NCM 103 Reviewer Midterms Exam PDF

NCM 103 – REVIEWER MIDTERMS EXAM Nursing as a Science: Definition and Characteristics Nursing as a science refers to a body of knowledge gained through scientific research and logical analysis. It emphasizes systematic approaches to understanding and addressing human health and well-being. Accordi...

NCM 103 – REVIEWER MIDTERMS EXAM Nursing as a Science: Definition and Characteristics Nursing as a science refers to a body of knowledge gained through scientific research and logical analysis. It emphasizes systematic approaches to understanding and addressing human health and well-being. According to the American Nurses Association (2015), it involves the diagnosis and treatment of human responses to actual or potential health problems. This definition highlights that nursing combines scientific knowledge with evidence-based practice to provide optimal care. Key Characteristics: 1. Abstract Knowledge: o Nursing is rooted in concepts, theories, and research findings. For instance, theories like Florence Nightingale’s Environmental Theory guide nurses in creating healthy environments for patients. 2. Systematic Knowledge and Skills: o Nurses use a structured process (e.g., the Nursing Process) to assist individuals in achieving health. For example, a nurse systematically assesses a patient with diabetes to address their dietary needs. 3. Evidence-Based Practice: o Nurses integrate research findings into care. For example, using evidence that certain wound dressings heal faster, they apply this to improve outcomes. 4. Blending Knowledge with Practice Standards: o Nursing combines the latest research with ethical and practice guidelines. For instance, nurses follow ANA’s standards of practice while incorporating the latest pain management techniques. The 5 Constructs of Nursing as a Science 1. Knowledge: o A collection of theoretical and practical insights. o Example: Understanding pharmacology helps nurses administer medications safely. 2. Critical Thinking: o Objective analysis and evaluation of a situation. o Example: When a patient presents with chest pain, critical thinking helps determine if it is cardiac-related or caused by anxiety. 1 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM 3. Nursing Process: o A systematic framework to solve problems and deliver care. o Example: A nurse uses the process to identify and address a patient’s post- operative pain. 4. Skills: o Practical abilities like administering IVs, dressing wounds, and performing CPR. 5. Research and Evidence-Based Practice: o Using the best available evidence to make decisions. o Example: Research supports the use of early ambulation to prevent post- surgical complications like blood clots. Nursing Process as a Scientific Framework The nursing process is central to nursing as a science, mirroring the scientific method: Scientific Method Nursing Process Ask a question Assessment Identify a problem Diagnosis Test a hypothesis Planning Experiment Implementation Analyze and conclude Evaluation Steps in the Nursing Process: 1. Assessment: o Collect data systematically about the patient’s condition. o Example: A nurse records a patient’s vital signs and notes that they have a fever and rapid heart rate. 2. Diagnosis: o Identify the problem based on data. o Example: For a patient with a fever, the diagnosis might be “Risk for Infection.” 3. Planning: 2 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM o Set goals and outline interventions. o Example: Plan to administer antibiotics and monitor for signs of infection. 4. Implementation: o Carry out the interventions. o Example: Administer medications and document the patient’s response. 5. Evaluation: o Determine if goals were met. o Example: If the fever resolves, the care plan is effective; if not, revise it. Importance of the Nursing Process 1. Individualized Care: o Each patient’s unique needs are addressed. o Example: Three cancer patients may have different concerns (e.g., pain, fear of death, hair loss), requiring tailored interventions. 2. Patient Involvement: o Encourages collaboration with patients in their care. o Example: A diabetic patient is involved in planning their diet. 3. Continuity of Care: o Facilitates communication among healthcare team members. o Example: A nurse communicates a patient’s wound care plan to the next shift. 4. Accountability: o Provides a framework for nurses to document and justify their actions. Nursing as an Art, Science, and Profession Art: Involves empathy, compassion, and interpersonal skills. Science: Relies on evidence-based methods. Profession: Adheres to ethical standards and lifelong learning. 3 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM Nursing Diagnoses A nursing diagnosis identifies patient problems that nurses can address independently. These are distinct from medical diagnoses, which focus on diseases. Types of Nursing Diagnoses: 1. Actual Diagnosis: o Problem exists; supported by signs and symptoms. o Example: "Impaired Skin Integrity related to immobility as evidenced by pressure ulcers." 2. Risk Diagnosis: o Problem may develop due to risk factors. o Example: "Risk for Falls related to muscle weakness." 3. Syndrome Diagnosis: o A cluster of related problems. o Example: "Post-Trauma Syndrome related to abuse." Developing Nursing Care Plans Care plans are blueprints for patient care, guiding nurses to set priorities and select appropriate interventions. Steps: 1. Set Priorities: o Example: Address life-threatening issues (e.g., airway obstruction) before non-critical issues (e.g., fatigue). 2. Establish Goals: o Goals should be SMART: Specific, Measurable, Achievable, Relevant, Time-bound. o Example: “The patient will walk 10 meters with assistance by the end of the week.” 3. Select Interventions: o Choose actions based on the diagnosis. o Example: For “Risk for Infection,” interventions include hand hygiene and sterile dressing changes. 4 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM Nursing Interventions Nurses perform three types of interventions: 1. Independent: o Actions initiated by nurses. o Example: Educating patients about medication. 2. Dependent: o Actions requiring physician orders. o Example: Administering prescribed medications. 3. Collaborative: o Actions involving the healthcare team. o Example: Coordinating with a dietitian for a patient’s nutrition plan. IMPLEMENTING AND EVALUATING THE NURSING PROCESS The nursing process is a systematic, patient-centered, goal-oriented method for providing effective nursing care. It consists of five phases: Assessing, Diagnosing, Planning, Implementing, and Evaluating. Here, we'll dive into the Implementing and Evaluating phases, detailing their components, key ideas, and practical applications. IMPLEMENTING Definition and Purpose The Implementing phase is the fourth step of the nursing process. It involves action- oriented, client-centered, and outcome-directed activities where the nurse carries out the interventions listed in the care plan. These activities are documented along with the client's responses. Action-Oriented: Nurses take deliberate actions to achieve goals. Client-Centered: Care focuses on the unique needs of the individual. Outcome-Directed: The goal is to achieve the planned outcomes. According to NIC (Nursing Interventions Classification), implementation involves both performing nursing actions and documenting the care and client responses. 5 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM How Implementing Relates to Other Phases 1. Assessing, Diagnosing, and Planning provide the foundation for implementation. 2. Interventions are based on data collected and goals set in earlier phases. 3. Implementation is followed by the Evaluating phase, where results are analyzed to assess the effectiveness of interventions. Standards of Implementation for Registered Nurses Nurses adhere to three key standards during implementation: 1. Coordination of Care: Ensuring smooth communication and collaboration among healthcare providers. 2. Health Teaching and Promotion: Educating the client and family about managing health conditions. 3. Consultation: Seeking expertise when needed to enhance care. Requirements for Successful Implementation To carry out nursing interventions effectively, nurses need three key skills: 1. Cognitive Skills Definition: Intellectual abilities such as problem-solving, decision-making, critical thinking, and creativity. Examples: o Critical thinking: Determining whether to adjust a patient's oxygen level based on their respiratory status. o Problem-solving: Modifying an intervention if a patient experiences side effects. Importance: These skills ensure safe, evidence-based, and intelligent care. 2. Interpersonal Skills Definition: Verbal and non-verbal communication techniques that foster therapeutic relationships. Examples: 6 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM o Using therapeutic communication to explain a procedure and address client concerns. o Advocating for a client’s cultural preferences during care. Importance: Builds trust, ensures understanding, and promotes collaboration. 3. Technical Skills Definition: Purposeful, hands-on skills that involve physical tasks requiring precision. Examples: o Administering an injection. o Changing a sterile dressing while maintaining infection control. Importance: Ensures interventions are carried out safely and effectively. 5 Key Activities of the Implementing Phase 1. Reassessing the Client Even if a nursing intervention is planned, the nurse must reassess the client’s condition to ensure the intervention is still appropriate. Example: If a client scheduled for a back massage is found sleeping, the nurse may defer the intervention to avoid disrupting the patient. 2. Determining the Nurse’s Need for Assistance The nurse may need help when: Safety is a concern (e.g., lifting a heavy client to prevent injury). Complex skills are required (e.g., assisting during a surgical dressing change). 3. Implementing Nursing Interventions Steps: o Base interventions on scientific knowledge (evidence-based practice). o Understand the purpose of each intervention. o Adapt interventions to meet individual needs. o Provide safe care. Example: Administering the correct dose of insulin and monitoring for potential side effects like hypoglycemia. 4. Supervising Delegated Care 7 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM If tasks are delegated to other healthcare providers, the nurse must ensure: Activities align with the care plan. Client responses are monitored. 5. Documenting Nursing Activities All actions and client responses must be recorded immediately after completion. Key Rule: Never document in advance. Guidelines for Implementing Nursing Interventions 1. Provide Teaching, Support, and Comfort: Explain procedures and expected outcomes to clients. 2. Be Holistic: Consider physical, emotional, and social aspects of the client. 3. Respect Dignity: Maintain privacy and involve clients in decision-making. 4. Encourage Participation: Allow clients to take an active role in their care. EVALUATING Definition and Purpose The Evaluating phase is the fifth and final step of the nursing process. It involves judging the effectiveness of nursing care by comparing actual outcomes with expected outcomes. Planned and Ongoing: Evaluation happens throughout care. Purposeful: Determines whether the care plan should continue, be modified, or be terminated. Relationship to Other Phases Evaluation relies on accurate assessment data and clear, measurable outcomes. Without proper implementation, there’s nothing to evaluate. Components of the Evaluation Process 1. Collect Data Related to Desired Outcomes o Example: If the goal was to reduce pain, assess the client's pain score after administering medication. 8 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM 2. Compare Data with Outcomes o Compare actual results (e.g., pain reduced to 3/10) with the goal (e.g., pain below 4/10). 3. Relate Nursing Activities to Outcomes o Identify if interventions contributed to achieving the goals. 4. Draw Conclusions o Determine whether the problem has been resolved or requires further action. 5. Decide on the Care Plan o Continue: If goals are being met, maintain current interventions. o Modify: Adjust interventions if progress is slow. o Terminate: Stop the plan if goals are fully achieved. Example: Evaluating a Care Plan A client with ineffective airway clearance was given interventions like chest physiotherapy and deep breathing exercises. If after evaluation the client’s lung sounds improve and oxygen saturation rises, the care plan may be continued or modified for maintenance. Reviewing and Modifying the Care Plan 1. Assessment: Ensure data is accurate and complete. 2. Diagnosis: Reevaluate the relevance of nursing diagnoses. 3. Planning: Revise unrealistic or outdated goals. 4. Implementation: Investigate if interventions were performed correctly. Comprehensive Explanation: Basic Safety Nursing Procedure PART 1: SAFETY Patient safety is a core principle in healthcare because unsafe medical practices can lead to injuries, harm, or death (morbidity and mortality). Errors in healthcare, though 9 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM often preventable, occur globally, making it critical for healthcare workers, especially nurses, to prioritize safety. 1. IMPORTANCE OF PATIENT SAFETY Patient Safety Culture: A system of values and behaviors in healthcare that emphasizes preventing errors and harm. Nurses’ Role: As the largest group of healthcare workers, nurses must lead initiatives to improve safety practices. FACTORS AFFECTING ABILITY TO PROTECT FROM INJURY Several factors determine a person's vulnerability to injury. Below are examples and situations for each: 1. Age and Development: o Example: Infants are prone to choking on small toys, while older adults may fall due to weakened balance. o Nursing Action: Provide age-appropriate interventions like childproofing homes or installing grab bars. 2. Lifestyle: o Example: Athletes are at risk for sports injuries, and individuals with sedentary lifestyles may develop chronic illnesses. o Nursing Action: Educate on lifestyle modifications, such as using protective gear or engaging in physical activity. 3. Mobility and Health Status: o Example: Bedridden patients are prone to pressure ulcers and falls. o Nursing Action: Regular repositioning and providing anti-slip footwear. 4. Sensory-Perceptual Alterations: o Example: Vision impairment increases the risk of falls. o Nursing Action: Ensure adequate lighting and remove tripping hazards. 5. Cognitive Awareness: o Example: Patients with dementia may wander and injure themselves. o Nursing Action: Use monitoring systems or safe room setups. 6. Emotional State: 10 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM o Example: A highly anxious patient might not follow safety instructions. o Nursing Action: Provide emotional support and clear guidance. 7. Ability to Communicate: o Example: A patient who cannot speak due to intubation may struggle to express discomfort. o Nursing Action: Use visual communication tools. 8. Safety Awareness: o Example: Children may not understand the danger of sharp objects. o Nursing Action: Teach safety habits appropriate to the patient's developmental stage. 9. Environmental Factors: o Example: Hospitals with slippery floors or exposed wires pose hazards. o Nursing Action: Conduct regular safety checks. ASSESSING CLIENTS AT RISK FOR INJURY 1. Nursing History and Physical Examination: o Collect data about previous injuries, chronic illnesses, and environmental factors. o Example: Ask if a patient has fallen before or has limited mobility. 2. Risk Assessment Tools: o Tools like the Morse Fall Scale assess fall risk. o Example: A high score indicates the need for closer monitoring. 3. Home Environment Assessment: o Evaluate hazards in the patient’s living space. o Example: Check for loose rugs or poorly lit stairs. NATIONAL PATIENT SAFETY GOALS (NPSGs) Developed internationally, these goals guide healthcare professionals in ensuring safety: 1. Improve Patient Identification: o Use at least two identifiers (e.g., name and birthdate). 11 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM o Example: Misidentifying patients can lead to medication errors. 2. Enhance Communication Among Caregivers: o Share critical updates through handovers or written reports. o Example: Prevent miscommunication during shift changes. 3. Medication Safety: o Label medications correctly and avoid mix-ups. o Example: Administering the wrong drug can have fatal consequences. 4. Reduce Clinical Alarm Risks: o Ensure alarms function correctly to prevent delays in emergencies. 5. Prevent Healthcare-Associated Infections (HAIs): o Practice hand hygiene and sterilize equipment. o Example: Use gloves and masks to reduce infection spread. 6. Prevent Patient Falls: o Educate on fall prevention, especially for older adults. 7. Prevent Pressure Ulcers: o Regularly reposition bedridden patients and use supportive devices. 8. Identify Safety Risks: o Address risks like suicidal tendencies or self-harm in patients. 9. Universal Protocol for Surgery: o Verify correct site, procedure, and patient identity before surgery. o Example: Prevent performing surgery on the wrong limb. SAFETY PROGRAM FRAMEWORK IN THE PHILIPPINES In the Philippines, the Department of Health (DOH) emphasizes the collaboration of various stakeholders: 1. Leadership: Ensures patient safety policies are implemented. 2. Institutional Development: Provides adequate infrastructure. 3. Feedback and Communication: Encourages patients and staff to report issues. 4. Patient Empowerment: Enables patients to voice safety concerns. 12 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM 5. Risk Management and Adverse Events Reporting: Identifies and addresses hazards. COMMON HAZARDS BY AGE GROUP Newborns and Infants: Hazards: Choking, suffocation, falls, burns. Example: A baby left unattended can fall from a bed. Nursing Action: Advise caregivers to never leave babies unsupervised. Toddlers: Hazards: Drowning, poisoning, and burns. Example: A toddler might ingest cleaning supplies. Nursing Action: Encourage childproofing and educate on poison control. Preschoolers: Hazards: Playground injuries, choking, and fire. Example: A preschooler might play with matches. Nursing Action: Teach fire safety and provide safe toys. Adolescents: Hazards: Substance abuse, reckless driving. Example: A teenager under peer pressure may experiment with drugs. Nursing Action: Provide health education on the risks of substance abuse. Older Adults: Hazards: Falls, burns, and vehicle accidents. Example: An older adult might trip on uneven flooring. Nursing Action: Install grab bars and ensure proper lighting. NURSING DIAGNOSES AND INTERVENTIONS FOR SAFETY Diagnoses: 1. Risk for Injury 2. Risk for Trauma 13 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM 3. Risk for Poisoning Interventions: Educate clients and families about environmental hazards. Reduce fall risks by lowering bed heights and providing assistive devices. Teach safety practices, like fire evacuation plans and poison control measures. PREVENTING COMMON HAZARDS Thermal Injuries: Keep hot liquids out of children’s reach. Monitor the temperature of therapeutic hot or cold compresses. Falls: Orient patients to surroundings. Ensure non-slip mats and footwear are available. Poisoning: Store toxic substances like cleaning agents out of children’s reach. Provide emergency contact numbers for poison centers. Seizures: Pad bed rails and have suction equipment ready. Avoid activities like swimming or driving for patients with uncontrolled seizures. Electrical Hazards: Use grounded electrical equipment and non-conductive gloves. Comprehensive Explanation: BASIC SAFETY NURSING PROCEDURES (Part 2) DESIRED OUTCOMES FOR INJURY PREVENTION The nurse's primary role in injury prevention is educative, which means guiding patients, families, and communities to prevent injuries and promote safety. Desired Outcomes: 1. Acquisition of Knowledge of Hazards 14 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM o Patients or caregivers must identify potential risks like slippery floors, sharp objects, or electrical hazards. o Example: Educating elderly clients about fall risks due to poor lighting or uneven surfaces. 2. Behaviors That Incorporate Safety Practices o Ensuring individuals develop habits like using seatbelts, wearing helmets, or following safety protocols at work. o Example: A child’s caregiver learns the importance of childproofing the house by covering sharp corners. 3. Skills to Perform in Emergencies o Training individuals to respond effectively to emergencies like fires or poisoning. o Example: Teaching CPR or the Heimlich maneuver to parents. Examples of Desired Outcomes: 1. Describe Methods to Prevent Specific Hazards o Example: A nurse explains to a construction worker how to wear proper protective gear to prevent injuries. 2. Report Use of Home Safety Measures o Example: A caregiver describes how they installed anti-slip mats in the bathroom to reduce fall risks for an elderly family member. 3. Alter Home Physical Environment to Reduce Risk of Injury o Example: Removing loose rugs, organizing cables, and installing grab bars in bathrooms. 4. Describe Emergency Procedures for Poisoning and Fire o Example: Teaching parents to keep chemicals out of children's reach and explaining fire escape plans. 5. Describe Age-Specific, Work, or Community Safety Risks o Example: A nurse discusses how toddlers are prone to choking hazards, while factory workers face risks from heavy machinery. 6. Demonstrate Correct Use of Child Safety Seats o Example: Training a mother to install a rear-facing car seat properly for her infant. 15 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM 7. Demonstrate Correct Administration of CPR o Example: Conducting a CPR training session in the community to teach individuals how to respond to cardiac arrests. ASEPSIS: Medical vs. Surgical Medical Asepsis (Clean Technique) Definition: Practices to confine microorganisms to specific areas and reduce their growth or transmission. Goal: Minimize the number of pathogens. Clean vs. Dirty: Objects are either clean (free of most microorganisms) or dirty (contaminated). Examples: o Washing hands before meals. o Wearing gloves when handling soiled linen. Surgical Asepsis (Sterile Technique) Definition: Practices to eliminate all microorganisms, including spores, from an area or object. Goal: Prevent contamination during invasive procedures. Examples: o Using sterile gloves and instruments during surgery. o Sterilizing a wound dressing tray. TYPES OF INFECTIONS 1. Local Infection o Limited to one body part or organ. o Example: A wound infection causing redness and swelling. 2. Systemic Infection o Spreads throughout the body, often through the bloodstream. o Example: Sepsis due to untreated pneumonia. 3. Bacteremia 16 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM o Bacteria are present in the blood. o Example: Bacteria entering the bloodstream during a catheter insertion. 4. Septicemia o Severe systemic infection due to bacteremia. o Example: Septic shock from untreated urinary tract infection (UTI). 5. Acute Infections o Sudden onset, short duration. o Example: Common cold. 6. Chronic Infections o Develop slowly and persist over time. o Example: Tuberculosis or hepatitis B. RISKS FOR NOSOCOMIAL INFECTIONS Nosocomial infections originate in healthcare facilities, often due to: 1. Diagnostic or Therapeutic Procedures: o Example: Iatrogenic infections from non-sterilized equipment during surgery. 2. Compromised Host: o Patients with weakened immune systems, such as those with diabetes or undergoing chemotherapy. 3. Insufficient Hand Hygiene: o Healthcare workers or visitors failing to wash hands before patient contact. ETIOLOGIC AGENT Key Terms: 1. Pathogenicity: Ability of a microorganism to cause disease. 2. True Pathogen: Causes disease in healthy individuals. o Example: Mycobacterium tuberculosis. 3. Opportunistic Pathogen: Affects only susceptible individuals. 17 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM o Example: Candida in immunocompromised patients. CHAIN OF INFECTION Breaking any of these links reduces infection risk: 1. Etiologic Agent (Cause): o Proper disinfection of instruments. 2. Reservoir (Source): o Cleaning damp linens, maintaining hygiene. 3. Portal of Exit: o Proper cough etiquette. 4. Transmission Method: o Using gloves and masks. 5. Portal of Entry: o Sterile technique during invasive procedures. 6. Susceptible Host: o Ensuring proper nutrition and immunizations. MODES OF TRANSMISSION 1. Direct Contact: o Skin-to-skin or mucous membrane contact. o Example: Touching an infected wound. 2. Indirect Contact: o Vehicle-Borne: Through inanimate objects like utensils. o Vector-Borne: Through animals like mosquitoes (e.g., malaria). 3. Airborne Transmission: o Microorganisms in droplets remain suspended in air. o Example: Tuberculosis. 18 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM DEFENSE MECHANISMS 1. Anatomic Barriers: Intact skin and mucous membranes. 2. Physiological Barriers: o Stomach acid, vaginal pH, tears, and saliva. o Example: Stomach acidity killing ingested bacteria. SPECIFIC DEFENSES: IMMUNITY 1. Active Immunity: o Natural Active: Antibodies from infection (e.g., chickenpox). o Artificial Active: Vaccination (e.g., flu shot). 2. Passive Immunity: o Natural Passive: Maternal antibodies via placenta or breastfeeding. o Artificial Passive: Antibodies from another source (e.g., antivenom). NURSING PROCESS: INFECTION CONTROL 1. Assessment: Observe for redness, swelling, fever, or elevated WBCs. 2. Diagnosis: Risk for infection or complications like fever. 3. Planning: Prevent infection spread through education and hygiene practices. 4. Implementation: o Proper hand hygiene. o Sterile technique for dressings. 5. Evaluation: Monitor patient outcomes, like reduced infection signs. Promoting Healthy Physiologic Responses A. Components in Assessing Physiologic Health To effectively assess a patient's physiologic health, nurses must consider several key components. These include: 1. Vital Signs: These are fundamental measurements that provide a snapshot of a patient's immediate health status. They include: 19 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM o Temperature: Measures the body's core temperature. o Pulse: Assesses the heart rate and rhythm. o Respiration: Measures the rate, depth, and rhythm of breathing. o Blood Pressure: Measures the force of blood against arterial walls. 2. Physical Assessment: A systematic examination of the body, including: o General Appearance: Overall impression of the patient's health. o Skin: Color, temperature, texture, and any lesions or wounds. o Head and Neck: Hair, scalp, eyes, ears, nose, mouth, and neck. o Chest and Lungs: Respiratory rate, breath sounds, and chest excursion. o Cardiovascular System: Heart sounds, peripheral pulses, and blood pressure. o Abdomen: Bowel sounds, tenderness, and distention. o Musculoskeletal System: Muscle strength, joint range of motion, and bone integrity. o Neurological System: Level of consciousness, motor function, sensory perception, and reflexes. B. Factors Influencing Physiologic Health Several factors can influence a patient's physiologic health, including: Age: As we age, our bodies undergo changes that can affect our physical health. Genetics: Genetic predispositions can increase the risk of certain health conditions. Lifestyle: Factors like diet, exercise, and substance use can significantly impact health. Environmental Factors: Exposure to pollutants, toxins, and extreme temperatures can affect health. Psychological Factors: Stress, anxiety, and depression can have physical manifestations. Socioeconomic Factors: Access to healthcare, education, and healthy food can influence health outcomes. C. Essential Components in Assessing Physiologic Health Conditions When assessing a patient with a specific physiologic health condition, nurses must consider the following: 20 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM History Taking: Gathering information about the patient's medical history, current symptoms, and any recent changes in health. Physical Examination: Conducting a thorough physical assessment to identify any physical signs and symptoms. Diagnostic Tests: Ordering and interpreting laboratory tests, imaging studies, and other diagnostic procedures. Patient's Perception of Illness: Understanding the patient's understanding of their condition and how it affects their daily life. D. Nursing Diagnoses and Outcome Criteria Nursing diagnoses are clinical judgments about a patient's actual or potential health problems. For patients with physiologic health problems, common nursing diagnoses include: Impaired Skin Integrity: Related to immobility, incontinence, or malnutrition. Ineffective Breathing Pattern: Related to pulmonary disease, pain, or anxiety. Risk for Impaired Skin Integrity: Related to decreased tissue perfusion or nutritional deficits. Impaired Physical Mobility: Related to injury, surgery, or chronic illness. Acute Pain: Related to tissue injury, surgery, or inflammation. Outcome criteria are specific, measurable goals that are developed in collaboration with the patient. For example, an outcome criterion for a patient with Impaired Skin Integrity might be: "Patient will maintain intact skin integrity, free from pressure ulcers, by [date]." E. Nursing Interventions to Promote and Maintain Physiologic Health Nursing interventions are specific actions taken by nurses to address a patient's health needs. The interventions listed in the prompt are essential for promoting healthy physiologic responses: 1. Hygiene: o Assisting with bathing, oral care, and perineal care. o Teaching proper hygiene techniques to prevent infection. 2. Skin Integrity: o Turning and repositioning the patient to prevent pressure ulcers. o Applying moisture barriers to protect the skin. o Inspecting the skin regularly for signs of breakdown. 3. Mobility/Activity: 21 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM o Assisting with ambulation and range-of-motion exercises. o Encouraging regular physical activity. o Using assistive devices as needed. 4. Rest and Sleep: o Creating a restful environment. o Administering sleep medications as prescribed. o Educating patients on sleep hygiene practices. 5. Comfort and Pain Management: o Administering pain medication as prescribed. o Using non-pharmacological pain relief techniques, such as relaxation and distraction. o Assessing pain regularly and adjusting interventions as needed. 6. Nutrition: o Assisting with feeding and monitoring nutritional intake. o Providing a balanced diet. o Educating patients on healthy eating habits. 7. Urinary Elimination: o Assisting with toileting and using urinary catheters as needed. o Promoting fluid intake. o Teaching bladder retraining techniques. 8. Bowel Elimination: o Promoting dietary fiber intake. o Encouraging fluid intake. o Administering laxatives or enemas as prescribed. 9. Oxygenation and Perfusion: o Administering supplemental oxygen as needed. o Positioning the patient to optimize lung expansion. o Encouraging deep breathing and coughing exercises. 10. Fluid, Electrolyte Imbalance: 22 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM Monitoring intake and output. Administering intravenous fluids as prescribed. Educating patients on fluid intake needs. By effectively implementing these nursing interventions, nurses can help patients maintain optimal physiologic health and prevent complications. PROMOTING PSYCHOSOCIAL HEALTH Sensory Perception Definition: Sensory perception is the process through which the body receives and interprets stimuli. These stimuli can be: External: Related to the five senses—sight, hearing, smell, touch, and taste. Internal: Associated with kinesthetic (awareness of body movement and position) or visceral (internal organ sensations, like stomach pain). Factors Affecting Sensory Perception: 1. Developmental Stage: o A child’s sensory system is still developing (e.g., newborns have limited vision but sensitive hearing). o Aging adults may experience vision loss (presbyopia) or hearing impairment (presbycusis). 2. Culture: o Cultural practices can influence sensory responses. For instance, some cultures emphasize touch as a form of communication, while others avoid it. 3. Level of Stress: o Stress can impair perception by causing distraction (e.g., inability to focus during extreme anxiety). 4. Medications and Illness: o Drugs like sedatives can dull sensory input, while illnesses such as diabetes can cause neuropathy, leading to reduced sensation. 5. Lifestyle and Personality: o A sedentary lifestyle can limit exposure to diverse sensory inputs, whereas an active lifestyle stimulates perception. 23 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM Sensory Alterations 1. Sensory Deprivation: A condition where meaningful stimuli are reduced or absent. o Example: A patient in an isolation room with no visitors may feel disconnected. o Clinical Manifestations: ▪ Yawning, sleeping excessively, confusion, hallucinations, or depression. o Situation: A bedridden elderly patient becomes confused and irritable because they lack social interaction or engaging stimuli. 2. Sensory Overload: A condition where too many stimuli overwhelm a person, making it hard to process. o Example: A patient in an ICU surrounded by beeping monitors and frequent interruptions may feel restless. o Clinical Manifestations: ▪ Anxiety, fatigue, irritability, scattered attention, and sleeplessness. o Situation: A postpartum mother in a noisy ward complains of being unable to rest or concentrate. Nursing Management for Sensory Perception Assessing: Gather the patient's history (e.g., vision/hearing changes). Conduct a mental status exam to check for confusion or altered perception. Assess the physical environment for risk factors like clutter (increases falls risk). Diagnosing: Example: Impaired Home Maintenance related to declining vision or Risk for Skin Impairment due to reduced tactile sensation. Planning Goals: Prevent injury (e.g., using bed rails for fall-prone patients). Encourage independence (e.g., arranging self-care items within reach). Reduce sensory overload or deprivation. 24 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM Interventions: 1. For Vision Impairment: o Keep pathways clear and inform the patient before rearranging furniture. o Place the bed in a low position to prevent falls. o Example: Provide a talking clock for a visually impaired patient. 2. For Hearing Impairment: o Gain attention before speaking and use visual aids when needed. o Example: Write instructions for a patient who relies on written communication. 3. For a Confused Client: o Reorient the patient to time and place regularly. o Minimize unnecessary stimuli (e.g., turn off the TV during conversations). Evaluation: Use tools like the Mini-Mental State Exam (MMSE) to track improvement in cognitive orientation. Check if the patient demonstrates behaviors like using hearing aids effectively or adapting to visual deficits. SELF-CONCEPT Definition: Self-concept is how a person perceives themselves, influencing behavior, choices, and interactions. Components: 1. Personal Identity: How one views their unique traits and roles. o Example: A mother identifies as a caregiver and nurturer. 2. Body Image: How one perceives their physical appearance and function. o Example: A patient post-amputation may struggle with their body image. 3. Role Performance: o Role Mastery: Successfully meeting expectations (e.g., excelling as a nurse). 25 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM o Role Conflict: When roles clash (e.g., balancing being a student and caregiver). 4. Self-Esteem: The sense of worth and value. Nursing Management: Ask open-ended questions like: o “What do you like most about yourself?” o “How do you feel about your current role as a patient?” Interventions focus on enhancing body image, boosting self-esteem, and reducing role strain. SEXUALITY Definition: Sexuality is a fundamental part of human identity, encompassing sexual orientation, body image, and gender identity. Components of Sexual Health: 1. Sexual Self-Concept: Confidence and comfort with one's sexuality. 2. Gender Identity: How one identifies (e.g., male, female, transgender). 3. Body Image: How physical appearance affects sexual expression. Nursing Management: Conduct sexual health assessments for patients receiving care for pregnancy, infertility, or STIs. Address misconceptions about contraception and STIs. Example: Educate a young couple about safe sexual practices and reproductive health. SPIRITUALITY Definition: Spirituality involves seeking meaning, hope, and peace, while religion refers to organized practices and beliefs. Key Practices: Prayer, sacred texts, rituals, and dietary restrictions. 26 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM Example: A Muslim patient may request prayer time and dietary accommodations during Ramadan. Nursing Interventions: Use the FICA Assessment: o Faith: “What spiritual beliefs are important to you?” o Impact: “How do your beliefs affect your coping?” o Community: “Do you meet with others who share your faith?” o Address: “How can we support your spirituality?” STRESS AND COPING Definition: Stress occurs when demands exceed an individual’s resources, leading to emotional or physical strain. Stressors: Life events like illness, job loss, or exams. Nursing Management: Teach stress-reduction techniques (e.g., deep breathing, yoga). Address ineffective coping strategies, like withdrawal or aggression. Example: Help a caregiver manage stress by organizing respite care and encouraging support group participation. LOSS, GRIEVING, AND DEATH Definitions: Grief: The emotional response to loss. Bereavement: The subjective experience of loss. Mourning: The process of adjusting to loss through rituals (e.g., funerals). Nursing Interventions: 1. Provide emotional support by using silence and active listening. 2. Educate families about hospice care for terminally ill patients to ensure comfort and dignity. 3. Example: Acknowledge a grieving mother’s feelings and provide resources for grief counseling. 27 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM Nursing as a Science Nursing is considered a science because it is based on a systematic body of knowledge and evidence. It integrates principles from biology, psychology, and social sciences to care for individuals across the lifespan. Problem-Solving Process This is a logical approach to identifying and solving problems. It involves the following steps: 1. Identify the Problem - Assess the situation to determine the issue (e.g., a patient has difficulty breathing). 2. Gather Information - Collect data (vital signs, medical history, patient interviews). 3. Generate Possible Solutions - Brainstorm interventions (e.g., administer oxygen or position the patient upright). 4. Select the Best Solution - Choose the most effective and feasible option (e.g., initiate oxygen therapy). 5. Implement the Solution - Carry out the chosen intervention. 6. Evaluate the Outcome - Monitor results and reassess the patient to determine if the intervention worked. Example: A patient reports severe abdominal pain. The nurse assesses the pain’s characteristics, suspects appendicitis, and notifies the doctor promptly. Nursing Process The nursing process is a structured framework for delivering quality care. It consists of five steps: 1. Assessment - Gather data through observation, interviews, and physical exams. o Example: Collecting blood pressure readings for a hypertensive patient. 2. Diagnosis - Use NANDA guidelines to identify actual or potential problems. o Example: "Impaired Gas Exchange related to fluid in the lungs as evidenced by low oxygen saturation." 3. Planning - Set SMART goals (Specific, Measurable, Achievable, Relevant, Time- bound). o Example: "Patient will achieve an oxygen saturation of 95% within 1 hour." 28 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM 4. Implementation - Carry out nursing interventions. o Example: Administer prescribed nebulization treatment. 5. Evaluation - Determine if goals were met. o Example: Rechecking oxygen saturation to confirm improvement. Basic Nursing Procedures Asepsis and Infection Control Asepsis refers to practices that minimize the presence of pathogens to prevent infection. Infection Control includes: o Medical Asepsis (Clean Technique): Washing hands, disinfecting equipment. o Surgical Asepsis (Sterile Technique): Maintaining sterility during invasive procedures. Example: A nurse wears sterile gloves to insert a urinary catheter, preventing bacteria from entering the bladder. Key Terms: o HAI (Hospital-Acquired Infections): Infections obtained during hospitalization. o Standard Precautions: Universal measures like handwashing and wearing PPE. Safety and Security and Emergency Preparedness Nurses ensure safety by minimizing risks of falls, injuries, or errors. Emergency Preparedness: o Be trained in disaster protocols (e.g., fire, earthquakes). o Provide basic life support (BLS) in emergencies. Example Situation: A nurse assists in evacuating patients during a hospital fire, prioritizing bedridden patients. 29 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM Complementary Therapies and Alternative These are non-traditional methods that complement conventional treatment: o Examples: Massage therapy, aromatherapy, acupuncture. o Situation: A cancer patient uses meditation to manage chemotherapy- induced nausea. Medications Nurses administer and monitor medications while following the 6 Rights of Medication Administration: 1. Right Patient 2. Right Medication 3. Right Dose 4. Right Time 5. Right Route 6. Right Documentation Example: A nurse checks a patient’s ID bracelet to confirm their identity before administering insulin. Nursing Interventions to Promote Healthy Physiologic Responses Hygiene Maintaining cleanliness to prevent infection and ensure comfort. Example: Helping a bedbound patient with a sponge bath. Skin Integrity Preventing pressure ulcers through regular repositioning and skincare. Situation: A nurse applies a hydrocolloid dressing on a stage II pressure ulcer. Mobility/Activity Encouraging movement to prevent complications like deep vein thrombosis (DVT). Example: Assisting a post-op patient in ambulating to improve circulation. 30 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM Rest and Sleep Promoting adequate sleep for recovery and well-being. Example: Adjusting the room environment to reduce noise for a hospitalized patient. Comfort and Pain Management Assess pain levels and use interventions like analgesics or relaxation techniques. Situation: Administering morphine to a patient with severe post-surgical pain. Nutrition Ensuring patients meet their dietary needs to support healing. Example: Assisting a stroke patient with swallowing exercises to prevent choking. Urinary and Bowel Elimination Promoting normal elimination patterns and addressing incontinence. Situation: A nurse monitors urine output in a dehydrated patient to assess kidney function. Oxygenation and Perfusion Maintaining proper oxygen supply and circulation. Example: A nurse adjusts a patient’s oxygen mask to ensure proper fit and delivery. Fluid and Electrolyte Balance Monitoring and correcting imbalances (e.g., administering IV fluids for dehydration). Situation: A nurse monitors potassium levels in a patient receiving diuretics. 31 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM Nursing Interventions to Promote Healthy Psychosocial Responses Self-Concept Helping patients maintain a positive self-image. Example: Encouraging a burn patient to express feelings about their appearance. Stress and Adaptation Teaching coping mechanisms to manage stress. Example: Guiding a patient through deep-breathing exercises before surgery. Loss, Grief, and Dying/Post-Mortem Care Supporting patients and families during end-of-life care and providing respectful post-mortem care. Example: Explaining hospice care options to a terminal cancer patient’s family. Sensory Functioning Addressing sensory deficits (e.g., vision, hearing). Example: Teaching a patient with glaucoma how to manage their condition. Sexuality Providing education and counseling on sexual health. Example: Helping a post-hysterectomy patient address concerns about intimacy. Spirituality Supporting patients’ spiritual needs. Example: Arranging for a chaplain to visit a patient requesting prayer. Nursing as a Science Problem-Solving Process 32 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM Nursing, as a science, employs a systematic approach to problem-solving.1 This process involves: 1. Identification of the Problem: This is the first step, where the nurse recognizes a patient's need or problem.2 For instance, a patient might complain of shortness of breath. 2. Data Collection: The nurse gathers information about the patient's condition, such as vital signs, medical history, and physical assessment findings.3 3. Analysis of Data: The nurse analyzes the collected data to identify the root cause of the problem. In the case of shortness of breath, possible causes could be pneumonia, heart failure, or anxiety. 4. Planning: The nurse develops a plan of care to address the problem.4 This plan includes specific interventions, such as administering oxygen therapy, providing emotional support, or administering medications. 5. Implementation of the Plan: The nurse carries out the planned interventions.5 6. Evaluation: The nurse assesses the effectiveness of the interventions and modifies the plan as needed.6 Nursing Process The nursing process is a systematic, rational method of planning and providing individualized nursing care.78 It involves five steps: 1. Assessment: The nurse collects subjective and objective data about the patient's health status.9 2. Diagnosis: The nurse analyzes the assessment data to identify actual or potential health problems.10 3. Planning: The nurse develops a plan of care, including goals and interventions, to address the identified problems.11 4. Implementation: The nurse carries out the planned interventions.12 5. Evaluation: The nurse evaluates the effectiveness of the interventions and modifies the plan as needed.13 Basic Nursing Procedures Asepsis and Infection Control Asepsis is the practice of preventing infection.14 It involves techniques like hand hygiene, wearing personal protective equipment (PPE), and using sterile technique.15 Infection control measures aim to reduce the spread of microorganisms.16 Safety and Security and Emergency Preparedness 33 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM Safety and security measures are essential to prevent accidents and injuries.17 Emergency preparedness involves planning for and responding to emergencies, such as fires, floods, and mass casualty events.18 Complementary Therapies and Alternative Complementary therapies are used alongside conventional medicine to enhance health and well-being.19 Alternative therapies are used instead of conventional medicine. Examples include acupuncture, massage therapy, and herbal medicine. Medications Medication administration is a critical nursing skill.20 Nurses must be knowledgeable about medications, including their indications, dosages, side effects, and contraindications.21 Nursing Interventions to Promote Healthy Physiologic Responses Hygiene Good hygiene practices, such as bathing, oral care, and hair care, are essential for preventing infection and promoting comfort.22 Skin Integrity Skin integrity refers to the condition of the skin.23 Nurses must assess the skin for signs of breakdown, such as pressure ulcers, and implement measures to prevent skin damage.24 Mobility/Activity Regular physical activity is important for maintaining health.25 Nurses can help patients maintain mobility through exercises, ambulation, and positioning.26 Rest and Sleep Adequate rest and sleep are essential for physical and mental health.27 Nurses can create a restful environment and promote sleep hygiene. Comfort and Pain Management Pain management is a priority for nurses.28 They can use various techniques to relieve pain, such as medication, positioning, and relaxation techniques. Nutrition Proper nutrition is essential for health.29 Nurses can assess patients' nutritional needs, provide dietary counseling, and assist with feeding.30 Urinary Elimination Normal urinary elimination is essential for health.31 Nurses can assess urinary function, promote bladder health, and assist with catheterization.32 34 | FNP by CJAA NCM 103 – REVIEWER MIDTERMS EXAM Bowel Elimination Normal bowel elimination is essential for health.33 Nurses can assess bowel function, promote bowel health, and assist with bowel regimens.34 Oxygenation and Perfusion Oxygenation and perfusion are essential for life.35 Nurses can assess respiratory function, administer oxygen therapy, and monitor vital signs. Fluid, Electrolyte Imbalance Fluid and electrolyte balance is essential for health.36 Nurses can assess fluid status, monitor electrolyte levels, and administer intravenous fluids.37 Nursing Interventions to Promote Healthy Psychosocial Responses Self-Concept Self-concept is how individuals perceive themselves.38 Nurses can promote positive self- concept by providing support, encouragement, and opportunities for self-expression.39 Stress and Adaptation Stress is a common human experience.40 Nurses can help patients cope with stress by teaching relaxation techniques, providing emotional support, and referring to counseling services. Loss, Grief, and Dying/Post-Mortem Care Loss, grief, and dying are natural parts of life.41 Nurses can provide emotional support, facilitate communication with loved ones, and assist with post-mortem care.42 Sensory Functioning Sensory functioning involves the senses of sight, hearing, touch, taste, and smell.43 Nurses can assess sensory function, provide sensory stimulation, and teach patients how to adapt to sensory changes.44 Sexuality Sexuality is a complex aspect of human experience.45 Nurses can provide education, counseling, and support related to sexuality.46 Spirituality Spirituality is a personal belief system that provides meaning and purpose in life.47 Nurses can respect patients' spiritual beliefs and provide support for spiritual practices.48 35 | FNP by CJAA