Untitled Flashcards Set

UNIT 1/2: Intro to Nurse Ed and Role of Nurse to Promote Wellness

• Unit 1: Intro to NSCC Nurse Ed program

• Module 1: 

  • 1: Discuss mission and philosophy of the program

  • Mission: Program prepares individuals for a career in nursing as an RN. Providing professional foundation that integrates nursing theory

  • Philosophy: 

    • The person as a holistic being with unique biophysical emotional, intellectual, social, cultural and spiritual dimensions who throughout the life span interacts w/ a changing environment

    • The environment including all factors, internal and external that impact an individual

    • Health as a dynamic state of wellness. It’s a fluctuating state of being, involving physical, psychological, and spiritual health

  • 2: Define Student Learning Outcomes

    • Demonstrate the use of clinical judgement to provide evidence based, patient centered care with a focus on the social determinants of health w/ core values of diversity, equity and inclusion

    • Utilize a caring professional identity and standards to provide ethical and legal nursing care for pt in diverse health settings

    • Uphold professional accountability while utilizing leadership skills to delegate nursing care and evaluate pt. Outcomes

    • Use info and tech to enhance therapeutic communication to support interdisciplinary pt. Care

    • Use and eval quality improvement strategies at the individual and systems level that lead to optimal outcomes

    • Establish a caring professional identity and grow as a provider of care engaging in ongoing professional development

• Unit 2: Nursing Role to Promote Wellness

  • Module 1: Health Wellness, and HC delivery systems

  • 1: Differentiate between health, wellness and well-being

    • Health One’s ideal state of physical wellness and mental well-being

    • Wellness and well-being Subjective, positive concepts emphasizing social and personal resources, as well as physical capacity

  • 2: State WHO definition of Health

    • Health: A state of complete physical, mental and social well-being and not merely the absence of disease of infirmity

  • 3: Identify factors affecting health status and HC adherence

    • Biological factors

    • Physical disease

    • Injury

    • Mental illness

    • Pain/Loss

    • Nutrition 

    • Physical activity

    • Sleep and rest

    • Meaningful Work

    • Meaningful relationships

      • Family/friends

    • Finances

    • Culture

    • Lifestyle choices

    • Religion and spirituality

    • Environmental factors

  • 4: Discuss Acute and Chronic illness and how it affects individual and family functions

    • Acute:  Occurs suddenly and lasts a limited amount of time

    • Chronic:  Lasts for an extended period of time, typically >6 months and often can be lifetime

    • Impact: There can be a host of things changing due to illness affecting family, behavior, emotional changes, body image, self-concept, family roles and dynamic, finances

  • 5: Discuss Healthy People 2030

    • Vision: A society in which all people can achieve their full potential for health and well-being across the lifespan

    • Mission: To promote, strengthen and evaluate the nation’s efforts to improve the health and well-being of people

    • Determinants:

      • Economic Stability

      • Education access and quality

      • HC access and quality

      • Neighborhood and built environment

      • Social and Community context

• 6/7: Discuss essential components of Health Promotion

  • Patient Centered Care

  • Communication

    • Establish trust

    • Provide healthing presence

  • Observe

    • Subjective/objective data

  • Goals/outcomes:

    • SMART goals

  • Examine life’s uncertainties

• 8 Discuss Health Care Delivery Systems

  • Types of service

    • Primary: Preventative; education/support

    • Secondary: Early diagnosis and tx for illness, disease and injury

    • Tertiary: Long-term care such as rehab/extended care

  • Financing Healthcare

    • Pay out of pocket

    • Individual Insurance

    • Employment insurance

    • Government financing

      • MEDICARE/MEDICAID, Children's Health Insurance program

  • Factors affecting Health Care Delivery

    • Natural Economy:  Full-time employment w/ health insurance benefits. 

      • Recession cause people to delay treatment because of absence of insurance

    • Growing proportion of older adults

    • Legislation

    • Nursing Shortages

    • Evidence based practice

    • Patient based care

    • Changes in healthcare consumer

• Module 2: Discuss the Role of the Nurse

  • 2: This was done in module 1 asking about philosophy in nursing

  • 3: Discuss each of the following scopes of nursing

    • Health Promotion

    • Maintenance of Health

    • Restoration of Health

    • Consolidation of Dying

  • 4: Discuss role and functions of the nurse

    • Assess clients

    • Administer treatment/meds

    • Provide education

    • Modify nursing care plans based on client response to treatment

    • Provide continuous holistic and comprehensive nursing care

    • Evaluate clients from holistic/comprehensive multi-team approach

  • 5: Explain the role of the nurse as a provider of healthcare

    • Nurses prove and coordinate patient care

    • Educate patient and public about various health conditions 

    • Provide advice and emotional support to patient and their family members

  • 6: Discuss Nursing research and its importance

    • Develops knowledge about health and promotion of health over the full lifespan, care of persons with health problems and disabilities

    • Nursing action to respond effectively to actual or potential health problems

  • 7: Identify the purpose of nursing theory 

    • Purpose is how actions of other have advanced the profession and how your actions and advocacy can make a difference

    • *Provides insight into the role of professional practice

      • Four basic concepts: 

        • Person

        • Environment

        • Health/illness 

        • Nursing

    • Important Figures

      • Florence Nightingale

        • Founder of modern day nursing

      • Mildred Montag

        • Created first associates degree in 1952 (ADN Degree)

      • Jean Watson’s Theory on the Science of Human Caring

      • Martha Rogers - Science of unitary beings

      • Patricia Brenner

        • Model of Development of clinical wisdom and competence

        • Describes the process of which a nurse acquires clinical skills and judgement

• Unit 2 Module 3: Ethical Behavior

  • 1: Define ethics and values

    •  Ethics: A system of moral principles or standards governing conduct (philosophy of what ought to be)

      • Bioethics: Moral inquiry into issues raised by health care education, practice and research

      • Nursing Ethics: Deals with the relationship of a nurse to the patient, family, fellow nurses and society at large

    • Values: Freely chosen, enduring beliefs or attitudes about the worth of a person, object, idea or actions

      • Based on moral thought-what is right and wrong

  • 2: Discuss statements listed in ANA Code of Ethics

    • A nurse's primary commitment is to the patient, family, or 3rd party.

      • Being compassionate, respectful to every patient 

      • Advocating for patients rights, health and safety

  • 3: Discuss ANA standards of Nursing Practice

    • The standards assure safe, competent care is provided to the public

  • 4: Discuss pertinent issues related to maintaining patient confidentiality 

    • HIPAA

    • Computer Access to patient records

    • Talking to family members

    • Student issues related to maintaining confidentiality 

  • 5: Discuss common ethical issues currently facing healthcare professionals

    • Quality of Life: Central to discussions about end-of-life care

    • Genetic Screening: Risks and benefits of attaining knowledge of underlying disease(s) that are not causing symptoms or may not be a cure available on an individual or societal level

  • 6: Describe ways in which Nurses can enhance their ethical decision making

    • Aware of own values and ethical aspects of nursing

    • Familiarity with nursing code of ethics

    • Respect values, opinions, responsibilities of other healthcare professionals that may differ

    • Participate in or establish ethics rounds

    • Severe on institutional ethics committees

    • Stive for collaborative practice in which nurses function in cooperation with other healthcare professionals

  • Discuss accountability and advocacy

    • Advocacy: Expressing and defending the cause of another

    • Accountablity: Responsible for ones actions

• Unit 2 Module 4: Legal Aspects of Nursing

  • 1: Identify four sources of Law

    • Constitutional Law:  3 Branches of government

    • Statutory Law: Law passed by legislative body

    • Judicial Law: Court decisions

    • Administrative Law: Government agencies

  • 2: Discuss the Laws and regulations that guide nursing practice

    • Law and the Role of the Student Nurse: You are held to the same standards of care as licensed nurses

    • Law and Role of the RN: 

      • State Nurse Practice Act: Define the scope of Nursing

      • Education: Define requirements sets by state regulations (statutory law)

      • Licensure: Define eligibility and requirements set by state regulation 

        • Obtaining an RN License:

          • Complete educational requirements

          • Meet citizenship/work visa requirements

          • Submit written application with photo ID, clear CORI process, DCF process if applicable

          • Meet criminal record requirements standards for “good moral character”

      • Black’s Law: Defines standard of care

        • The degree of care which is reasonable prudent person should experience under the same or similar conditions 

        • The skills and knowledge base commonly possessed by professional members

• 3: Discuss principles of criminal law that affect Nursing Practice

  • Good samaritan Law: Protect from liability those who provide emergency care

  • Nurse Practice Law: Protect the public, regulate scope of practice, approve nursing programs

  • Mandatory Reporting Laws: Requires reporting of certain conditions and circumstances for health care workers

    • Usually unsafe or unkept conditions especially for patients

  • Patient Self Determination Act: Provide written information regarding the right to make decisions, document advanced directives and treat everyone the same regardless of advance directives

  • Crime: An offense against a person, property or state. This can happen in the scope or Nursing practice

  • Felony: A crime punishable by more than 1 year in jail (usually violent crimes)

  • Misdemeanor: Minor charge compared to felony usually involving less jail time than a year

  • Tort: A wrongful act or an infringement of a right leading to civil legal liability

• 4: Explain and give examples of the following wrongdoings

  • Assault: An act intended to invoke fear

  • Battery: Offensive or harmful physical contact without consent

  • Fraud: False representation of significant facts by words or conduct

  • Slander: Verbal defamation

  • Libel: Written defamation

  • Invasion of privacy: Release of information to unauthorized individuals (HIPAA)

• 5: Difference between neglect and malpractice

  • Negligence: When a healthcare professional accidentally causes harm during medical practice

  • Malpractice: When a healthcare professional makes a mistake or decision while being aware of the potentially harmful consequences

• 6: Good Samaritan Laws

  • Laws to provide immunity for individuals who are assisting in urgent care situations. These are state laws

• 7: Vicarious Liability: Being legally accountable for our own actions or inactions (employer may have this)

  • Ex: Captain of the ship, borrowed servant doctrine, respondeat superior (these do not negate nursing accountability)

• Tips for Charting:

  • F: Factual

  • A: Accurate

  • C: Complete

  • T: Timely

  • U: Unusual (always include)

  • A: Assessment (always include data/plan)

  • L: Legal record/ hold up in court

• Unit 2 Module 5: Define and Describe Well Elder

  • 1: Health Assessment and promotion in the well elder

    • Vital Signs

    • Height Measurement

    • BMI

    • Lipid panel screening

    • Blood glucose screening

    • Annual clinical breast screening

    • Breast self-awareness

    • Biannual mammogram or thermography

  • 2: Identify factors that influence aging:

    • Sun exposure

    • Genetics

    • Exercise

    • Smoking

    • Disease

    • Diet

    • Medication

    • Alcohol Consumption

    • Stress

    • Environment

    • Study done in 2000 

      • Identical twins aging factors

        • Smoking/sun exposure

• 3: Define and differentiate 

  • Common terminology relating to aging and the older patients:

    • Young-old: Ages 65-74

    • Middle-old: Ages 75-84

    • Old-old: Ages >85

    • Centenarians: People aged >100 years old

    • Frail Elderly: Characterized by health status rather than age

    • Ageism: Age discrimination

  • Theories of Aging:

    • Wear-and-tear theory: Repeated injuries and accumulation of metabolic waste eventually causes cells to cease function

    • Genetic Theory: Aging proposes that cells have a preprogrammed finite number of cell divisions. Suggesting death can be determined at birth

    • Cellular Malfunction: Hypothesizes that a malfunction in a cell causes changes in cellular DNA, leading to problems with cellular replication

      • Cross-linking: Theory that accumulation of crosslinking proteins damages cells and tissues, slowing bodily processes resulting in aging

      • Free radical: Abundance of damaging cells that impair their ability to function normally

      • Toxin Theory: Buildup of toxins over time leading to cell death

    • Autoimmune Reaction: Theory that hypothesizes that cells change overtime and the immune system perceives some cells as foreign substances triggering it to destroy cells

    • Disengagement Theory: Hypothesizes that the older adult and society gradually and mutually withdraw or disengage from each other

      • Mandatory retirement

      • Chronic illness

      • Death of relatives and friends

      • Poverty are factory that can contribute to this phenomenon

    • Activity Theory: Older adults should stay active and engaged as possible to enjoy the highest life satisfaction

      • Essentially finding activities to fill their time

      • Having physical activity among social

    • Erikson’s Psychosocial Development Theory: A theory that states personality evolves throughout the lifespan

      • Stage 1: Trust vs mistrust (birth - 18 months)

      • Stage 2: Autonomy vs shame and doubt (18 months - 3 yrs)

      • Stage 3: Initiative vs guilt (3-5 yrs)

      • Stage 4: Industry vs inferiority (6-11 yrs)

      • Stage 5: Identity vs Role Confusion (11-21 yrs)

      • Stage 6: Intimacy vs Isolation (21- 40 yrs)

      • Stage 7: Generativity vs Stagnation (40-65 yrs)

      • Stage 8: Ego Integrity vs Despair (>65 yrs)

• 4: State at least 6 developmental tasks of older adulthood 

  • Adjusting to decreasing health and physical health

  • Adjusting to retirement

  • Adjusting to lower income

  • Adjusting to death of a spouse

  • Establishing an open affiliation with one’s age group

  • Adopting flexible social roles

  • Establishing satisfactory physical living arrangements

• 5: Describe in general terms physical, cognitive and psychosocial changes which occur within the process of aging

  • Physical: 

    • Decrease in density of muscle/bone

    • Joint mobility

    • Immune function

    • Senses impairments (hearing/touch)

  • Cognitive:

    • Slows in reaction time

    • Short-term memory declines

    • Response time to stimulus becomes longer

    • Ability to process incoming information becomes slower

UNIT 3 Module 1: The Nursing Process and Clinical Judgement

• 1: Define Critical Thinking and Clinical Judgement

• Critical Thinking: As applied to nursing, it can be defined as cognitive process that uses intellectual standards based on evidence that uses intellectual standards based on evidence and science to approach a subject, content or problem

  • Also: The ability to apply higher-order cognitive skills (conceptualization, analysis, evaluation) and disposition to be deliberate about thinking (open minded or intellectually honest) that lead to action that is logical and appropriate 

    • Linked to evidence-based practice

    • Critical thinkers are flexible, non-judgemental, inquisitive, honest and interested in seeking the truth

• Clinical Judgement: YAY MULTIPLE DEFINITIONS!!!

  • National Council of State Board of Nursing (NCSBN): 

    • To observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence based solutions in order to deliver safe client care

  • Tanner’s Model: 

    • Interpretation or conclusion about a patient needs concerns or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient response

• Benner, Tanner, Chelsea: 

  • Ways in which nurses come to understand the problems, issues, or concerns of client and patients, to attend salient information, and to respond to concerned and involved ways

2: Discuss the Skills and attitudes that foster critical thinking and clinical judgment

• Skills: Refers to the cognitive (intellectual) processes used in complex thinking operative such as problem solving and decision making

• Attitudes: Consists of beliefs, feelings and views towards something or someone. This can determine whether you are using thinking skills fairly

3: Compare and Contrast critical thinking, clinical judgement, problem solving and decision making

• Problem solving:

  • Five step process that nurses should use to guide their professional actions. ADPIE

• Critical thinking: 

  • Higher cognitive thinking that leads to logical decision

• Clinical Judgement: 

  • Interpretation and conclusion about a patient's problems or decision to take action to change standards made

• Decision making: 

  • Response to various levels of patient cues not limited to physiological cues alone but complex factors such as progression of change

4: Maslow’s Hierarchy of Needs

• Physiological:

  • Food, air, water, temperature regulation, elimination, rest, sex and physical activity

• Safety and Security:

  • Protection, emotional and physical safety and security, order, law, stability, shelter

• Love and Belonging: 

  • Giving and receiving affection, meaningful relationships, belonging to group(s)

• Self-Esteem: 

  • Pride, sense of accomplishment, recognition by others

• Self-actualization: 

  • Personal growth, reaching potential

Unit 3 Module 2: Define the components of of the Nursing Process

• 1: Define the Nursing Process

  • A multi step systematic problem-solving process that guides all nursing actions

    • It’s the diagnosis and treatment of human responses to actual or potential health problems

    • Problem solving method to help the nurse provide goal-directed, client centered care

• 2: Discuss the Steps of the Nursing Process

  • Assessment: 

    • Information collection, gathering and sorting data

  • (Nursing) Diagnosis:

    • Analyze assessment data to identify the patients needs for nursing care

  • Planning:

    • Set nursing goals, desired outcomes; and planning interventions (SMART GOALS)

  • Implementation:

    • Perform nursing interventions

  • Evaluation:

    • Patient’s status and effectiveness of nursing interventions

      • Were the patient's outcomes met?

  • Evolving process, can change constantly while treating a patient

• 3: Discuss Values on Using the Nursing Process System

  • It's a scientific, cylindrical process that helps Nurses provide safe, efficient, and high quality care to patients

• 4: Discuss how the Nursing Process is used to write care plans and document care

  • Systematic approach to gather info, identify patients:

    • Needs

    • Set goals

    • Execute interventions

    • Monitor effectiveness of care delivered

Unit 3 Module 3: Define the process of Assessment

• 1: Describe ways in which the Nurse assesses the patient 

  • Gathering data

    • Lab results

    • Vitals

    • Subjective/Objective data

  • Observation: Deliberate use of all senses to gather and interpret patient and environmental data

• Physical: 

  • Most objective data by palpation, percussion, direct auscultation( listening with unaided ear), and indirect auscultation (stethoscope)

• Interviewing: Purposeful, structured communication in which one questions the patient, in order to gather subjective data for the nursing database

• Types:

  • Initial and Ongoing:

    • First completed on arrival

    • Initial: Are related to the person’s reason for seeking nursing or medical assistance and provide guidance of care

      • Help determine need for further assessment

    • Ongoing:

      • Help identify new problems and follow up on previous ones

  • Comprehensive: 

    • Global assessment patient nursing database

    • Provide holistic info about client’s overall health status

    • Enables you to identify client problems and strengths 

    • Enhances your sensitivity to a patient's culture, values, beliefs and economic situation

    • Uses the nursing skills of observation, physical assessment, and interviewing

  • Focused:

    • Obtain data about an actual, potential or possible problem that's been identified or is suspected

      • Focuses on particular topic or body part

  • Special Needs:

    • Provides in-depth information about a particular area of patients functioning

      • Accrediting agency standards may require

      • You may also perform special needs any time assessment cues suggest risk factors or problems for the patient

• 2: Describe the Nursing History as a tool for gathering patient data

  • The nursing history is used as a tool to gain trust of the patient and engage in plans within an appropriate time frame

    • What the effect the injury has on the patient’s ability to perform ADLs and identify strengths to begin planning discharge

    • Gather details about a patient's past and present health conditions, including 

      • Medical history

      • Family history

      • Social factors

      • Lifestyle habits

• 3: State the principles of interviewing used in obtaining a nursing history

  • Using close-ended questions as well as open-ended questions

    • Biographical data

    • Chief complaint

    • History of illness

    • Clients perception of health status and expectations for care

    • Past health history

    • Family health history

    • Medication hsitory and device use

    • Complementary and alternative modalities (CAM)

    • Review of body systems and associated functional abilities 

• 4: Describe a nursing physical assessment. Identify examples of normal findings that change throughout the adult lifespan

  • NAH

• 5: Describe clustering data using Maslow’s Hierarchy of Needs

  • Maslow's model groups data according to human needs, from basic to highest by setting priorities when planning nurse care

• 6: Describe methods of validating data

  • Information gathered during the assessment phase must be complete, factual and accurate because the nursing diagnosis and interventions are based on this information

    • Validating is an act of “double-checking” or verifying data to confirm that it is accurate and factual

  • Book info: 

    • Need to validate under certain circumstances

      • Subject/object data do not agree or make sense together

      • The patients statements differ at different times in the interview

      • The data falls far outside normal range

      • Factors are present that interfere with accurate measurement 

Unit 3 Module 4: Discuss the process of determining a nursing diagnosis

• 1: Describe the components of the 3 art NANDA nursing diagnosis

  • PES Format: 

    • Problem, etiology and symptom format

      • Primarily for student, this method helps ensure there is enough data to support the problem identified 

      • Problem: Nursing Diagnosis, from approved list

      • Etiology: Cause of the problem R/T

      • Signs and Symptoms: Evidence “as evidenced by”

        • Defining characteristics

      • Format of PES

• Etiology: It directs nursing care, its similar to risk factors

  • Branch of medical science concerned with the causes and origin of disease

• NANDA: Classification system provides a standardized terminology, or standardized language to use when describing human responses

• Diagnostic Label: (Title or name)

  • A word or phase that provides a name for diagnosis

  • Represents a pattern of cues and describes a problem or wellness response

  • Definition:

    • Explains the meaning of the label

    • Distinguishes it form similar nursing diagnosis

  • Defining Characteristics:

    • Cues (signs/symptoms) that allows you to identify a problem or wellness diagnosis

    • A cluster of defining characteristics must be present in the patient data to use the problem label appropriately 

  • Cluster Cues:

    • In the nursing process it's a grouping or related signs, symptoms or behavior to better understand a patient's health

• 2 Identify the relationship between the patient’s problems and the diagnostic statement

  • The problem is the core element of a diagnostic state, summarizing the nature of the patient’s health issue

• 3: Explain the etiology portion of diagnostic statement

  • Etiology: Contains one or more factors that cause, contribute or create a risk for a patient

    • Related factor or risks:

      • Gives direction to the nursing treatment 

      • May be attributed to pathophysiology, psychosocial behavioral, situational, developmental, cultural or environmental factors

• 4: Explain “defining characteristics”

  • Signs and Symptoms (cues)

    • Symptoms are changes that the patient feels and expresses verbally (subjective)

    • Signs are observable of a health need (objective)

    • Absent in potential problem

• 5: Explain the difference between a problem based diagnosis and a risk based diagnosis

  • Problem Based Diagnosis: 

    • Issues or problems that are present and observable during the assessment phase

  • Risk based Diagnosis: 

    • Is a clinical judgement that a problem doesn’t exist but the presence of risk factors indicated that a problem is likely to develop unless nurses intervene 

Unit 3 Module 5: Describe Planning Nursing Care

• 1: State the guidelines for writing Nursing Care Plans

  • Central source of information needed to guide holistic, goal-oriented care to address each patients unique needs

    • Specifies dependent, interdependent and independent nursing actions

  • Assessment

  • Diagnosis

  • Outcomes

  • Implementation

  • Evaluation

  • Standardized care plans are beneficial because it helps ensure that interventions are not overlooked

• 2: Discuss the process of setting priorities using Maslow’s Hierarchy of Needs when writing a care plan

  • Identify most basic needs first and then move from there

    • ABCs

• 3: Describe the need to establish goals as the first part of the plan of the Nursing Process

  • Central source of information needed to 

    • Guide holistic goal-oriented care

    • Address each patient’s unique needs

• 4: Describe the relationship between the goal statements and the nursing diagnosis

  • Expected outcomes derive directly from the nursing diagnosis

  • Problem statement describes the response and health status to be changed

  • Desired outcomes states the opposite of the problem response

• 5 State guidelines for correctly writing a goal statement

  • Components

    • Subjective

    • Actions

    • Performance Criteria

    • Target time

    • Special Conditions

  • SMART Goals:

    • Specific

    • Measurable

    • Appropriate

    • Realistic

    • Timeframe

Unit 3 Module 6: Describe Implementing and Evaluating Nursing Care

• 1: Explain the relationship between between implementing and other phases of the nursing process

  • Involves action and thinking, but the emphasis is on doing

    • During implementation, you perform or delegate planned interventions that is to carry out the care plan

    • This phase ends when you document the nursing actions

    • Implementation evolves into evaluation as you document the resulting client responses

• 2: Explain the process of implementation

  • Implementation is intricately tied into every other step of the nursing process

    • Assessment: 

      • Implementation provides opportunity to assess patient at every contact

      • When performing ongoing assessment you are doing both

    • Diagnosis: 

      • Use to identify new diagnosis or revise the existing care

    • Evaluation:

      • When eval patient health status and progress towards goals you will compare the responses you observe during implementation with the existing goals

    • Putting the care plan into action

      • Independent nursing interventions/dependent

      • Collaborative nursing interventions

      • Rationale: Critical thinking

• 3: Describe the process of selecting appropriate interventions

  • Make sure it makes sense for the patient

  • Utilize evidence based interventions and to specify to the diagnosis or problem

  • Utilizes community resources and systems to implement the plan

  • Collaborates with nursing colleagues and others to implement the plan

• 4: Differentiate between independent, dependent and interdependent (collaborative) nursing interventions

  • Independent:

    • Interventions that do not require a provider's prescription that the RN’s are accountable for

  • Dependent:

    • Interventions prescribed by a physician or advanced nurse practice but carried out by a nurse 

      • Diagnostic test

      • Medications

      • IV therapy

  • Interdependent: 

    • Interventions carried out in collaboration with other healthcare team members

• 5: Explain the purpose of writing rationale

  • To explain why a particular intervention is necessary for the patient's care plan

• 6: Explain the relationship between evaluating and other phases of the nursing process

  • Final step to the nursing process

  • Essential for ensuring quality nursing care

  • Evaluate

    • Clients progress towards goals

    • Effectiveness towards nursing care plan

    • Quality of care in the healthcare setting

  • Review every step of the way to ensure a high quality nursing care plan

Unit 3 Module 7: Describe Methods of Documenting and Reporting Nurse Care

• 1: List the purpose of documentation systems and define nursing informetrics:

  • Purpose:

    • Communication

    • Continuity of care

    • Quality improvement

    • Planning and evaluation of patients outcomes

    • Legal record

    • Professional standards of care

    • Reimbursement and utilization review

      • The act of documenting a patient assessment is written or electronic forms

  • Nursing Infometrics:

    • Integrates nursing science with multiple information management and analytical sciences to identify, define, manage and communicate data, information, knowledge and wisdom in nursing practice

      • Supports the way nurses work and function

      • Enhances nursing practice through improved access to information and clinical decision-making tools

• 2: Define Problem-oriented Medical Record

  • POR

    • Organized around patient problems

    • Four components

      • Database

      • Problem list

      • Plan of care

      • Progress notes

      • Promotes greater collaboration

    • Method of organizing patient information by medical problems instead of chronological order

• 3: Explain the SOAP note method of writing progress notes

  • Subjective: What the client or family members tell you about the client’s signs and symptoms and the reason for seeking healthcare quoting real words used by patient

  • Objective: Factual-measurable clinical findings such as vital signs, test results and quality of breath sounds

  • Assessment: Conclusion drawn from subjective/objective data

  • Plan: Short-term and long-term goals and strategies that will be used to relieve patients problems

  • IER

    • Interventions: Actions of the healthcare team performed to achieve expected outcomes

    • Evaluation: An analysis of effectiveness of interventions

    • Revision: Changes made to the original plan

• 4: Describe focus charting:

  • 3 column charting typically used during acute care setting

    • First: Contains the time/date

    • Second: Focus on problem being addressed

    • Third: Documentation DAR format: Data, action, response

  • Structures method of organizing and documenting a patient's health information in nursing records

• 5: Discuss legal and ethical components of the electronic health record

  • Legal Guidelines:

    • Correct all errors promptly, using the correct method

    • Record all facts; do not enter personal opinions

    • Do not leave blank spaces in the nurses’ notes

    • Write legibly in permanent black ink

    • If an order was questioned, record clarification was sought

    • Chart only for yourself

    • Avoid generalizations

    • Begin entry with date/time and end with signature

    • Keep computer password secure

  • Confidentiality:

    • Nurses are legally and ethically obligated to keep all patient information confidential

    • Nurses are responsible for protecting record from all unauthorized readers

    • HIPAA requires that disclosure or requests regarding health information are limited to the minimum necessary

• 6: List guidelines for charing accurately

  • Factual

  • Accurate

  • Complete

  • Current

  • Organized

• 7: Define specific types of documentation and their purpose

  • Flow Sheets: 

    • Record routine aspects of care (hygiene, turning)

    • Document assessments, usually organized according to body systems

    • Track client response to care

    • Use graphic records to record vital signs

    • Record I&Os

  • Kardex:

    • A portable “flip-over” file or notebook with patient information

  • Incidence Reports:

    • Formal report of unusual outcome or accident

    • Not a part of patient’s health record

    • Quality improvement

  • QA reviews:

    • Quality Assurance

    • A process the ensures nursing practices meet quality standards and help improve patient care

• 8: Describe types of verbal reports and their essential elements

  • Change of Shift

    • Handoff report 

      • Client status

      • Recent status changes

      • Planned activities

      • Diagnostic tests or concerns that require follow-up

    • Use a standardized format such as IPASS, SBAR, or PACE

      • Keep it CUBAN

        • Confidential

        • Uninterrupted

        • Brief

        • Accurate

        • Named nurse

• 9: lol idk

• 10: Describe Essential Elements of the admission and discharge note

  • Admission:

    • Patient ID

    • Medical/Medication history

    • Allergy

    • Vital signs

    • Detailed Physical assessment

• Discharge:

  • Summary

  • Plans

  • Medication reconciliation

  • Communication

  • Involve patient and caregivers

  • Continuity of care

• 11: Identify how to give verbal report

  • SBAR

    • Make a clear, concise, description of situation

    • Provide background information about patient

    • Give the receiver your assessment of situation

    • Recommendation of what is needed

  • Situation:

    • Patient has this diagnosis

  • Background:

    • Why they came in relevant history

  • Assessment

    • Objective/subjective data

  • Recommendation

    • An order for the nursing diagnosis or ask for a recommendation

Unit 3 Module 8: Discuss the Continuum and Management of Care

• 1: Define and interpret the following terms:

  • Case Management:

    • A model of nursing care in which a nurse oversees the management of patients with specific and complex health problems

      • Coordinates and links health care services across all levels of care for patient and families

  • Continuity of Care:

    • Ongoing healthcare management

    • Quality of care overtime

      • Possible scenario: Home, HCP -> Hospital -> admission -> Med-surg floor -> Rehab facility -> Home -> outpatient care:

  • Discharge Planning:

    • Begins moment a patient is admitted to a healthcare facility

    • Involved patient/family in the planning

    • If family can provide care

    • Home assessment

• Discharge Against Medical Advice (AMA)

  • Patient is of sound mind has the right to leave the hospital, even when further medical care and treatment are recommended

    • Assess knowledge and try to educate

    • Provider must be notified

    • Most hospitals have a policy in place for AMA

• Durable Medical Equipment:

  • Medical equipment adjusted and adapted for home use

• Home Health Care:

  • Hospice

  • Adult day care center and senior center

  • Meals on wheels

  • Ambulatory Care Center

  • PT/OT/SLP/ Social Services

• 2: Interpret the nurse’s role in maintaining a patient’s continuity of care, with a focus on patient transfer and discharge from a healthcare facility

  • Patient Transfer:

    • Current status includes

      • Medications

      • Treatment/tubes in the clients; when next meds are due

      • Presence of wounds or open areas of skin

      • Special directives

        • Code status

        • Preferred intensity of cure

        • Isolation required (contact precautions)

      • Always ask receiver if they have questions

  • Discharge:

    • Condition of patient

      • Self care abilities and needs

      • Head to toe assessment

      • Care needs

    • Teaching conducted, handouts, informational matter provided to client

      • Diet modifications

    • Discharge instructions 

      • Medications

      • Treatment

      • Activity

        • When to notify healthcare provider

• Follow-up appointments or referrals given

  • When or how to obtain further treatment and follow-up assessments

  • Access to community resources 

• Basically trying to have patient continue to get better when care is no longer yours

• 3: Identify purposes of healthcare referrals

  • To ensure that the patients are seeing the correct providers for correct problems

• 4: Discuss the healthcare team’s role in discharge planning, including the role of patient, family and nurse

  • The role is to see if we can set up patient for success

    • Using education, home assessment and referrals 

    • See if family can provide care or if patient need short/long-term care facility

    • Outpatient care needs, adult day care centers, and programs

• 5: Discuss the impact of Health care financing on patient care

  • Lots of information 

  • Dependent on what insurance will pay for 

    • Usually need prescriber for approval of tests/medications

• 6: Identify sources of community healthcare and services provided

  • Skilled nursing facilities

  • Nursing

    • PT

    • OT

    • SLP

    • Adult Day Care program

UNIT 4: Meeting Patient Safety Needs

Unit 4 Module 1: Apply the Nursing Process in Care of the Patient with Pain

• 1: Identify factors affecting the body temperature

  • Heat Production:

    • Basal metabolism

    • Muscular activity (shivering)

    • Thyroxine and epinephrine (stimulating effects on metabolic rate)

    • Temperature effect on cells

    • Normal range:

      • 96.8 - 100.9

• Heat Loss

  • Radiation: Heat from one another by electromagnetic waves

  • Conduction: The transfer of heat through a substance

  • Convection: The movement of particles through a substance, transporting heat energy from areas to cooler areas

  • Evaporation (Vaporization): Turning liquids into gas or vapor

• Non-shivering thermogenesis: 

  • A natural method by which newborns can produce body heat by increasing metabolic rate

    • Disappears after 3 months of age

• Age:

  • Infants and childrens temperatures are more viable 

  • Older adults are more prone to hypothermia

• Exercise:

  • Stimulates muscle activity which increases heat production thus increasing body temperature

• Hormones:

  • Women have wider fluctuations due to hormone changes and subcutaneous fat

• Stress:

  • Elevates temperature

• Environment: 

  • Infants/elders more sensitive to change 

• Hyper/Hypothyroidism:

  • Can affect BMR which in turn affects body temperature accordingly

• Developmental Stages:

  • Newborns:

    • Lose approximately 30% of body heat through head 

    • Stabilizes in early childhood

  • Older Adults:

    • Trouble maintaining body heat because BMR slows down

      • Decreased vasomotor control

      • Loss of subcutaneous tissue

• 2: Define the following terms

  • Febrile: 

    • Temperature is above normal range

  • Afebrile: 

    • No fever - normal body temperature

  • Hypothermia: 

    • Core body temperature is less than normal due to heat loss or decreased heat production

  • Pyrexia: 

    • Fever - induced body temperature due to pyrogens (bacterial/viral)

  • Hyperthermia:

    • Inability for the body to promote heat loss or reduce heat production

  • Diaphoresis:

    • Excessive perspiration, sweating

  • Stages of Pyrexia:

    • Early Stage:

      • Increased pulse

      • Respirations

      • Shivering

      • Pallor

      • Cold skin

      • Goosebumps

      • No sweating

      • Chill

    • Later Stages:

      • No chills

      • Increased pulse/respirations

      • Increased thirst/dehydration

      • Malaise

      • Decreased appetite

      • Drowsy delirium

      • Convulsions

    • Fever abatement

      • “Breaking the fever” skin is warm, flushed and sweating

    • Antipyretics: 

      • Motrin, tylenol

• 3: THERMOMETERS ARE DUMB

• 4: Describe Variations in normal body temperature that occurs from infancy to old age

  • Infancy you are warmer, while you age it gets slightly “cooler” but becomes from difficult to retain heat

  • Body temperature tends to lower as we age but only slightly

    • Newborn to adult: 98-100

    • Older adult: 95-97

• 5: Identify factors affecting pulse

  • Age

  • Gender

  • Exercise

  • Medications

  • Hypovolemia

  • Stress.Emotions

  • Position changes

  • Temperature

  • Quality:

    • 0: Absent 

    • 1: Weak or thready - pulse is barely felt and can be easily obliterated by press with fingers

    • 2: Normal - Easily palpated, not weak or bounding

    • 3: Bounding or full - Easily felt with little pressure not easily obliterated 

• 6: Define the following terms:

  • Tachycardia: 

    • HR rate >100 bpm

  • Bradycardia: 

    • HR rate <60 bpm

  • Irregular Pulse:

    • An arrhythmia

  • Pulse deficit:

    • Difference between # of heartbeats and number of pulses felt in 1 minute

  • Bounding:

    • Strong throbbing feeling in an artery caused by a forceful heartbeat

• 7: Identify pulse sites (9) and how to assess each (auscultate and palpate)

  • Temporal

  • Facial

  • Carotid

  • Brachial

  • Radial

  • Femoral

  • Popliteal

  • Posterior Tib

  • Dorsalis Pedis

  • Apical

• 8: Describe variations in normal heart rate that occur from infancy to old age

  • Normal: 60-100 

  • Tachycardia: > 100

  • Bradycardia: < 60

  • As we age it decreases until 15 yrs old

    • Newborn: 100-160

    • 0-3 Months: 70-170

    • 6-12 Months: 80-140

    • 1-3 years: 80-130

    • 3-5 years: 80-120

    • 11-14 years: 70-110

    • ≥ 15 years old: 60-100

• 9: Identify factors affecting respirations:

  • Blood CO₂  levels 

  • Blood glucose levels

  • Body Temperature

  • Emotions/exertion 

  • Activity level/ Level of consciousness

  • Pain

  • Medication

  • Lung Conditions/ Heart Disease

  • Age

  • Environmental factors

  • Neurological conditions

• 10: Define the following terms:

  • Apnea: No breaths

  • Dyspnea: Shortness of breath, difficult, labored breathing

  • Hyperpnea: Force respirations, breathing more deeply sometimes faster than usual

  • Hypoventilation: Very slow, shallow respirations

    • Bradypnea: Respiratory <12 breaths per minute

  • Hyperventilation: Rapid, deep respirations

    • Tachypnea: Respiratory > 20 breaths per minute

  • Othophean: Difficulty breathing while lying down

  • Perfusion: Distribution of RBCs to and from pulmonary capillaries

  • Diffusion: Movement of 0₂ and CO₂ between alveoli and RBCs

• 11: Assess depth, rhythm and characteristics of respirations

  • Sounds:

    • Wheezes

    • Rhonchi: Whistling/ snoring sound heard during auscultation

    • Crackles (rales)

  • Depth:

    • Watching of chest

    • Hyper/Hypoventilation

  • Characteristics:

    • Relaxed breathing

    • Labored breathing (dyspnea)

    • Orthopnea

  • Rhythm: Regular/irregular

    • Quality and Character: Relaxed breathing

    • Same as characteristics

• 12: Describe variations in normal respiratory rate that occur from infancy to old age

  • Increased:

    • Metabolism

    • Stress

    • Environmental temperature

    • Decreased Oxygen at high altitude

    • Smoking

    • Exercise

    • Fever

    • Pain

    • Disease

  • Decreased:

    • Some medications (opioids)

    • Pain

    • Anxiety/Fear

    • Fever

    • Disease

    • Smoking

  • Measure for 1 full minute

  • Newborns:

    • Irregular breathing pattern

      • Breath, breath, breath, reeeeest, then repeat

Unit 4 Module 2: Assessing Blood Pressure, Oxygen Saturation, Intake and Output

• 1: Identify Factors affecting blood pressure

  • Pumping action of the heart

    • Weak = lower BP

    • Strong = higher BP

  • Peripheral Vascular Resistance

    • Increased vasoconstriction = increased BP

    • Decreased = Lower BP

  • Cardiac Output = HP x Stroke Volume

    • Amount of blood ejected everytime heart pumps

  • Blood Volume:

    • Increases/Decreases is r/t BP

  • Blood Viscosity:

    • Increased viscosity (thickness) = increased hematocrit

      • RElation to RBCs to Plasma

  • Other Factors:

    • Position

    • Age

    • Exercise

    • Stress

    • Genetics/Gender

    • Medications

    • Obesity

    • Race

    • Environment

    • Disease process

    • Smoking

• 2: Explain the following terms:

  • Systolic:

    •  Pressure of the blood from ventricular contractions

  • Diastolic: 

    • Pressure of the blood when ventricles rest

  • Pulse Pressure: 

    • Difference between the two 

      • Measured in mm/Hg recorded as fraction 120/80 = 40

  • Hypertension:

    •  BP is greater than normal

      • Usually asymptomatic

      • Unknown cause: Primary hypertension

      • Known cause: Secondary hypertension

      • Diagnosis after 2 or more readings over 130-140/90

  • Hypotension:

    • BP is less than normal: systolic consistently under 85-110

      • If pulse is elevated its indicative of shock or hemorrhage

  • Orthostatic Hypotension:

    • Postural hypotension

• 3: Identify the process of assessing blood pressure

  • Direct-catheter: 

    • Placed on brachial, radial, or femoral artery

  • Non invasive: Auscultation, palpation

    • Important that the patient's position during BP be the same during each assessment to permit a meaningful comparison of values

  • Korotkoff Sounds:

    • First sounds = systolic pressure

    • Last sounds = diastolic pressure

  • Assessment:

    • Usually in arm

    • Occasionally the thigh

  • Avoid sites:

    • IV

    • Mastectomy: axillary nodes have been removed on that side

• 4: Describe variations in normal BP that occur from infancy to old age

  • Newborns - 1 month old: 60-90  / 20-60

  • Infants: 87-105 / 53-66

  • Toddlers: 95-105 / 53-66

  • Preschoolers: 95-110 / 56-70

  • School-aged children: 97-112 / 57-71

  • Adolescents: 112-128 / 66-80

  • 18-39 yrs old:

    • Women: 110/68 

    • Men: 119/70

  • 40-59 yrs old: 

    • Women: 122/74

    • Men: 124/77

  • 60+ yrs old:

    • Women: 139/68

    • Men: 133/69

• 5: Identify factors affecting SpO₂ saturation

  • Lung disease Normal: 95-100%

    • COPD

    • Pneumonia

  • Nail polish/ artificial nails

  • Bright light / direct sunlight

  • Excess movement

  • Skin pigmentation

  • Decreased perfusion

• 6: Define Following Terms:

• Pulse Oximeter:

  • Non-invasive way to measure arterial blood oxygen saturation

  • Sensory is attached to 

    • Digit

    • Earlobe

    • Forehead

  • Detects hypoxemia 

  • Normal: 95-100% 

    • 70% is life threatening

  • Hypoxemia: Low level of oxygen in the blood

• 7: Identify the process for assessing SpO₂ saturation

• Pulse oximeter shining light through tissue and calculating the amount of light absorbed by oxygenated and deoxygenated hemoglobin

• 8: Describe variations in normal SpO₂ saturation that occur from infancy to older adult

  • Older adults have lower O₂ saturation but typically range from 95-100% in all age categories

    • Poor circulation may give a bad reading

• 9: Explain the purpose of intake and output assessment

  • Intake:

    • All fluids which at room temperature are in liquid form

    • All IV’s including fluids, TPN blood products

    • All tube feedings (NG tube, G tube, PEG tube)

    • All medications in liquid form

    • TPN:

      • Total parenteral nutrition

    • Normal Adult intake = 2 liters a day

  • Output

    • Urine

    • Feces

    • Emesis

    • Drainage that can be measured

    • Should equal to what has been intaken

  • I&O’s calculated in intervals and then totaled at end of 24 hours

    • Adequate intake:

      • Females: 2,700 ml/day 

      • Males: 3,700 ml/day

      • 80% fluids 20% food

        • Adequate output - never less than 30 ml per hour!

  • Purpose:

    • To make sure patient is getting enough fluids

Unit 4 Module 3: Apply the Nursing Process in Care of the Patient with Pain

• 1: Describe Nature and physiology of pain

  • Nature:

    • Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage (APS, 1994)

    • Pain is whatever the person says it is, existing wherever the person says it is (McCaffery & Pascro, 1999)

  • Pain PhysiologyL

    • Nociception:

      • The peripheral nervous system included primary sensory neurons specialized to detect tissue damage and to evoke the sensation of touch, heat, cold pain and pressure

      • The receptors that transmit pain sensation are called nociceptors

        • Transduction is the conversion of painful stimuli to an electrical impulse through peripheral nerve fibers called nociceptors

        • Transmit occurs as the electrical impulse travels along the nerve fibers and is regulated by neurotransmitters

• Pain Threshold:

  • The point at which one feels pain

• Pain tolerance:

  • The amount of pain one is willing to bear

• Pain is a sensory component

• Perception:

  • Persons reaction and response to pain

  • COgnitive and affective components. Cognitively patient recognizes there is pain

  • Source and meaning of pain may alter its perception

• 2: Define the following terms

• Intractable:

  • Pain unrelieved by usual means of treatment

• Cutaneous:

  • Originates in the skin or subcutaneous tissue

• Referred:

  • Perceived some (physical) distance from the source

• Somatic: 

  • Source is usually muscles, tendons, bones

• Phantom:

  • Pain perceived in a body part that is missing 

    • Occurs when patients with amputations and spinal cord injuries

• Pain threshold:

  • The point at which a person feels pain

• 3: Describe theory and response to pain

• Gate theory:

  • Pain is a function of balance between information that travels through the CNS through large nerve fibers. If the relative amount of activity is greater than in large nerve fiber, there should be little to no pain. However if more activity is in small nerve fibers there will be pain

• 4: Identify Factors affecting pain

• Culture: 

  • May be seen as macho or stoic

• Developmental Stages:

  • May not know how to describe pain

• Environmental:

  • Hospital may be stressful for patient can cause more pain

• Experience:

  • May think pain level is intolerable if pain is not experienced often or vice versa 

• Meaning:

  • They may think that they deserve this pain

• Stress:

  • Again stress levels can increase pain levels 

• 5: Assessment of patient having pain

• Pattern:

  • Onset, duration, frequency

• Area:

  • Where radiating to locations

• Intensity:

  • Dull, stabbing, burning

• Nature:

  • Acute, chronic, 

  • Neuropathic: 

    • Nerve pain from nerve damage

  • Nociceptive:

    • Pain resulting from tissue damage

• Rating Scales

  • 0-10 

  • Wong Baker Faces

    • Used for 3 years old 

    • Developmentally challenged patients

  • FLACC: 

    • Used with infants

    • Face, Legs, activity, cry, consolability

  • Ok

  • Nonverbal signs of pain:

    • Crying

    • Restlessness

    • Grimacing

    • Holding extremity 

    • Complaints of N/V

    • Excessive gait

    • Excessive stoicism

  • When to assess

    • On admission

    • When pt reports pain

    • Post-op or post-procedure

  • With each nursing assessment (5th vital sign)

  • After a pain intervention 

    • Medications/holistic

      • Can vary depending on route

  • How to assess:

    • Complete pain assessment includes

      • Timing

      • Location

      • Severity

      • Quality

      • Aggravating factors/relief factors

      • Behavioral factors

      • Influence of ADLs

• 6: Describe nursing interventions which may affect pain

• Dependent: Requires prescription 

  • Medications

• Interdependent:

  • PT

  • Acupuncture

• Independent:

  • Positioning

  • Immobilization

  • Massage

  • Heat/ice

    • These can be dependent/interdependent as well per policy

  • Distraction

    • Guided imagery

    • Relaxation techniques

    • Breathing techniques

• Non-pharma:

  • Cutaneous stimulation

    • TENS unit

    • PENS unit

    • Acupuncture/Acupressure

    • Massage

    • Heat/cold application

    • Contralateral stimulation

    • Immobilization

    • Cognitive-behavioral

      • Distraction

      • Hypnosis

      • Therapeutic

      • Touch

      • Humor 

• Pharmacological:

  • Analgesics

    • Nonopioid:

      • Tylenol

      • NSAIDs

    • Opioids

      • Oxycodone

      • Hypomorphone 

• 7: Describe measures utilized to evaluate the effectiveness of pain management strategies

  • Reassessment:

    • Pain is a multi factored and dynamic

    • Requires continuous assessment

    • Rx depends on orders and protocol

      • Our observation

      • Compassion

      • Patients willingness to express their pain

    • Evaluate:

      • Pain is subject so include patient in planning methods for relieving pain

      • Asking what has worked in the past

      • Enlisting patients ideas of what will and wont make pain better

      • Advocating for patient

    • Documentation:

      • Be sure to record pain assessment

      • Record a pain rating on the flow sheet and include interventions

    • Special Nursing Considerations

      • Pain management in elderly

        • Use lower doses

      • Managing pain for patients with addictions 

      • Use placebo’s

Unit 4 Module 4: Mobility and Immobility

• 1: Describe elements of normal movement

  • 4 elements: 

    • Body mechanics:

      • Coordinated efforts of musculoskeletal and nervous system

    • Alignment and balance:

      • Also refers to as posture

    • Gravity:

      • Weight force exerted on the body

    • Friction:

      • Force that occur in a direction opposite to movement

  • Normal Movement:

    • Characterized by a smooth, coordination flow of motion with appropriate ROM of each joint, involving elements of:

      • Proper alignment

      • Balance

      • Muscle activation

      • Efficient energy expenditure

      • Adaptability to changing environments

      • Ability to control movement with precision

• 2: Identify physiologic changes associated with immobility

• Physiologic Changes: 

  • Calcium imbalance

  • Decreased BMR

  • Increased cardiac workload

  • Increased catabolism of protein

• Fluid and electrolyte Changes:

  • Diuresis begins on the first day

    • Lying down causes a major shift in the blood volume

    • Blood pressure changes

    • Electrolytes are lost

• Nutrition Changes:

  • The activity of the pancreas decreases

  • Metabolism decreases

  • Protein is broken down

  • Body fat may be increased

• Gastrointestinal:

  • Decreased appetite and peristalsis

    • Constipation 

• Respiratory Changes:

  • Lungs shift position by 90 degrees

  • Decreased lung expansion

  • Decreased movement of secretions

  • Disturbed O₂/CO₂ 

• Cardiovascular:

  • Orthostatic hypotension

  • Increased heart workload

  • Thrombus formation

• Musculoskeletal:

  • Decreased muscle mass/atrophy 

  • Loss of endurance

  • Impaired calcium metabolism

  • Joint abnormalities

  • Bone demineralize

  • Contractures

• Immune System:

  • Decreased ability of leukocytes to capture microorganisms and lymphatic system

• Integumentary: 

  • Pressure ulcers; perspiration and skin breakdown

• Urinary System:

  • Urinary stasis

  • UTI

  • Renal Calculi

    • Hard deposits of mineral and salts that form in the urinary tract

  • Incontinence

• Effects who the most:

  • Elderly

  • Chronically ill

  • Women/children

  • Diabetic

  • Alcoholics

  • Liver disease

  • Cardiovascular disease

• Define the following:

  • Alignment: 

    • The way the body’s head, shoulders, spine, hips, knees and ankles line up with each other

  • Posture:

    • Position of the body in relation to surrounding space

  • Mobility:

    • A person's ability to move freely

  • Immobility:

    • The inability to move about freely caused by any condition where movement is impaired or therapeutically restricted

  •  Bedrest:

    • Placement of patient in their bed

  • Balance:

    • Position in which a persons center of gravity is correctly positioned to not fall

  • Coordinated movement:

    • A result of weight, center of gravity, balance

  • ROM: 

    • Range of motion of a joint from maximum flexion to extension

  • Gait:

    • Manner of walking characterized by rhythm, cadence, step, stride, speed

• 3: Discuss the hazard of bedrest

• Psychosocial effects:

  • Sleep pattern changes

  • Feeling of helplessness

  • Bored, angry, depressed, hostile, anxious

  • Decrease in sensory stimulation

  • Isolation, disorientation, apathy

  • Behavior/mood changes

  • Time perception altered

• Physical:

  • As above question 2

• 4: Describe nursing assessment of mobility/immobility and activity tolerance

  • Inspect: 

    • How does look? 

    • Can they tolerate anything

  • Palpate:

    • Skin turgor and muscle tone/strength

  • Auscultate:

    • Listen to lung sounds

    • Bowels

    • HR

  • Measure:

    • Height/weight

    • I&O’s

    • Labs

    • Vitals

    • O₂ stats

    • Muscle circumference

      • Assess ROM:

        • Making note of pain, differences in ROM, gait, ADL tolerance, posture

    • Activity Tolerance:

      • Persons ability to perform an activity w/o experiencing excessive physical, emotional, or psychological fatigue

• 5: Identify intervention for patients on bedrest, and those with potential problems of immobility

  • Ok

  • Proper positioning, body alignment, posture

  • ROM exercises:

    • Active/passive

      • Moving joint in fullest ranges help maintain musculature

  • TCDB:

    • q 1-2 hrs

    • Decreases chances of pneumonia 

  • Devices:

    • Pillows

    • Trapeze

    • Footboard

    • TEDs

    • Gait belt

    • Walkers

    • Canes

    • Wheelchairs

    • Slide board

    • Egg Crates

    • Sheepskin

    • Crutches

    • Sandbags

    • Side rails

    • Special beds

    • Fucking everything under the sun

  • PT exercise programs

  • If not done often enough can lead to joint contractures

    • Foot-drop plus other problems

  • Foot-drop:

    • Results from extended periods of time in plantar flexed position

      • If not corrected can lead to muscle paralysis

  • Proper positioning:

    • Safety is top priority

    • Ask patient for as much help as possible

      • Within their comfort level and comprehension

      • Ask for assistance in moving patient

      • Utilize safe lifting equipment

      • Moving up in bed

        • Turning

        • Logrolling

    • Helping client out of bed

      • Transfer board

      • Mechanical lift

      • Transfer belt

    • Assisting with ambulation

      • This may require conditioning exercises 

      • Obtain appropriate assistive devices

• 6: Define principles of body mechanics

  • Be a good lifter

  • To move your body without causing injury

  • Use proper alignment

  • Have wide base of support

  • Avoid bending/twisting

  • Squat to lift

  • Objects close when lifting

  • Raise beds

  • Push vs lift

  • Assistance

  • Reaching is acceptable for some reason

    • Was on a test

  • Body mechanics:

    • Utilization of correct muscles to complete a task safely and effectively, without undue strain on any muscles or joints

Unit 4 Module 5: Promote Personal Hygiene 

• 1: Identify Factors influencing Hygiene 

  • Personal Preferences

    • Where to bathe, products to be used

  • Culture and religion/spirituality

    • Belief about hygiene and cleanliness

  • Economic status:

    • Availability of facilities

    • Monetary constraints

  • Developmental Level

    • Parents, media, peers, age

  • Knowledge and cognitive levels

  • Social Patterns:

    • Ethnic, social and family influences on hygiene patterns

  • Body Image:

    • A person’s subjective concept of their own body appearance

  • Health Benefits and Motivation:

    • Gotta be motivated to clean yah ass

  • Developmental Stage:

    • Skin:

      • Sensitive neonate skin

      • Active glands in puberty

      • Thinning and drying with age

    • Mouth:

      • Teeth: 

        • Teething

        • Cavities,

        • Gum disease

        • Edentulous

    • Ears, eyes, nose

      • You can figure it out

• 2: Describe hygiene needs of patients

  • Bathing: Can help prevent infections

  • Oral Care: Prevent aspiration, pneumonia and infections

  • Hands: Helps control spread of infections

  • Elimination: Help prevent infections when assisting

  • Hair care: Clean/soft can check for problems

  • Nail Care: Help prevent spreading of bacteria

  • Clothing: Changing clothes can help cleanliness

  • Foot care: Prevention of fungal/other germs

• 3 Describe Nursing Assessment finding during hygiene care

• Obtain health history

• Determine preferences/practices for bathing

• Assess for sensory disturbances

• Pain-assess prior to and after ADLs

• Limitations of ROM

• Use of assistive devices

• Obstacles that may be present

• Skin Assessment

  • Age of patient

  • Intact/ broken skin

  • Temperature

  • Color

  • Moisture/dryness

  • Odor

  • Skin turgor

  • Dampness

  • Dehydration

  • Nutritional status

  • Insufficient circulation

  • Skin disease

  • Color

  • REPOSITION q2h

• 4: Identify the purpose of bathing and various types of baths

  • Purpose is to keep patient clean and assess for obvious health reasons

    • Can assess skin

    • See if something is worsening/healthing

  • Types:

    • Self care “Towel Bath”

    • Partial Care “Bag Bath”

    • Complete Care “Packaged Bath”

• 5: Describe steps for various hygiene products

• Peri-Care:

  • Try to get patient to do as much as possible

  • Make sure patient uses bathroom (bed pan) prior to bath

  • Prevention of infection

    • Odor

    • Skin excoriation

  • Female

    • Front to back

  • Males 

    • Retract foreskin if not circumcised

      • Make sure its back into right position after drying

  • Wash around insertion site of foley catheter-empty bag

  • Watch for incontinence

    • Keep area clean/apply moisture barrier ointment to maintain skin

  • Foot/Nail Care:

    • Fingers

      • Soak hand in warm water. Do not cut nails

    • Toes

      • Soak feet. Do not cut nails

    • May use an emery board to file nails

    • Be aware of diabetic patients:

      • Assess circulation

      • Skin breakdown

      • Pedal pulses

      • Color/temp

  • Mouth Care:

    • Check for:

      • Halitosis, dental cavities, gingivitis, tooth loss

    • Assess patient ability for self care

    • Do normal brushing routine

    • NPO:

      • Foam swabs

      • Lemon glycerin swabs: not for long term use

        • Dryness and damage to tooth enamel

    • Risk factors for oral problems:

      • Past history

      • Pregnancy can lead to gum disease

      • Socio-economic factors

      • Certain medications

      • Compromised self-care abilities

    • Dentures:

      • Make sure you know where that shit is

      • Remove daily to clean

      • Tepid water. Not hot

      • Brush dentures like normal teeth

      • Store in labeled container

    • Hair Care:

      • Non-rinse shampoo

      • Air dry

      • Comb/brush

      • Assess texture

        • Pediculosis: Lice

        • Alopecia

      • Care for beard/mustache

    • Shaving Care:

      • Check medications first: anti-coagulants

      • Use gloves

      • Electric razor preferred

        • Avoid nicking

    • Eye Care:

      • Wash from inner to outer canthus

      • No soap only warm water and washcloth

      • Unconscious patient: Provide artificial tears/saline drop q 2-4 hr to prevent dryness

      • Glasses/lenses

        • Soft wet cloth to clean daily

Unit 4 Module 6: Maintaining Skin Integrity

• 1: Describe factors affecting skin integrity

  • Age:

    • Elders: Less elastic, dryer and slow regenerations more prone to injury

  • Immobility:

    • Increased pressure, shearing, and fraction can lead to breakdown

  • Nutrition/hydration:

    • Poor nutrition: Impacts regeneration

    • Hydration: Poor skin turgor

  • Sensation level:

    • Diminished sebastian level leads to increased risk of pressure ulcers and breakdown

  • Impaired Circulation:

    • Negatively affects tissue metabolism

  • Medications:

    • Side effects, itching/rashes and other allergic reactions

  • Infection:

    • Impedes healing, if not treated can lead to systemic circulation causing sepsis

  • Moisture:

    • Leads to maceration: Softening/breakdown of skin caused by prolonged exposure to moisture

  • Fever:

    • Depletes moisture

    • Increase metabolism

  • Lifestyle:

    • Bathing, tanning, piercings

• 2: Describe Nursing Assessments to identify pressure ulcer formation utilizing pressure ulcer staging system:

• Assessments:

  • Focused skin assessment

  • Sensory perception

  • Moisture

  • Activity level

  • Mobility

  • Nutrition

  • Friction/shearing forces

• Stages:

  • Stagable by level of tissue involvement

    • Blanchable erythema: Precursor to pressure ulcer formation

      • Means that it does not turn white when pressed

    • Stage I:

      • Non-blanchable erythema: Localized area/ no skin breakdown (non-reactive hypererythema)

    • Stage II:

      • Partial skin thickness loss

    • Stage III:

      • Full thickness loss with damage to subcutaneous tissue

    • Stage IV:

      • Full thickness loss with extensive tissue destruction or damage to muscle, bone or supporting structures

    • Unstageable: 

      • Full thicken loss, base of wound is obscured

    • DTI:

      • Deep tissue injury

        • Intact but persistently discolored red/purple can be painful 

          • Can occur from underlying soft tissue damage or shear

• 3: Discuss wound healing and factors that impede/promote healing

• Types of Healing:

  • Regenerative/epithelial: 

    • Takes place when a wound affects only the epidermis and dermis

  • Primary (First) intention healing:

    • Occurs when a wound involves minimal o tissue loss and has edges taht are well approximated (close)

      • Ex: clean surgical incision 

  • Secondary Intention:

    • Occurs when a wound 

      • 1: Involves extensive tissue loss that prevents wound edges from approximating

      • 2: Should not be closed

        • Due to infection

        • Wound is left open, healing from inner layer to surface with beefy red granulation tissue

        • More prone to infection/scarring heals slower

  • Tertiary Intention:

    • Aka delayed primary closure

    • Occurs when two surfaces of granulation tissue are brought together

  • Complications:

    • Hemorrhage

    • Infections

    • Dehiscence

    • Evisceration

    • Fistula Formation:

      • When artery and vein are joined together

  • Promote:

    • Address underlying processes

    • Promote nutrition

      • Carbs/protein/amino acids

• 4: Explain Nursing interventions to prevent pressure ulcers and assistive devices used

• Meticulous Skin Care

• Adequate nutrition/fluids

  • Protein

  • Vitamins

    • C

    • A

    • B₁

    • B₅

    • Zinc

    • 2,500cc fluids

  • Frequent repositioning

  • Therapeutic mattresses

  • Client/family teaching

  • Support wound healing

• Devices:

  • Pillow wedges

  • Special bedding/padding

    • Gel flotation pads

    • Heel Protectors

    • Sheep skins

    • Egg crate mattress

    • Foam mattress

    • Alternating pressure mattresses

    • Water bed

      • Specialized beds

• Random

  • Braden Scale

    • Scale used to assess a patients risk for developing pressure ulcers

      • Mild Risk: 15-16

      • Moderate Risk: 12-14 

      • Severe Risk: ≤11

UNIT 5: Meeting Safety Needs

Unit 5 Module 1: Explain the principles related to Asepsis

• 1: Explain the concepts of medical and surgical asepsis

• Medical: 

  • Clean technique: All practices intended to confine a specific microbe to one area and limit their

    • Growth

    • Number 

    • Transmision

      • Includes: Hand washing, environmental cleanliness, standard precaution, protect isolation

• Surgical:

  • Sterile technique: Those practices that keep an area free of microbes. Including practices that destroys organisms or spores

    • Not required for all patients

    • Accomplished through the use of special gases/high heat, special solution and procedures

• 2: Discuss types of infection including nosocomial

  • Surgical:

    • An infection that occurs in the area of the body where a surgical procedure was done

  • Lower Respiratory Tract:

    • Infections that affect the airways (below the level of the larynx) including the trachea and alveolar sacs

  • Urinary Tract Infections:

    • Bacterial infection that causes inflammation or discomfort in urinary tract

      • Can happen because of catheter

    • Ventilator Associated Pneumonia:

      • A type of lung infection that occurs in people who are on VAPs

        • Caused by microaspirations of bacteria that colonize in oropharynx and upper airways

  • Nosocomial:

    • Hospital/Facility Acquired

    • Happen during or after hospitalization

    • Endogenous: Originate with patient

      • Most common

    • Exogenous: 

      • From hospital environments or personnel

    • Latogenic:

      • From therapeutic procedures

        • IV Line

    • Insurance wont pay

  • Random Definitions:

    • Pathogen

      • Microorganism that can cause disease

    • Virulence:

      • Ability to grow and multiply (strength of organism)

    • Pathogenicity:

      • Ability for organism to cause disease

    • Colonization

      • Presence of pathogens without tissue invasion or damage 

    • Incubation:

      • Period of time from exposure to organism to signs and symptoms of disease

• 3: Discuss the Chain of Infection

  • Ok

  • Chain of infection

    • A process by which an infection spreads

  • Includes: 

    • Pathogens

      • Largest group: Bacteria, viruses and fungi (yeast and mold)

      • Less common: Protozoa, helmiths (worms) and prions

        • Prions: Infectious protein particles that cause certain neurological disease

    • Reservoir:

      • A source of infection where pathogens survive and multiply

        • Living organism: Most pathogens flourish in warm, moist, dark environments.

          • Human Body is common for this

        • Nonliving: Soil, water, food and environmental surfaces

          • Healthcare: Sinks, bed rails, bed linens

• Modes of Transmission:

  • Direct Contact: 

    • Usually involves physical contact, sec, and wound drainage contact, can involve scratching and biting

  • Indirect Contact:

    • Involves contact with a fomite

      • Fomite: contaminated object that transfers a pathogen

  • Droplet Transmission: 

    • Pathogen travels in water droplets expelled as an infected person exhales, coughs, sneezes or talks

  • Airborne:

    • Microorganisms float considerable distances on air current yo infect large numbers or people

  • Vector:

    • An organism that carries a pathogen to susceptible host

      • Ex: mosquito

• Portal of Entry:

  • Ways pathogens enter the body

    • Normal Body Openings: 

      • Conjunctiva of eyes, nares, mouth urethra, vagina, anus

    • Abnormal:

      • Cuts, scrapes, surgical incisions, bites

• Host:

  • Susceptible Host: 

    • A person at risk for infection because inadequate defense against the invading pathogen

    • Increased susceptibility 

      • Young/Old

    • Compromised immune system 

      • Immunosuppression for organ transplantation, treatment for cancer

    • Immune Deficiency conditions:

      • HIV

      • Leukemia

      • Malnutrition

      • Lupus

• 4: Describe general principles for controlling the spread of communicable disease

• Cultural Practices:

  • The fuck does this mean

• Immunizations:

  • Train immune system to create antibodies that can fight off germs, viruses/bacteria

• Isolation:

  • Simply separating one or more people who are sick from healthy people

• Handwashing:

  • Absolute staple in preventing spread in disease

• Standard precautions:

  • Hand hygiene

  • PPE

  • Respiratory hygiene

  • Sharps safety

  • Cleaning/disinfection

  • Waste management

  • Linen handling

• Transmission Based Precautions

  • Same as above

  • Contact Precautions:

    • Help prevent the spread of infectious diseases that can be transmitted through direct or indirect contact with an infected person and their environment

  • Droplet Precautions:

    • Used to prevent the spread of illnesses by germs that spread through respiratory droplets

      • Surgical mask

  • Airborne Precautions:

    • Used to prevent the spread of airborne pathogens 

      • N95

      • Negatively pressurized room

• PPE:

  • Gloves

  • Face Shield

  • Goggles

  • Gowns

  • Masks

Unit 5 Module 2: The Role of the Nurse Providing Peripheral IV therapy

• 1: Explain the purpose for which intravenous infusions are administered

• To aid patients in replacing fluids and electrolytes, provide medications and replenish blood volume

• Rest GI tract

• 2: Describe and differentiate Basic Types of IV infusions:

• Central:

  • Central Venous Access Device (CVAD):

    • IV line inserted into major vein

      • Subclavian or internal jugular vein

      • Catheter is advanced to superior vena cava

  • Advantages:

    • Accommodate highly irritating/hyper osmolar solutions because the blood and solution mix rapidly in infusion site

    • Can be left in longer than peripheral lines

• Implanted venous access port (IVAD)

  • Central access device that enter the internal jugular vein or the neck but is tunneled to a completely implanted subcut reservoir in upper chest

• Peripheral:

  • A short plastic catheter thats placed into vein usually in hand, elbow or foot sometimes the scalp

    • PICCs:

      • Inserted at the antecubital fossa through the basilic or cephalic vein of the arm then advanced to superior vena cava

      • Used for intermediate/long term use unless complication is inspected 

    • Midline: 

      • Same as PICC but shorter in length with catheter only going into upper arm

• Continuous Infusions:

  • Change the primary and secondary sets no more frequently than 96 hrs, but at least q 7 d

• Intermittent: 

  • Change administration sets q 24 h because of repetitive disconnections and reconnections increased likelihood of contamination

• 3: Discuss Complications of IV therapy and Nursing Interventions

• LOCAL:

• Infiltration: 

  • IV fluid infuses into subcutaneous tissue around IV site due to IV insertion device puncturing vein

    • Symptoms:

      • Edema

      • Pallor

      • Discomfort

      • Coolness or edemotous skin as compared to normal

      • Pump continues to run until severe

      • Gravity IV will slow

  • Interventions:

    • Prevention: 

      • Stabilization, avoid joints

    • Thoroughly assess

    • Stop IV and remove device, restart elsewhere

    • Elevate arm and apply warm heat according to policy

• Extravasation:

  • Seepage of vesicant solution

    • Vesicant: Capable of causing tissue necrosis

  • Symptoms

    • Pain

    • Burning

    • Swelling at IV site

    • Blanching / coolness of surrounding skin

    • Blistering if late sign

  • Interventions:

    • Stop IV immediately

    • Administer antidote if available

    • Apply cold compress, elevate

• Phlebitis:

  • Vein inflamed

    • Irritated by IV & Solution

  • Symptoms:

    • Pain

    • Warmth

    • Redness may be seen along vein path

    • Erythema at or above insertion site

    • Localized edema

  • Interventions:

    • Prevention: 

      • Adequate stabilization

      • Maintain correct rate and dilution of fluids

      • Routine site changes

    • Stop IV and remove device

    • Thoroughly assess

    • Apply warm heat according to agency policy