Exam 3: Self-Assessment Notes

Functional Ability

  • Difference between Public and Community Health
      - Public Health:
        - Focuses on large populations.
        - Involves government initiatives and prevention programs.
      - Community Health:
        - Focuses on specific groups or local populations.
        - Involves direct care in clinics and schools.

  • Levels of Prevention
      - Primary Prevention:
        - Objective: Prevent disease.
        - Example: Vaccines.
      - Secondary Prevention:
        - Objective: Early detection of disease.
        - Example: Screenings.
      - Tertiary Prevention:
        - Objective: Manage disease after it has been diagnosed.
        - Examples: Rehabilitation, medication management.

  • Nursing Process
      - Steps: Assess → Diagnose → Plan → Implement → Evaluate (ADPIE).

  • Roles of the Nurse
      - Key Roles:
        - Caregiver
        - Educator
        - Advocate
        - Communicator
        - Leader.

  • Key Terms in Legal and Ethical Practice
      - Autonomy:
        - The right of patients to make decisions about their care.
      - Beneficence:
        - The ethical principle of doing good for patients.
      - Nonmaleficence:
        - The ethical obligation to not inflict harm.
      - Justice:
        - Fair treatment and distribution of resources.
      - HIPAA:
        - Health Insurance Portability and Accountability Act; protects patient privacy.

  • Role of Informatics in Clinical Practice
      - Application of technology (e.g., Electronic Health Records, barcode scanning) to improve safety and efficiency in patient care.

  • Difference Between Chronic and Acute Illness
      - Acute Illness:
        - Short-term illness, often sudden onset.
      - Chronic Illness:
        - Long-term condition, requires ongoing management.

Healthcare Models

  • Guidance in Clinical Practice
      - Healthcare models provide frameworks (e.g., patient-centered care) to direct decision-making and treatment approaches.

  • Application to Clinical Practice
      - Involves implementing knowledge into actual patient care situations.

  • Risk Factors for Mobility Issues
      - Examples:
        - Age, surgery, weakness, obesity, immobility.

  • Difference Between SCDs and TED Hose
      - SCDs (Sequential Compression Devices):
        - Inflate and deflate to prevent blood clots.
      - TED Hose (Thrombo-Embolic Deterrent Hose):
        - Provide constant compression to improve venous return.

  • Proper Body Mechanics
      - Essential for preventing injury to the nurse and for ensuring the safety of patient movement.

  • Principles of Delegation
      - Right task, right person, right situation, right communication, right supervision.

  • A&P Related to Pathophysiology
      - Understanding how disease affects body systems is critical for effective patient care.

  • Role Across the Lifespan
      - Nursing care should be tailored based on patient age and developmental stage.

Anatomy & Physiology (A&P)

  • Relation to Pathophysiology
      - Importance of understanding how normal body functions change when disease processes occur.

  • Role Across the Lifespan
      - Nursing care adjustments are necessary based on age-related needs.

Professional Identity

  • Roles and Functions of the Nurse
      - Comprises several key roles:
        - Caregiver
        - Advocate
        - Educator
        - Communicator.

  • Nursing Theories
      - Example: Watson’s theory guides nursing care and practice.

  • Criteria of the Profession
      - Important elements include:
        - Education
        - Standards
        - Ethics
        - Licensure.

  • Practice Guidelines
      - Evidence-based recommendations are essential for effective patient care.

Attributes of Professional Identity

  • Key Attributes
      - Compassion, accountability, competence are fundamental attributes.

  • Beliefs vs Values
      - Beliefs: What one thinks to be true.
      - Values: What one prioritizes highly.

  • Concept of Caring
      - Involves providing holistic, patient-centered care that considers the entirety of the patient's experience.

  • Types of Baths
      - Different types include:
        - Bed bath
        - Partial bath
        - Complete bath.

  • Safety in Relation to Hygiene
      - Importance of hygiene practices includes preventing falls, infections, and skin breakdown.

  • Types of Pain
      - Categories include:
        - Acute pain
        - Chronic pain
        - Neuropathic pain.

  • Pain Scales
      - Commonly used scales:
        - Numeric scale (0–10)
        - Faces scale: Wong-Baker
        - FLACC scale (Face, Legs, Activity, Cry, Consolability).

Communication

  • Concept of Communication
      - Defined as the exchange of information between nurse and patient.

  • Verbal vs Nonverbal Communication
      - Verbal: Communication conveyed through spoken words.
      - Nonverbal: Communication through body language and gestures.

  • Phases of Nurse-Patient Relationship
      - Key phases include:
        - Orientation
        - Working
        - Termination.

  • Patient Education
      - Involves teaching patients clearly based on their individual needs and understanding.

  • Characteristics of the Nursing Process
      - Defined as systematic, patient-centered, and goal-oriented.

  • ISBAR Communication Framework
      - Acronym stands for Situation, Background, Assessment, Recommendation for effective communication.

  • Delegation in Communication
      - Emphasizes the necessity to provide clear instructions and ensure follow-up on delegated tasks.

Infection Control

  • Understanding Sterility
      - Defined as the complete absence of microorganisms, essential for preventing infection.

  • Chain of Infection
      - Components include:
        - Agent → Reservoir → Exit → Transmission → Entry → Host.

  • Signs of Infection
      - Symptoms include fever, redness, swelling, and pain.

  • Medical vs Surgical Asepsis
      - Medical Asepsis: Clean technique aimed at minimizing pathogens.
      - Surgical Asepsis: Sterile technique to eliminate all microorganisms.

  • Skin Integrity Tools
      - Example tool: Braden Scale for assessing pressure ulcer risk.

  • Importance of Hygiene
      - Hygiene prevents infection and promotes overall comfort for patients.

  • Analyzing Cues
      - Recognition of changes in a patient's condition is vital for timely intervention.

  • Cultural Considerations in Hygiene
      - Importance of respecting patient preferences and beliefs related to hygiene practices.

Clinical Judgment

  • Etiology of a Nursing Diagnosis
      - Defined as the underlying cause of the patient's problem.

  • Subjective vs Objective Data
      - Subjective Data: Information relayed by the patient.
      - Objective Data: Information that is observed or measured by the nurse.

  • Actual vs Risk Diagnoses
      - Actual Diagnosis: Represents a currently observed problem.
      - Risk Diagnosis: Indicates a potential problem that may occur.

  • Nursing Process Knowledge
      - Familiarity with ADPIE: Assess, Diagnose, Plan, Implement, Evaluate.

  • Goal Statements
      - SMART Goals:
        - Specific, Measurable, Achievable, Relevant, Time-bound objectives.

  • Independent vs Dependent Interventions
      - Independent Interventions: Actions that the nurse can take without a provider's order.
      - Dependent Interventions: Actions that require an order from a healthcare provider.

  • Critical Thinking
      - Defined as making safe, evidence-based decisions in nursing practice.

  • Traits of Critical Thinking
      - Includes analysis, reasoning, open-mindedness, and reflection.

  • Legal and Ethical Issues in Documentation
      - Importance of accurate, truthful, and timely charting to maintain legal standards.

  • Vital Signs
      - Key measurements: Temperature, pulse, respiration, blood pressure, oxygen levels.

  • Factors Affecting Vital Signs
      - Influencing factors include age, medication use, stress levels, and illness status.

Ethics

  • Key Ethical/Legal Terms
      - Important concepts include:
        - Autonomy
        - Beneficence
        - Justice.

  • Informatics in Ethics
      - Role of informatics includes protection of patient data and privacy compliance.

  • Informed Consent
      - Defined as the patient's understanding and agreement to proceed with treatments.

  • HIPAA
      - Legal act designed to protect patient privacy and confidentiality.

Documentation & EHR

  • Incident Reports
      - Used for documenting errors or events in patient care that are not charted in patient records.

  • Documentation Standards
      - Criteria for documentation include clarity, accuracy, and timeliness in recording patient information.

  • EHR Terms
      - Familiarity with terminology such as charting, Medication Administration Record (MAR), and flowsheets is essential for effective electronic documentation.

Informatics

  • Benefits of Informatics
      - Enhances safety and efficiency in patient care through technology integration.

  • Uses of Informatics
      - Common applications include Electronic Health Records, barcode scanning, and alert systems to support caregivers.

  • Role in Informatics
      - Responsibility to utilize technology safely in the delivery of patient care.

Safety

  • Safety as an Umbrella Concept
      - It applies universally across all aspects of nursing care, encompassing various dimensions of patient interactions.

  • Common Safety Concerns
      - Categories of safety issues include:
        - Falls
        - Infections
        - Medication errors.

  • Relation of Nursing Process to Safety
      - The nursing process is integral in identifying and preventing risks to patient safety.

  • Importance of Delegation in Relation to Safety
      - Ensures that tasks are performed correctly and safely, thus enhancing overall patient care quality.

  • Impact of Lifespan on Safety
      - Different age groups face varying safety risks, necessitating tailored approaches (e.g., risk of falls in elderly patients, confusion in pediatric populations).