Nursing 270 Exam 1 PDF

Nursing exam 1: ​ Concepts of foundational nursing ADPIE ➔​ Define clinical judgment and differentiate it from clinical reasoning and critical thinking ◆​ Clinical judgement: outcome of critical thinking that can be seen in the decisions n...

Nursing exam 1: ​ Concepts of foundational nursing ADPIE ➔​ Define clinical judgment and differentiate it from clinical reasoning and critical thinking ◆​ Clinical judgement: outcome of critical thinking that can be seen in the decisions nurses make to deliver the best evidence-based care to patients ◆​ Clinical reasoning vs critical thinking: ​ Critical thinking: Purposeful process that is disciplined, active, multidimensional, reasonable, rational, and reflective to arrive at insight and draw conclusions ​ Critical reasoning: the process of analyzing information to make decisions about patient care ➔​ Describe the nursing process and each of its phases ◆​ Assessment: gathering data on the patient ◆​ Diagnosis: prioritizing data and giving the patient a nursing diagnosis ◆​ Planning: making a plan of care based on the diagnosis ◆​ Implementation: the doing of the plan that has been made ◆​ Evaluation: reflecting on the plan and seeing if there are any changes that need to be made ➔​ Compare the common types of nursing assessments. ◆​ Admission: initial type of assessment ◆​ Focused or problem orientated: focused on a specific problem when assessment is done ◆​ Time-lapse reassessment: conducted at scheduled intervals to monitor the progress of a patient’s health status and evaluate the effectiveness of implemented interventions ◆​ Emergency: emergent assessment in a critical situation ➔​ Explain the importance of using an organizing framework for assessment data, and briefly describe 3 possible frameworks. ◆​ Importance: ◆​ 3 types of framework: ​ Functional health approach: assessing the patient's ability to perform activities essential for daily living, understanding how well they function physically, emotionally, and socially ​ Head-to-model: perform a physical assessment of the patient ​ Body systems model: understand and assess the functioning of different body systems such as the cardiovascular, respiratory, gastrointestinal, musculoskeletal, etc ➔​ Differentiate between objective and subjective data. ◆​ Objective: signs ◆​ Subjective: symptoms, the patient says these ➔​ Describe the purposes and techniques of data collection methods: observation, interview and physical assessment. ◆​ Observation: using your senses ◆​ Interview: consists of asking questions designed to elicit subjective data from the patient or family members. ​ “OLD CARTS”→Onset, Location, Duration, Characteristics, Aggravating, Radiating, Timing, Severity ​ Closed vs. open ended questions ​ Learn to be a good listener ◆​ Physical assessment: palpation, inspection, percussion, auscultation ➔​ Explain the process of validating data and inferences. ◆​ cross-checking information, considering the patient’s history and context, and using clinical reasoning to draw appropriate conclusions. ◆​ collaborate with other healthcare professionals, involve the patient in the process, and document findings to confirm that inferences are evidence-based and align with the patient’s care plan. ◆​ Regular evaluation of outcomes helps refine the care approach. ◆​ Establishing patient problem priorities: maslows’ & ABC’s ◆​ Accuracy vs. incongruence ➔​ Explore common problems encountered in data collection and strategies to overcome these problems. ◆​ Common problems: incomplete or inaccurate patient information, poor communication, biases in assessment, and equipment malfunctions ◆​ Strategies to overcome: ensure thorough documentation→SOAPIER: Symptoms, Objective, Assessment, Planning, Implementation, Evaluation, use standardized assessment tool, double-check equipment calibration, and communicate clearly with patients and the healthcare team ➔​ Explain the process of data analysis leading to nursing diagnosis/problem identification. ◆​ Data Collection: The nurse gathers comprehensive data through patient assessments, including physical exams, interviews, lab results, and observations. ◆​ Data Clustering: The nurse organizes the collected data into patterns or groups (such as symptoms, vital signs, medical history) to identify any significant trends or abnormalities. ◆​ Data Interpretation: The nurse critically analyzes the grouped data to understand the patient's condition and identify potential health issues. This step involves using clinical reasoning to differentiate between normal variations and signs of potential problems. ◆​ Problem Identification: Based on the analysis, the nurse identifies actual or potential health problems. This includes recognizing deviations from normal health patterns, risks, or complications (e.g., impaired mobility, risk for infection). ◆​ Nursing Diagnosis: The nurse formulates a nursing diagnosis by defining the health problem, its cause (etiology), and the evidence supporting it. For example, "Impaired  physical mobility related to pain and weakness as evidenced by difficulty walking and decreased range of motion." ◆​ Validation: The nurse verifies the findings through patient feedback, collaboration with ➔​ Differentiate between medical and nursing diagnoses. ◆​ Meidcal diagnosis: identification of a disease, syndrome, or injury ◆​ Nursing diagnosis: focuses on the patients responses to health & illness, problem can be treated with nursing practice only ➔​ Describe how patient goals/expected outcomes and nursing interventions are derived from diagnoses/patient problems. ◆​ Based on assessment findings because you have to use the data found to come up with an accurate diagnosis for your patients problem. Without data you cannot know the scientific cause of what is going on with your patient. You can come up with a diagnosis by identying patient’s patterns and trends, comapring objective and subjective data found w expected standards and ranges. ​ Ex: fall risk assessment→help diagnose a fall risk and help guide the planning of nursing interventions that need to be done. ➔​ How to prioritize patient health problems & nursing responses ◆​ Nursing priority: use Maslows→ ◆​ Nursing responses: ​ ABC’s ➔​ Differentiate nurse-initiated interventions, physician-initiated interventions, and collaborative interventions. ◆​ Nurse-initiated interventions ◆​ Physician-initiated interventions ◆​ Collaborative-initiated interventions ➔​ Use cognitive, interpersonal, technical, ethical/legal, and QSEN competencies to determine how to safely and effectively implement a plan of nursing care ◆​ Cognitive: problem-solving, decision-making, and teaching ◆​ Interpersonal: ability to work with others to accomplish goals ◆​ Technical: being able to use equipment, machines, and supplies in a particular specialty ◆​ ethical/legal: record all and any nursing interventions used in a Timely and accurate fashion ◆​ QSEN: launched a Practice Strategies Repository to make data available for ongoing quality improvement in nursing care ➔​ Describe evaluation, its purpose, and its relation to the other steps in the nursing process. ◆​ Evaluation is the reflection part of the nursing process. Its there to check on the plan and diagnosis that you made and to see if it is positively effective. Documentation & Records: ➔​ Describe the purposes of the patient record and the importance of timely, accurate communication in healthcare. ◆​ Communication is a big reason why medical records and cahrting need to be update in an accurate and timely manner. There are multiple healthcare workers working together to make sure that this patient is being taken care of so the chart is a form of communication for the team to figure out what is being done and how the patient is doing ➔​ List key principles of charting ◆​ Be accurate ◆​ Be thorough ◆​ Be concise ◆​ Be objective ◆​ Be timely ➔​ Outline guidelines for effective nursing documentation. ◆​ Be accurate ◆​ Be thorough ◆​ Be concise ◆​ Be objective ◆​ Be timely ➔​ Describe methods and formats of nursing documentation ◆​ SBAR ◆​ SOAPIER: ​ Subjective ​ Objective ​ Assessment ​ Planning ​ Implementation ​ Evaluation ​ Reflection ◆​ PIE: Problem-Implementation-Evaluation ◆​ focus DAR ➔​ Identify critical components and tools for safe patient handoff. ◆​ Should include: demographic information, medical diagnosis, an overview of health status, plan of care, recent progress, any alterations that might become an urgent or emergent situation, directives for any assessments of client care situation, directives for any assessments or client care essential within the next few hours ➔​ Identify measures to protect confidential patient information. ◆​ Never share your log in information ◆​ Log off from the computer before leaving the workstation ◆​ Never leave a medical record in an area whre PHI can access it  ◆​ Shred any printed or written client information for reporting or client care after use Nurse-patient Relationship & Communnication: ➔​ Describe the attributes and phases of a therapeutic nurse-patient relationship. ◆​ Orientation: introduction + establish expectations and boundaries + set client goals ◆​ Working phase: ongoing data collection + build interpersonal relationship + work together to solve problems and accomplish goals ◆​ Termination: summarize goals and achievements reached + discuss feelings of termination + establish plan for continuing assistance ➔​ Discuss components and techniques of therapeutic communication and related challenges. ◆​ Components of therapeutic communication: ​ Informal contracts ​ Advocacy ​ Confidentiality ​ ingredients= empathy, positive regard and self-awareness Nutrition: ➔​ Discuss the components of a nutritional assessment and factors affecting nutrition. ◆​ Components: ​ Interview: ○​ Risk identification: ◆​ SDOH ◆​ Psychological state ◆​ Gender ◆​ Lifestyle & habits ◆​ Physiological ​ Intake of nutrients ​ Ability to use ingested nutrients ​ Metabolism demand ○​ Pattern identification ○​ Dysfunction identification ​ Physical exam: ○​ BMI ○​ Anthropometric measurements ○​ Calorie count ○​ General state: what do they look like? ○​ Mouth and swallowing inspection ​ Labs: ○​ Pre albumin and serum albumin ◆​ Serum should not be less than 3.5 g/dL ○​ CBC: hematocrit and hemoglobin ○​ Transferrin  ○​ Creatinine ○​ Allergy testing ➔​ Differentiate normal from abnormal nutritional assessment findings, including signs and symptoms of malnutrition and risk identification. ◆​ Malnutrition: ​ Based on the three assessments of nutrition. ​ Interview: ○​ Risks identification? ○​ Pattern identification? ○​ Dysfunction identification? ​ Physical exam: ○​ Vital signs: Over or under average BMI, weight, high or low BP, high or low pulse ○​ General state: abnormalities in appearance? ○​ Mouth and swallowing: abnormalities? ​ Labs: ○​ Any abnormal values? ➔​ Analyze nutritional assessment findings and develop nursing diagnosis/ actual and potential problem lists related to nutritional needs. ◆​ ➔​ Formulate properly constructed outcomes that relate to nursing interventions.​ ◆​ EX: ​ Nursing intervention= change of diet ​ outcome= patient has better nutrition ➔​ Describe evidence-based nursing interventions that involve nutritional problems. ◆​ Patient education ◆​ Meal planning and assisting ◆​ Tube feeding and parenteral nutrition ◆​ Nutrition supplements ◆​ EX: ​ Impaired swallowing diagnosis ○​ Nursing intervention: Diet dysphagia→ thickened liquids and pureed diet ➔​ Identify nursing interventions to safely deliver oral, enteral, and parenteral nutrition.​ ◆​ Nursing interventions: ​ Head of bed 30 to 45 degrees ideally 90 degrees ​ Always check proper tube placement before beginning tube feedings to prevent accidental aspiration of feedings. ​ prevention and assessment of complications, such as nausea, vomiting, aspiration, fluid and electrolyte imbalance, diarrhea, intestinal cramping, tube occlusion, and hyperglycemia.  ◆​ Oral: assisted feeding for patients who cannot physically feed themselves, for swallowing impairment a dysphagia diet may be needed ◆​ Enteral: ​ Nasogastric: insert a tube through the nose into the stomach or intestine or ​ Gastrostomy and Jejunostomy: through the skin of the abdominal wall into the stomach or intestine ​ selected based upon patient-specific factors (long term or short term) ◆​ Parenteral: intravenous feeding straight into the blood stream ➔​ Discuss client education in relation to specific nutritional needs. ◆​ Need to increase weight r/t being underweight: ​ Nursing education: educate patient on Recommended Daily Allowance of calories and how we should all try and stay at this number rather than under it. ➔​ Evaluate nursing care and document interventions related to outcomes. ◆​ Be able to come up with interventions that relate to patient problems and expected patient outcomes for that problem Mobility: ➔​ Define and describe the concept of mobility ◆​ the ability to move freely and control one's body position ➔​ Describe the normal functions of the musculoskeletal system and normal movement and joint motion ◆​ Exercise: ​ Normal functions: ○​ Full range of motion: ○​ Flexion, extension, lateral flexion, rotation, Supination, pronation, inversion, eversion, opposition, hyperextension, dorsiflexion, plantar flexion, circumduction, adduction, abduction ​ Types: ○​ Anaerobic vs aerobic ○​ Isontonic vs isometric ➔​ Identify factors that affect mobility, including lifespan considerations. ◆​ Lifestyle and habits ◆​ Intact musculoskeletal systems ◆​ Nervous system control ◆​ Circulation and oxygen ◆​ Energy ◆​ Congenital problems: someone can be born with, abnormalities ◆​ Affective disorders ◆​ Therapeutic modalities ◆​ Age ➔​ Compare and contrast the effects of exercise and immobility on physiologic function. ◆​ Cardio: ​ Immobile: ○​ ↑ risk of bloot clots, DVT’s(symptoms: eryothema, swelling, pain, + homin sign) ​ Active: ○​ ↑efficiency of heart, ○​ ↓ resting heart rate and BP ○​ ↑blood flow and oxygenation of all body parts ◆​ Respiratory: ​ Immobile: ○​ ↓ lung expansions: rate and depth ○​ Impaired gas exchange: ↑ risk of atelectasis ○​ Pooling of secretions ​ Active: ○​ ↑ depth of respirations ○​ ↑ respiratory rate ○​ ↑ gas exchange ◆​ GI: ​ Immobile: ○​ decreased GI motility and constipation ○​ ↓ peristalsis ○​ Disturbance in appetite ​ Active: ○​ ↑ appetite ○​ ↑ intestinal tone ◆​ Urinary: ​ Immobile: ○​ urinary stasis→kidney stones and UTI ○​ ↓ bladder muscle tone ​ Active: ○​ ↑ blood flow to kidneys ○​ ↑ efficiency of excreting body waste and maintaining fluid-acid balance ◆​ Muscoloskeletal: ​ Immobile: ○​ ↓ muscle size, tone and strength→ ↑muscle atrophy, osteoporosis risk, contractractures risk, and bone demineralization risk ○​ ↓ joint mobility and flexibility ​ Active: ○​ ↑ muscle efficiency, coordination, and nerve impulse transmission ◆​ Metabolic ​ Immobile: ○​ ↑ risk for electrolyte imbalance ​ Active: ○​ ↑ efficiency for metabolic system ◆​ Integument: ​ Immobile:  ○​ pressure injuries and skin breakdown ​ Active: ​ ○​ Improved skin from improved circulation ◆​ Psychological well-being: ​ Immobile: ​ ○​ ADLS: ↓function in ADL’s→bathing, showering , shaving, cooking, eating, dressing ○​ ↓ self-concept, confidence and interaction ​ Active: ○​ ADLS: ↑ function in ADL’s→bathing, showering , shaving, cooking, eating, dressing ○​ ↑ self-concept, confidence and interaction ○​ ↑ sleep, appearance energy vitality ➔​ Determine fall risk using an evidence-based data collection tool and associated nursing implications. ◆​ Hendrich II Fall Risk Model: ◆​ Score of 5 or greater is a fall risk ​ confusion/alteration ​ Symptomatic depression ​ Altered elimination ​ Dizziness or vertigo ​ Gender ​ Any administered medications ​ Get up and go test: ○​ Ability to rise in single movement ○​ Pushes up in one attempt ○​ Multiple attempts to pull up but successful ○​ Unable to rise ➔​ Collect subjective data related to the musculoskeletal system via a health history ◆​ “ i cant move my leg because it hurts when I move it” ◆​ Take a history of the present illness: ​ OLD CARTS: ○​ Onset? ○​ Location? ○​ Duration? ○​ Characteristics? ○​ Aggravtion? ○​ Radiating? ○​ Timing? ○​ Severity? ◆​ “ I cant walk because i broke me hip” ◆​ “ I had a stroke and cannot move my right arm because I cannot feel it” ➔​ Identify components of the physical assessment of the musculoskeletal system. ◆​ Osthostatic vital signs ◆​ Risk of falls ◆​ Activity tolerance ◆​ GALS: Gait- Arms-Legs-Spines ​ Inspection: muscle and joint (posture, Alignment, Balance, Coordination, Gait, Muscle mass, tone and strength, Joint structure and function) ​ Palpation: muscle and joint ( tenderness, temp, tone, edema) ​ Movement: muscle (involuntary movement), joints (ROM) ​ Strength: muscle (grade 0-5) ○​ ⅘: complete ROM against gravity and moderate resistance ○​ ⅗: complete ROM against gravity ○​ ⅖: comple ROM w/ the joint supported but cannot preform ROM against gravity ○​ ⅕: muscle contraction detectable, but no movement of the joint ○​ 0: no visible muscle contraction ➔​ Construct nursing diagnoses that correctly identify mobility problems. ◆​ EX: ​ Risk for fall →Hendricks Fall risk model ◆​ Impaired mobility related to: ​ Age related ​ Musculoskeletal ​ Psychological ​ Neurological deficits ​ Pain ​ AEB→Activity intolerance: ○​ Can’t get up from chair ○​ Limited range of motion ➔​ Plan,implement, and evaluate nursing care related to select nursing diagnoses involving changes in mobility. ◆​ Plan: help patient gain mobility in 1 week for _____. ​ Nursing intervention: ○​ encourage patients to participate in their own care as much as possible ○​ Physical therapy for gain of mobility ○​ Education on safe mobility ○​ Nursing adaptive devices→walker, cane, crutch ◆​ Implement: ​ Ask patient if they would like to try and wash any parts of them they think they can do safely ​ Help or quide patient if they want to try and preform care on themselves whenever needed  ​ Assist patient with any and all ADL they need help with ◆​ Evaluate: ​ Did the patient acquire better mobility from said problem? ➔​ Implement safe patient handling and movement techniques and equipment when positioning, moving, lifting, and ambulating patients ◆​ Use assistive devices when applicable ◆​ Make sure to use correct body mechanics ◆​ Ask for help when needed ◆​ Avoid using your back to lift rather use legs and arms Skin Integrity and Wound Healing: ➔​ Identify the component of the nursing assessment of tissue integrity ◆​ This is the skin check where you check a patients skin for any signs of abnormal skin integrity. ◆​ Interview: ​ ​ Risk identification: ○​ Allergy history: ○​ Recent exposure to factors that can cause skin trauma, rash, or lesions. ○​ Factors that may delay wound healing, such as malnutrition, impaired circulation, immunosuppression, obesity, smoking, diabetes mellitus, or infection. ○​ Risk for pressure injury formation ​ Dysfunction identification ○​ If any skin problems (rashes, wounds, lesions) are present ​ Symptoms: is it painful or itchy? ◆​ Physcial examination ​ Inspection: color, vasculairty, turgor, texture, lesions ​ Palpation: temperature size and depth ◆​ Wound assessment: ​ Wound type: Surgical versus nonsurgical; acute versus chronic. ​ Wound location ​ Wound size: Measure the length, width, and depth in centimeters. ​ Wound classification: Partial versus full thickness; stage only if a pressure ulcer. ​ Wound base (percentage of viable vs. nonviable tissue): Viable, healthy tissue appears pink to red; nonviable or necrotic tissue is white to yellow (slough) or brown to black (eschar). ​ Wound drainage ​ Undermining/tunneling: Assess the wound edges ​ Tubes/drains: Check patency and stabilization.  ​ Signs and symptoms of infection: Local (pain, redness, swelling, firmness, or purulent drainage) or systemic symptoms (fever) ​ Condition of the surrounding skin: Palpate to assess for swelling, warmth, tenderness, and firmness. Observe for redness, irritation, or fragility. ​ Pain ➔​ Identify normal and abnormal findings related to the integumentary system ◆​ Normal: ​ Color: pink ​ Vascularity: warm and bouncy ​ Turgor: good pinch test comes back quickly ​ Texture: smooth, normal roughness ​ Absence of lesions ◆​ Abnormal: ​ Color: red, white, blue, black ​ Vascularity: cold and pruning ​ Turgor: bad pinch test, skin takes a while to come back ​ Texture: moist, cracking, flaky ​ presence of lesions ​ Types: lesions ○​ Primary: appear first ◆​ Macule: circumscribed, Flat, Nonpalpable Changes in Skin Color ◆​ Papule: palpable elevated solid mass up to 0.5 cm ◆​ Nodule: larger than 0.5 cm; often deeper and firmer than a papule ◆​ Wheal:somewhat irregular, relatively transient, superficial area of localized skin edema ◆​ Tumor: ◆​ Plaque: ◆​ Bulla: Circumscribed Superficial Elevations of the Skin Formed by Free Fluid in a Cavity Within the Skin Layers ◆​ Pustule ◆​ Vescicle ○​ Secondary: comes after primary lesions ◆​ Scales ◆​ Crusts ◆​ Fissures ◆​ Ulcers ◆​ Scars ◆​ Atrophy ➔​ Describe different stages of pressure injuries ◆​ Stage I: persistent redness of intact skin  ◆​ Stage II: partial-thickenss skin loss w exposed dermis ◆​ Stage III: full-thickness skin loss, not involving underlying fascia ◆​ Stage IV: full-thickness skin and tissue loss ◆​ Unstageable PE: concealed full-thickness and tissue loss ➔​ Identify factors affecting integumentary function ◆​ Circulation: ​ The heart must be able to pump adequately. ​ The volume of circulating blood must be sufficient ​ Arteries and veins must be patent and functioning well. ​ Local capillary pressure must be higher than external pressure. ◆​ Nutrition ​ Hydration status: fluid loss or swelling can cause skin to break down ​ With a deficiency of protein or calories hair becomes dull and dry and may fall out. Skin also becomes dry and flaky. ◆​ Conditions of the epidermis ​ Abnormal moisture or maceration can cause skin breakdown ◆​ Allergy ​ Histamine can cause dermatitis ◆​ Infections ​ Toxins can destroy skin tissues ◆​ Abnormal growth rate ​ Psoriasis causes too much skin growth which causes flakes ◆​ Systemic disease ​ can produce skin abnormalities and ulceration ◆​ Substance misuse ​ Can cause many different abnormal skin diseases and issues based on the different drugs ◆​ Trauma ◆​ Burns ◆​ Mechanical forces: pressure, friction, shear ➔​ Identify factors that affect wound healing and describe phases of wound healing ◆​ Factors that affect wound healing: ​ Systematic ○​ Nutrition: poor nutrition leads to poor wound healing proteins and amino acids are essential ○​ circulation and oxygen: need red blood cells to heal ○​ immune cellular function ​ Individual: ○​ Age, obesity, ○​ smoking, medication, stress ​ Local  ○​ Nature of the injury: infection, local wound enviroment ◆​ Phases: ​ Hemostasis: vasoconstriction=clotting to stop the wound from bleeding out ​ Inflammatory: immune system kicks in-> inflammation to clean the wound and get ready for next phase ​ Proliferative: ○​ Partial: epithelialization to heal ○​ Full thickness wound: granulation tissue needs to form first then epithiliaization ​ Remodeling: 3 weeks after injury and only return 70-80% of baseline strength ➔​ Develop actual and potential nursing diagnoses or problem lists and outcomes related to tissue integrity​ ◆​ Impaired tissue integrity: diabetic patient who has bad peripheral circulation has a pressure ulcer on his foot. ➔​ Identify evidence-based nursing interventions to promote, prevent, and treat alterations in tissue integrity ◆​ Nursing promotion: education on promotion of wound healing including nutrition education on foods high in protein. If applicable education on exercise which promotes circulation adn osygenaztion which also promotes wound healing. ◆​ Nursing prevention: pressue wound from worsening or becoming infected, obtaining more pressure injuries, preventing impaired prolonges mobility from this injury ◆​ Nursing treatment: using barrier creams and foams to protect the injury while it heals, making sure the patient is eating a healthy high-protein diet in order to promote wound healing, making sure the patient is being moved and repositioned every hour or 2 to avod further injuries, physical therapy with the patient to prevent this patient form losing thier mobility, offering assistive devices to the patient if they need in order to perform ADL’s ➔​ Describe specific evaluation strategies used to determine if patient outcomes have been met regarding tissue integrity ◆​ Use scale to determine what level the injury is at. ◆​ Compare data from admission to discharge ◆​ Ask the patient if they are feeling better or worse after treatments have been implemented