NURS 20020 Final Exam PDF

NURS 20020 Final Exam Study online at https://quizlet.com/_5r4t20 Founder of modern nursing Introduced education to nurses Florence Nightingale Began nursing research during...

NURS 20020 Final Exam Study online at https://quizlet.com/_5r4t20 Founder of modern nursing Introduced education to nurses Florence Nightingale Began nursing research during the Crimean war (washing hands standard of care) Noticed relationship between environment and health Dorothea Dix Established the Nurse Corps in the US Army Clara Barton Organized the American Red Cross Nightingale environmental theory (sunlight, fresh air, nutrition) Peplau focused on interpersonal relationship energy fields in the environment, holistic approach, comforted via Rogers noninvasive ways Henderson assist patient to gan as much independence as possible Orem self care theory King goal attainment theory Neuman individuals response to stress Roy adaptive responses lead to better health Maslow's Hierarchy of Needs establishes priority in nursing care Airway ABCs Breathing Circulation Chest compression Airway CABD Breathing Defibrillation established nursing code of ethics (the boundary and duty of American Nurses Association (ANA) nursing practice) American Association of Colleges of Nursing commission of collegiate nursing education accreditation agency Quality and Safety Education for Nurses QSEN establishes a culture of safety instead of a culture of blame and ensures care for the community to prepare nurses with the competencies necessary to continu- purpose of QSEN ously improve the quality and safety of the healthcare systems in which they work Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice QSEN competencies Quality Improvement Safety Informatics Recognize the patient as the source of control and full partner Patient Centered Care in providing compassionate and coordinated care based on the respect for patient's preferences, values, and needs a joint action by 2 or more people, each person contributes Teamwork and Collaboration Joint decision making among all healthcare parties Integrates best current evidence with expertise for optimal health Evidence Based Practice care Monitors outcome of Care Continuously improve quality and safety of the health care sys- Quality Improvement tems Nurses and students are part of the system that affects outcomes Minimize harm to patient and providers through both system ef- Safety fectiveness and individual practice 1 / 17 NURS 20020 Final Exam Study online at https://quizlet.com/_5r4t20 Use of information and technology to communicate, manage Informatics knowledge, mitigate error, and support decision making Learned skill (unnatural) Therapeutic Communication Focuses on the patient and their concerns Verbal and Nonverbal Sender The person who encodes the message Communication channel The median through which the message is sent Receiver The decoder- person who can understand the message Feedback The receiver's response to a message Written/electronic communication Documentation, EHR, written instructions, emails Self-talk, powerful form of communication that occurs within the Intrapersonal Communication individual One on one interactions between the nurse and the patient, occurs Interpersonal Communication face to face and is most frequently used by the nurse Vocabulary: no medical jargon Pacing: slow speech down so pt. can understand Verbal Communication Intonation: tone of voice affects the message Clarity and Brevity: simple, few words Timing and relevance: know when to communicate Eye Contact, facial expression, posture, gait, gesture, personal appearance, sounds Nonverbal Communication Includes 5 senses Can reveal true meaning 80% of communication Verbal and nonverbal communication need to be consistent with Communication Congruence one another to avoid confusion and prevent sending "mixed mes- sages" 0-18 inches Intimate Zone Most nursing care performed here 18 inches to 4 feet Personal Zone Sitting at bedside, taking patient history, giving information 4 to 12 feet Social Zone Rounds with the physician 12ft and beyond Public Zone Community forum, lecturing Gender: women generally prefer more details than men Cultural/Language: ethnic background, not all words translate Roles and relationships: stereotyping based on occupation Factors influencing communication Altered sensory perception: do not assume all elderly are deaf Mental and Emotional States Values Environment 1. Orientation/initiating Nurse-client relationship phases 2. Working 3. Termination Orientation/initiating phase Establish trust/rapport The patient becomes an active participant Working phase Implementing nursing interventions to achieve patent outcomes Closure of the relationship when the patient is discharged Key component=discharge planning Termination phase Continued contact beyond professional responsibilities is unpro- fessional 2 / 17  NURS 20020 Final Exam Study online at https://quizlet.com/_5r4t20 Conversations skills, listening skills, use of silence, therapeutic Therapeutic Communication Skills touch (noninvasive way to comfort and show you care), humor (can be over played) Open-ended questions Validating/clarifying Reflective Silence Communication Techniques General Leads Direct Questions Providing info needed to understand situation Sharing observations False reassurance Close ended questions Giving advice (NO) Responses to Avoid in Therapeutic Communication Sharing personal opinions Changing the subject Using personal terms of endearment Asking for explanations/ Why? questions Pallor (face and mucous membranes) Cyanosis (circumorial or nails) Color Assessment Jaundice (sclera) Erythema (sacrum, heels, greater trochanter) Hydration (dryness or oiliness) Diaphoresis (perspiration) Flaking, scaling, or crusting (more common in elderly, overuse of Moisture Assessment soap) Dryness (dehydration, smoking, stress, sun exposure) Excessive dryness (eczema or dermatitis) Dependent on the amount of blood circulating through the dermis Best assessed through palpation Temperature Assessment Compare symmetrical body parts Be alert to areas of warmth and erythema (may be a stage one pressure ulcer) Sensory perception, moisture, activity, mobility, nutrition, friction Braden Scale and shear Score 6-23 (high-low risk) Smooth Rough Thin Thick Texture Assessment Tight Indurated Scarred Wrinkled Elasticity (edema, dehydration, age) Turgor Assessment Pinch forearm and release Tenting indicates dehydration Tenting poor skin turgor/dehydration Observe/inspect for reddened, pink or pale areas Vascularity Assessment Petechiae Pin point purple or red spots May indicate blood clotting disorders, drug reactions, or liver dis- Petechiae ease Small hemorrhages Observe/inspect and palpate for fluid build up in tissues Edema Assessment May be secondary to: direct trauma or impaired venous return More common in dependent areas 3 / 17  NURS 20020 Final Exam Study online at https://quizlet.com/_5r4t20 Pitting Edema Indentation remains after 5 seconds of applied pressure Observe/inspect and palpate: blemishes, bruising, birthmarks, Lesion Assessment freckles, moles, keratosis, angiomas, warts, macule, papule, nod- ules, tumors, wheals, pustules, ulcers, cancer Deadliest form of skin cancer Begins as small, mole-like growth Melanoma Encourage patient to use ABCDE rule to assess warning signs Educate patient to notify their healthcare provider if lesions do not heal, change in color or appearance ABCDE asymmetry, border, color, diameter, evolving Observe/inspect: Color, Distribution, Quantity, Thickness, Texture, Hair Assessment Sheen, Hirsutism (female facial hair) Palpate: Condition, Smooth, Pliant, Texture, Thick, Thin, Brittle Observe/inspect: lesions, bruises, hair loss, dandruff, psoriasis, Scalp Assessment lice, ticks, ringworm Palpate: lumps, tenderness Observe/inspect and palpate: cleanliness, shape and contour, Nail Assessment consistency, color, capillary refill Press on the patient's nailbed and release Normal capillary refill = < 3 seconds Capillary Refill Assessment Abnormal capillary refill = >3 seconds (peripheral vascular dis- ease, arterial blockage, heart failure, shock) Risk for impaired skin integrity Impaired skin Integrity Impaired tissue integrity Skin, Hair, and Nails Nursing Diagnosis Bowel Incontinence Ineffective individual self coping Self-mutilation Disturbed body image Establish a database of the patient's abilities (obtain a baseline with which to compare) Purpose of Health Assessment Interpret physical data and compare findings laterally and with normal Decide on interventions based on data obtained Primary source Information directly from the patient Information from other than the patient (family members, old Secondary Source charts) Organized system for gathering physical data Head to Toe Assessment Brief Focus on specific body systems Focussed Assessments Very detailed E.g. cardiovascular Gordon's Functional Health Patterns (FHP), more holistic, assess Functional Assessments patient spirituality, physically, emotionally, and psychologically Assessment of Health Perception Client's perspective of his/her health status Gait and balance Assessment of Activity Exercise Decreased mobility Assessment of Nutrition and Metabolism Dietary habits and metabolic needs Assessment of Elimination Adequacy of bowel and bladder function Assessment of Rest and Sleep Client's normal sleep patterns Assessment of Cognition and Perception Client's ability to think Assessment of Self-Perception and Self-concept Client's feelings about self Assessment of Roles and Relationships Client's roles and how illness affects roles 4 / 17 NURS 20020 Final Exam Study online at https://quizlet.com/_5r4t20 Assessment of Coping and Stress Tolerance How does the client cope with stressors Assessment of Sexuality and Reproduction Client's sexual role and satisfaction Spiritual assessment Assessment of values and beliefs May focus on religious beliefs Physical observations of the client General survey: overall appearance of the pt. Inspection Side to Side (look) Using the hands to feel the skin and accessible underlying organs Palpation and other tissues (touch) Tapping on a surface to determine the difference in the density of Percussion the underlying structure The use of a stethoscope to listen to sounds within body cavities Auscultation (listen) Order of Abdominal Assessment Inspection, auscultation, percussion, palpation Five Vital Signs Temperature, pulse, respiration, blood pressure, pain Nurse collaborates with the physician to determine the frequency Guidelines for Vital Sign Assessment of assessment depending the patients condition Cannot be interpreted in isolation Oral: 98.6 F/ 37 C Tympanic: 99.5 F/ 37.5 C Temperature Axillary: 97.5 F/ 36.5 C Rectal: 99.5 F/ 37.5 C Temporal: 98.6 F/ 37 C Thermoregulation Heat production- heat loss= body temperature Hypothalamus: senses internal temperature and signals the body Neural and Vascular Temperature Regulation to change temperature Basal Metabolic Rate (BMR) Voluntary movement Heat Production Shivering Release hormones Radiation Heat radiates out Conduction Transfer of heat from the body to another surface (contact) Convection Dispersion of heat by air currents Evaporation Dispersion of heat through water vapors Diaphoresis Profuse sweating Fever 102.2 F / 39 C Severe >104 F/ 40 C Hyperthermia Etiology: bacteria and viruses Metabolism increases Treatment: antipyretics and hypothermia blanket Temp 106-113 F/ 41.1-44.9 C Etiology: excessive environmental temperature, high humidity, medications, excessive exercise Heat Stoke Signs/symptoms: hot, dry skin, giddiness, delirium-> confusion-> unconsciousness, excessive thirst, muscle cramps, increased pulse and BP Temp 20 rpm bradypnea 180/>120 hypotension Systolic 30, 70, male >80 Race (White, Asian, Native American, Northwestern Europe) Blonde or red hair, freckles Light body frame, thin Sway back Lordosis Increase in lumbar curvature Abnormal lateral curvature of the spine Scoliosis Begin testing at age 11-14 or until growth plates close Hypertonicity spasticity Hypotonicity flaccidity Prone lying face down Supine lying face up Side-laying laying on side body position in which a person is lying on his left side with the Sims upper knee flexed and raised toward the chest semi-sitting body position in which a person's head and shoulders Fowlers are elevated 45 to 60 degrees Semi-fowlers head of bed raised 30 degrees dorsal recumbent lying on back with legs bent and feet flat Trendelenburg position on back feet elevated higher than head 13 / 17 NURS 20020 Final Exam Study online at https://quizlet.com/_5r4t20 the patient rests on his or her knees and chest; the head is turned to one side, and the arms are extended on the bed, the elbows Knee chest flexed and resting so that they partially bear the weight of the patient Altruism Concern for the welfare of others Autonomy Respect for the patient's rights Human Dignity Treat as a being of worth Integrity Provides care based on a code of ethics Social Justice Fairness; equal to all Ethics Standards of conduct and moral judgement Personal values What the person feels is highly important Process by which people come to understand their own values Values clarification and value system Institutional policies Make up guidelines and policies for hospitals Utilitarianism Greatest good for the greatest number of people Focuses on the rights of the individual, does not consider the Deontology greater good or the consequences of specific actions for others Beneficence Doing good or promoting good on the behalf of others Nonmaleficence Avoidance of doing harm; preventing harm to others Justice fairness Veracity Telling the truth; commitment to honesty Fidelity Commitment to keeping promises Statutory Law Law passed by the U.S. Congress or state legislatures The body of law created by administrative agencies (in the form of rules, regulations, orders, and decisions) in order to carry out Administrative law their duties and responsibilities They give authority to the State Boards of Nursing Legal scope of practice Nurse Practice Act Obtain a copy from state board of nursing General term that refers to ways in which professional competence Credentialing is maintained Educational programs evaluated and recognized as having met Accreditation certain standards To be an RN- must successfully pass an accredited nursing pro- Licensure gram and the NCLEX Certification Demonstrates advanced proficiency in nursing (e.g. CCRN) Assault & Battery Intentional Torts False Imprisonment Defamation of Character Assault threat of harm Battery any unwanted touch wrongfully hurting a person's good reputation Defamation of character Oral=slander Written=libel Patient can leave AMA if they are A&Ox3 and not a threat to false imprisonment themselves or others Unintentional Torts negligence and malpractice Negligence Practice below standard of care, did not mean to harm someone 14 / 17 NURS 20020 Final Exam Study online at https://quizlet.com/_5r4t20 Acting outside of one's scope of practice/standard of care Malpractice Intent to harm does not have to be shown Active Euthanasia taking specific steps to cause a patient's death Assisting in suicide and participating in a active euthanasia is in ANA Position on Euthanasia violation of the Nursing Code of Ethics clinical decision making that integrates the best available research Evidence Based Practice with clinical expertise and patient characteristics and preferences Step 1: Ask a question about a clinical area of interest or an intervention. Step 2: Collect the most relevant and best evidence. Steps in Implementing EBP Step 3: Critically appraise the evidence. Step 4: Integrate the evidence with clinical expertise, patient pref- erences, and values in making a decision to change. Step 5: Evaluate the practice decision or change. produces data in the form of numbers, can be measured accu- Quantitative Research Methods rately and precisely (objective) Basic Research Generates and refines theory (pure theory) Applied Research Practice research, designed to improve clinical practice Conducted to gain human insight by discovering meanings and Qualitative Research Methods in-depth understanding of human behavior (subjective) Person, population, or problem of interest Intervention of interest PICO Comparison of interest Outcome of interest Critical Reasoning ways of thinking about patient issues Clinical Judgement Conclusions, decisions or opinion Includes both reasoning and judgement, helps choose solutions, Critical Thinking guided by standards of care 4th-5th intercostal space, left mid clavicular line Apex of the Heart Location of apical pulse Point of maximum impulse Systole ventricles contract Diastole ventricles relax Cardiovascular Inspection Skin color, pedal edema, observe for visible pulsations Assess capillary refill Cardiovascular Palpation Assess for pulse deficit Aortic, Pulmonic, Tricuspid, and Mitral Cardiovascular Auscultation S1, S2 Dysrhythmias, murmurs, clicks, rubs Mitral valve closing prior to left ventricular contraction S1 Auscultated as "lub" Aortic valve closes after left ventricular contraction S2 Auscultated as "dub" Dysrhythmia Abnormal heart rhythm Extra heart sounds S3, S4, murmurs, clicks, rubs Inadequate blood flow through the arteries arterial insufficiency Poor circulation (cold), cyanosis, leg cramps, pain inadequacy of the venous valves and impairment of venous return Venous Insufficiency from the lower limbs (venous stasis), often with edema and some- times with skin ulcers (particularly at the ankles) 15 / 17 NURS 20020 Final Exam Study online at https://quizlet.com/_5r4t20 Evaluates blood pressure Monitors blood flow and health of both arteries and veins through- out the body Peripheral Vascular Assessment Assesses the effectiveness of circulation throughout the body Reveals the effectiveness of the heart to pump blood to the pe- riphery of the body arterial issue cool to touch due to vasoconstriction Atherosclerosis build up of fat/cholesterol in artery walls Arteriosclerosis hardening of the arteries Palpate separately Normal findings: strength should be equal bilateral Carotid Artery Assessment Abnormal findings: bruit heard during auscultation (turbulent blood flow) Carotid Sheath common carotid artery, internal jugular vein, vagus nerve blowing, swooshing sound heard through a stethoscope when an Bruit artery is partially occluded Assess jugular vein distention/pressure Jugular Vein Assessment Provides insight into RIGHT heart function May be performed when suspect heart failure Blood volume Capacity of the right atrium to receive and expel blood to the right JVD influenced by ventricle Ability of the right ventricle to move blood into the pulmonary arteries Rate (radial only) Rhythm - regularity of the beats Peripheral Pulse Assessment Symmetry - compare side to side Amplitude - the strength of the beat absent pulse 0 thready pulse 1 normal pulse 2 bounding pulse 3/4 determining the patency of the radial and ulnar arteries by com- Allen Test pressing one artery site and observing return of skin color as evidence of patency of the other artery color (skin, mucosa, nailbeds), skin temp/condition/pain (occlu- Tissue Perfusion Assessment sion= pain, pallor, pulseless), cyanosis (central-heart disease, peripheral-vasoconstriction= blue lips, earlobes, nail beds) A test that evaluates distal circulatory system function by squeez- ing (blanching) blood from an area such as a nail bed and watching Capillary Refill the speed of its return after releasing the pressure. 20 seconds to rebound inflammation of a vein can lead to DVT Phlebitis Most common aerator clots= claves note warmth, redness, tenderness, and swelling 16 / 17 NURS 20020 Final Exam Study online at https://quizlet.com/_5r4t20 ventilation movement of air in and out of the lungs diffusion O2 and CO2 movement between alveoli and blood perfusion circulation of blood through an area of the body The primary control. Requires sensory input from chemoreceptors (chemical control), lung receptors (irritant and stretch), and other Autonomic Control of Ventilation receptors (baroreceptors, temperature, pain, and muscle recep- tors). Willfully increasing the frequency and/or depth of breathing Voluntary Control of Ventilation Breathing exercises vibration caused by speaking that is palpable vocal fremitus if vibration not palpable, can indicate accumulation of mucus, lung collapse, lung lesion fine crackling or bubbling sounds, commonly heard during inspi- Crackles ration when there is fluid in the alveoli; also called rales Loud, low pitched rumbling coarse sounds heard throughout lung fields Rhonchi Typically secondary to mucus/fluid in larger airways May be cleared with coughing High-pitched continuous musical sounds, usually heard on expi- ration Wheezes Caused by high velocity airflow through significantly narrowed airway Harsh honking wheeze with severe bronchospasm Stridor Air passing through a very constricted airway Secondary to croup or a swallowed object caught in airway continuous, dry grating sound caused by inflammation of pleural pleural friction rub surfaces and loss of lubricating pleural fluid Air or gas in the pleura cavity Pneumothorax Result of a puncture through chest wall Causes collapse of lung requiring a chest tube for ventilations Collapsed lung; incomplete expansion of the alveoli Atelectasis Result of mucus, hypoventilation, or compression by tumors/en- larged lymph nodes Leak of air from lung tissue into subcutaneous tissue subcutaneous emphysema At risk patients: post-op thoracic surgeries & blunt trauma patients A type of hyperventilation, exaggerated, deep, rapid and often Kussmaul respirations labored breathing pattern often associated with severe diabetic ketoacidosis or kidney failure Alternating periods of deep, rapid breathing followed by periods of Cheyne-Stokes respiration apnea Associated with end of life Irregular pattern characterized by varying shallow respirations Biot's Respirations followed by periods of apnea Associated with intracranial pressure & respiratory compromise 17 / 17