Exam 1 (Ch 15-20, 28-30, 44, 48 & 49)
Name the steps of the nursing process in order.
Remember ADPIE:
Assessment - Collection of subjective and objective data with the use of patient interview and physical examination
Diagnosis - Nursing diagnosis is created by using the steps: 1) Observation 2) Organization of data into meaningful clusters 3) Interpret data 4) Write nursing diagnosis/diagnostic label 5) Writes etiology
Planning - Consider the patient's and family's needs when creating the care plan; plans should be focused on outcomes that are measurable and attainable
Interventions - Consider environmental factors and resources: time management, equipment, personnel, environment, and the patient
Evaluation - Determines whether a patient's condition or well-being improved after implementation of interventions; Determines effectiveness of nursing care
Critical thinking considers what is important in any given situation and is applied with the nursing process to make the best clinical decisions.
Name 3 of the 7 rights of medications.
1. The right medication - verify order and that it is the correct medication = Compare the label of medication with MAR 3 times (before removing form med drawer/cabinet; when removing from container; and at bedside when administering)
2. The right dose - Proper medication calculation/pump set up - unit-dose helps minimize errors
3. The right patient - Use two patient identifiers and barcode scanning to verify correct patient.
4. The right route - Follow ordered route - contact provider if one is not provided.
5. The right time - Consider frequency of medication frequency and timing required for particular medications
6. The right documentation - Document accurately at time of med admin - patient's full name, full name of medication, time of admin, and dosage, route and frequency of admin
7. The right indication - Make sure the medication is being used appropriately - medication reconciliation can help ensure proper ordering
This is how a person thinks/views self.
Self-concept
Assess: identity, body image, coping behaviors, consider environmental factors, talk to significant others/assess support from significant others, make note of non-verbal cues
Self-esteem is how one feels about self.
Name 2 of the competencies/skills needed for community-based nursing.
Caregiver (manage and care for health of patients/families/communities)
Case manager (access for transportation to and from appointments and how to pay for these)
Change agent (Identify and implement new and more effective approaches to problems)
Patient advocate (Ensure patients have information to make informed decisions)
Collaborator (Work with patients, families, and other members of the health care team)
Counselor (helps patients identify and clarify health problems and helps take appropriate action to solve problems)
Educator (demonstrate techniques for providing care for a patient and their family member)
Epidemiologist (collect data and identify causation)
*Community nursing - Priority is health promotion*
*Public health nursing - specialty requires an understanding of needs of a population or collection of individuals who have one or more personal/environmental characteristics in common
Name the 5 stages of the transtheoretical model of change.
Precontemplation - no intent for change within next 6 months
Contemplation - considering a change within the next 6 months
Preparation - making small changes in prep for change in next month
Action - actively engaged in strategies to change behavior - lasts up to 6 months
Maintenance - sustained change over time; begins 6 months after action started and continues indefinitely
*Will always start back to precontemplation/contemplation if ever a lapse
When applying sterile gloves, name at least 2 important considerations to maintain sterility of glove placement.
Only touch the inside of the gloves/never the outside surface; Once first hand is gloved, fingers can slip into the folded/cuffed portion of the glove; The outer paper packaging of the glove should not be ripped or torn; glove package should be open on a clean, flat surface; only allow gloves to be above the waistline; glove the dominant hand of the nurse first; after second glove is on - interlock hands; the sterile gloves should not touch anything that is considered clean in order to maintain sterility
*Handwashing is an important aspect of infection prevention.
Name 1 consideration for safe patient handling when preparing to move a patient who is able to assist.
Face the direction of the movement; Use proper body mechanics; Keep a wide base of support; Keep the body's center of gravity low; Use arms and legs; Leverage, rolling, turning, or pivoting requires less work than lifting
Name 1 item you will include in a spiritual assessment.
Any topic from Box 35.1: Spirituality & spiritual health; faith/belief/fellowship; life and self-responsibility; life satisfaction; connectedness; vocation
To evaluate a patient's spiritual care, these items will guide the evaluation process:
Review patient's view of purpose in life; ask whether the patient's expectations were met; review the patient's self-perception regarding spiritual health; discuss with family and friends the patient's connectedness
Level I evidence is the most reliable level of evidence. Name 1 example of Level I evidence.
Level I (best to use) = Systematic review or meta-analysis of randomized controlled trials (RCTs); Evidence-based clinical practice guidelines based on systematic reviews
Level II = A well-designed RCT
Level III= Controlled trial without randomization (quasi-experimental study)
Level IV=Single nonexperimental study (case control, correlational, cohort studies)
Level V = Systematic reviews of descriptive and qualitative studies
Level VI = Single descriptive or qualitative study
Level VII (lowest level of evidence) = Opinion of authorities and/or reports of expert committees
List 2 ways that a nurse can demonstrate compassion and caring to patients.
Providing presence - sitting with the patient, staying with the patient during a bedside procedure, saying "I'm here", asking about fears, explaining each step of the procedure
Providing touch - placing a hand on a patient's shoulder while talking; holding patient or family members hand
Providing a listening ear - being present and hearing what the patient has to say; not focused only on charting or next task; actively engaged listener
Providing family care - Including the family in the care; hearing the family's voice; advocating for their needs as well
Name 2 factors that can influence blood pressure
Age - Varies throughout lifetimeBP tends to rise with advancing age
Stress - Emotional stress/anxiety/fear; acute pain
Ethnicity and genetics - HTN in African Americans in US is among highest in world; >40% non-Hispanic African American men and women have high blood pressure; assess patien'ts family history
Gender - No clinically significant difference - tend to see males after puberty to have higher BP readings and women after menopause to have higher BP than men of similar age
Daily variation - BP varies throughout the day - lower BP during sleep between midnight and 0300. 0300-0600 is slow and steady rise; early morning surge when patient awakens; highest during day between 1000 and 1800 *Temperature has similar trends
Medications - antihypertensive, diuretic, cardiac meds - lower BP; opioids lower BP; vasoconstrictors and excess volume of IV fluids increase BP; caffeine increases BP for up to 3 hrs
Activity and weight - exercise can falsely elevate BP initially; then, moderate exercise can reduce BP for several hours afterward; increase in O2 demand by body during activity increases BP; inadequate activity can contribute to weight gain and obesity is a link to HTN development
Smoking - causes vasoconstriction (narrowing of blood vessels); BP rises when a person smokes and returns to baseline about 15 mins after stopping smoking
Equipment - Size of blood pressure cuff can cause errors - higher or lower depending on size; manual vs. automatic
*Measuring BP - onset of sound is the systolic and disappearance of sound is the diastolic
Name 2 considerations when suctioning a patient with a tracheostomy.
Limit length of suctioning to 10 seconds; Do not apply suction when inserting the catheter; Apply intermittent suction when removing gently rotating and removing the catheter; Set suction from 80-150 mm Hg; monitor O2 saturation; Hyperoxygenate (if warranted) before and after
General Adaptation Syndrome has three stages. Name the three stages.
In order:
Alarm
Resistance
Exhaustion
In nursing, this is term that refers to respect for the patient's freedom from external control. This means a commitment to including patients in decisions about all aspects of care. This is a key to patient-centered care.
Autonomy
Other terms to review:
Beneficence - taking positive actions to help others
Nonmaleficence - avoidance of harm or hurt
Justice - fairness and the distribution of resources
Fidelity - faithfulness or the agreement to keep promises
Name 2 of the essential components of the Chronic Care Model.
Community - partnerships to enhance effectiveness of chronic disease management programs - community partnerships with health systems and local, state, and national agencies
Self-management support - places patient in center of disease management; providers to collaborate with patients and helps empower the patient to take responsibility for and manage chronic disease
Health system - constantly attempts to improve management of chronic illness and focus on safety and quality of care
Delivery system design - Use EBP care that is patient-centered, preventative, and occurs in variety of settings
Decision support - implement EBP guidelines, patient education, and encourages patients to participate in care
Clinical information system - maintain and share patient health information among providers and patients - ensures effective communication and quality patient care
Name the best way to assess severity of pain for a young child.
FACES scale
Adults who are verbal do best with asking them to rate the level of pain (0-10 scale)
Other assessments to consider regarding characteristics of pain in addition to severity include: timing, location, aggravating factors, and quality
Name 2 assessment findings of an IV that has infiltrated.
Edema of the extremity near the insertion site; Skin discolored or pale in appearance; Skin cool to the touch; Skin taut/shiny
Name 2 types of patients that you would prioritize as most at need of regular perineal care.
Anyone at risk for infection; Pt with rectal/genital surgical dressings; urinary/fecal incontinence; indwelling foley catheter; bariatric patient; uncircumcised male; bed bound patient; patient who just had a baby (childbirth); someone having menstrual cycle
This is the resource used during a lawsuit to determine whether the nurse has acted in a prudent manner.
Scope and Standards of Nursing Care
Would accept: policy and procedure, standard of proof (what a reasonably prudent nurse would do under similar circumstances in location event occurred), nurse expert
The priority action for achieving cultural awareness by the nurse is this.
Assessing own biases and attitudes
This is the lab that you should monitor for a patient who has a pressure ulcer with a nursing diagnosis of Impaired Skin Integrity.
Prealbumin - best measure of nutritional status because it reflects not only recently ingested food but what has been absorbed, digested, and metabolized.
Name 1 normal assessment findings of a stoma placed 1 day ago.
Moist; Shiny; Pink
Concerning if dark purple/black = Lack of circulation
True or false: This is the correct order for the administration of an enteral feeding.
1)Check for gastric residual volume
2) Verify tube placement
3)Elevate the HOB to at least 30 degrees
4) Flush the tubing with 30 mL of water
5) Initiate the feeding
False
Correct order:
1) Elevate head of bed to at least 30 degrees
2) Verify tube placement
3) Check for gastric residual volume
4) Flush tubing with 30 mL of water.
5) Initiate the feeding
Best method to verify tube placement after insertion = X-ray
Name 2 important requirements for an order of restraints to be considered legal.
The order must include:
Provider must order after a face-to-face assessment of the client
Order must include reason, type, location, duration (how long), and circumstances/behaviors that warrant restraints
Never PRN orders for restraints
Prescription is good for 4 hours in adults up to 24 hours before provider needs to re-assess
List the meaning of each of the letters of the LEARN mnemonic for communication
Listen to the patient's perception of the problem. Be nonjudgmental and use encouraging comments: "Tell me more" or "I understand what you are saying."
Explain your perception of the problem
Acknowledge not only the differences between the two perceptions of the problem but also the similarities. Recognize the differences but build on the similarities
Recommendations must involve the patient
Negotiate a treatment plan considering that it is beneficial to incorporate selected aspects of the patient's culture into the plan