Exam 3 Study Guide PDF

NU226 Exam 3 Study Guide Communication  In the interest of patient safety and to ensure nursing is giving complete, accurate information to the physician, use the following acronym to communicate to the physician: S (the current Situation or problem) SB...

NU226 Exam 3 Study Guide Communication  In the interest of patient safety and to ensure nursing is giving complete, accurate information to the physician, use the following acronym to communicate to the physician: S (the current Situation or problem) SBAR B (a little about the patient’s Background) A (your Assessment of the patient) R (your Recommendation of what is needed from the physician) 4 SBAR 5 Interviewing Techniques Open- Closed Validating Clarifying ended questions questions questions questions or or or or comments comments comments comments Reflective Sequencing Directing questions questions questions or or or comments comments comments  Open-ended questions-tell me how you take your medication at home? Closed questions- Do you take aspirin daily? Validating questions –What I heard you saying was.. Interviewing Clarifying questions –Could you explain what you mean Techniques Reflective questions-Repeating back..You are worried about the surgery. Sequencing questions –when did this occur? Directing questions –need to obtain more information. You mentioned earlier… Blocks to Communication Failure to listen Using judgmental Nontherapeutic comments comments and questions Changing the subject Belittling clients concerns Giving false assurance “ don’t worry Using closed questions Using “why” and “how” Probing for information 8 Oxygenation Assessment Usual Pattern of Pain respirations or recent changes Medications Dyspnea Smoking Fatigue Respiratory Infection; Allergies cough, sputum, fever 9  Physical Assessment Inspection Auscultation Appearance Adventitious sounds Crackles – soft Work Effort high-pitched, heard on inspiration (fluid) Course-low pitched, secretions can clear with coughing Wheezes – Musical sound heard on inspiration and/or expiration 10 Hypoxia What does it mean? What are the symptoms? Likely cause? What is difference between acute and chronic hypoxia? 11 Selected Diagnostic Test Purpose Tests Chest X-ray Diagnosis Arterial blood gases Check oxygenation, (ABGs) ventilation & perfusion Complete blood count Hgb and Hct Anemia ECG Electrical activity of heart PFT (Pulmonary Assess respirator Function Studies) function; how well the lungs are working. 1 2  Test Purpose Pulse Oximetry Measure arterial Pulse oxyhemoglobin saturation (SaO2) Oxyimetry 95-100% is normal < 90% abnormal Capnography Measure ventilation and indirectly blood flow through the lungs. Exhaled air pases through a sensor that measures the amount of carbon dioxide exhaled with each breath. 1 3 Diagnostic Test: Thoracentesis Puncture the chest wall to remove pleural fluid from pleural space Signed informed consent needed Diagnostic or therapeutic Post-procedure: 1. Assess for changes in respirations 2. Hemopytsis or severe cough  report immediately 3. CXR done afterwards 14  Positioning Promoting Optimal Functionin Adequate Fluid g Nursing Intake Care for Acute Humidified Air Patient 15 Promoting Proper Breathing Prevents Respiratory Complications Deep Breathing Incentive spirometer Pursed-lip breathing COPD Diaphragmatic breathing 16 Teaching: Cough and Deep Breath Deep Breathing Effective Coughing Semi-Fowlers position Semi-Fowlers position & a splint pillow Ask patient to: Ask patient to: Inhale & exhale Exhale completely deeply slowly thru Inhale through the nose nose Take deep breath & Hold 3-5 seconds hold 3 secs. Exhale thru pursed lips Cough deeply 1-2 Repeat times Done every 2 hours while Done every 1-2 hours awake 17  Types of Cough Medications Expectorants Suppressants Facilitate removal of Used for dry, non- secretions by productive cough thinning secretions Depresses cough Guaifenesin reflex Codeine – (Robitussin) prescription Humidified air & Usually at bedtime Adequate fluid intake 18 Administering Inhaled Medications Bronchodilators: open narrowed airways Nebulizers: disperse fine particles of liquid medication into the deeper passages of the respiratory tract Meter-dose inhalers: deliver a controlled dose of medication with each compression of the canister Dry powder inhalers: breath- activated delivery of medications Metered Dose Inhalers: Common Mistakes Patients Make Failing to shake the canister Inhaling through the nose rather than mouth Inhaling too quickly Stopping inhalation when feeling the drug Failing to hold breath afterwards Inhaling two sprays with one breath 20 Providing Supplemental Oxygen 1. Normal air has 21% oxygen, this is increased with supplemental oxygen. 2. Oxygen (O2) is considered a medication Order is needed for the flow rate 3. Supplied via wall outlet or portable tank 4. Humidification Commonly used with higher flow rates 21 Supplemental Oxygen Simple Non-Rebreather Face Mask 22 Suctioning Sterile Technique To prevent hypoxia Hyper-oxygenate Limit time to 10-15 seconds (prevent hypoxia) Do NOT suction during insertion of catheter Apply intermittent suction while withdrawing catheter Procedure 39-2 To prevent atelectasis Use appropriate pressure 80-150 mmHg 23  Aging: Physiological Changes 24 Body System Examples Integumentary ↓ elasticity results in wrinkling and sagging, drier, thinning hair, fragile skin, nails become thicker and yellow Cardiopulmonary Edema lower extremities, fatty plaque deposits, clearing of secretions less efficient, respiratory rate may increase Gastrointestinal Malnutrition and anemia common, constipation ↓peristalsis, dry mouth due to decreases saliva production Muscular Skeletal ↓ muscle mass & strength, joints stiffen; less mobile; less subcutaneous tissue; bone demineralization (fractures) Neurological Responses slower to multiple stimuli; reflexes slower; less sensation in extremities; issues with balance, sleep disturbance  Physiological Changes - Sensory 25 Sensory Examples System Eyes ↓ accommodation, yellowing lens, difficulty adjusting to light, more problems with light (e.g. glare) Ears ↓ high frequency tones, cerumen (wax) build up Taste ↓ taste buds; sweet and salty Smell ↓ sense of smell  Mental Impairment in Older Adults  Dementia  Alzheimer disease  Sundowning syndrome-confusion & agitation after dark  Cascade iatrogenesis  Dementia is progressive and usually develops gradually. It involves a group of symptoms that affects mental cognitive tasks such as memory and reasoning. Dementia is an umbrella term that Alzheimer's disease can fall under  Dementia 27 Types of Dementia  Alzheimer's is most common (60-80%)  Vascular – 2nd most frequent due to multiple infarcts/strokes  Mixed dementia Age is the greatest risk factor Mild Cognitive Impairment  There is evidence of memory loss, but it does not disrupt daily life  Does not always progress to Alzheimer's dementia http://www.alz.org/documents_custom/  Treatment & Prevention 28 Treatment – none that cure Alzheimer's dementia  There are drugs to slow the progression of the disease  Donezpril (Aricept) 5 – 10 mg daily  Active management improves quality of life  Use of treatment, supportive services, coordination of care, use of adult day services, management of other health conditions Prevention – no specific interventions  Management of cardiovascular, diabetes and other health conditions may help avoid or delay Alzheimer's http://www.alz.org/documents_custom/  Cascade of Iatrogenesis 29 Stepwise Decline Example is the serial development of multiple medical complications that can be set in motion by a seemingly harmless first event..such as a fall  Assessment Tool: SPICES S – Sleep disorders P – Problems with eating or feeding I – Incontinence C – Confusion E – Evidence of falls S – Skin breakdown (Fulmer & Wallace, 2012) It provides a simple system for flagging areas in need of further assessment. SPICES is an alert system and refers to only the most frequently- occurring health problems of older adults. Significance of Detecting Delirium 31  Delirium is a reversible condition, it is temporary state of confusion  Differentiate delirium from demetia  Common reasons: medications - especially if new one, infection or dehydration  For hospitalized patients with dementia, 32% developed delirium  Stayed 4 days longer than patients without delirium  Reduced level of physical and mental activity at hospital discharge and a month later  They were more likely to die a month after discharge Medscape summary – Sept. 16 2013. D. Fick lead author  Delirium Risk Factors 32 Six Key Risk Factors 1. Cognitive Impairment 2. Sleep deprivation 3. Immobility 4. Visual Impairment 5. Hearing Impairment 6. Dehydration  Elder Maltreatment  As many as two million people older than 65 years of age suffer from abuse, neglect, or exploitation, inflicted by family members in 90% of cases (National Center on Elder Abuse, 2019).  Physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, and financial or material exploitation are all types of elder maltreatment (National Center on Elder Abuse, 2019).  Reporting in MA http://www.mass.gov/elders/service-orgs-advocates/pro tective-services-program.html  34 Torts: wrongful act Intentional Unintentional Assault = threat Negligence: Battery = actual Below the standard of care, “reasonably prudent person” contact Malpractice Defamation of Failure to carry out duty  character caused injury Invasion of privacy False imprisonment Fraud Four Elements of Liability: Malpractice Elements 1. Duty: You have an obligation to use due care. This is what a reasonable and prudent nurse would have done in the same circumstances. Defined by standard of care. 2. Breach of Duty- failure to meet the standard of care 3. Causation –need to prove that failure to meet the standard of care (breach of duty) caused harm or the injury. 4. Damages: Is the actual harm or injury that occurred to the patient Good documentation usually makes proof impossible. Legal Safeguards for Nurses: Incident Report & Risk Management Incident Report: document harm to a client, employee or visitor. Risk management: Identify these risks. Identifying high- risk patterns and initiating in-service programs to prevent future problems. Minimizing Chance of Liability Practice within legal Delegate appropriately boundaries of practice Protect clients from injury Promptly and accurately Report all incidents document all assessments Always check any order and care that is questioned Perform procedures Know own strengths and correctly and weaknesses appropriately Maintain clinical Administer the right competence medication, in the right Refusing to accept dose, via the right routes, responsibilities for which at the right time, to the you are unprepared right client Following institutional procedures and policies  Competent practice Informed consent or refusal Contracts Collective bargaining Legal Patient education Safeguards Executing physician orders for Nurses Documentation Legal Safeguards for Nurses Professional liability insurance Just culture Incident, variance, or occurrence reports Sentinel events and Never events Student liability HIPAA – Invasion of Privacy All information is confidential Reminders: Breaches Discussing information in public areas Interacting with the patient’s family in ways not authorized by the patient Using tape recorders, dictating machines, computers without taking precautions to ensure the patients confidentiality Improperly accessing information Preparing school assignments about patients without concealing their identity Social networks 40  Elements of Informed Consent Disclosure Comprehension Competence Voluntariness Purposes of Patient Records Communication Diagnostic and therapeutic orders Care planning Quality process and performance improvement Research; decision analysis Education Credentialing, regulation, and legislation Reimbursement Legal and historical documentation  43 Electronic Medical Records Uniform and standardized database Computer security reminders: ▫ Never give your personal password to anyone ▫ Don’t leave computer open & unattended Documentation Guidelines: Accountability Sign your first initial, last name, and title to each entry. Do not sign notes describing interventions not performed by you that you have no way of verifying. Do not use dittos, erasures, or correcting fluids. Draw a single line through an incorrect entry and write the words “mistaken entry” or “error in charting” above or beside the entry and sign. Then rewrite the entry correctly. Identify each page of the record with the patient’s name and identification number. Recognize that the patient record is permanent. Follow facility policy pertaining to the color of ink and the type of pen or ink to be used. Ensure that the patient record is complete before sending it to medical records. 44 Informatics The ANA defines nursing informatics (NI) as “the specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice. NI supports nurses, consumers, patients, the interprofessional health care team, and other stakeholders in their decision making in all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes, and 45 Variables Influencing Bowel Elimination Developmental considerations- older adult Daily patterns Food and fluid Activity and muscle tone Lifestyle Psychological variables Pathologic conditions Medications Diagnostic studies Surgery and anesthesia Medications  47 Bowel Elimination: FOCUSED Assessment Patient Assessment Physical Assessment Usual pattern  Sequence: inspection, auscultation, percussion to Aids for elimination palpation  Document as hypoactive, Any changes? hyperactive or inaudible Problems with bowel elimination Consider the physiologic process of bowel elimination Stool Stool Collections Collections Stool Culture Occult Blood Pinworms Promoting Timing Regular Bowel Habits Positionin Promoting g Regular Privacy Bowel Habits Nutrition Exercise  50 Prevention & Treatment of Diarrhea Prevention Treatment Follow CDC food safety guidelines Treat cause of diarrhea (look over in text) Oral Rehydration/ may need IV fluids Skin care Avoid certain foods-raw seafood & Monitor electrolytes uncooked eggs Medications ▫ Loperamide (Immodium) Hand washing ▫ Bismuth(Pepto-bismol) antimicrobial Travel precautions Constipation: Types of Enemas Cleansing ▫ Tap water ▫ Soap suds ▫ Fleets most common Retention ▫ Oil ▫ Medicated  Large volume is most cleansing  Small volume-fleets and retention Enema administration 1. Sterile technique is unnecessary. 2. Wear gloves. 3. Lubricate tip 4. Explain the procedure, positioning (left side-lying) and length of time necessary to retain the solution before defecation. 52 Bowel Diversions Opening into the abdominal wall for fecal elimination: Stoma Temporary or permanent ▫ Ileostomy: liquid fecal content from the ileum of small intestine ▫ Colostomy: formed feces from the colon 5 3  54 Stoma Color and expectations for stool production after surgery.  Remember TEACH T: Tune into the patient Nurse as E: Edit patient information A: Act on every teaching moment a C: Clarify often Teacher H: Honor the patient as a partner in the education process  Adults over age 65 Patients with limited education or low incomes Who is Non-native speakers of English at Racial or ethnic groups Greatest Recent refugees and immigrants Adults with any type of disability, Risk for difficulty or illness Health Most adults will struggle with limited health literacy at some Literacy point in their lives  Health Literacy: Ask Me 3 Campaign Ask Me 3 is a patient education program designed to promote communication between health care providers and patients in order to improve health outcomes. 1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this? 57 http://www.npsf.org/askme3/PCHC/  Three Learning Domains Cognitive: storing and recalling of new knowledge in the brain Psychomotor: learning a physical skill Affective: changing attitudes, values, and feelings  Questions You Need to Ask Before You Begin?? What is the knowledge, attitude and skills that is necessary for the patient and family to learn? Are they ready to learn? What is the persons ability to learn? What are their learning strengths? 59  Steps of the Teaching–Learning Process Assess Learning Needs and Learning Readiness Identify the Patient’s Learning Needs Develop Learning Outcomes Develop a Teaching Plan Implement Teaching Plan and Strategies Evaluate Learning  Culturally Considerate Patient Teaching Develop an understanding of the patient’s culture. Work with a multicultural team in developing educational programs. Be aware of personal assumptions, biases, and prejudices. Understand the core cultural values of the patient or group. Listen to the patient and family/caregivers. Explore customs or taboos. Understand the patient’s religious practices and determine how their beliefs influence perceptions of health and health care. Develop written materials in the patient’s preferred language. Complementary Health Approaches and Integrative Health Care Using distraction Employing humor Listening to music Using imagery Mindfulness practice Cutaneous stimulation Hypnosis Biofeedback Therapeutic touch Animal-assisted intervention Pain Assessment Scales and Indications 0–10 Numeric Rating Scale Adults and children (>9 years old) in all patient care settings who are able to use numbers to rate the intensity of their pain Pain Assessment in Advanced Dementia Scale (PAINAD) Patients whose dementia is so advanced that they cannot verbally communicate Wong–Baker FACES Pain Rating Scale Adults and children (>3 years old) in all patient care settings Critical-Care Pain Observation Tool (CPOT) Adults who are sedated and nonresponsive Pain Assessment Scales and Indications Adult Nonverbal Pain Scale (NVPS) Adults who are sedated and nonresponsive Behavioral Pain Scale (BPS) Useful with intubated, critically ill patients; measurement of bodily indicators of pain; and tolerance of intubation CRIES Instrument Neonates (ages 0–6 months) Faces Pain Scale—Revised (FPS-R) Children (4–16) in parallel with numerical self-rating scales (0–10); patients choose the depiction of a facial expression that best corresponds with their pain Administering Analgesics An analgesic drug is a pharmaceutical agent that relieves pain. Analgesics function to reduce the person’s perception of pain and to alter the person’s responses to discomfort. There are three general classes of drugs used for pain relief: Opioid analgesics (all controlled substances, e.g., morphine, codeine, oxycodone, meperidine, hydromorphone, methadone) Nonopioid analgesics (acetaminophen and nonsteroidal anti- inflammatory drugs [NSAIDs]) Adjuvant analgesics (anticonvulsants, antidepressants, multipurpose drugs) Sensory Functioning Sensory overload is excessive stimuli over which a Sensory deprivation is insufficient person feels little control; the brain is unable to quantity or quality of stimuli; may result meaningfully respond to or ignore stimuli. from decreased sensory input or Nursing Interventions monotonous, un-patterned, and unmeaningful input. Provide a consistent, predictable pattern of stimulation to help the patient develop a sense of Nursing Interventions control over the environment. Maintain sufficient level of arousal by Offer simple explanations before procedures, tests, increasing sensory stimuli from all and examinations. sensory modalities: Establish a schedule with the patient for routine Instruct the patient in self-stimulation care such as eating, bathing, turning, positioning, methods: counting, singing, reading, coughing, and exercising. reciting poetry. Speak calmly with the patient and move slowly; Structure meaningful tangible stimuli communicate confidence. into the patient’s external environment; include a variety of Explore with the patient what stimuli are most people, ideas, sensations; a pet may distressing and develop a plan to reduce or provide excellent stimulation. eliminate them (e.g., incoming phone calls, visitors); earplugs or pain medication may be indicated. Noise-reducing headphones may be helpful. Be careful not to cause sensory deprivation. Identify and, wherever possible, eliminate culturally