Exam 5 Review PDF

Exam 5 Review Patient Education Ch. 16 Patient education is a critical aspect of nursing care. Nurses play a vital role in providing patients with the knowledge and skills needed to manage their health conditions effectively. The Three Domains of Learning Cognitive Domain The cognitive domain fo...

Exam 5 Review Patient Education Ch. 16 Patient education is a critical aspect of nursing care. Nurses play a vital role in providing patients with the knowledge and skills needed to manage their health conditions effectively. The Three Domains of Learning Cognitive Domain The cognitive domain focuses on intellectual skills and the ability to recall and apply knowledge. It includes thinking, problem-solving, and remembering information. Psychomotor Domain of Learning The psychomotor domain encompasses the physical skills and procedures that are learned through hands-on practice. Nursing students learn many psychomotor skills in their training, such as taking vital signs, administering medication, and assisting patients with activities of daily living. Patients may need to learn how to perform certain tasks, such as self-administering insulin or changing a wound dressing. Affective Domain of Learning Changing Feelings Beliefs and Attitudes The affective domain focuses Students' values and beliefs on how people feel about influence their engagement learning and their motivation. with new information. Personal Growth Learning in the affective domain encourages personal reflection and the development of empathy. Five Rights of Teaching 1 Right Time 2 Right Context 3 Right Goal When the learner is receptive and Where the learner feels Specific, measurable, achievable, ready to learn. comfortable and safe. relevant, and time-bound. 4 Right Content 5 Right Method Information presented in a clear, concise way, using Teaching methods tailored to the learner's learning style appropriate language and visuals. and preferences. Documenting & Reporting Documentation Electronic health record (EHR) systems Chapter 17 Importance of Standardized Language Make nursing visible Support nursing research Provide standardized terminology to use in Standardized language helps to Consistent terminology allows for electronic health record highlight the essential contributions easier analysis and comparisons in (EHR) systems of nursing to patient care. nursing research, leading to valuable Standardized language ensures clear insights. communication and efficient data exchange within EHR systems, leading to improved patient care. Source-oriented system How it works: Disadvantage: Disciplines document in Data is scattered; may lead to separate sections of the chart. fragmentation. Contains a variety of sections (e.g., admission, H&P, diagnostic, graphic, nurses' notes, progress notes, lab, rehab, D/C plan, etc.). Problem-oriented system Organized around client Four components: Promotes greater problems database, problem list, collaboration plan of care, and progress notes Charting by exception Only significant findings Uses preprinted flow sheets Can lead to omission of are documented information and errors in Uses preprinted flow sheets to care Only significant findings are streamline documentation and ensure However, this method can lead to the documented, reducing the amount of consistency. omission of important information time spent on documentation. and errors in care. Home Healthcare Documentation Homebound Status Assessment of Client's Condition Interventions Performed Caregiver Interaction and Teaching Document the client's status as Include detailed assessments, Record all interventions Document any interactions or homebound, including any highlighting any changes in the provided, such as wound care, teaching provided to caregivers, limitations or need for client's condition or status. teaching, and other necessary ensuring continuity of care at assistance. services. home. Interaction with Provider Report any interactions with the client's provider, including medication changes or updates on the client's condition. Long-Term Care Documentation MDS-Within 14 days of admission Summary by Nurse- weekly Medicare-reimbursed services- documentation is required with each shift. SBAR, IPASS, or PACE Confidential Uninterrupted Brief Accurate Keep patient information private. Deliver the report without distractions. Concisely communicate the Ensure information is correct essential information. and up-to-date. Named nurse Identify the specific nurse providing the report. Verbal/Telephone Provider Prescriptions Verbal Orders (V.O.) Telephone Orders (T.O.) Spoken to you; often during a client emergency. Should be Received by phone and transcribed onto the provider made for critical change in client condition. order sheet. Have an increased risk for errors. Skin Integrity & Wound Healing This chapter explores the principles of skin integrity and wound healing. It covers the structure and function of skin, as well as the stages of wound healing. Structure of the Skin The skin is the body's largest organ, providing a protective barrier against the environment. It is composed of three main layers: epidermis, dermis, and subcutaneous layer. Epidermis Stratum corneum: outermost layer; composed of dead cells that protect against infection and water loss. Stratum germinativum: innermost layer; contains melanin, which gives skin its color, and keratinocytes, which produce keratin, a protein that gives skin its strength. Dermis The dermis is the middle layer of skin. It contains blood vessels, nerves, hair follicles, and sweat glands. Subcutaneous Layer The subcutaneous layer is the innermost layer of skin. It is composed of fat and connective tissue, providing insulation and cushioning. Factors Affecting Skin Integrity 1 Age 2 Nutrition Older adults have thinner A diet lacking in protein skin, which is more prone and vitamins can to tears and injury. contribute to impaired wound healing. 3 Medications 4 Underlying Some medications, such as Conditions steroids, can thin the skin. Diabetes and chronic diseases can compromise circulation and impair healing. Factors Affecting Skin Integrity Nutrition/Hydration Sensation Level Impaired Circulation Medications A balanced diet with Individuals with impaired Poor blood flow Certain medications can sufficient protein, sensation may be at compromises tissue cause side effects such as vitamins, and minerals is increased risk for skin oxygenation and nutrient itching, rashes, or crucial for healthy skin. injury due to their inability delivery, making the skin dryness, which can Dehydration can also to perceive pain, more vulnerable to disrupt skin integrity. negatively affect skin pressure, or temperature breakdown. integrity. changes. Factors Affecting Skin Integrity Moisture Fever Excessive moisture can lead Fever increases metabolic to maceration, a softening of rate, depleting the body's skin that can increase risk of resources and compromising breakdown. skin integrity. Infection Lifestyle Infections disrupt the skin's Factors like nutrition, protective barrier, leading to hygiene, and physical activity inflammation, redness, and all play a role in maintaining potential breakdown. skin integrity. Classification of Wounds Closed Wound Open Wound Acute Wound Chronic Wound A closed wound is a type of An open wound is a type of An acute wound is a type of A chronic wound is a type wound that does not wound that involves a wound that heals within a of wound that does not involve a break in the skin. break in the skin. predictable timeframe. heal within a predictable timeframe. Classification of Wounds Clean Clean/Contaminated Contaminated Infected A clean wound is uninfected A clean contaminated Include open, traumatic Wounds are considered with minimal inflammation wound is a surgical wounds or surgical infected when bacteria incision that enters the GI, incisions in which a major counts in the wound GU or respiratory tract. break in asepsis occurred. tissues are above 100,000 Risk is increased but no The risk of infection is organisms per gram of obvious infection high for these wounds. tissue. However, the presence of beta- hemolytic streptococci, in any number, is considered an infection. Classification of Wounds Superficial Partial-thickness Full-thickness Penetrating Wounds involve only the Extend through the Extend into the Added to indicate the epidermal layer of the epidermis but not through subcutaneous tissue and wound involves internal skin. The injury is usually the dermis beyond. organs the result of friction, shearing, or burning Wound Healing Processes Primary Intention- wound involves minimal or no tissue loss and has edges that are well approximated (closed), primary (first) intention healing takes place. Little scarring is expected. A clean surgical incision heals by this method. The healing process aims to restore the integrity of damaged tissue and protect the body from infection. Wound healing is a complex process that involves a series of steps, including inflammation, proliferation, and maturation. Wound Healing Processes Secondary Intention Wound edges are not approximated. Tissue loss occurs. Heals from the inner layer to the surface. Wound healing is slower due to a larger wound area. Higher risk of infection, scarring, and contracture. Wound Healing Processes Tertiary intention healing is a delayed primary closure. This healing occurs when a wound is left open for several days to allow for drainage or debridement. It is later closed by sutures, staples, or other techniques, once the wound is clean and free of infection. Tertiary intention healing involves delayed closure of wound edges. The wound is allowed to granulate for several days to weeks, then closed surgically. This method is common for wounds that are heavily contaminated, have extensive tissue loss, or are at a high risk for infection. Phases of Wound Healing Inflammatory Phase The initial phase involves hemostasis and inflammation. Proliferative Phase The second phase is characterized by granulation tissue formation and epithelialization. Maturation Phase The final phase involves collagen remodeling and wound contraction. Types of Wound Drainage Serosanguinous Serous Purulent Sanguineous Mix of serous and Clear, watery fluid. Normal Thick, yellow, green, or Bloody drainage. Indicates sanguineous drainage. in early stages of healing. brown drainage. May bleeding. Pinkish in color. indicate infection. Complications of Wound Healing Hemorrhage Infection Bleeding from a wound can be a serious Wound infection is a common complication. complication. It can be caused by trauma, Signs of infection include redness, swelling, infection, or poor clotting. pain, warmth, and drainage. Dehiscence Evisceration Wound dehiscence is a separation of wound Evisceration is the protrusion of internal edges. It can occur due to tension on the organs through a wound. It is a serious wound or poor healing. complication that requires immediate medical attention. Complications of Wound Healing Dehiscence Evisceration Partial or total separation of wound layers. Occurs along Protrusion of internal organs through an open wound. surgical incision. Occurs when wound dehisces. Nursing Assessment: Skin and Wounds Focused Skin Assessment Braden Scale Includes visual inspection of the Evaluates six factors to determine skin for color changes, the risk of pressure injury temperature, texture, and development. moisture. A total score of less than 18 Assess for any signs of wounds, indicates a high risk of pressure such as breaks in the skin, injury development. abrasions, or ulcers. Norton Scale Assesses five factors to evaluate the risk of pressure injury development. Factors include physical condition, mental state, activity, mobility, and incontinence. A Wound for Special Consideration: Pressure Injury Pressure Injury Cause Pressure injury is a serious wound that Pressure injury is caused by unrelieved affects 15% of hospitalized patients, and pressure to an area, resulting in ischemia, nurses play a vital role in prevention and a condition where tissue lacks adequate treatment. blood flow and oxygen. Pressure Ulcers: Stage 1 Non-blanchable erythema of intact skin. The area may be painful, firm, or warmer or cooler compared to adjacent tissue. The skin appears reddened and does not blanch. It's the first sign of pressure injury, and early intervention is crucial to prevent progression. Pressure Ulcers Stage II The skin usually breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. Skin may be damaged beyond repair. Pressure Ulcers: Stage III The ulcer extends through the dermis and into the subcutaneous tissue. May have undermining and tunneling, which are pockets of tissue damage that extend under the skin. Fat may show in the sore, but not muscle, tendon, or bone. Pressure Ulcers: Stage IV Tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Deep Tissue Injury (DTI) Sometimes a pressure injury does not fit into one of these stages. Deep tissue injury (DTI) is a pressure injury characterized by persistent, non-blanchable deep red, maroon, or purple discoloration. The injury may be painful, firm, boggy, mushy, warmer or cooler as compared to adjacent tissue. Pressure Ulcers: Unstageable The full depth of tissue damage cannot be determined because it is obscured by slough (yellow, tan, gray, or brown) or eschar (tan, brown, or black) in the wound bed. Before staging, the slough or eschar must be removed to determine the true depth of the wound. Once the slough or eschar is removed, the pressure ulcer can be staged appropriately. Nursing Interventions: Pressure Injury Prevention Meticulous Skin Care Adequate Nutrition Frequent Repositioning Preventing pressure injuries Regular skin care with Proper nutrition, particularly is paramount. Early moisture control, such as with sufficient protein and Repositioning at least every intervention and proactive cleansing and moisturizing, calories, aids in tissue repair 2 hours helps to reduce care are essential. is crucial for maintaining and wound healing. prolonged pressure on bony skin integrity. prominences.  Chapter 38 Nursing Informatics Copyright ©2020 F.A. Davis Company  Elements of Informatics Data: Unprocessed numbers, symbols, words; no context Information: Groupings of data Knowledge: Meaningful information created by grouping and compiling information Wisdom: Appropriate use of knowledge Computers Electronic means of processing information/data Functions Input Process Output Storage Reducing Error With Automation There are different types of errors: Errors of commission-When the wrong action occurs Errors of omission-When the correct action does not occur Errors in planning-When the original intended action or plan was not correct Errors of execution-When the correct action is taken but does not proceed as intended  Benefits of an Electronic Health Record Improves efficiency, productivity, and continuity of care Reduces redundancy Improves accessibility Serves as a clinical support tool Reduces physician order entry errors (CPOE) Privacy Public health benefits  How Informatics Enhances the Nursing Profession Reduces barriers to evidence-based practice Facilitates a literature search Provides online sources for and of nursing research Provides literature databases  Evidence Based Practice How to locate EBP materials Databases Journals by Title CINAHL International journal of MEDLINE nursing sciences Google Scholar Johns Hopkins nursing AWHONN  Chapter 39 Legal Accountability/Leading & Managing Copyright ©2020 F.A. Davis Company State Laws Guiding Nursing Practice Mandatory reporting laws Communicable disease Abuse Good Samaritan laws Differ by state Nurse practice acts Credentialing Licensing Discipline Torts and Nursing Practice Intentional torts Assault and battery Performing a procedure without consent False imprisonment Restraining a client against his or her will Invasion of privacy Breach of confidentiality Fraud Failing to provide essential information for informed consent  Quasi-Intentional Torts Defamation of character is false communication to a third-person Slander is the spoken or verbal form of defamation of character. Libel is the written or published form of defamation of character.  Torts and Nursing Practice Negligence Failure to perform as a reasonable, prudent person would Failure to follow standards of practice No intent to harm is present  Torts and Nursing Practice Malpractice Professional form of negligence Four elements necessary to collect damages Existence of a duty Breach of a duty Causation Damages  Common Malpractice Claims Failure to assess and diagnose Failure to communicate Failure to implement a plan of care Failure to evaluate Minimizing Malpractice Risk Practice proper documentation. Observe standards of practice. Use nursing process; follow professional standards. Avoid medication and treatment errors. Report and document accurately. Obtain informed consent. Attend to client safety. Minimizing Malpractice Risk Maintain client confidentiality. Provide education and counseling. Delegate, assign, and supervise properly. Accept appropriate assignments. Participate in continuing education. Observe professional boundaries. Observe mandatory reporting regulations. Be aware of legal safeguards for nurses. Chapter 41 Ethics & Values  Nursing Ethics Ethical questions that arise out of nursing practice What will your level of participation be in a given ethically challenging situation? Can you support clients’ decisions based on their ethical beliefs? What are your feelings about the results of decisions made by others?  Whistleblowing Identification of an unethical or illegal situation Can involve one person or an entire organization Reporting such an action to someone in authority Need accurate information May have consequences; THINK before you act American Nurses Association (ANA) working to protect whistleblowers  Ethical Principles Autonomy Nonmaleficence Beneficence Fidelity Veracity Justice  Professional Guidelines for Ethical Decision Making Codes of Ethics for Nurses American Nurses Association Standards of care Patient Care Partnership The Joint Commission  Ethics Models Ethics committees usually follow one of three models when discussing a dilemma Autonomy Model Patient Benefit Model Social Justice Model