arms and legs)

6. Back and spine.

7. Skin.

Chapter 25 safety

Alternatives to physical restraints

• Orient the patient to the surroundings and explain all care-related interventions.

• Relocate the patient to a room near the nurse's station.

• Use pressure-sensitive and motion-sensitive bed and chair alarms consistently. Tabs and bed check alarm systems can be used in the bed or chair.

• Ensure that alarms and sensors are properly placed and functioning, and perform battery checks according to facility protocol.

• Encourage the family and significant others to spend time with the patient.

• Minimize environmental stimuli (Noise, bright lights)

• Provide distractions based on patient preferences (music, television, a doll hold).

• Provide complementary and alternative therapies:

• Promote relaxation through gentle massage.

• Use aromatherapy to relax the patient.

• Assess for sources of agitation and ensure that the patient's basic needs are met. (Food., fluids, toileting, pain, or discomfort, relief, sleep, and ambulation)

• Obtain an order for a twenty four hour sitter (UAP)

• Cover or disguise tubes or drains with clothing or wrap in intravenous sides with gauze so that they are kept out of the patient's sight.

• Use Untied, Cloth-padded protective mitts on the patient's hands to prevent the patient from removing tubes or drains.

Physical restraints can be applied ONLY with a primary care provider order and ONLY after all reasonable alternatives to restraint use have failed.

• Medical Necessity

• Behavioral or mental health issues

Examples of common reasons:

• Immobilize on extremity

• Prevent harmful patient behavior

• Allowed treatment or procedures to proceed without patient interference.

1. Conducting forest assessments to identify higher risk

2. Implementing appropriate interventions based on patient's individual needs and risk factors

3. Educate patients and their families about fall prevention strategies

4. Providing assistive devices like bed alarms or non-slip socks to patients who needs them

5. Reviewing medications and adjusting them if necessary to minimize fall risk.
   Chapter 26 Infection Control

• Airborne transmission- When microorganisms are dispersed by air contact and held or deposited on the skin of a susceptible host. (Example of illness- Tuberculosis, measles, and chicken pox)

• Contact- when body surfaces touch surfaces of other bodies or obiects. The most common means of transmission is contaminated hands.

• Droplet transmission - occurs when The Mucus membranes of the respiratory tract (Nose, mouth, or conjunctiva) Are exposed to the secretions of an affected individual. Droplets cannot remain suspended in the air for long periods and seldom travel more than three feet.
  (Examples of illness transported by droplets are influenza and respiratory syncytial virus infection.

• Viruses- smallest microorganisms reproduce. Inside the living cells of the host, they are responsible for causing many different tves of diseases.

• Bacteria- single-cell organisms live on and in the skin, eyes, nose, mouth, upper throat, lower urethra, lower intestines, and large intestines. They have different sizes, shapes, growth, patterns, and means of replication.

• Fungi- like bacteria, or single-celled organisms, that can cause infection. Mold and yeasts are examples of fungi that are present in the air, soil, and water and are responsible for athlete's foot, ringworm, and yeast infections.
  Contact, Airborne, and droplet precautions

• Contact: use soap and water to disinfect hands against C.
  Diff. Use gloves routinely if splashing possible, used conservative judgment about whether other PPE is necessary.

• Multi drug resistant organisms, including VRE, MRSA

• C. Diff, RSV, Hep. A

• Scabies, and herpes simplex virus

• Draining wounds in which certain organisms have been cultured

• Hepa filtration required

• All PPE

• No live plants, fresh flowers, fresh, raw fruit or vegetables May harbor bacteria and fungi

• Must mark "isolation precautions required" on chart

Airborne- negative- pressure

• A room with a high-efficiency part particulate air (HEPA)
  Filtration system is necessary.

• Special N95.

• Eye protection, such as goggles or a face shield.

Disease in pathogens:

• Varicella (chicken pox)

• Rubeola (measles)

• Tuberculosis (TB)

• Covid-19

Droplet precautions:

• Cough, sneezes, or talk

• Suctioning, endotracheal intubation, cardiopulmonary resuscitation, Chest physiotherapy

Diseases:

• Pharyngeal Diphtheria

• Moms, rubella, and pertussis

• Streptococcal pharyngitis, & scarlet fever

• Pneumonias (streptococcal, mycoplasma, meningococcal)

• Pneumonic plague

• Meningococcal sepsis

• Influenza

Systemic Infection VS. Local Infections

• Systemic: Infections that infiltrate the bloodstream. Causes: fever, increases HR, RR, Lethargy, Anorexia, tenderness, or enlargement of lymph nodes.

• Local Infections: Causes redness, swelling, warmth, pain, tenderness, drainage, numbness or tingling, and loss of function to the affected area.

* Altered vital signs can indicate an infection. Blood pressure rises and pulse in respiratory rate increases. Some patients with sepsis may have Damage to the body organs and maybe hypothermic.
Decreasing blood pressure is a late sign of infection, indicating septicemia and shock.

Asepsis - Refers to freedom from and Prevention of disease-causing contamination.

Medical Asepsis- referred to as the clean technique, includes hand washing, wearing gloves, gowning, and disinfecting.

Surgical Asepsis- the sterile technique used to prevent the introduction of organisms from the environment to the patient.

Used for cauterization, procedures that invade the bloodstream or break the skin, dressing changes, and wound care.

Sterilization- the process used to destroy all microorganisms, including their spores.

Septicemia- life-threatening complications of affection

Chain of infection- describes how microorganisms are transmitted from one person or place to another. This could be someone's hands, object, through the air, or bodily contact.

Healthcare- Associated infections- individuals with weakened immune systems, such as those undergoing medical treatment or surgeries, are more susceptible. Individuals with chronic illnesses or conditions may be at higher risk.

Systemic infection- Can affect anyone, but certain populations like the elderly, young children, pregnant and those with preexisting health conditions may be more susceptible.

Local infections- factors such as poor hygiene, compromised skin integrity, or exposure to contaminated environments, can increase the risk.

Chapter 19 vital signs

Afebrile- A person who maintains a normal body temperature.

Febrile- a person with a fever.

5 sites for assessing temperature: Mouth (oral), Ear (tympanic)

Rectum (rectal), Forehead (temporal), Axilla (armpit).

9 pulse sites: Temporal, carotid, Apical/Mitral, brachial, radial, femoral, popliteal, posterior tibial, pedal (dorsalis pedis).

• Checking radial in older adults may be challenging if tremors are present.

• In an emergency or during cardiopulmonary resuscitation, carotid or femoral. Brachial pulse is used in children during emergencies. Dorsalis Pedis and posterior tibial pulses are used to evaluate the effectiveness of the peripheral vascular system, but not to assess heart rate or rhythm.
  
  

Factors affecting heart rate

• • Age- Pulse rate decreases

• Gender- male pulse is lower after puberty.

• Fever- increases because of increased metabolic rate and peripheral vasodilation that occurs.

• Medications- can either increase or decrease pulse rate.

• Hypovolemia- Loss of blood increased pulse rate from SNS

• Hypoxia and hypoxemia- When oxygen levels decrease, cardiac output increases to attempt to compensate, resulting in increased pulse rate.

• Stress- SNS from stress, fear, anxiety and perception of pain increase heart rate.

• Pathology- Heart conditions or illnesses that impair oxygenation can alter pulse rate. Head injuries can cause a decrease in heart rate for increase in intracranial pressure.

• Electrolyte imbalance- changes in potassium and calcium can affect pulse rate and rhythm.

• Check apical for one full minute.

• Use Doppler ultrasound to obtain a pulse.

Pulse intensity

Scale description

1. Absent pulse, (unable to palpate)

2. Diminished (weaker than expected)

3. Normal (able to palpate with normal pressure)

4. Bounding (may be able to see pulsation)

Respirations- act of breathing

Inspiration (inhalation)

Expiration (exhalation)

Hypoxemia (low 02 levels)

Hypercapnia (high 02 levels)

Factors include: age, exercise, illness, acid base balance,

Acidosis, alkalosis, medications, pain, emotions.

Eupnea- Normal respiration

Blood pressure

Systolic pressure- peak of the pressure wave

Diastolic pressure, lowest pressure on arterial walls, which occurs when the heart rests.

Factors affecting blood pressure:

Age- Elasticity in arteries Decrease, which causes increased blood pressure.

Factors that contribute to blood pressure errors

Factors

Inaccurate-  Defective equipment

Reading - Equipment not

Calibrated. 

Equipment. - Improper use of

positioned correctly- Patient not

Falsely low 

above heart level - Arm positioned

Reading incorrectly- Cuff to wide, Stethoscope placed

Tubing- Brakes or kinks in cuff

Falsely high

soon after exercising or smoking- Assessing too

Readings slowly- Cuff to narrow, Releasing valve too

Reading valve too slowly- Reflating The pressure

before it has deflated- Reflating bladder

Chapter 27 hygiene and personal care.

Types of bathing:

• Complete bed bath- bed ridden, performs ROM exercises and wash the patient.

• Partial Bed Bath only part of the body is washed. Includes face, hands, axilla, and perineum.

• Sink bath- patients who are ambulatory may prefer to wash while standing or sitting. May need assistance with legs, feet, and back.

• Shower- full shower for patients who are strong enough to shower independently.

• Chair shower- washed in the shower while sitting in a chair. For patients with dementia, establish individualized routine.

• Perineal care- involves cleaning the genital area.

• Sitz bath- Sometimes used after perineal surgery or childbirth to cleanse the area.

Many older adults have excessive drying of skin if doing a complete bed bath.

AIRBORNE: Pressure room, private room, mask.

"My chicken Hez Te"

Measles, Chicken pox, Herpes zoster, Tuberculosis

DROPLET: private room e mask.

"SPIDERMAn

Sepsis            Pertussis    Influenza  Diphtheria  Epiglottitis Rubella Mumps    Adenovirus

Scarlet fever   Pneumonia                                                                 Meningitis

                       Parvovirus

CONTACT: gown, gloves, goggles, private room.

(contact) "MRS. WEE"

Mrsa  Rsv  Skin infection   Wound infections  Enteric infection  Eye infection 

Vrsa

DELEGATION'" RN'S DO NoT delegate what they Can EAT

Evaluate, Assess, Teach