final study guide
name some characteristics of a self-actualization person
self-knowledge and acceptances
achievement
openness, flexibility
universal knowledge
aesthetics: artistic appreciations, talent
What is active listening?
An active listener maintains eye contact without staring, gives the patient full attention, and makes a conscious effort to block out other distractions. Responding to the content and feelings of the message by stating what you, as the listener, understand was said by the patient completes the process
How would you communicate with a patient who is hard of hearing?
Face the patient so that your lips can be seen. If the patient wears a hearing aid, be certain it is placed and turned on.Position yourself on the side with better hearing. Touch the patient's arm or shoulder gently to gain her attention before you start speaking.
Why is QSEN important for nursing skills?
(QSEN) Quality and Safety Education of Nursing advocate adding the letter I at the beginning of the acronym (Introduction of yourself and your patient, including roles and unit) and the letter R at the end of the acronym for (Readback,to encourage verification) when communicating with people over the phone. ISBAR-R Introduction, Situation, Background, Assessment, Recommendation, Readback
Why do we use the nursing process and how does a nurses diagnosis differe from a doctors diagnosis.
Why do we use it: the nursing process is a tool for identifying patients problems or potential problems and an organized method for meeting patients needs. Doctor Diagnosis: deals with a disease or medical condition. Nurses Diagnosis: deals with a human response to actual or potential health problems. ex: fatigue
second intention wound healing
are wounds with tissue loss, as in decubitus(pressure) injuries or severe lacerations, wounds remain open and fills with scar tissue. Because of the longer healing period, the chance of infection is higher.
Third intention of wound healing
are the type of wounds with delayed or secondary closure such as draining abdominal wounds. Occurs when there is delayed suturing of the wound.
what is the patient education process with the elderly?
analyzing assessment data, establishing behavioral objectives/ goals, creating a plan for assisting the pt in achieving these goals in the most timely and effective manner. use behavioral objectives: they state what you are trying to to teach the pt to do.
What are some s/s of dehydration?
Dizziness
· Confusion
· Cool, dry skin
· Dark, concentrated urine
· Decreased blood pressure
· Decreased urine production
· Dry, cracked lips & tongue
· Dry mucous membrane
· Elevated temp
· Flat neck veins when lying down
· Increased pulse rate
· Poor skin turgor
· Postural hypotension
· Thick saliva
· Thirst
· Weak thready pulse
· Weakness
- Type of IV Solution: Isotonic solution (0.9% saline)
- Type of nursing care provided:
· Encourage intake of 8 oz of fluid every hour
· Provide mouth care q 4 h & before meal
· If pt unable to consume liquid via PO then consider IV therapies
· Track pt I & O
what are the Standards of Clinical Nursing Practice and what do they govern?
-Clinical practice guidelines: are the product of evidence-based research, and they serve as a way for nurses to implement the evidence-based practices.
- The practice acts are designed to protect the public, and they define the legal scope of practice.
Describe liver dysfunction and medication administration
Changes in the kidney and liver of the older adult indicate a need for smaller doses of the drug than those of middle age patients. For older adults with chronic medical conditions and take multiple medications; check drug interactions carefully.
what electrolytes need to be monitored when giving an enema?
Sodium r/t hypernatremia from loss due to excessive BMs, Potassium r/t Hypokalemia from loss due to loss from GI tract through frequent BM, and Magnesium r/t hypermagnesemia from overuse of cathartics containing magnesium.
how do you write a nursing goal?
- Determine short term goal & long term goal
- Expected outcome
- What are the priorities of care?
- What are the goals for the specific pt?
- How can they be expressed as expected outcomes so that the success of nursing care can be easily evaluated?
Nursing cautions & education that should be provided w/ St John’s Wort & Gingko biloba (when given coumadin)
- St. John’s wort
· Short term treatment for depression
· Well tolerated in recommended dosages for 1-3 months
· May lead to serious interactions w/ herbs, supplements, OTC drugs or prescription drugs
· Interferes w/ the metabolism of drugs that use cytochrome P450 enzyme system
· May lead to increased side effects when take with other antidepressants
· Advise pt to consult a health care professional before self-medicating w/ St. John’s Wort
- Gingko Biloba
· Symptoms of claudication
· Generally well tolerated in recommended dosages for up to 6 months
· May increase the risk of stroke
· May increase the risk of bleeding esp pt w/ Coumadin consumption
· May effect blood glucose level
Describe patient safety for a confused patient.
• Raise head of the bed, turn patient laterally on the side nearest you (preferably left side to prevent aspiration)
• Provide full mouth care to an unconscious patient at least every 4 hours, if patient is mouth breathing perform care every 4 hours
• Perform mouth swabbing of the mouth Q2 or PRN to maintain the integrity of the oral cavity
What are the differences and steps taken for precautions: droplet, contact, airborne?
Donning: gown, mask/respirator, goggles/face shield, gloves.
o Removal of PPE: gloves, face shield/goggles, gown and then mask
o Standard precautions: PPE based on the risk of exposure to blood/ bodily fluid. Gloves if contacting with hands, gown/face shield if risk for splash.
o Use with all/any patients, including those with blood borne pathogen infection
o Air-borne: N95 mask, have a private negative pressure room
o TB, Varicella, measles
o Droplet: regular/surgical mask within 3 feet or patient. Pt wears mask when transported from room
o Flu, meningitis, mumps, pneumonia
o Contact: wear gloves when entering the room, wear a gown when going to be in proximity of patient
o MRSA, VRE, C-Diff (wash hands, no hand sanitizer)
Describe Patient education for a cardiac cath, pap smears and how would you explain the process to your patient.
- Cardiac Cath ( a complex procedure in which q long catheter is passed through an artery/vein to the heart to obtain info about defects, valves, patency of coronary arteries, pressure and blood specimens)
· Educate pt regarding the procedure
· Pt requires to signs a consent form & must have a complete history & physical examination before the procedure
· NPO for at least 6 hours
· A sedative narcotic may be given to lessen apprehension and anxiety
- Pap Smears (A frequent diagnostic test for cervical, vaginal or endometrial cancer)
· A chaperone may accompany the pt or may required by the facility
· Pt should not use vaginal meds/douche for 24 hr prior test
What are the phases of nociceptive pain?
transduction: tissue damage causes release of substance that stimulate nocioreceptors and start pain
transmission: involves movement of the pain sensation to the spinal cord.
perception: pain impulses reach the brain and is recognized
modulation: neurons of the brain send signals back down the spinal cord by release of neurotransmitters.
Name the different bacterial infection suffix
o Cocci (round) Bacilli (rod shaped) Spirochetes (spiral)
o Streptococci: chains Diplococci: pairs Staphylococci: Clusters
o Prions: protein particles that lack nucleic acids, cause degenerative neurologic disease such as Creutzfeldt- Jakob disease
o Protozoa: one-celled microscopic organisms belonging to the animal kingdom. Ex: malaria
o Viruses: can grow and replicate only within a living cell. Survival and multiplication depend on the host.
o Rickettsia: transmitted by the bites of lice, ticks, fleas, and mites. EX: rocky mountain spotted fever and typhus.
o Fungi: Yeast and molds. Thrive in warm, moist environments. Reproduce by means of spores. Ex: vaginal candidiasis
o Helminths: parasitic worms of flukes. Ex: pinworms, roundworms, and tapeworms
What is the difference between a stage 1 and stage 2 for a wound?
Stage 1:
• Area of intact skin is red, deep pink, or mottled skin that does not blanch with fingertip pressure.
• Warmth, edema and induration in comparison to surrounding tissue may be signs of stage 1
Stage 2:
• Partial-thickness skin loss w/ exposed dermis. Wound bed is pink or red and moist
• May appear as intact or ruptured blister
Name the age related changes in the respiratory system
-After age 70 there is decreased elasticity of the thorax and respiratory tissues.
-Total body water decreases 50% after age 70, leading to dry respiratory membranes and thicker mucus.
-Airway cilia experience some degree of impairment, decreasing their efficiency in removing mucus and foreign material
-There is a loss of elastic recoil during expiration, and respiratory muscles must be used to complete expiration.
-Tissue changes cause thickening of the alveolar membrane, decreasing the ease of gas diffusion across the membrane. Oxygen saturation decreases, with partial pressure of oxygen(PaO2) dropping to 75 to 80 mm Hg from the usual 80 to 100 mm Hg.
-The older adult has less respiratory reserve, making it more difficult for the body to meet increased oxygen demand.
Patient teaching and steps for sputum collection.
A sputum specimen is best obtained just after the patient awakens or after a nebulizer treatment because this is when mucus is more available or easier to cough up. Provide a sterile sputum cup. Instruct patient to:
-Rinse mouth with water
-Open the sputum cup and place the lid upside down on the counter or table.
-Take several deep breaths, forcefully huff-cough to move secretions up, and expectorate produced sputum into the cup.
-Take several more deep breaths, force another huff-cough and expectorate produced sputum into the cup.
-Repeat until about a half teaspoon of sputum is in the cup.
-Place the lid on the cup without contaminating the inside of the lid or the lip of the cup.
-Cleanse the mouth
-Ring for the nurse, who will collect the specimen and send it to the laborator
What is the problem solving approach?
The nursing process is a scientific method for problem solving.
assessment: collecting, organizing, doc, validating data. Assessment data obtained from patient, family, provider, diagnostic test, info from other specialist.
Diagnosis: assessment data assorted and finalized so potential health problems are identified. Nursing diagnosis is chosen.
planning: steps by which nurse and the pt set priorities & goals to eliminate/ diminish the identified prob. goals= outcomes. pt and nurse make interventions & listed on nursing care plan. must have a timeframe.
implementation: carrying out interventions.
Evaluation: assessing pts response to nursing interventions. they are compared and determined if achieved. Care plan is reassessed and necessary changes are made.
What are the meanings of communication for focusing, restatement and summarizing?
· Focusing: Asking goal-oriented question helps the patient focus on key concerns. Ex: “Do you have any questions about your chemotherapy?”
· Reflection: reflects received message back to the patient, encourages further verbalization of feelings. Can be used if pt. is unable to verbalize or if nonverbal info. is incongruent with verbal. Ex: pt. says “I’m so scared about the surgery, anesthesia terrifies me. Nurse says, “something scares you about anesthesia?”
· Restatement: Restates in different words what the pt. said, encourages further communication on that topic. Ex: pt. says, “I tossed and turned last night”, nurses says: “You feel like you were awake all night”
· Summarizing: sums up the important points of an interaction. Ex: “you’ve identified your alt. pretty clearly.” “ you are aware of the important signs and symptoms to report to your PCP, you plan to call to make an appointment next week.”
explain Hans Selyes GAS for stress management.
(GAS) General adaptation syndrome occurs in response to long-term exposure to stress.
#1) Alarm stage- hormone released mobilizes the body defense.
ex: slight rise in temp , loss of energy, decreased appetite
#2) Stage of resistance- body is battling for equilibrium
ex: Stress-Related Disease and Disorder (Box 2.2)
:Headache, Allergies, Gastritis, Hypertension, Asthma, Cancer, Lower-back pain, Sexual dysfunction, Infection, Crohn’s disease, Irritable bowel syndrome
#3) Stage of exhaustion: if the stressor is severe enough or presents over a long enough time to deplete the body’s resource for adaptation.
ex: trauma, burns, infection, severe cold and emotional upsets, in death