foundations final exam

Foundations Final Exam Study Notes

Modern Nursing

• Founder: Florence Nightingale

• Theory: Environmental Theory

  • Emphasizes:

    • Fresh air

    • Pure water

    • Efficient drainage

    • Cleanliness

    • Sunlight

Nursing Delegation Principles

• Knowledge & Licensing: Nurses must be knowledgeable and licensed.

• Delegation Limitations:

  • RNs cannot delegate assessment, planning, evaluation, or accountability.

  • The delegate cannot further delegate the task.

5 Rights of Safe Delegation

1. Right Task

2. Right Circumstances

3. Right Person

4. Right Direction/Communication

5. Right Supervision/Evaluation

Maslow's Hierarchy of Basic Human Needs

• A framework for prioritizing nursing diagnoses and interventions:

  1. Physiological Needs

  2. Safety Needs

  3. Love/Belonging Needs

  4. Esteem Needs

  5. Self-Actualization

Ethical Principles in Nursing

• Autonomy: Freedom to make informed decisions.

• Non-maleficence: Do no harm.

• Beneficence: Doing good.

• Justice: Acting fairly.

• Fidelity: Keeping commitments.

• Accountability: Responsibility for actions.

• Veracity: Truthfulness.

• Advocacy: Supporting and promoting others' interests.

Informed Consent

• Requirements:

  • Exact details of treatment

  • Necessity for treatment

  • Known benefits and risks

  • Alternatives available

  • Risks of refusing treatment

Legal Boundaries of Nursing Practice include understanding the scope of practice, adhering to state regulations, and ensuring informed consent is obtained from patients before any treatment.

Legal Boundaries of Nursing PracticeLegal boundaries for nursing practice are defined by the Nurse Practice Act (NPA) of the respective state, which serves as a statute that outlines the scope of practice for registered nurses (RNs) and licensed practical nurses (LPNs). The NPA ensures that nurses have the necessary education, training, and qualifications to provide safe and effective patient care.

Key aspects of the Nurse Practice Act include:

• Scope of Practice: The NPA delineates which nursing activities are permissible for RNs and LPNs, including assessments, interventions, and the delegation of tasks.

• Licensure Requirements: The act also specifies the educational credentials required for licensure, the examination process (such as the NCLEX-RN or NCLEX-PN), and the continuing education necessary to maintain that license.

• Disciplinary Procedures: Provisions for handling violations of the nursing regulations, including disciplinary actions such as license suspension or revocation for misconduct or incompetence.

• Patient Safety: The NPA emphasizes the importance of patient safety and the legal consequences for failing to adhere to established nursing standards.

• Advance Practice Roles: Outlines the requirements for advanced practice registered nurses (APRNs), including nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives, who may have expanded scopes of practice based on additional education and certification.

Overall, the Nurse Practice Act is essential for ensuring ethical and competent nursing care, safeguarding public health, and providing a framework for nursing practice within that state.

SOAPIE Documentation Significance

• SOAPIE: Subjective, Objective, Assessment, Plan, Intervention, Evaluation.

Normal Biological Ranges

• Temperature: 98.6-100.4 °F (36-38 °C)

• WBC Count: 4,500 to 11,000 cells per microliter.

• Platelets: 150,000 to 450,000 per microliter.

• Fasting Blood Glucose: 70 to 99 mg/dL.

Elevated ESR Indicator

• Indicates inflammation or infection.

Urine Output Guidelines

• Report: If urine output is less than 30 ml/hr.

• Normal: 1-2 liters/day.

PPE Usage Guidelines

• Donning Order: 1. Gown 2. Face Mask 3. Goggles 4. Gloves

• Doffing Order: 1. Gloves 2. Goggles 3. Gown 4. Mask

Wound Healing Intention

• Primary Intention: Skin edges are approximated (surgical wounds).

• Secondary Intention: Involves tissue loss (burns, pressure ulcers).

  • Scar tissue forms.

Health Proxy Significance

• Designates a person to make medical decisions for the patient.

Glasgow Coma Scale

• Assesses consciousness based on eye opening, verbal response, motor response.

Hypercalcemia Definition

• High calcium levels causing muscle weakness and constipation.

Phosphorus Level Impact

• High phosphorus correlates with symptoms of hypocalcemia (muscle spasms).

Handling Medications

• Before Mixing: Inject air into both vials first.

Additional Concepts

• Controlled Fall: Technique for safely lowering a patient to the ground to avoid injury.

• Common DVT Signs: Pain, cramping in the calf, redness, swelling, warmth in the extremity.

• IM Injection Angle: Administer at 90-degree angle.

• Anuria Definition: Absence of urine or <50-100mL/day.

• Cognitive Impairment: Engage using physical touch and observe non-verbal cues.

• Acute vs Chronic Wounds: Acute heals rapidly; chronic fails to heal timely.

• Active Listening Importance: Engage fully with the patient utilizing techniques like SOLAR.

• Advocacy Meaning in Nursing: Supporting patients’ interests.

• Confidentiality: Protecting patient information.

Infection Control Principles

• Standard Precautions: Hand hygiene and PPE use.

Nutritional Guidance & Management

• Normal Stoma Appearance: Pink to red, moist, slightly protruding.

• Fluid Intake Recommendation: 8-10 cups (2-2.5 liters) daily.

• Fiber Intake Recommendation: 25-30 grams/day for adults.

• Malnutrition Signs: Weight loss, energy depletion.

• Diabetic Foot Care: Regular checks, keeping foot hygiene.

Coordination and Delegation Insights

• Importance of assessing delegatee competency.

• Communication is vital for clear delegation and expectations.