Nursing Fundamentals Exam Review
Nursing Fundamentals
Affordable Care Act (ACA)
Definition: An act passed by the government to increase access to health insurance for all.
Key Points:
Prevents denial of care due to pre-existing conditions.
Includes preventative care services.
Allows individuals to stay on their parents' insurance until age 26.
Increases access to care for all individuals, regardless of employment status, health status, or pre-existing conditions.
Insurance: Medicare and Medicaid
Medicaid:
Designed for individuals with low income.
Eligibility required based on specific criteria.
May cover individuals with terminal illnesses.
Medicare:
Primarily for individuals aged 65 or older.
Admission Process
Nurse's Role:
Confirm patient's name and date of birth.
Conduct a patient interview.
Collect both objective and subjective data (assessment).
Check the patient's belongings (inventory).
Check medications for accuracy and completeness.
Document all admission information comprehensively.
Orient the patient to the room to ensure their comfort.
Purpose of Thorough Documentation:
To ensure correct patient identification.
To ensure correct procedures are followed throughout care.
Provides legal protection for the nurse.
Nurse's Highest Priority:
Establish a baseline of the patient's condition upon admission.
Collect pertinent information to understand the patient's chief complaint, medications, and overall health status.
Patient's Feelings Upon Admission
Common emotional responses include:
Fear.
Anxiety.
Loss of control.
How to Help Patients Feel More Comfortable:
Use a soft tone of voice to convey care.
Maintain eye contact to foster connection.
Engage with the patient to establish rapport and trust.
Create a welcoming and familiar environment.
Against Medical Advice (AMA)
Definition: A situation where a patient chooses to leave a healthcare facility against the advice of medical professionals.
Process:
The patient must sign an AMA form to formally document the decision.
It is the nurse's responsibility to explain the risks of leaving without medical care.
Ensure the patient understands the potential consequences associated with refusing care.
The patient retains the right to refuse treatment and leave the facility.
End-of-Life Care
Hospice:
Designed for patients with a prognosis of six months or less to live.
Focuses solely on comfort measures and minimizing suffering.
Does not include curative treatments.
Palliative Care:
For patients with serious illnesses, regardless of whether they are terminal.
Aims to provide comfort and improve quality of life while continuing medical treatments.
Not centered on curing the illness.
Curative Care:
The goal is to cure the patient.
Involves interventions aimed at managing symptoms and restoring health.
Suggestions for a Person When a Loved One is Nearing the End of Life:
Say goodbye to express closure.
Voice "I love you" to show affection.
Say "Thank you" to express gratitude for shared experiences.
Say "I forgive you" to facilitate emotional healing.
Say "Forgive me" to seek forgiveness for past grievances.
Types of Nursing
Primary Care Nursing:
One nurse is responsible for a small group of patients.
Client-Centered Care Nursing:
Care revolves around the specific needs and preferences of the patient.
Team Nursing:
A collaborative approach where a group of nurses works together to care for patients.
Case Management:
Coordinating a patient's care across multiple disciplines and settings, ensuring comprehensive management of conditions.
Stroke Patient Referrals
Disciplines to Refer To:
Physical therapy for mobility rehabilitation.
Occupational therapy for daily living activities support.
Speech therapy for dysphagia (difficulty swallowing and communicating).
Registered dietitian for dietary adjustments due to swallowing difficulties.
Case Management: Coordinating Care
Key Factors for Effective Case Management:
Appropriate care tailored to the patient’s illness and needs.
Insurance coverage considerations to ensure services are accessible.
Emphasis on cost-effectiveness of care delivery.
Discharge Process
Included Elements of Discharge:
Patient education to ensure understanding of care post-discharge.
Medication reconciliation to confirm accuracy of prescribed medications.
Instructions on how to take medications effectively.
Provide written instructions for future reference.
Information about follow-up appointments to ensure continuity of care.
Main Goal:
To ensure the patient can return home safely and successfully, equipped with necessary information and resources for continued care.
Do Not Resuscitate (DNR)
Definition: An order indicating that CPR and other life-saving measures should not be performed on a patient.
Nurse's Responsibility:
Determine which patients have DNR orders at the beginning of each shift to ensure compliance.
Follow the DNR order if the patient experiences cardiac arrest or respiratory failure.
Emancipation
Definition: A minor who has been granted the rights of an adult before reaching the age of 18.
Key Point: Emancipated minors can make their own medical decisions, independent of parental consent.
Note: Age requirements for emancipation vary by state.
Healthcare Team Members
Who Can Diagnose and Prescribe Medications:
Physician (MD or DO).
Nurse Practitioner (NP).
Physician Assistant (PA).
Who Cannot Diagnose and Prescribe Medications:
Registered Nurse (RN).
Physical Therapist (PT).
Case Manager.
Managed Care
Definition: A system that controls healthcare costs by managing and limiting services offered.
Goal: To achieve cost control and efficiency in healthcare delivery.
Stages of Grief
Familiarize with the stages of grief including descriptions and examples for each stage to provide supportive care during loss.
Living Will vs. Last Will and Testament
Living Will:
Specifies a patient's wishes regarding medical treatment when they can no longer make decisions for themselves.
Last Will and Testament:
Specifies how a person’s assets and belongings should be distributed after their death.
Power of Attorney
Definition: A document granting someone the authority to make decisions on another person’s behalf.
Types:
Financial Power of Attorney.
Durable Power of Attorney.
Medical Power of Attorney.
Nurse's Role
Key Responsibilities Include:
Collecting patient information and performing assessments to understand health status.
Providing care as ordered by physicians and planners.
Administering treatments as per protocols.
Supporting patients and families through challenges.
Advocating for patients’ needs and rights.
Educating patients about their conditions and care plans.
Referring a Patient to Another Discipline:
Act as an advocate for the patient to ensure appropriate referrals for specialist care.
Transferring a Patient to Another Facility
Nurse's Responsibilities:
Obtain patient consent to release medical records to the receiving facility.
Contact the receiving facility to provide a complete report on the patient’s condition.
Ensure copies of necessary medical records are seamlessly sent for continuity of care.
Nursing Process: ADPIE
A - Assessment:
Collect both subjective and objective data to form a comprehensive view of the patient’s condition.
D - Diagnosis:
Identify the patient’s problem based on assessment findings.
P - Planning:
Set goals and desired outcomes, both short-term and long-term, in collaboration with the patient.
I - Implementation:
Carry out the planned interventions as delineated.
E - Evaluation:
Assess whether the interventions were effective and if the goals set were achieved.
Note: The Nursing Process is cyclical and continuous, necessitating ongoing reassessment.
Critical Thinking: Pain Assessment Example
Assessment Components:
Location: Where is the pain felt in the body?
Intensity: Rate the intensity of pain using a pain scale (e.g., 1-10).
Characteristics: Describe the pain as radiating, sharp, dull, etc.
Duration: How long has the pain been present?
Possible Causes: Identify potential causes (e.g., injury, diet, underlying condition).
Documentation
Types of Data:
Subjective Data: Information provided by the patient (e.g., "My stomach hurts").
Objective Data: Measurable or observable information (e.g., blood pressure, heart rate).
HIPAA
Definition: Health Insurance Portability and Accountability Act.
Purpose: To protect patient privacy and the confidentiality of medical information.
Violations Include:
Discussing patient information in public areas (e.g., hallways, lounges).
Accessing patient information without a need to know.
Sharing patient information with unauthorized individuals.
Leaving patient data unsecured in any format.
Protecting HIPAA Rights When Family Calls:
Verify the caller's identity before disclosing any information using security questions or passwords.
Writing Information Down:
Permissible as long as documents are kept secure and shredded after use.
Sharing Passcodes:
Never share computer login credentials or locker combinations with anyone else.
Incident Reports
Purpose: To document events that could cause harm or have caused harm in any form (physical, emotional, etc.).
Examples of Incidents Include:
Medication errors.
Patient falls.
Near misses where harm was avoided by chance.
Injuries to patients, visitors, or staff.
Needle sticks from sharps disposal mishaps.
Development of pressure injuries from prolonged bedrest.
Any incidents involving violence within the healthcare setting.
Procedure for Documenting Incidents:
Complete an incident report following facility policy accurately.
Do NOT include the incident report itself in the patient's medical chart.
Document the event dispassionately in the patient’s chart, stating observable details and actions taken.
Maslow's Hierarchy of Needs
Concept: Understanding the hierarchy allows nurses to prioritize patient needs effectively based on fundamental and progressive needs, impacting care decisions.
SOAP/SOAPIER
SOAP Format:
S - Subjective Data: Information reported directly by the patient.
O - Objective Data: Observations and measurements taken by the healthcare professional.
A - Assessment: Interpretation of data and conclusions drawn by the clinician.
P - Planning: Development of a care plan based on assessment.
SOAPIER Format Extended:
I - Implementation: Documenting the actions taken based on the plan.
E - Evaluation: Reviewing the effectiveness of the interventions.
R - Revision: Adjusting the plan based on ongoing assessment of the patient's condition.
Safety Guidelines in Nursing
ABC of Patient Safety:
A - Airway: Ensure the airway is clear for breathing.
B - Breathing: Assess whether the patient is breathing adequately.
C - Circulation: Monitor the circulatory status, checking for pulse and perfusion.
Note: Prioritize ABCs in all patient assessments for safety and efficacy in care.
Body Mechanics
Proper Techniques for Lifting:
Bend at the knees to maintain back safety.
Maintain a wide base of support to enhance stability.
Keep objects close to the body to minimize strain.
Use of Assistive Devices:
Utilize assistive equipment whenever possible to prevent injury.
Disaster Nursing/Triage
Triaging Patients:
Prioritize patients based on acuity levels and likelihood of survival with interventions, especially in disaster scenarios.
Fire Safety
Fire Extinguishers:
Know the different types of fire extinguishers:
Class A: Ordinary combustibles.
Class B: Flammable liquids.
Class C: Electrical fires.
Class D: Combustible metals.
Class K: Cooking oils.
In Case of Fire:
RACE Approach:
R - Rescue: Remove patients from immediate danger without delay.
A - Alarm: Activate the nearest fire alarm system.
C - Contain: Close doors and windows to prevent spread.
E - Extinguish/Evacuate: Extinguish the fire if safe to do so, or evacuate if necessary.
PASS Technique for Extinguishers:
P - Pull: Pull the pin on the extinguisher.
A - Aim: Aim at the base of the fire to effectively target.
S - Squeeze: Squeeze the handle to release the extinguishing agent.
S - Sweep: Sweep the nozzle from side to side to cover the area.
Fall Prevention
Bed Positioning:
Keep the bed in a low position when not in use.
Ensure the patient can easily reach the call light.
Common Risk Factors for Falls Include:
Clutter in the patient area.
Patient confusion or disorientation.
Presence of urinary tract infections (UTIs).
Incorrect use of assistive devices.
Preventative Interventions:
Clear all pathways to guarantee unobstructed movement.
Utilize non-slip socks or shoes for added safety.
Conduct fall risk assessments regularly.
Position patients close to the nurse's station when feasible.
Implement bed alarms upon doctor's recommendation for high-risk patients.
Restraint Policies:
Utilizing all four bed rails may constitute a restraint and should be avoided unless absolutely necessary.
Oxygen Safety
Flammability of Oxygen:
Recognize that oxygen is a highly flammable substance.
Safety Precautions Include:
No smoking in areas where oxygen is present.
Store oxygen tanks in secure positions away from heat sources.
Avoid trip hazards involving cords and tubing.
Apply only water-soluble lubricants (e.g., K-Y Jelly) to moisten dry nares; avoid petroleum-based products (e.g., Vaseline).
Restraints
Types:
Soft restraints, wrist restraints, vest restraints, belt restraints, mitt restraints.
Mittens Restraints:
Designed to prevent the patient from using their hands inappropriately (e.g., scratching, pulling at tubes or equipment).
Vest Restraints:
Create a restraint that prevents the patient from exiting a chair or wheelchair.
Wrist Restraints:
Apply using a slip knot (quick-release knot).
Tie restraints to a non-movable part of the bed frame.
Ensure two fingers fit under each restraint for circulation safety.
Remove restraints every two hours for range of motion, toileting, and circulation checks.
Continuously check restraints every 30 minutes for skin integrity and proper fit.
Seizures
Interventions During a Seizure:
Protect the patient from sustaining injury during the episode.
Turn the patient onto their left side to reduce the risk of aspiration.
Do NOT attempt to restrain the patient.
Do NOT place objects in the patient's mouth during the seizure.
Necessary Equipment to Have on Hand:
Suction as needed for airway management.
Oxygen for potential respiratory assistance.
Use padded side rails for patient protection in bed.
National Patient Safety Goals
Established By: The Joint Commission (JCO) to enhance safety and quality in healthcare.
Examples of Goals Include:
Using two unique patient identifiers for verification.
Following safety checks consistently across all disciplines.
Adhering to the seven rights of medication administration to prevent errors and ensure patient safety.