Exam 1study guide.pdf

Exam 1 Clinical judgement- chpt 2 Critical thinking/critical judgment- what is it? Requirement to use processes to achieve desired client outcomes. They require nurses to assess/recognize evidence of the client problems, interpret the problems, priorit...

Exam 1 Clinical judgement- chpt 2 Critical thinking/critical judgment- what is it? Requirement to use processes to achieve desired client outcomes. They require nurses to assess/recognize evidence of the client problems, interpret the problems, prioritize a response, take action, evaluate outcomes, and modify actions to meet the client’s needs. How does a nurse use critical thinking Objectively gathering information on a problem or issue Recognizing the need for more information Evaluating the credibility and usefulness of sources of information Recognizing gaps in one’s own knowledge Recognizing differences and similarities among things or situations Listening carefully; reading thoughtfully Evidenced based practice- what is it A research-based method for judging and choosing nursing Critical thinking attitudes p. 34 in the book Intellectual autonomy Intellectual curiosity Intellectual humility Intellectual empathy Intellectual courage Intellectual perseverance Fair-mindedness Confidence in reasoning Caring- what is it and what does it involve Caring involves personal concern for people, events, projects, and things. It allows you to connect with others and to give help as well as receive it. It has five components: knowing, being with, doing for, enabling, maintaining belief Nursing process- chpt 3 What is the nursing process? Is the five-step problem-solving process that nurses use to guide their professional actions. ADPIE Know the 5 parts and recognize what falls into each (ADPIE) Assessment- involves gathering data about the patient and their health status  Diagnosis- using critical-thinking skills, the nurse analyzes the assessment data to identify patterns in the data and draw conclusions about the client’s health status, including strengths, problems, and factors contributing to the problems Planning- encompasses identifying goals and outcomes, choosing interventions, and creating nursing care plans Implementation- involves performing or delegating planned interventions, and creating nursing care plans Evaluation- occurs as the last step of the process and involves making judgements about the client’s progress toward desired health outcomes, the effectiveness of the nursing care plan, and the quality of nursing care in the healthcare setting Recognize how to gather information, cluster data and come up with a nursing diagnosis Know what a nursing diagnosis is Know the parts of a nursing diagnosis: Stem (or label), etiology (or r/t) and supporting data (AEB) What are collaborative problems? Collaborative problems are “certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician- prescribed and nursing-prescribed interventions to minimize the complications of the events” What is the difference between actual and risk for dx Risk for tells you to monitor Actual is the for sure dx What is a nursing care plan? Is the central source of information needed to guide holistic, goal-oriented care to address each patient’s unique needs. It specifies dependent, independent, and independent nursing actions necessary for a specific patient What are long term and short-term goals? What needs to be included in those goals? Short-term goals- are those you expect the patient to achieve within a few hours or days. Long-term goals are changes in health status that you wish to achieve over a longer period- perhaps a week, a month, or longer. Short-term goals are most relevant in settings such as acute care and clinics, while long- term goals are more likely to be utilized in home healthcare, extended care, and rehabilitation centers What are interventions? How does the nurse choose interventions? Nursing interventions are actions based on clinical judgement and nursing knowledge that nurses perform to achieve client outcomes. They can either be direct-care interventions or indirect-care interventions Direct-care interventions are performed through interaction with the client(s) Indirect-care interventions are performed away from the client but on behalf of a client or group of clients What is the difference between independent, dependent and collaborative interventions? Independent interventions- are those that RNs are accountable for and are licensed to prescribe, perform, or delegate based on their knowledge and skills Dependent interventions- are those prescribed by a physician or advanced practice nurse but carried out by the nurse. Collaborative interventions- interventions carried out in collaboration with other health team members How does the nurse evaluate the care plan? Relate outcomes to interventions Draw conclusions about problem status Revise the care plan What is discharge planning? When does planning begin? Who is involved? Discharge planning- is the process of planning for self-care and continuity of care after the patient leaves a healthcare setting Discharge planning begins at initial assessment. What are the principles of delegation? What are the 5 rights of delegation? Delegation takes place when the RN, who holds the authority for nursing care delivery, transfers responsibility for the performance of a task to UAP while retaining accountability for a safe outcome Five rights of delegation Right task Right circumstance Right person Right direction/communication Right supervision/evaluation Know the nurse’s responsibility for delegating of care. Who can the nurse delegate to? What can be delegated? Know the difference between delegation and assigning. Hygiene chpt 22 Why is hygiene important? – what types of baths can we do based on patient need? Hygiene- describes activities involved in maintaining personal cleanliness and grooming Types of baths Assist bath o The nurse helps the patient with areas that may be difficult to reach, such as the back, feet, and legs Complete bath o The nurse washes the patient’s entire body without assistance from the patient Partial bath o The nurse cleanses only the areas that may cause odor or discomfort, such as the axillae and perineum. If a complete bath would be stressful to the patient, you may choose to give a partial bath Specific needs of patient with dementia or obesity? Mouth care and problems associated with mouth/gum disease Periodontal disease- is the major cause of tooth loss in adults 35 years and older. It is an inflammation characterized by bleeding and receding gums and destruction of the surrounding bone structure. Gingivitis- is inflammation of the gum tissue surrounding the teeth. If left untreated, can lead to periodontal disease Halitosis- also known as bad breath, results from poor oral hygiene, eating certain foods, tobacco use, dental caries, infections or even systemic diseases Stomatitis- an inflammation of the oral mucosa, has numerous causes, including bacteria, mechanical trauma, irritants, nutritional deficiencies, and systemic infection Glossitis- an inflammation of the tongue, is caused by deficiencies of vitamin B12, folic acid, and iron Cheilosis- is a cracking and/or ulceration of the lips, in the form of reddened fissures at the angles of the mouth Reasons patient may have poor oral care History of periodontal disease Lack od money or insurance Pregnancy Poor nutrition and eating habits Medications Medical treatments Any situation that causes dry mouth Compromised self-care abilities Oral care with patients who have dementia, dentures, unconscious, critically ill Dentures- remove dentures from the mouth and clean at least once a day, preferably after each meal. Use regular toothpaste or special denture-cleaning compounds. Do not use hot water, it may damage them. Store dentures in a denture cup, in water, to prevent drying. Hair care, shaving, beard and mustache care Brush the hair daily to remove tangles, massage the scalp, stimulate the circulation, and distribute oil down the hair shaft. Beards should be washed daily during a bath or shower and combed and trimmed as necessary Oxygenation Chpt 33 Know the following terms and how they affect respiratory system: Ventilation-is the movement of air into and out of the lungs through the act of breathing Respiration- is the exchange of the gas’s oxygen and carbon dioxide in the lungs Inhalation- is the expansions of the chest cavity and lungs to negative pressure inside the lungs and causes air to be drawn in through the nose or mouth and airways Exhalation- is when the diaphragm and intercostal muscles relax, allowing the chest and lungs to return to their normal resting size external respiration- internal respiration (and muscles used) Factors that affect ventilation: rate and depth- Rate- is how fast you breathe depth- is how much your lungs expand to take in air hyperventilation- occurs when a person breathes fast and deeply to move a large amount of air through the lungs, causing too much carbon dioxide to be removed by the alveoli hypoventilation- occurs when a decreased rate or shallow breathing moves only a small amount of air into and out of the lungs. Can lead to hypoxia. lung elasticity- refers to the tendency of the elastin fibers to return to their original position away from the chest wall after being stretched lung compliance- refers to the ease of lung inflation airway resistance- is the resistance to airflow within the airways and when these might happen How breathing is controlled: Chemoreceptors- located in the medulla of the brainstem, the carotid arteries, and the aorta, detect changes in blood pH, O2, and CO2 levels and send messages back to the central respiratory center in the brainstem lung receptors- located in the lung and chest wall, lung receptors are sensitive to breathing patterns, lung expansion, lung compliance, airway resistance, and respiratory irritants Drive to breath for patients with no respiratory issues and drive to breath for COPD patients Factors that affect Pulmonary function- developmental stages, environment, lifestyle, smoking, meds Pathophysiological conditions that alter gas exchange- structural, alveolar-capillary disorders, central nervous system disorders, neuromuscular abnormalities Terms: Hypoxemia- low blood oxygen levels Hypoxia- an oxygen deficiency in the blood tissues Hypercapnia- high CO2 blood levels, can happen with hypoventilation Hypocapnia- low level of dissolved CO2 in the blood, can happen with hyperventilation atelectasis- anything that reduces ventilation, can happen with a tumor or obstructed airway Assessment: breathing patterns- Eupnea- normal breathing rate 12 to 20 breaths/min Tachypnea- fast, shallow breathing; more than 24 breaths/ min. Generally caused by hypoxemia or increased oxygen demand Bradypnea-slow respirations; fewer than 10 breaths/min. May cause poor gas exchange Kussmaul- increase in rate and abnormally deep respirations. These may occur as a compensatory mechanism for metabolic disorders that lower blood pH biot’s- irregular respirations of variable depth (usually shallow), alternating with periods of apnea. This pattern is often associated with damage to the medullary respiratory center or high intracranial pressure as result of brain injury Cheyne-stokes- gradual increase in depth of respirations, followed by a gradual decrease in depth, tthan a period of apnea. This pattern is often associated with damage to the medullary respiratory center or high ICP as a result of brain injury Apnea- absence of breathing. Respiratory arrest requires immediate cardiopulmonary resuscitation s/s of respiratory issues diagnostic tests: sputum samples- examined microscopically and cultured in the laboratory to identify organisms and test for sensitivity to different ant-infective agents TB testing-used to detect exposure and antibody formation to the tubercle bacillus allergy testing- uses skin testing to identify antigens that may cause hypersensitivity reactions in susceptible individuals pulse oximetry- is a noninvasive estimate of arterial blood oxygen saturation PFT’s,- a series of tests to detect lung volume and capacity ABG’s,- measures the levels of oxygen and carbon dioxide in arterial blood. peak flow meter-measures the amount of air that can be exhaled with forcible effort. Pt’s with asthma use PEFR monitoring to detect subtle changes in their condition bronchoscopy- insertion of a flexible endoscope to examine the larynx, trachea, and bronchial tree CPAP- provides positive pressure during inspiraton and expiration to keep alveoli open in a spontaneously breathing pattern BiPap- Ventilator- a machine that assists a patient to breathe interventions for patients with respiratory problems Interventions to help someone quit smoking Motivational counseling- includes discussion about the connection between tobacco use and current health status, the risks of continued tobacco use, the rewards of quitting, anticipated barriers to quitting, and strategies for addressing barriers Combining medication and counseling- is more effectives than either used alone. Oxygen therapy- why we use it, different systems used, know what oxygen toxicity is and what causes it Oxygen therapy- provides oxygen at concentrations greater than the level found in room air. Room air only contains about 21% oxygen. Oxygen toxicity can develop when O2 concentrations of more than 50% are administered for longer than 48 to 72 hours. Prolonged use of high O2 concentrations reduces surfactant production, which leads to alveolar collapse and reduced lung elasticity Tracheal oxygen delivery Pharyngeal airways Endotracheal airways Know what a Yankauer- is a rigid device for suctioning the oral cavity. UAPs may use this to suction the oral cavity as part of maintaining hygiene and preventing aspirations of oral secretions nasal cannula- air is administered through the nose through two tubes. Used to give oxygen to pt face mask- fit with a strap and placed over the pt to administer oxygen to the pt. tracheostomy-is a surgical opening into the trachea through the neck. It may be permanent or temporary. Oxygen will be delivered this way and bypass the upper airway. Nonrebreather- a type of reservoir bag mask; a valve keeps exhaled air from entering the reservoir bag venturi mask- a cone shaped adapter that serves as a mixing valve to control the amount of O2 and room air that flows through the mask are- the differences between them and when we use them Suctioning- what it is, why we use it, ways to suction To remove secretions and maintain patency. Signs that indicate the need for suctioning include: Agitation Gurgling sounds during respiration Restlessness Labored respirations Decreased oxygen saturation Increased heart rate and respiratory rates Adventitious breath sounds on auscultation Chest tube- what it is and why we use it A flexible, hollow tube that drains air, fluid, or blood from the chest cavity to treat conditions that can cause a lung to collapse Hemothorax- accumulation of fluid and blood in the pleural space interferes with lung expansion, ventilation, and gas exchange Pneumothorax- air in the pleural space creates positive pressure, causing lung tissue to collapse Asepsis and preventing infection- chpt 20 Know what the following agencies do in relation to preventing/managing infection: CDC-responds to new emerging health threats worldwide, detects and tracks disease with advanced technology and data analytics, and provides health information to prevent and control the spread of disease in healthcare settings and throughout the community Agency for healthcare research and quality- is an agency within the U.S department f health and human services. The agency’s mission is to provide scientific evidence to make healthcare safer and make health information, tools, and resources available for both healthcare providers and consumers the joint commission- is a quality oversight agency. Its standards for performance include extensive criteria describing what healthcare organizations must do to minimize the risks of infection US department of health Know what the following infections are and ways to help prevent them CLABSI-central line-associated bloodstream infection SSI-surgical site infection CAUTI-catheter-associated urinary tract infection MRSA/MSRO-methicillin-resistant staphylococcus aureus infection VAP- ventilator-associated pneumonia CDI-C difficile infection The WHO is committed to reducing healthcare-associated complications, preventing SSI, combating antimicrobial resistance, preventing sepsis and catheter-associated bloodstream infections, preventing catheter-associated urinary tract infections, and improving response and recovery of infection. Know what healthcare- associate infections and nosocomial infections are and why hospitalized patients are at an increased risk for developing these infections Healthcare-associated infections- refers to infections associated with healthcare given in any setting. nosocomial infection- refers more specifically to infections acquired in the hospital Reasons for the high incidence of healthcare-related infections In hospitals and other facilities, patients encounter many care providers who can transmit pathogens to them Ill patients are vulnerable to infection due to lowered resistance, and they are a source of infection for others inpatients undergo many invasive procedures, which can be a source for microbes to enter Know the difference between local and systemic infections, primary or secondary infections, exogenous. or endogenous, acute or chronic local-are those that cause harm in a limited region of the body, such as the upper respiratory tract, skin, urethra, or a single bone or joint systemic- occur when pathogens invade the blood or lymph and spread throughout the body primary- is the first infection that occurs in a patient secondary- is one that follows a primary infection, especially in immunocompromised patients exogenous- the pathogen is acquired from the healthcare environment endogenous- the pathogen arises from the patient’s normal flora, when some form of treatment causes the normally harmless microbe to multiply and cause infection acute- have a rapid onset but last only a short time chronic- develop slowly and last for weeks, months, or even years latent- cause no symptoms for long periods of time, even decades endemic, pandemic, epidemic endemic- condition occurs at a stable, predictable rate within a particular environment, region, or population pandemic- is an exceptionally widespread epidemic-that is, one that affects a large number of people in an entire country or worldwide epidemic- is an outbreak of a disease that spreads over a large geographic region or in a defined population group body defenses to help keep the host from getting infected superinfection and opportunistic infections- what are these and how do they happen Factors that increase someone’s risk for infection Know the difference between cleaning, disinfection, and sterilizing Cleaning- is the removal of visible soil from objects and surfaces Disinfection- removes pathogens on inanimate objects by physical or chemical means, including steam, gas, chemicals, and ultraviolet light Sterilizing- is the elimination of all microorganisms in or on an object Precautions- standard and then contact (cdiff, rotavirus,- gloves and gown, mask if potential for getting something splashed in eyes, should use disposable equipment that can be left in room), droplet (mumps, pneumonia, diphtheria, pertussis, influenza, meningitis, Rubella- mask and eye protection) airborne (TB- needs a negative pressure room, measles, chicken pox, disseminated herpes zoster- mask-N95 for staff and surgical mask on patient if traveling out of room, gown and gloves if coming in contact with bodily fluids, door remains closed) Safety chpt 21 Joint commission safety goals 2021- see box on page 705 in text, be able to identify ways to meet these goals in the hospital setting goal 1: identify patients correctly goal 2: improve staff communication goal 3: use medicines safely goal 6: use alarms safely goal 7: prevent infection goal 15: identify patient safety risks What factors increase the risk of errors occurring Organizational factors contribute to errors and to safety problems in healthcare, including the following poor design maintenance failures unworkable procedures shortfalls in training less than adequate tools and equipment inadequate staffing disruptive behavior and intimidation in the workplace  culture of disrespect among healthcare professionals Serious reportable events- what are they, give some examples Serious reportable events- are healthcare-acquired complications that can cause serious injury or death to a patient and should never happen in a hospital Examples: air embolism foreign object administering the wrong type of blood severe pressure injuries falls and trauma infections associated with urinary catheters Root cause analysis- what is it, how is it used in the hospital Root cause analysis- tries to solve problems by identifying and correcting the underlying causes of events as opposed to simply addressing their symptoms. RCA provides an organized structure for analysis of errors and is designed to answer three basic questions What happened? Why did it happen? What can be done to prevent it from happening again? What are ways to keep the patient safe in the hospital setting? Be able to discuss equipment related accidents, alarm safety, fire and electric hazards, restraints Key components of a culture of safety include the following: Team empowerment- every individual has the opportunity to be heard, feel important, and be a valued team member for the contribution offered Communication- open and honest lines of communication are needed between the team members and from the team to other hospital units Transparency- team members are united in their efforts to eliminate rumors and operate with only the facts, contributing to mutual team goals Accountability- staff claim ownership for human error and are willing to disclose the error and help prevent similar errors Know the physical and emotional effects of restraints with patients- what are some of the nursing responsibilities related to restraint use potential physical effects- restraint-imposed immobility can cause pressure injuries, contractures, and loss of strength, and affect nearly every body system potential emotional effects- the person may suffer anger, fear, humiliation, and diminished self- esteem how do healthcare workers keep safe and from getting an injury? What are some common injury risks as a healthcare worker Common accidents include back injuries, needlestick injuries, radiation injury, and violence Falls risk- who is at greater risk? What scale is used to identify risk? (Morse falls scale)- what interventions do we do to help prevent falls The morse fall scale- this is a rapid and simple method of assessing a patient’s likelihood of falling. Falls are a part of the routine assessment of all older adults Get up and go test- use if there is a history of falls Timed up and Go test-if the patient is seeking care because of a fall or if you observe any difficulty with ambulation