Fundamentals of Nursing Final Exam Practice Flashcards

Chapter 1: Nursing Today

Core Components of Nursing - Nursing is defined as a profession that combines the art of caring with the science of healthcare. - Nurses serve multiple roles including: - Caregivers: Providing direct physical and emotional support. - Advocates: Safeguarding and protecting the rights of the patient. - Educators: Teaching patients and their families about health and recovery. - Leaders: Managing care teams and influencing health policy. - Communicators: Facilitating information exchange between the patient and the healthcare team. - Patient-centered care: A philosophy where the patient is the central focus of all healthcare decisions and actions.
Benner’s Stages of Nursing Proficiency 1. Novice: A beginning nursing student or any nurse entering a situation where there is no previous level of experience. 2. Advanced Beginner: A nurse who has had some level of experience with the situation which may only be observational in nature. 3. Competent: A nurse who has been in the same clinical position for $2$ to $3$ years. 4. Proficient: A nurse with more than $2$ to $3$ years of experience in the same clinical position who perceives a patient’s clinical situation as a whole. 5. Expert: A nurse with diverse experience who has an intuitive grasp of an existing or potential clinical problem.
Key Vocabulary in Professional Nursing - Accountability: State of being professional and legally responsible for one's nursing actions. - Advocacy: The support and protection of patient rights. - Burnout: A state of emotional and physical exhaustion resulting from prolonged exposure to job-related stress. - Autonomy: The initiation of independent nursing interventions without medical orders.

Chapters 15–20: Critical Thinking & Nursing Process

The Nursing Process (ADPIE) - The standard five-step process for providing high-quality nursing care: 1. Assessment: The systematic collection of data regarding the patient's health status. 2. Diagnosis: Identifying the patient's problems based on the assessment data. 3. Planning: Developing goals and expected outcomes and choosing nursing interventions. 4. Implementation: Performing the nursing interventions identified in the plan. 5. Evaluation: Determining whether the goals were met and if the patient's condition improved.
Critical Thinking and Clinical Judgment - Critical Thinking: The use of logic and reasoning to make safe and effective nursing decisions. This skill is vital for prioritizing care and preventing medical errors. - Clinical Judgment: The process of making decisions based on synthesized patient data and established nursing knowledge.
Data Types in Assessment - Subjective Data: Symptoms or verbal descriptions provided by the patient that cannot be independently measured. Example: A patient stating, ‐I have pain.‑ - Objective Data: Findings that are measurable and observable by the nurse. Example: A Blood Pressure (BP) reading of $180/90\,mmHg$ .
Nursing Diagnosis Formulation - The structural formula for a nursing diagnosis is: [Problem] related to [Etiology/Cause] as evidenced by [Defining Characteristics/Signs and Symptoms]. - Verbatim Example: ‐Impaired skin integrity related to immobility as evidenced by open wound on coccyx.‑
SMART Goals - Goals for patient care must be: - Specific - Measurable - Attainable - Realistic - Timed
Priority Frameworks - The ABCs (Immediate Life Threats): 1. Airway (Must be clear for breathing). 2. Breathing (Effective ventilation). 3. Circulation (Adequate perfusion/heart rate/BP). - Maslow’s Hierarchy of Needs (Order of Importance): 1. Physiological needs: Food, water, warmth, rest (Highest priority). 2. Safety and security. 3. Love and belonging. 4. Esteem. 5. Self-actualization: Achieving one's full potential (Lowest clinical priority).
Vocabulary and Definitions - NANDA-I: Use of the North American Nursing Diagnosis Association International system for standardized nursing diagnoses. - Collaborative Problem: A physiological complication that requires both nursing and prescriber (provider) interventions to manage. - Implementation: The phase where interventions are actively performed. - Evaluation: The phase used to determine if patient goals have been successfully met.

Chapter 28: Infection Prevention & Control

The Chain of Infection - To prevent infection, one must break the link between any of these six elements: 1. Infectious agent (Pathogen). 2. Reservoir (Place where pathogen survives). 3. Portal of exit (Way to leave the reservoir). 4. Mode of transmission (How it moves to a new host). 5. Portal of entry (How it enters the new host). 6. Susceptible host.
Modes of Transmission - Contact: Direct or indirect touch. - Droplet: Large particles from the respiratory system (travels short distances). - Airborne: Small particles that remain suspended in the air. - Vector: Transmission via insects or animals. - Vehicle: Transmission via contaminated items like food, water, or blood.
Personal Protective Equipment (PPE) - Standard items include: Gloves, Gown, Mask, and Goggles/face shield.
Isolation Precautions and Examples - Contact Precautions: Used for organisms like MRSA (Methicillin-resistant Staphylococcus aureus) and C. diff (Clostridioides difficile). - Droplet Precautions: Used for infections such as Influenza and Meningitis. - Airborne Precautions: Used for diseases including TB (Tuberculosis), Measles, and Varicella (Chickenpox).
Hand Hygiene Standards - Use soap and water specifically for hands that are visibly soiled or when caring for patients with C. diff. - Scrub hands for at least $20\,seconds$ .
Health Care-Associated Infections (HAIs) - CAUTI: Catheter-Associated Urinary Tract Infection. - CLABSI: Central Line-Associated Bloodstream Infection. - VAP: Ventilator-Associated Pneumonia. - SSI: Surgical Site Infection.
Vocabulary - Colonization: The presence of a microorganism on or in the body without causing tissue invasion or damage (disease). - Inflammation: A protective vascular and cellular response to injury or infection. - Convalescence: The final stage of infection where symptoms disappear and the patient recovers.

Chapter 40: Hygiene

Clinical Best Practices - Always maintain patient dignity during care. - Eye Care: Wipe the eyes from the inner to the outer canthus. - Perineal Care: Wipe from front to back (anterior to posterior) to prevent infection. - Oral Care: Regular mouth care reduces the risk of pneumonia, especially in hospitalized patients.
Care for High-Risk Patients - Diabetes: Foot care is extremely important; nurses should not cut toenails without specialized training. - Anticoagulant Therapy: For patients on blood thinners, an electric razor is the safest option for shaving to prevent bleeding.
Vocabulary - Aspiration: The accidental inhalation of fluids, food, or foreign objects into the lungs. - Perineal care: The procedure for cleaning the genital and anal areas. - Body mechanics: The coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and alignment during movement to prevent injury.

Chapter 46: Urinary Elimination

Common Urinary Problems - Retention: The inability to partially or completely empty the bladder. - UTI: Urinary Tract Infection. - Incontinence: Involuntary loss of urine.
Types of Incontinence - Stress: Leakage during physical exertion (coughing, sneezing, lifting). - Urge: Sudden, strong desire to void that is difficult to suppress. - Overflow: Dribbling of urine because the bladder is overfull. - Functional: Leakage due to factors outside the urinary tract (e.g., mobility or cognitive issues). - Reflex: Involuntary loss at somewhat predictable intervals when a specific bladder volume is reached.
Catheter Types - Indwelling Foley: Remains in place for continuous drainage. - Suprapubic: Surgically inserted through the abdominal wall above the symphysis pubis. - Intermittent: Used for one-time bladder emptying and then removed. - External catheter: A condom-like device for males attached to a drainage bag.
UTI Prevention and Management - Practice front-to-back wiping. - Maintain adequate hydration. - Perform regular catheter care. - Avoid unnecessary Foley use to reduce CAUTI risks.
Vocabulary - Dysuria: Painful or difficult urination. - Oliguria: Diminished or low urine output. - Polyuria: Excessive output of urine.

Chapter 47: Bowel Elimination

Common Bowel Problems - Constipation: Infrequent or difficult evacuation of stool. - Diarrhea: Increase in the number of stools and the passage of liquid, unformed feces. - Impaction: A collection of hardened feces wedged in the rectum that a person cannot expel. - Incontinence: Inability to control the passage of feces and gas.
Stool Diversions (Ostomies) - Colostomy: An opening (stoma) into the colon. - Ileostomy: An opening (stoma) into the small intestine (ileum).
Constipation Risk Factors - Diets with low fiber. - Physical immobility. - Use of opioids (analgesics). - Low fluid intake.
Vocabulary - Melena: Dark, black, tarry stools usually indicating upper gastrointestinal bleeding. - Hematochezia: The passage of fresh, bright red blood in the stool. - Flatulence: The accumulation of gas in the intestines causing the walls to stretch.

Chapter 48: Skin Integrity & Wounds

Stages of Pressure Injuries - Stage 1: Intact skin with nonblanchable redness over a localized area. - Stage 2: Partial-thickness skin loss involving the epidermis and/or dermis. Presents as a blister or shallow open sore. - Stage 3: Full-thickness skin loss where subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. - Stage 4: Full-thickness skin loss with exposed bone, tendon, or muscle. - Unstageable: Full-thickness tissue loss where the actual depth of the ulcer is completely obscured by slough (yellow) or eschar (black).
Types of Wound Drainage - Serous: Clear, watery plasma. - Sanguineous: Bright red, indicates active bleeding. - Serosanguineous: Pale, pink, watery; a mixture of clear and red fluid. - Purulent: Thick, yellow, green, tan, or brown; indicates pus and infection.
Wound Complications - Dehiscence: Partial or total separation of wound layers. - Evisceration: Protrusion of visceral organs through a wound opening (a surgical emergency). - Infection: Bacterial contamination. - Hemorrhage: Excessive bleeding from a wound site.
Prevention Strategies - Turn and reposition patients at least every $2\,hours$ . - Ensure adequate nutrition and hydration for tissue repair. - Use pressure relief devices.
Vocabulary - Braden Scale: A standardized tool used to predict pressure injury risk. - Eschar: Black, brown, or tan necrotic (dead) tissue. - Slough: Soft, yellow or white stringy necrotic tissue.

Chapter 27: Safety

Fall Risk Populations - Older adults. - Patients taking sedatives. - Patients exhibiting physical weakness or mental confusion.
Fire Safety Mnemonics - RACE (The order of action during a fire): 1. Rescue: Protect and evacuate patients in immediate danger. 2. Alarm: Activate the fire alarm and report the fire. 3. Confine: Close doors and windows to contain the fire. 4. Extinguish/Evacuate: Put out the fire or leave the area. - PASS (The steps for using a fire extinguisher): 1. Pull the pin. 2. Aim low at the base of the fire. 3. Squeeze the handle. 4. Sweep from side to side.
Clinical Prioritization - Generally, the nurse must prioritize and treat the patient who will die first without immediate intervention.
Vocabulary - Restraints: Devices used to restrict a patient’s physical activity or normal access to their body. - Nocturia: Awakening at night to urinate.

Chapters 38/39: Mobility & Exercise

Systemic Effects of Immobility - Skin: Pressure injuries. - Respiratory: Pneumonia. - Cardiovascular: DVT (Deep Vein Thrombosis). - Gastrointestinal: Constipation. - Musculoskeletal: Muscle atrophy (wasting).
DVT Prevention Strategies - Use of SCDs (Sequential Compression Devices). - Early and frequent ambulation. - Performing leg exercises.
Transfer Assistance Levels - Independent: No help needed. - Standby assist: Oversight needed for safety. - Minimal assist. - Moderate assist. - Maximal assist. - Dependent: Full assistance required.
Vocabulary - ROM: Range of motion; the maximum amount of movement available at a joint. - Contracture: Permanent shortening of a muscle or joint resulting in deformity.

Chapter 29: Vital Signs

Normal Adult Reference Ranges - RR (Respiratory Rate): $10-20\,breaths/min$ . - SPO2 (Oxygen Saturation): $95-100\%$ . - BP (Blood Pressure): $120/80\,mmHg$ . - HR (Heart Rate): $60-100\,bpm$ . - Temp (Temperature): $98.6^{\circ}F$ .
Definitions of Abnormal Values - Tachycardia: Heart Rate > $100\,bpm$ . - Bradycardia: Heart Rate < $60\,bpm$ . - Tachypnea: Respiratory Rate > $20\,breaths/min$ . - Bradypnea: Respiratory Rate < $12\,breaths/min$ . - Hypotension: Low blood pressure. - Hypertension: High blood pressure.

Chapter 45: Nutrition

Essential Nutrients - The body requires six classes of nutrients: Carbohydrates, Proteins, Fats, Vitamins, Minerals, and Water.
Body Mass Index (BMI) - Formula: - $\text{BMI} = \frac{\text{weight (lb)}}{\text{height (in)}^2} \times 703$
BMI Classification Ranges: - Underweight: < $18.5$ - Healthy weight: $18.5\u201324.9$ - Overweight: $25\u201329.9$ - Obese: \u2265 $30$
Therapeutic Diets - NPO: Nothing by mouth. - Clear liquid: Broth, coffee, tea, clear fruit juices, gelatin, popsicles. - Full liquid: Clear liquids plus smooth-textured dairy like ice cream and custards. - Mechanical soft: Ground or finely diced meats, flaked fish, etc. - Diabetic: Balanced intake of carbs, fats, and proteins. - Low sodium: Limiting salt intake.
Vocabulary - Dysphagia: Difficulty swallowing. - Aspiration: Inhalation of food or liquid into the lungs.

Chapter 42: Fluids & Electrolytes

Fluid Compartments - Intracellular fluid (ICF): Fluid within cells ( $2/3$ of total body water). - Extracellular fluid (ECF): Fluid outside of cells ( $1/3$ of total body water).
Normal Electrolyte Ranges - Sodium ( $Na^{+}$ ): $136-145\,mEq/L$ - Potassium ( $K^{+}$ ): $3.5-5.0\,mEq/L$ - Magnesium ( $Mg^{2+}$ ): $1.3-2.1\,mEq/L$ - Calcium ( $Ca^{2+}$ ): $9.0-10.5\,mg/dL$ - Chloride ( $Cl^{-}$ ): $98-106\,mEq/L$ - Phosphorus ( $PO_{4}^{3-}$ ): $3.0-4.5\,mg/dL$
Clinical Signs of Impaired Balance - Dehydration: Tachycardia, dry mucous membranes, hypotension, confusion, and decreased urine output. - Fluid Volume Overload: Edema (swelling), crackles in the lungs, hypertension, and rapid weight gain.
Vocabulary - Hypokalemia: Low potassium level in the blood. - Hyperkalemia: High potassium level in the blood. - Hypovolemia: Decreased circulating blood volume.

Chapter 36: Loss, Grief, & End-of-Life

Kubler-Ross Stages of Grief 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance
Care Settings - Palliative Care: Focused on providing comfort and symptom relief while the patient is still receiving curative treatment for a disease. - Hospice Care: Focused specifically on comfort and quality of life for terminally ill patients, typically with a life expectancy of less than $6\,months$ .
Physiological Signs of Approaching Death - Mottling: Blue/purple blotching on skin due to poor circulation. - Cheyne-Stokes breathing: Irregular respiratory pattern with alternating periods of apnea and hyperventilation. - Decreased BP (Blood Pressure). - Cool extremities.

Chapter 22 & 23: Ethics & Legal

Ethical Principles - Autonomy: Respect for the patient’s right to make their own decisions. - Beneficence: Taking positive actions to help others. - Nonmaleficence: The avoidance of harm or hurt. - Justice: Fairness and distribution of resources. - Fidelity: Keeping promises; being faithful to the patient.
Legal Vocabulary - Negligence: Conduct that falls below the generally accepted standard of care. - Malpractice: Professional negligence. - Assault: A threat toward another person that creates a reasonable fear of harmful contact. - Battery: Any intentional offensive touching without consent or lawful justification. - False imprisonment: Restraining a patient without legal warrant.
Advanced Directives - Living will: Documenting the patient's wishes regarding medical treatment. - Durable power of attorney: Designating a person to make decisions on the patient’s behalf if they become incapacitated.

Chapter 24: Communication

Therapeutic Communication Techniques - Effective Actions (GOOD): - Using open-ended questions (encourages broad responses). - Using silence (allows patient time to think). - Clarifying (validating what the patient said). - Active listening. - Non-therapeutic Behaviors (BAD): - Asking ‐Why‑ questions (can sound accusatory). - Giving advice. - Providing false reassurance (e.g., ‐Everything will be okay‑). - Changing the subject.
SBAR Standardized Reporting - Situation: What is happening right now? - Background: Relevant clinical history. - Assessment: What the nurse thinks is going on based on data. - Recommendation: What the nurse thinks should be done.

Chapter 44: Pain Management

Physiology of Pain

The physiology of pain involves a complex process of signal generation and interpretation. Key components include:

Transduction: The initial process where a noxious stimulus (chemical, thermal, or mechanical) is converted into electrical energy by nociceptors.
Transmission: The process by which the pain impulse moves from the site of transduction to the spinal cord and then to the brain.
Pain Threshold: The point at which a person first perceives a stimulus as painful. This is generally similar across different individuals.
Pain Tolerance: The maximum level of pain that a person is willing or able to endure. Unlike the threshold, tolerance varies significantly between individuals and can be influenced by psychological and cultural factors.
Perception of Pain: The conscious awareness of pain that occurs once the signal reaches the cerebral cortex.
Breakthrough Pain: A transient spike in pain intensity that occurs in patients whose baseline pain is otherwise stable and adequately controlled by medication.
Modulation: The inhibition or facilitation of pain signals through the release of endogenous opioids (endorphins and enkephalins) and neurotransmitters like serotonin and norepinephrine.

Categories of Pain

Pain is classified according to its duration, underlying pathology, and origin:

Acute Pain: Pain that is protective, has an identifiable cause, is of short duration (typically less than six months), and has limited tissue damage or emotional response.
Chronic Pain: Pain that lasts beyond the typical healing time (usually longer than six months), may not have a specific identifiable cause, and serves no protective purpose.
Cancer or Noncancer Pain: Categorization based on the presence or absence of malignancy.
Idiopathic Pain: Chronic pain in the absence of an identifiable physical or psychological cause.
Nociceptive Pain: Pain resulting from damage to or inflammation of tissue other than that of the peripheral and central nervous systems. Subcategories include: * Somatic: Pain arising from the musculoskeletal system (skin, muscles, joints). * Visceral: Pain arising from internal organs (e.g., the thoracic or abdominal cavity). * Cutaneous: Pain originating from the skin or subcutaneous tissue.
Neuropathic Pain: Pain caused by a primary lesion or dysfunction in the nervous system, often described as burning, tingling, or shooting.

Factors Influencing the Pain Experience

A multidimensional array of factors affects how an individual experiences and expresses pain:

Age: Perception and response to pain can vary across the lifespan, from neonates to the elderly.
Fatigue: High levels of exhaustion can heighten the perception of pain and decrease coping abilities.
Genetic Sensitivity: Hereditary factors can influence how pain receptors function and how individuals metabolize analgesic medications.
Cognitive Function: Cognitive impairment may hinder a patient's ability to report or describe pain accurately.
Prior Experience: Previous encounters with pain can either increase or decrease a patient's sensitivity to current pain.
Anxiety and Fear: Emotional distress can intensify the perception of pain.
Support System: The presence of family or friends can provide emotional comfort and help mediate pain perception.
Coping Styles: Individual strategies for managing stress affect how pain is handled.
Culture: Cultural background influences how pain is expressed, interpreted, and managed.

Areas Impacted by Pain

Chronic or severe pain has broad implications for a patient's functional status and well-being:

Quality of Life: Overall satisfaction and physical/mental health.
Self-care: The ability to perform Activities of Daily Living (ADLs) such as bathing and dressing.
Work and School: Attendance, productivity, and the ability to fulfill professional or educational roles.
Social Support: The maintenance of relationships and participation in community activities.

Populations at Risk for Undertreatment of Pain

Certain groups are statistically more likely to receive inadequate pain management:

Infants: Due to an inability to verbally communicate pain.
Children: Who may lack the vocabulary to describe pain or fear clinical procedures.
Older Adults: Often due to misconceptions that pain is a "normal" part of aging or fears regarding medication side effects.
Patients with Substance Use Disorder: Patients who currently have or have a history of substance use may be stigmatized or have higher tolerance levels, leading to undertreatment.

Pain Assessment Strategies

Pain assessment is a critical nursing responsibility and is guided by the principle that pain is always subjective—it is whatever the patient says it is.

Physical Assessment and Vital Signs: While vital signs (tachycardia, hypertension) can reflect acute pain, they are not reliable indicators of chronic pain.
Characteristics of Pain: * Timing: When the pain started and how long it lasts. * Onset: Was the pain sudden or gradual? * Location: Where exactly the pain is felt and if it radiates. * Severity: Measured using standardized pain scales (e.g., $0$ to $10$ scale, FACES scale). * Quality: The nature of the pain (e.g., sharp, dull, burning, stabbing). * Aggravating and Precipitating Factors: What makes the pain worse (e.g., movement, coughing). * Relief Measures: What methods the patient has used to successfully alleviate the pain.

Functional and Behavioral Assessment

Beyond the physical sensation, the nurse must assess the holistic impact of pain:

Behavioral Effects: Observable signs such as grimacing, moaning, restlessness, or social withdrawal.
Influence on ADLs: Assessing if pain prevents the patient from eating, sleeping, or moving.
Concomitant Symptoms: Other symptoms that occur alongside pain, such as nausea, dizziness, or headache.
Focused Pain Assessment: A targeted evaluation based on the specific location or type of pain reported.

Nonpharmacological Interventions

These measures should be used in conjunction with or as an alternative to medications:

Patient Comfort: Ensuring proper positioning and a supportive environment.
Cognitive-Behavioral Measures: Aiming to change the patient's perception of pain.
Relaxation and Guided Imagery: Techniques to lower physiological arousal and distract the mind.
Cutaneous Stimulation: Methods including massage or TENS units.
Distraction: Focusing attention on something other than the pain.
Music: Used for therapeutic calming and distraction.
Elevation of Edematous Extremities: Reducing swelling to alleviate pressure-related pain.
Ice and Heat: Thermal therapies to reduce inflammation (cold) or improve circulation and muscle relaxation (heat).

Pharmacological Pain Therapies

Pain management in acute care settings often involves a variety of pharmacological agents and delivery methods:

Analgesics: The primary class of medications for pain relief. * Nonopioids: Including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). * Opioids: Controlled substances for moderate to severe pain. * Multimodal Analgesia: The use of two or more classes of analgesic agents to provide superior pain relief and reduce the side effects of individual drugs.
Adjuvants: Medications primarily used for other conditions but effective in pain management, including: * Anticonvulsants. * Antianxiety agents. * Tricyclic antidepressants. * Anesthetics. * Antihistamines. * Glucocorticoids. * Antiemetics. * Bisphosphonates and Calcitonin.
Delivery Systems: * Patient-Controlled Analgesia (PCA): Allows patients to self-administer small, predetermined doses of intravenous analgesics. * Local Anesthesia via Injection: Numbs a specific area. * Perineural Local Anesthetic Infusion: Continuous delivery of anesthetic near a nerve. * Epidural Analgesia: Medication delivered into the epidural space for regional anesthetic effect.

Nursing Implications and Safety

Monitoring for Adverse Effects of Opioids: Nurses must vigilantly monitor for: * Sedation. * Respiratory depression. * Orthostatic hypotension. * Urinary retention. * Nausea and Vomiting. * Constipation.
Complications: Undertreatment of pain is considered a serious medical complication. Conversely, overdosing can lead to sedation, respiratory depression, and coma.
Emergency Intervention: Administer Naloxone (Narcan) immediately if the patient's respiratory rate is below $8/\text{min}$ and respirations are shallow.

Simulation Resources

ATI Swift River Simulations 2.0: Includes case studies such as Cooper Thomas for practical application of pain management principles.

Page 1: Chapter 49 - Sensory Alterations

This section covers Chapter $49$ : Sensory Alterations, presented by Allison Keen, MSN/ED, RN. The material explores the physiological and psychological aspects of human sensation, including the identification of sensory deficits, assessment strategies, and nursing interventions designed to maintain patient safety and promote self-care.

Page 2: Classification of the Five Senses

Sensory function is categorized into five distinct primary senses, which are essential for environmental interaction and perception. These including the following terminology:

Sight (Visual): The capacity to observe and interpret visual stimuli through the eyes.
Hearing (Auditory): The ability to process acoustic information and sound waves.
Touch (Tactile): The perception of pressure, texture, temperature, and pain through skin receptors.
Smell (Olfactory): The chemical sensing of airborne molecules and odors.
Taste (Gustatory): The chemical sensing of substances through the tongue and palate.

Page 3: The Process of Normal Sensation

For an individual to experience and respond to their environment, sensation must progress through three distinct stages:

Reception: This involves the initial stimulus of nerve cells and the transmission of impulses along sensory neurons to the central nervous system. It is the raw data collection stage.
Perception: This is the conscious mental registration of the sensory stimulus. During this stage, the brain interprets the nature and meaning of the received sensory information, influenced by the person's level of consciousness.
Reaction: The final stage involves the body's response to the perceived sensation. Only significant or meaningful stimuli typically elicit a reaction, as the brain often filters out redundant or insignificant data.

Page 4: Primary Sensory Alterations

There are three main categories of sensory alterations that healthcare professionals must recognize:

Sensory Deficits: Occurs when there is a deficit in the normal function of sensory reception and perception (e.g., blindness or deafness).
Sensory Deprivation: This is defined as an inadequate quality or quantity of stimulation. It often occurs when a person experiences reduced sensory input, elimination of patterns or meaning from input, or restrictive environments.
Sensory Overload: This occurs when a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli. This often leads to confusion and anxiety.

Page 5: Factors Influencing Sensory Function

Several variables can impact how a person receives and processes sensory information throughout their lifespan:

Age: Sensory function changes significantly as individuals age; for example, older adults are more prone to vision and hearing loss.
Meaningful Stimuli: The presence of positive stimuli (like music or pets) can reduce the negative effects of sensory deprivation.
Amount of Stimuli: Excessive stimuli in the environment (such as high-traffic hospital units) can lead to sensory overload.
Social Interaction: Frequent interaction with family and friends helps maintain sensory health and cognitive alertness.
Environmental Factors: Occupations involving loud noises, chemical exposure, or repetitive tasks can impact long-term sensory health.
Cultural Factors: Cultural background influences how individuals perceive, report, and manage sensory impairments.

Page 6: Contributing Factors and Specific Sensory Disorders

Various medical conditions and environmental factors contribute to specific sensory losses:

Vision Loss

Presbyopia: A gradual, age-related loss of the eyes' ability to focus actively on nearby objects.
Cataracts: Clouding of the lens in the eye that affects vision.
Glaucoma: A group of eye conditions that damage the optic nerve, often caused by abnormally high pressure in the eye.
Diabetic Retinopathy: Damage to the blood vessels in the tissue at the back of the eye (retina) caused by diabetes.
Macular degermation: A condition characterized by the deterioration of the central portion of the retina.
Other Factors: Infection, inflammation, traumatic injury, and brain tumors.

Hearing Loss

Conductive Hearing Loss: Caused by issues in the external or middle ear. Factors include physical obstructions, wax (cerumen) accumulation, tympanic membrane perforation, ear infections, and otosclerosis.
Sensorineural Hearing Loss: Caused by damage to the inner ear or the nerve from the ear to the brain. Factors include exposure to loud noises, ototoxic medications, the aging process, and acoustic neuroma.

Taste and Neurologic Deficits

Taste Deficit: Often manifests as xerostomia (severely reduced salivation), which impacts taste perception and oral health.
Neurologic Deficits: Includes peripheral neuropathy and peripheral numbness, often resulting in lost tactile sensation in extremities.
Stroke: Can lead to a multifaceted loss of sensation, difficulty speaking (aphasia), and significant visual field deficits (e.g., hemianopsia).

Page 7: Comprehensive Sensory Assessment

Nursing assessment must be holistic and examine the patient's subjective experience alongside physical findings:

Through the Patient’s Eyes: Evaluate the patient's own perception of their sensory loss and its impact on their quality of life.
People at Risk: Identify vulnerable populations, such as the elderly or those in isolated living conditions.
Sensory Alterations History: Determine the onset, duration, and severity of the impairment.
Mental Status: Assess cognitive function, emotional stability, and orientation.
Physical Assessment: Perform objective tests for vision, hearing, touch, smell, and taste.
Ability to Perform Self-Care: Evaluate how the sensory deficit affects activities of daily living (ADLs).
Health Promotion Habits: Assess the use of protective eyewear, hearing protection, and regular screenings.
Environmental Standards: Evaluate safety hazards in the home or healthcare setting.

Page 8: Specific Assessment Concerns

To develop an effective plan of care, the nurse must also evaluate:

Communication Methods: How does the patient communicate? (e.g., sign language, writing, lip-reading).
Social Support: Identify the family members or friends available to assist the patient.
Use of Assistive Devices: Check for the presence and proper function of hearing aids, glasses, or tactile aids.
Other Factors Affecting Perception: Assess medications, stress levels, and existing comorbidities that might skew sensory interpretation.

Page 9: Nursing Considerations and Adaptations

Nursing interventions focus on safety, communication, and environmental modifications:

Establishing Safe Environments: Minimize clutter and ensure adequate lighting.
Adaptations for Visual Loss: Use large print, high-contrast colors, and describe surroundings using a clock-face orientation.
Adaptations for Reduced Hearing: Speak slowly, face the patient directly, and minimize background noise.
Adaptations for Patients with Aphasia: Use simple gestures, pictures, and allow extra time for the patient to respond.
Adaptations for Reduced Tactile Sensation: Protect the patient from temperature extremes (e.g., monitoring hot water heaters).
Adaptations for Disoriented Patients: Provide regular reorientation to person, place, and time.
Orientation to the Environment: Introduce patients to the layout of their room and keep call bells within reach.
Safety Measures and Communication: Ensure all staff are aware of the patient's sensory limitations.
Health Promotion and Screenings: Encourage regular vision and hearing exams to detect issues early.
Promoting Self-Care: Assist the patient in finding ways to remain independent despite sensory changes.

Definition and Scope of Perioperative Nursing Care

Definition of Perioperative Nursing:
This specialized field encompassing all nursing care associated with surgical procedures. It is divided into three distinct phases:
- Preoperative Phase: The period before surgery.
- Intraoperative Phase: The period during the surgical procedure. - Postoperative Phase: The period following surgery until recovery is complete.
Purposes of Surgery: Surgical interventions are performed for various clinical reasons, including:
- Diagnostic: To determine the cause of symptoms or confirm a diagnosis. - Curative: To treat a condition, such as removing a cancerous tumor. - Cosmetic: To alter or enhance physical appearance. - Transplant: To replace a diseased organ or tissue.
Direct Clinical Experiences: The instructor shared personal experiences during clinical rotations and teaching: - C-Section Observation: Observed a C-section while being highly stressed after a classmate broke the sterile field. The instructor had to wipe blood off the surgeon's feet because a surgical bag broke. - Robotic Surgery: Taught clinical at Parkview Pascagoski, observing surgeons using robotic technology where techs are instructed to switch tools remotely.

Types of Surgery and Consent

Inpatient vs. Outpatient Surgery: - Ambulatory/Outpatient Surgery: These terms are used interchangeably. The patient has the procedure and is typically discharged to home on the same day. - Inpatient Surgery: The patient is admitted to the hospital and remains for a period of time post-surgery for monitoring and recovery.
Elective vs. Emergent Surgery: - Elective/Necessary: Scheduled procedures where the patient must be fully informed. - Emergent/Trauma: Life-saving procedures where consent is assumed because the patient is unable to sign papers and immediate action is required to maintain life.
Informed Consent: - Crucial for elective procedures. - The surgeon is responsible for providing the primary informed consent (explaining risks, benefits, and alternatives). - The nurse serves as the witness to the signing of the consent form, confirming the surgeon spoke with the patient and the patient agrees.
Safety: Safety remains the primary priority across all phases of perioperative care.

The Preoperative Phase (Pre-op)

Timing: Begins when the surgical procedure is scheduled (could be weeks or minutes before) and officially ends when the patient is transferred to the surgical suite.
Psychosocial and Educational Focus: Preparing the patient involves ensuring they understand the procedure, the risks, and what to expect during their recovery.
Medical History and Assessment: - Past Surgical History: Must identify previous surgeries and specific reactions to anesthesia. - Anesthesia Reactions: Document issues like coding (cardiac arrest) under anesthesia or becoming violent (post-anesthesia emergence delirium). - Medication Review: Identify all current medications and substance abuse. Street drugs can interact fatally with anesthetic agents, requiring the anesthesiologist to adjust the medication cocktail. - Pregnancy Status: Surgery is unsafe for pregnant patients unless absolutely necessary. Patients of childbearing age must have a pregnancy test (urine cup) prior to surgery. - Discharge Planning: This process begins during the pre-op phase. - Baseline Establishment: Obtain baseline vital signs and labs (sometimes done a week in advance) to identify changes during surgery. - Head-to-Toe Assessment: Includes cardiovascular, respiratory, and skin assessments. Skin assessment is vital for surgeries lasting up to $12$ hours to identify risks for pressure wounds.

Preoperative Preparation and Education

Marking the Surgical Site: The surgeon must mark the correct surgical site to prevent wrong-site surgery. Typically, this involves an "X" and the surgeon's initials. This is mandatory even if a patient is not oriented.
Dietary Restrictions (NPO): - Patients are usually NPO (nothing by mouth) starting at midnight before the surgery. - Rationale: To prevent aspiration of stomach contents while under anesthesia. - Risk Factor Example: The instructor's grandmother attempted to drink black coffee before surgery. While some surgeons allow black coffee because it is a thin liquid, substance in the coffee (like creamer) will result in immediate rescheduling of the surgery.
Bowel Preparation: For procedures like colonoscopies, patients must clear the bowels (using medication that causes frequent defecation). If the bowel is not clear, surgeons cannot visualize the colon.
Preoperative Medications: - Reglan (Metoclopramide): Given IV to decrease nausea and the risk of vomiting. - IV Tylenol (Acetaminophen): Often used in orthopedic cases to manage pain before the procedure starts. - IV Antibiotics: Given to decrease the risk of surgical site infection.
Physical Preparation: - CHG Bath/Hibiclens Shower: Patients often perform a Chlorhexidine Gluconate (CHG) bath or shower to reduce skin bacteria. - Mepilex Dressings: Frequently applied to the coccyx before surgery to prevent skin breakdown during long procedures. - Gown only: No underwear, bras, or personal clothing. Identification (ID) bands must include name, date of birth, and a separate allergy band (with specific allergies listed). - Belongings: No fingernail polish or artificial nails (to ensure cleanliness and observe nail bed color). All jewelry and piercings must be removed. Dentures, glasses, and prosthetics are typically removed, though some anesthesiologists prefer dentures stay in to help secure respiratory tubes.

Intraoperative Phase (Inter-op)

Roles in the Operating Room (OR): - Circulating Nurse: A non-sterile role. Acts as the primary patient advocate. Coordinates supplies, maintains the environment, and facilitates communication. - Scrub Nurse: A sterile role. Sets up equipment, hands instruments to the surgeon, and is responsible for the manual count of all sponges and instruments to ensure nothing is left inside the patient. - Clinical Lead: Oversees the quality and safety of surgical procedures across the facility, ensuring adherence to high-standard protocols.

Postoperative Phase (Post-op)

Phase 1: Immediate Recovery: - This occurs in the PACU (Post-Anesthesia Care Unit) or sometimes the ICU. - Nurses are ACLS (Advanced Cardiac Life Support) trained and ICU-skilled. - Nursing ratios are usually $1:1$ or $1:2$. - Monitoring: Vital signs are checked every $5$ minutes at minimum. - Blood Pressure: A significant drop in blood pressure is a primary indicator of internal bleeding. - Urinary Output: Monitored for retention. Bladder scans or straight catheterization may be used if the patient cannot urinate. - Hand-off Report: Includes types of anesthesia used, as many complications are drug-related.

Post-op Risk Factors and Complications

Smoking: Increases risks for clotting and bleeding. Also indicates potential COPD or emphysema, increasing respiratory risks.
Age: Older adults ( $85+$ years) have higher rates of chronic diseases, decreased organ function, and reduced skin elasticity, making them prone to incision dehiscence (opening).
Nutrition: Poor nutrition significantly delays the healing process.
Obesity: Increases the risk of DVT (Deep Vein Thrombosis), infections, and respiratory strain due to weight on the chest. Obstructive Sleep Apnea (OSA) is a major concern when patients are flat on their backs.
Immunosuppression: Leads to increased infection rates and prolonged healing times.
Fluid and Electrolyte Balance: - Meds are hard on the kidneys; renal function must be monitored. - Electrolyte imbalances can cause seizures or cardiac complications.
Specific Complications: - PONV: Postoperative Nausea and Vomiting. Must be controlled with meds to prevent abdominal muscle strain. - PUR: Postoperative Urinary Retention. Often caused by anesthesia or recent catheter use ("lazy bladder"). - VTE: Venous Thromboembolism. Prevented by SCDs (Sequential Compression Devices) and early mobility.

Phase 2: Recovery and Maintenance

Ambulatory Phase: Monitoring frequency reduces as the patient stabilizes. - Standard Monitoring Protocol: Every $15$ minutes for the first hour, every $30$ minutes for the next $2$ hours, and then hourly.
Respiratory Maintenance: - Atelectasis: Partial or focal collapse of the lung. Prevented by using the incentive spirometer, deep breathing, and early walking to keep alveoli open. - Oxygenation: Patients may need supplemental $O_2$ to wean off anesthesia.
Cardiac Monitoring: - Notify the surgeon if blood pressure changes by $25\%$ (higher or lower) from the patient's baseline.
Dietary Progression: Start with liquids and gradually increase based on tolerance (juice/pizza vs. liquids).
Incision Care: - Pressure Dressings: DO NOT remove the initial pressure dressing placed by the surgeon, even if blood is visible. Monitor the drainage and wait for the surgeon to perform the first dressing change.
Malignant Hyperthermia (MH): - A life-threatening reaction to certain anesthetic agents. - Facilities maintain an "MH Cart" with specific medications (e.g., Dantrolene). - Requires manual temperature monitoring, as it is often not continuously measured via electronic monitors.

Safety Guidelines and Discharge

Coughing Restrictions: While coughing and deep breathing are generally encouraged, they are CONTRAINDICATED for patients following brain, spinal, head, neck, or eye surgeries because coughing increases intracranial and ocular pressure.
Promoting Peristalsis: Listen for bowel sounds; though they may be absent initially, hydration and mobility help them return. Patients often must pass gas or urinate before discharge.
Medication Teaching: - Narcotics side effects: Sleepiness, nausea. - Instruct patients to take pain meds with food to prevent sickness and not to overdose. - Narcan may be sent home with some patients as a safety precaution.
Home Care: Educate on handwashing, proper showering, and managing drains/catheters (some patients remove their own catheters $3$ days later).
Discharge Prerequisite: Follow-up appointments should be scheduled on the patient's calendar before they leave the hospital.