101 Exam 2 Knowledge QUIZ
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Questions and Answers

What is the primary focus of nursing assessment compared to medical assessment?

  • Target data pointing to pathologic conditions
  • Focus on the patient’s response to health problems (correct)
  • Analyzing laboratory test results
  • Documenting the patient's medical history

    • The assessment phase of the nursing process is a one-time event.

    False

    What are the five steps of the nursing process?

    Assessing, Diagnosing, Planning, Implementing, Evaluating

    ________ assessment is conducted during a crisis situation to address immediate physiological or psychological issues.

    <p>Emergency</p> Signup and view all the answers

    Match the types of assessments with their descriptions:

    <p>Initial Assessment = Admission &amp; comprehensive assessment Focused Assessment = Assessment of pre-existing conditions Emergency Assessment = Assessment during a physiological or psychological crisis Ongoing Assessment = Continuous evaluation of patient status</p> Signup and view all the answers

    What is the primary focus of a Nursing Diagnosis?

    <p>Holistic response to disease or injury</p> Signup and view all the answers

    A Nursing Diagnosis can change from day to day based on the patient's response.

    <p>True</p> Signup and view all the answers

    What type of Nursing Diagnosis describes a problem response likely to happen in a vulnerable patient?

    <p>Risk Diagnosis</p> Signup and view all the answers

    An example of an actual Nursing Diagnosis is __________.

    <p>Impaired Gas Exchange</p> Signup and view all the answers

    Match the following Nursing Diagnosis types with their definitions:

    <p>Actual Diagnosis = Describes a problem response that exists at the time of assessment Risk Diagnosis = Describes a problem response that is likely to happen Possible Diagnosis = Describes a situation with incomplete evidence about a health problem Potential Diagnosis = Synonymous with Possible Diagnosis</p> Signup and view all the answers

    What defines ethnicity?

    <p>A collective cultural group's heritage</p> Signup and view all the answers

    Cultural shock refers to the feeling of comfort when placed in a different culture.

    <p>False</p> Signup and view all the answers

    What is cultural competence in nursing?

    <p>Attending to the patient's total situation.</p> Signup and view all the answers

    ____ refers to the unfair treatment of people based on characteristics like race and gender.

    <p>Discrimination</p> Signup and view all the answers

    Match the following cultural groups with their associated health issues:

    <p>Native Americans = Diabetes Mellitus African Americans = Sickle Cell Anemia Asians = Cancer of the Liver Hispanics = Lactose Intolerance</p> Signup and view all the answers

    Which of the following is a characteristic of culturally sensitive nursing?

    <p>Understanding and respecting cultural differences</p> Signup and view all the answers

    Cultural imposition is the practice of respecting all cultural beliefs equally.

    <p>False</p> Signup and view all the answers

    What does 'cultural blindness' mean?

    <p>Ignoring cultural differences and treating everyone the same.</p> Signup and view all the answers

    The concept of ________ refers to the state of being different, including variations in religion and language.

    <p>Diversity</p> Signup and view all the answers

    Which demographic group is associated with a high risk of hypertension?

    <p>African Americans</p> Signup and view all the answers

    What is one characteristic of the Magico - Religious Health Belief System?

    <p>Illness is considered a punishment from god.</p> Signup and view all the answers

    The Scientific Health Belief System acknowledges the control of physical and biochemical processes by humans.

    <p>True</p> Signup and view all the answers

    What does holistic health emphasize?

    <p>Natural balance or harmony.</p> Signup and view all the answers

    In traditional African American healthcare, the use of ______ and faith healing is common.

    <p>herbs</p> Signup and view all the answers

    Match the cultural belief systems with their associated practices:

    <p>Chinese Medicine = Yin and Yang balance Spanish Folk Medicine = Curanderos Native American Healing = Shaman Caucasian Folk Medicine = Self-diagnosis of illness</p> Signup and view all the answers

    What is a nursing consideration when dealing with Hispanic clients regarding health and illness?

    <p>Health and illness equate to God’s will.</p> Signup and view all the answers

    In Native American healthcare practices, direct eye contact is preferred as a sign of respect.

    <p>False</p> Signup and view all the answers

    Which type of healthcare system may involve the use of heat and massage?

    <p>Native American Folk Health.</p> Signup and view all the answers

    The Nursing Process includes five steps: Assessment, Diagnosis, ______, Implementation, and Evaluation.

    <p>Planning</p> Signup and view all the answers

    What can be a nursing diagnosis related to communication barriers?

    <p>Impaired Verbal Communication.</p> Signup and view all the answers

    What does a Wellness Dx aim to achieve?

    <p>Transitioning to a higher level of wellness</p> Signup and view all the answers

    The etiology in a nursing diagnosis refers to the interventions planned for the client.

    <p>False</p> Signup and view all the answers

    What are the two types of goals in nursing planning?

    <p>Short-Term and Long-Term</p> Signup and view all the answers

    The nursing diagnosis includes the components of Problem, Etiology, and __________.

    <p>Signs &amp; Symptoms</p> Signup and view all the answers

    Match the types of planning with their descriptions:

    <p>Initial Planning = Developed by the nurse who performs the initial assessment. Ongoing Planning = Carried out by any nurse interacting with the client. Discharge Planning = Information needed before the client is discharged.</p> Signup and view all the answers

    Which of the following represents an example of an affective outcome?

    <p>Client expresses a change in attitude towards health.</p> Signup and view all the answers

    NANDA, NIC, and NOC are all classifications related to nursing interventions and outcomes.

    <p>True</p> Signup and view all the answers

    What is the purpose of the initial planning phase in nursing care?

    <p>To develop a care plan based on initial assessment.</p> Signup and view all the answers

    What is a key feature of a Nursing Diagnosis?

    <p>Considers the patient's holistic response</p> Signup and view all the answers

    Nursing diagnoses can change daily based on the patient's responses.

    <p>True</p> Signup and view all the answers

    What are the three types of Nursing Diagnosis?

    <p>Actual, Risk, Possible</p> Signup and view all the answers

    The Nursing Diagnosis statement includes the components of Problem, Etiology, and __________.

    <p>Signs &amp; Symptoms</p> Signup and view all the answers

    Match the following types of Nursing Diagnoses with their examples:

    <p>Actual Dx = Impaired Gas Exchange Risk Dx = Risk for Infection Possible Dx = Potential risk for skin breakdown Health Promotion Dx = Readiness for Enhanced Nutrition</p> Signup and view all the answers

    What is the primary goal of Quality Improvement (QI) in healthcare?

    <p>To improve quality of client care</p> Signup and view all the answers

    A nursing audit only examines data related to patient satisfaction.

    <p>False</p> Signup and view all the answers

    What are the two types of nursing audits?

    <p>Concurrent and Retrospective Audits</p> Signup and view all the answers

    The focus of Quality Improvement is on client care rather than __________.

    <p>organizational structure</p> Signup and view all the answers

    Match the following elements of environment safety with their descriptions:

    <p>Free of clutter = Keeps pathways accessible and safe Emergency alarms = Alerts for urgent situations Cleanliness = Prevents infections and hazards No debris = Avoids tripping hazards</p> Signup and view all the answers

    What is the primary purpose of the document related to patient status post-accident?

    <p>To help in lawsuits and prevent future incidents</p> Signup and view all the answers

    Smoke inhalation is a common cause of death in fires.

    <p>True</p> Signup and view all the answers

    List the steps involved in the RACE fire safety protocol.

    <p>Rescue, Alarm, Contain, Extinguish</p> Signup and view all the answers

    The acronym PASS refers to the correct use of a fire extinguisher and stands for Pull, Aim, Squeeze, and __________.

    <p>Sweep</p> Signup and view all the answers

    Match the age group with their respective common safety concerns:

    <p>Fetus = Abnormal growth and development Neonate = Infection, falls, suffocation Young adult = Motor vehicle collisions, drugs/alcohol Elderly = Home hazards, vision or hearing loss</p> Signup and view all the answers

    What is the main focus of a Wellness Diagnosis?

    <p>Transitioning to a higher level of wellness</p> Signup and view all the answers

    Which of the following is a common cause of fires in hospitals?

    <p>Malfunction of electrical equipment</p> Signup and view all the answers

    Physical restraints should only be used as a last resort in patient care.

    <p>True</p> Signup and view all the answers

    The Planning Phase involves solely the nurse and does not include the client.

    <p>False</p> Signup and view all the answers

    What is a common safety concern for toddlers?

    <p>Drowning, suffocation, inhalation of foreign bodies</p> Signup and view all the answers

    What are the two types of goals in nursing planning?

    <p>Short-Term and Long-Term</p> Signup and view all the answers

    The three components of a Nursing Diagnosis are Problem, Etiology, and __________.

    <p>Sign &amp; Symptoms</p> Signup and view all the answers

    Match each type of nursing diagnosis with its definition:

    <p>Wellness Dx = Focuses on health enhancement Risk Diagnosis = Describes potential problems Actual Diagnosis = Indicates a current health issue Possible Diagnosis = Uncertain health problem presence</p> Signup and view all the answers

    Which of the following best describes the role of NANDA in nursing?

    <p>Classifying nursing diagnoses</p> Signup and view all the answers

    Cognitive outcomes in nursing describe the development of new skills in a patient.

    <p>False</p> Signup and view all the answers

    What begins during the client's admission and aids in preparing for discharge?

    <p>Discharge Planning</p> Signup and view all the answers

    Which of the following is a reason for applying restraints?

    <p>Discipline patient actions</p> Signup and view all the answers

    Heat therapy should last more than 30 minutes to be effective.

    <p>False</p> Signup and view all the answers

    What type of restraint is typically used when a patient is sitting up in a chair?

    <p>Belt restraint</p> Signup and view all the answers

    After applying cold therapy, the duration should not exceed ______ minutes.

    <p>20</p> Signup and view all the answers

    Match the type of thermotherapy with its key feature:

    <p>Heat therapy = Vasodilation and sedative effect Cold therapy = Vasoconstriction and numbing effect Moist heat = Requires frequent changes to maintain warmth Dry cold = Used to create a cooling effect without moisture</p> Signup and view all the answers

    Which of the following is a contraindication for heat therapy?

    <p>Open wounds</p> Signup and view all the answers

    Skin integrity checks should be performed every 4 hours when restraints are applied.

    <p>False</p> Signup and view all the answers

    What physiological effect does heat therapy have on blood vessels?

    <p>Vasodilation</p> Signup and view all the answers

    For cold therapy, the recommended application time is ______ minutes.

    <p>15-20</p> Signup and view all the answers

    Match the types of restraints with their descriptions:

    <p>Belt restraint = Prevents rising but allows upper body mobility Jacket/vest = Minimizes upper body mobility to prevent rising Mitt = Prevents fine motor grasping Wrist/Ankle = Restricts all movement of extremities</p> Signup and view all the answers

    Which of the following describes the rebound phenomena after heat therapy?

    <p>Increased cardiac output and perspiration</p> Signup and view all the answers

    Cold therapy is effective for all conditions regardless of patient sensitivity to temperature.

    <p>False</p> Signup and view all the answers

    What is the primary purpose of using mitt restraints?

    <p>To prevent fine motor movements, like pulling out tubes.</p> Signup and view all the answers

    The physician must reassess restraints every ______ hours.

    <p>24</p> Signup and view all the answers

    Match the type of thermal therapy with its description:

    <p>Electric heating pad = Warmed before use and positioned to avoid burns Ice bag = Filled with crushed ice and covered with a towel Sitz bath = Warm soak for perineum to reduce inflammation Hot water bag = Filled to a specific level to avoid burns</p> Signup and view all the answers

    Which of the following is NOT a required blended skill for nurses?

    <p>Financial skills</p> Signup and view all the answers

    The assessment phase of the nursing process is a continuous process of data collection.

    <p>True</p> Signup and view all the answers

    What is the primary purpose of conducting an initial assessment in nursing?

    <p>To establish a database for a client in order to meet the patient's nursing care needs.</p> Signup and view all the answers

    The type of assessment performed during a physiologic or psychological crisis is called __________.

    <p>Emergency Assessment</p> Signup and view all the answers

    Match the following nursing process steps with their descriptions:

    <p>Assessment = Collecting and documenting client data Diagnosis = Analyzing client data to identify problems Planning = Specifying client outcomes and nursing interventions Evaluation = Measuring the extent of outcome achievement</p> Signup and view all the answers

    Which type of nursing intervention requires a physician's order?

    <p>Dependent</p> Signup and view all the answers

    Quality assurance focuses solely on patient outcomes.

    <p>False</p> Signup and view all the answers

    What are the four steps involved in the Evaluation Phase of nursing care?

    <p>Review evaluative criteria, collect data, interpret findings, document judgment.</p> Signup and view all the answers

    The __________ phase involves carrying out the planned nursing interventions.

    <p>Implementation</p> Signup and view all the answers

    Match the types of nursing actions with their definitions:

    <p>Independent = Nurse initiates actions without a physician's orders Collaborative = Nurse works jointly with other healthcare team members Dependent = Actions performed under physician's orders</p> Signup and view all the answers

    Which outcome indicates a patient's achievement of new skills?

    <p>Psychomotor</p> Signup and view all the answers

    The Implementation Phase includes supervision of delegated nursing care.

    <p>True</p> Signup and view all the answers

    What is the primary focus of Quality Assurance in healthcare?

    <p>Evaluation of structure, process, and outcomes.</p> Signup and view all the answers

    What does the RACE acronym stand for in fire safety protocols?

    <p>Rescue, Alarm, Contain, Extinguish</p> Signup and view all the answers

    Smoke inhalation is the most common cause of death in hospital fires.

    <p>True</p> Signup and view all the answers

    What is one common cause of fires in hospitals?

    <p>Malfunction of electrical equipment</p> Signup and view all the answers

    Which of the following is NOT a type of intervention for sensory-perception alterations?

    <p>Structured environments</p> Signup and view all the answers

    To use a fire extinguisher, you must remember the acronym PASS: P for Pull, A for aim, S for __________, S for __________.

    <p>Squeeze, Sweep</p> Signup and view all the answers

    Assistive devices are typically used to help with mobility.

    <p>True</p> Signup and view all the answers

    Match the developmental stage with its common safety concerns:

    <p>Infant = SIDS; burns, injury from toys Toddlers = Drowning; suffocation; inhalation of foreign bodies School Age/Adolescence = Chemical security; bullying; sports injuries Elderly = Home hazards; falls; vision loss</p> Signup and view all the answers

    What type of restraint involves equipment that restricts patient movement?

    <p>Physical Restraints</p> Signup and view all the answers

    What are the common characteristics of a fall risk patient?

    <p>History of falls, gait disturbance, dizziness, visual impairment, medication list, incontinence issues.</p> Signup and view all the answers

    Alternative restraints can only include physical items or devices.

    <p>False</p> Signup and view all the answers

    The ______ technique involves only allowing sterile objects to touch other sterile objects.

    <p>sterile</p> Signup and view all the answers

    Match the following interventions with their corresponding conditions:

    <p>Assistive devices = Mobility Memory aids = Cognitive Awareness Education on safe home environment = Environmental Factors Communication assessments = Language Barriers</p> Signup and view all the answers

    What is the primary goal of the document related to patient status post-accident?

    <p>To investigate and prevent future incidents</p> Signup and view all the answers

    What is one potential risk of using side rails in a hospital setting?

    <p>Suffocation</p> Signup and view all the answers

    Providing a hand to hold while getting in and out of bed is a benefit of using side rails.

    <p>True</p> Signup and view all the answers

    What should a nurse do when a patient experience an injury?

    <p>Assess, treat the problem, notify the physician, stabilize the patient, and complete an injury report.</p> Signup and view all the answers

    Poor ______ is identified as an environmental factor that can affect patient safety.

    <p>lighting</p> Signup and view all the answers

    Match the types of asepsis with their definitions:

    <p>Medical Asepsis = Clean technique to prevent infection Surgical Asepsis = Sterile technique to eliminate all microorganisms</p> Signup and view all the answers

    What is the primary purpose of using restraints?

    <p>To protect the patient and others</p> Signup and view all the answers

    Restraints should always be applied without prior reassessment.

    <p>False</p> Signup and view all the answers

    How often should skin integrity checks be performed when restraints are applied?

    <p>Every 2 hours</p> Signup and view all the answers

    The __________ effect of heat therapy involves increasing tissue metabolism and reducing muscle tension.

    <p>sedative</p> Signup and view all the answers

    Match the type of restraint with its description.

    <p>Belt Restraints = Used while sitting in a chair, allows upper body movement Jacket/Vest = Prevents rising but allows extremities to be free Mitts = Prevents fine motor grasping Wrist/Ankle = Prevents all extremity movements</p> Signup and view all the answers

    What is the maximum recommended duration for cold therapy?

    <p>15-20 minutes</p> Signup and view all the answers

    Heat therapy is contraindicated for open wounds.

    <p>True</p> Signup and view all the answers

    What physiological effect does heat have on blood vessels?

    <p>Vasodilation</p> Signup and view all the answers

    Cold therapy helps to __________ peripheral blood vessels, reducing blood flow to the area.

    <p>constrict</p> Signup and view all the answers

    Match the type of thermal therapy with its application.

    <p>Dry heat = Electric heating pads Moist heat = Sitz bath Cold = Ice bags Moist cold = Warm compress</p> Signup and view all the answers

    What is a potential risk if heat therapy is used improperly?

    <p>Tissue damage</p> Signup and view all the answers

    The rebound phenomenon is a normal response after thermal therapy.

    <p>True</p> Signup and view all the answers

    What should be done if a patient expresses discomfort during thermal therapy?

    <p>Remove the therapy immediately</p> Signup and view all the answers

    Cold applications should not be used on individuals with impaired __________ circulation.

    <p>peripheral</p> Signup and view all the answers

    Match the guideline to thermal therapy with its corresponding action.

    <p>Tolerance = Assess patient's ability to handle therapy Assessment = Monitor the site of application Remove = Take away therapy if discomfort is reported Revisit = Check for any changes in condition</p> Signup and view all the answers

    Study Notes

    Cultural Nursing

    • Cultural Sensitivity: Acknowledging and respecting cultural differences without judgment.
    • Cultural Appropriateness: Providing care that is compatible with a patient's cultural beliefs and practices.
    • Cultural Competence: Understanding and responding to the needs of a diverse patient population, encompassing the patient's entire situation.

    Culture

    • Definition: A shared system of beliefs, values, and behavioral expectations that influences roles, interactions, and daily living.
    • Characteristics:
      • Learned through generations, both formally and informally.
      • Includes values, beliefs, attitudes, practices, habits, likes and dislikes, customs, and rituals.

    Ethnicity

    • Definition: A sense of identification with a collective cultural group based on heritage.
    • Examples: Religion and language.

    Religion

    • Definition: A system of beliefs, practices, and ethical values about divine or superhuman powers.

    Diversity

    • Definition: The state of being different, including language, sexual orientation, religion, and others.

    Stereotyping

    • Definition: Assuming that everyone from the same culture, race, or ethnicity behaves alike.

    Cultural Imposition

    • Definition: The belief that everyone should conform to one's own belief systems.

    Cultural Blindness

    • Definition: Ignoring cultural differences and proceeding as if they do not exist.

    Cultural Conflict

    • Definition: Becoming aware of cultural differences and feeling threatened, leading to ridicule of others' beliefs and traditions to feel more secure about one's own values.

    Subculture

    • Definition: A large group of people within a larger cultural group who share certain ethnic, occupational, or physical characteristics not common to the larger culture.

    Cultural Acculturation or Assimilation

    • Definition: A process where a minority group living with a dominant group loses cultural characteristics that made them different and adopts the values of the dominant group.

    Cultural Shock

    • Definition: Experiencing a different culture as strange.

    Race

    • Definition: Based on physical characteristics such as skin pigmentation, body stature, facial features, and hair texture.

    Discrimination

    • Definition: Unfair or prejudicial treatment of people and groups based on characteristics like race, gender, age, or sexual orientation.

    Ethnocentrism

    • Definition: The belief that one's own culture's ideas, beliefs, and practices are superior to those of other cultures.

    Prejudice

    • Definition: An opinion formed without adequate knowledge, thought, or reason.

    Bicultural

    • Definition: Combining cultural attitudes and customs between two nations.

    Dominant vs. Minority Group

    • Definition: The dominant group holds the most power in society compared to minority groups.

    Nursing Assessment Parameters

    • Physiological Variations
    • Reactions to Pain
    • Language and Communication
    • Economic Barriers
    • Gender Roles
    • Mental Health
    • Gender Roles

    Physiological Variations

    • Native Americans & Alaska Natives: Heart disease, cirrhosis of the liver, diabetes mellitus, fetal alcohol syndrome.
    • African Americans: Hypertension, stroke, sickle cell anemia, lactose intolerance, keloids.
    • Asians: Hypertension, cancer of the liver, lactose intolerance, thalassemia.
    • Hispanics: Diabetes mellitus, lactose intolerance.
    • Whites: Breast cancer, heart disease, hypertension, diabetes mellitus, obesity.
    • Eastern European Jews: Cystic fibrosis, Gaucher’s disease, spinal muscular atrophy, Tay-Sachs’s disease.

    Pain

    • Subjective Experience: Pain is whatever and whenever a patient says it is.

    Communication

    • Verbal Communication: Language usage, voice quality, use of silence, gender of speaker, use of interpreter.
    • Non-Verbal Communication: Eye movement/eye contact, facial expression, use of touch, hand movement, body posture.

    Time Orientation

    • Past: History and traditions guide the present and future (e.g., East Asia).
    • Present: "Eternal present," instant gratification and short-term benefits (e.g., American, African, and Native Americans).
    • Future: Planning for the future, long-term worldview (e.g., Chinese and Japanese).

    Personal Space

    • Intimate Zone: 6 to 18 inches.
    • Personal Zone: 1.5 to 4 feet.
    • Social Zone: 4 to 12 feet.

    Health Belief Systems

    • Health Belief System: A framework influencing views on the causes of illness, prevention, treatments, and health promotion and maintenance activities.
      • Magico-Religious Health Belief System: Supernatural forces, evil spirits, God’s will. Illness is a punishment from God. (Example: Hispanics, African, and Caribbean).
      • Scientific Health Belief System (Biomedical): Controlled physical and biochemical processes analyzed and manipulated by humans.
      • Holistic Health Belief System: Natural balance or harmony (e.g., Yin and Yang, energy, mind-body-spirit). Illness is a disequilibrium or disharmony. (Example: Chinese medicine and Native Americans).

    Folk and Traditional Healthcare

    • Asian: Well-being is related to balance (Yin and Yang, energy, mind-body-spirit). Hot and cold remedies, and herbs.
    • Spanish: Curanderos (folk healers). Respect according to age or gender. Roman Catholic Church influences.
    • Caucasian: Self-diagnosis of illness, use of over-the-counter (OTC) drugs, extensive use of exercise and facilities.
    • African Americans: Varies; may include herb doctors, voodoo, and faith healing.
    • Native Americans: Shaman (medicine man), herbs, psychological treatments, ceremonies, fasting, medications, heat, and massage.

    Nursing Diagnosis Examples

    • Impaired Verbal Communication: Related to inability to speak English and interpreter available.
    • Ineffective Management of Therapeutic Regimen: Related to mistrust of traditional healthcare personnel.

    Nursing Process

    • Purpose: To identify health status, problems, and needs.
    • Steps:
      • Assessment: Collecting, validating, and communicating client data.
      • Diagnosis: Analyzing client data to identify client strengths and problems.
      • Planning/Outcome Identification: Specifying client outcomes and related nursing interventions.
      • Implementation: Carrying out the plan of care.
      • Evaluation: Measuring the extent to which a client achieved outcomes.

    Assessment

    • Definition: A systematic process of data collection, involving continuous collecting, organizing, validating, and documenting data information.
    • Purpose: To establish a database about a client to meet their nursing care needs.
    • Types:
      • Initial: Admission and comprehensive assessment (establishes data baseline).
      • Focused: Pre-existing condition (ongoing assessment).
      • Emergency: When a physiologic or psychological crisis presents.

    Medical vs. Nursing Diagnosis

    • Medical Diagnosis: Focuses on identifying and describing a disease, illness, or injury.
    • Nursing Diagnosis: Focuses on behaviors, responses, and reactions to disease, injury, or other stressors.

    Diagnosis Phase

    • Steps:
      • Interpret data/cues (analyze data) already gathered.
      • Cluster cues (organize data).
      • Confer with approved list from NANDA (identify health problems, risks, and strengths).
      • Formulate diagnosis statements (write it).

    Types of Nursing Diagnoses

    • Actual: Describes a problem response that exists at the time of assessment, identified by signs and symptoms (cues) that are present. (Example: Impaired Gas Exchange).
    • Risk: Describes a problem response that is likely to happen in a vulnerable client if the nurse does not intervene. (Example: Risk for Falls, Risk for Infection).
    • Possible: Describes a situation where evidence about a health problem may be incomplete or unclear. (Example: Potential risk for skin breakdown, Possible risk for infection).
    • Wellness: Describes the transition of an individual, family, or community from one level of wellness to a higher level of wellness. There is no identified health problem. (Example: Readiness for enhanced health maintenance).

    Components of a Nursing Diagnosis (PES)

    • Problem: Identifies what is unhealthy about the client.
    • Etiology: Identifies factors maintaining the unhealthy state.
    • Signs and Symptoms: Identifies the subjective and objective data that signal the existence of a problem.

    Planning Phase

    • Purpose: The nurse works with the client and family to prioritize problems, formulate goals, select evidence-based interventions, and write nursing orders.
    • Elements:
      • Initial: Developed by the nurse who performs the initial nursing history and physical examination.
      • Ongoing: Carried out by any nurse interacting with the client to keep the plan up-to-date.
      • Discharge: Information or teaching needed before discharge. Planning begins when a client is admitted.

    Goals

    • Short-Term: Achieved within a few hours or days.
    • Long-Term: Achieved over a longer period: weeks to months, or more.

    Categories of Outcomes

    • Cognitive: Describes an increase in client knowledge or intellectual behaviors.
    • Psychomotor: Describes a patient’s achievement of new skills.
    • Affective: Describes changes in a client’s values, beliefs, and attitudes.

    NANDA, NIC, and NOC

    • NANDA: North American Nursing Diagnosis Association.
    • NIC: Nursing Interventions Classification: Standardized classification of interventions. Describes direct or indirect care activates by nurses.
    • NOC: Nursing Outcomes Classification: Standardized system.

    Patient Safety

    • Purpose of safety measures is to improve patient outcomes by maintaining safe environments and implementing proper care practices.
    • Safety considerations include:
      • Environmental safety: keeping rooms, hallways, and walkways free of clutter and debris
      • Emergency alarms: readily accessible for prompt response
      • Medication administration safety: assessing patients before and after medication administration
    • Documentation: An investigative tool to identify the who, what, when, why, and how of an incident. It allows for analysis and corrective actions to prevent future occurrences.

    Fire Safety

    • Common causes of fires in hospitals: Malfunction of electrical equipment, damaged wires, patient or employee smoking, unsafe disposal of cigarettes, and combustion of anesthetic gasses.
    • Common cause of death in fires: Smoke inhalation
    • RACE: A fire safety protocol:
      • Rescue: Evacuate individuals in immediate danger
      • Alarm: Activate fire alarms, call the operator, or dial 911
      • Contain: Confine the fire or smoke by closing doors
      • Extinguish: Attempt to extinguish the fire
    • PASS: A guide for using a fire extinguisher:
      • Pull: Pull the pin
      • Aim: Point the nozzle at the base of the fire
      • Squeeze: Squeeze the handle
      • Sweep: Sweep the extinguishing agent from side to side

    Developmental Considerations

    • Fetus: Abnormal growth and development
    • Neonate: Infections, falls, and suffocation
    • Infant: Car seat safety, drowning, crib compliance with railings, SIDS, burns, injuries from toys, and inhaling foreign objects
    • Toddlers: Injuries such as cuts, burns, drowning, suffocation, inhaling foreign objects, window locks
    • School Age/Adolescence: Chemical security, potential for drowning, substance use, bullying, and sports injuries
    • Young Adults: Motor vehicle accidents, drugs/alcohol, drowning, workplace injuries, domestic violence and stress
    • Elderly: Home hazards, vision or hearing loss, decreased reflexes, falls, abuse, and motor vehicle accidents

    Restraints

    • Physical restraints: Devices that prevent body parts from moving freely, used for positioning support, or necessary treatment
    • Alternative restraints: Staff and environmental involvement:
      • 1:1 sitters
      • Cameras
      • Behavior management: structured activities
    • Contradictions of restraints:
      • Convenience for staff
      • Disciplining patients
    • Before applying restraints:
      • Physician approval, explore alternative methods
    • Types of restraints:
      • Belt restraints: used when sitting in a chair, prevents rising from chair, allows extremity and upper body mobility
      • Jacket/vest restraints: for bed or chair, limits rising and upper body mobility, allows extremity movement
      • Mitt restraints: prevents grasping, allows upper extremity movement
      • Wrist/Ankle restraints: limits upper and lower extremity movement

    Gait Belt

    • A safety device used to assist patients with ambulation, reducing the risk of falls for both patients and caregivers.

    Hot & Cold Therapies

    • Physiological Effects:
      • Heat:
        • Vasodilation: dilates blood vessels, increases blood flow to the area, promotes healing, reduces muscle tension
        • Increased capillary permeability: potentially causes edema
        • Sedative effect, muscle relaxation, can cause tissue damage if used for an extended time
      • Cold:
        • Vasoconstriction: constricts blood vessels, reduces blood flow to the area, reduces inflammation
        • Decreased capillary permeability: potentially causes tissue damage if used for an extended time
        • Local anesthetic effect, numbs the area, can cause tissue damage in prolonged use
    • Rebound phenomena: The opposite effect occurring after ending therapy:
      • Heat: Increased cardiac output, diaphoresis, increased pulse rate, decreased blood pressure, vasoconstriction
      • Cold: Increased blood pressure, shivering, tissue injury, vasodilation.
    • Contradictions of hot and cold therapy:
      • Conditions where heat would increase inflammation or circulation:
        • Open wounds
        • Hemorrhage
        • Presence of edema
        • Inflamed areas
        • Localized malignant tumors
        • Testes
        • Abdomen of pregnant woman
        • Over area of a metallic implant
      • Conditions where cold would decrease circulation or increase risk of injury:
        • Open wounds
        • Impaired peripheral circulation
        • Hypersensitivity to cold
    • Thermal Therapy Guidelines:
      • Tolerance: Assess patient's ability to tolerate the treatment
      • Contradictions: Evaluate contraindications for the chosen method
      • Explanation: Clearly explain the treatment to the patient
      • Assessment: Monitor the patient for any adverse reactions
      • Discomfort: Address any discomfort the patient may experience during the treatment
      • Revisit: Frequently check the areas treated
      • Remove: Be prepared to remove the treatment if necessary
      • Examine: Inspect the skin for any signs of injury

    Types of Thermal Therapy

    • Heat:
      • Dry: Hot water bags, electric heating pads, Aquathermia pads, hot packs
      • Moist: Warm moist compresses, Sitz bath, warm soaks
    • Cold:
      • Dry: Ice bags, cold packs, hypothermia blanket, glove ice pack
    • Elder considerations:
      • Lifespan
      • Sensory losses
      • Decreased reflexes
      • Reduced kidney function

    Health Assessment

    • A thorough assessment of the patient's condition and medical history is crucial for safe and effective care.

    Nursing Process

    • Focus: Client-centered care
    • Steps:
      • Assessing: Data collection
      • Diagnosing: Data analysis
      • Planning: Outcome identification and nursing interventions
      • Implementing: Carrying out the care plan
      • Evaluating: Measuring outcome achievement
    • Characteristics: Interpersonal, systematic, dynamic, multi-dimensional, knowledge-based, critical thinking, cyclical
    • Application of Critical Thinking:
      • Purpose of thinking
      • Adequacy of knowledge
      • Potential for problems
      • Helpful resources
      • Critique of judgments/decisions
    • Nurse Blended Skills:
      • Cognitive skills
      • Technical skills
      • Interpersonal skills
      • Ethical/legal skills

    Assessment Phase

    • Purpose: Establishes a client database for individualized care
    • Types:
      • Initial: Admission, establishes baseline data
      • Focused: Pre-existing condition, ongoing assessment
      • Emergency: Crisis situation
    • Data Collection: Systematic, continuous process of collecting, organizing, validating, and documenting data
    • Medical Assessment: Pathologic conditions
    • Nursing Assessment: Client's response to health problems

    Planning/Outcome Identification Phase

    • SMART Outcomes:
      • S: Specific
      • M: Measurable
      • A: Attainable
      • R: Realistic
      • T: Time-bound

    Implementation Phase

    • Nursing Actions:
      • Independent: Initiated by the nurse
      • Collaborative: Joint efforts with other healthcare professionals
      • Dependent: Physician's orders
    • Process:
      • Reassess the client
      • Determine assistance needed
      • Organize resources and care delivery
      • Implement nursing actions
      • Supervise delegated care
      • Document all activities and interventions

    Evaluation Phase

    • Purpose: Determine outcome achievement
    • Steps:
      • Review evaluative criteria and standards
      • Collect data to assess achievement
      • Summarize findings
      • Document judgment
    • Outcomes:
      • Cognitive: Increased client knowledge
      • Psychomotor: New skills acquisition
      • Affective: Changes in beliefs, values, and attitudes
      • Physiologic: Physical changes

    Quality Assurance (QA)

    • Focus: Organization-wide evaluation
    • Goal: Evaluate:
      • Structure: Physical environment, standards, policies, procedures, equipment
      • Process: Activities and performance criteria
      • Outcomes: Measurable changes in health status or end results of care
    • Methods:
      • Quality by Inspection: Identify and remove deficient workers
      • Interventions: Education, exercise, rehabilitation, support groups, health screenings

    Patient Safety

    • Mobility:
      • Risks: Falls, skin breakdown, fractures
      • Interventions: Assistive devices, fall prevention strategies, safe environment, exercise
    • Sensory-Perception Alterations:
      • Risks: Impaired senses, inability to perceive dangers
      • Interventions: Assessment, adaptations, assistive devices, clear communication
    • Cognitive Awareness:
      • Risks: Confusion, dementia, Alzheimer's, unsafe behaviors
      • Interventions: Structured environments, clear instructions, memory aids, assessments
    • Communication:
      • Risks: Language barriers, impairments
      • Interventions: Assess communication abilities, use adaptations, ensure understanding
    • Environmental Factors:
      • Risks: Poor lighting, clutter, unsafe equipment
      • Interventions: Education on safe environment, environmental assessments, recommendations for modifications
    • Asepsis:
      • Medical Asepsis: Clean technique, standard precautions, handwashing, transmission-based precautions
      • Surgical Asepsis: Sterile technique

    Side Rails

    • Pros:
      • Assist with turning and repositioning
      • Provide support for getting in and out of bed
      • Comfort and security
      • Reduce fall risk
      • Easy access to the bed
    • Cons:
      • Suffocation
      • Strangulation
      • Injury
      • Death
      • Falls

    Fall Risk

    • Preventing Hospital Injuries:
      • Nurse Role: Comprehensive assessment, risk assessment
      • Previous Safety Concerns: Injuries, falls, home hazards
        • Common Risk Characteristics:
          • History of falls
          • Gait disturbance
          • Dizziness
          • Visual impairment
          • Medication list
          • Incontinence
          • Frequency issues
      • Nurse Interventions:
        • Side rails up
        • Education for patients, family, and staff
        • Restraints
        • Fall Alert

    Patient Injury – Nursing Responsibilities

    • Assess: The situation
    • Treat: The problem
    • Notify: Physician and family
    • Stabilize: The patient
    • Complete: Injury report
    • Revise: Plan of care

    Incident Report

    • Documentation:
      • How the patient was found
      • Vital signs
      • Treatment provided
      • Patient status post-accident
    • Purpose: Investigate and learn from incidents to prevent recurrence

    Fire Safety

    • Common Causes of Fires:
      • Malfunctioning electrical equipment
      • Damaged wires
      • Smoking
      • Improper disposal of cigarettes
      • Anesthetic gas combustion
    • Common Cause of Death in Fires: Smoke inhalation
    • RACE:
      • R: Rescue
      • A: Alarm
      • C: Contain
      • E: Extinguish
    • PASS: Fire Extinguisher Operation:
      • P: Pull
      • A: Aim
      • S: Squeeze
      • S: Sweep

    Developmental Considerations

    • Fetus: Abnormal growth and development
    • Neonate: Infections, falls, suffocation
    • Infant: Car seat safety, drowning, crib safety, SIDS, burns, toy-related injuries, inhaling foreign objects
    • Toddlers: Cuts, burns, drowning, suffocation, inhaling foreign objects, window locks
    • School Age/Adolescence: Chemical safety, potential hazards, drowning, substance use, bullying, sports injuries
    • Young Adult: Motor vehicle accidents, drug/alcohol use, drowning, workplace injuries, domestic violence, stress
    • Elderly: Home hazards, vision/hearing loss, decreased reflexes, falls, abuse, motor vehicle accidents

    Restraint

    • Physical Restraints: Devices restricting movement
    • Alternative Restraints: Staff and environment involvement, structured activities
    • Contradictions:
      • Convenience of staff
      • Discipline
    • Before Applying Restraints:
      • Physician must know if alternatives have been used, emergency protocol
    • Reassessing and Reordering: Physician re-evaluates restraints every 24 hours, documentation every 2 hours, skin integrity check
    • Types of Restraints:
      • Belt: Prevents rising
      • Jacket/Vest: Minimizes upper body mobility
      • Mitt: Prevents grasping
      • Wrist/Ankle: Prevents upper/lower extremity movement

    Gait Belt

    • Used for support and ambulation

    Hot and Cold Therapies

    • Physiologic Effects:
      • Heat (Vasodilation):
        • Dilates blood vessels
        • Reduces blood viscosity
        • Increases capillary permeability
        • Promotes healing
        • Sedative effect
        • Muscle relaxation
        • Increases tissue metabolism
      • Cold (Vasoconstriction):
        • Constricts blood vessels
        • Decreases pain-producing histamine
        • Reduces edema
        • Decreases inflammation
        • Alters tissue sensitivity (numbness)
    • Rebound Phenomena:
      • Heat: Increased cardiac output, sweating, increased pulse rate, decreased blood pressure, vasoconstriction
      • Cold: Increased blood pressure, shivering, tissue injury, vasodilation
    • Contradictions:
      • Heat: Open wounds, hemorrhage, edema, inflammation, malignant tumors, testes, abdomen of pregnant women, metallic implants
      • Cold: Open wounds, impaired circulation, hypersensitivity to cold

    Guidelines for Thermal Therapies

    • Tolerance: Duration of therapy
    • Contradictions: Conditions precluding therapy
    • Explanation: Inform the patient about the therapy
    • Assessment: Monitor for adverse reactions
    • Discomfort: Manage and reduce
    • Revisit: Reassess the patient
    • Remove: Therapy if necessary
    • Examine: The patient for complications

    Thermal Therapies

    • Heat:
      • Dry:
        • Hot water bags: Fill ⅓ to ⅔ full, expel air, apply for 30 - 45 minutes
        • Electric heating pads: Warm up before use, place laterally or anterior, never under the patient, assess skin
        • Aquathermia pads: Fill with distilled water, apply for 20 - 30 minutes, secure in place
        • Hot packs: Cover with a washcloth, assess skin frequently
      • Moist:
        • Warm moist compress: Apply moist cloth, change frequently
        • Sitz bath: Soak perineum or rectal area, reduce inflammation
        • Warm soaks: Immerse body part in warm water
    • Cold:
      • Dry:
        • Ice bags: Fill ⅔ full with crushed ice, cover with a towel
        • Cold packs: Apply and assess frequently
        • Hypothermia blanket: Body temperature regulation
        • Glove ice pack: Postpartum patients
    • Elderly Patient Considerations:
      • Lifespan: Decreased physiological reserve
      • Sensory Losses: Vision, hearing, touch
      • Decreased Reflexes: Reduced response time
      • Reduced Kidney Function: May affect fluid balance and medication excretion
      • Skin Integrity: Increased risk of skin breakdown

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    Exam 2 Oulines PDF

    Description

    Test your knowledge on nursing assessments and their role in patient care. This quiz covers the differences between nursing and medical assessments, the five steps of the nursing process, and crisis situation assessments. Challenge yourself with matching types of assessments with their descriptions.

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