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Fundamentals Summer 2017 Exam #1 Material Chapter 1 – Nursing Today Chapter 2 – The Health Care Delivery System Chapter 3 – Community-Based Nursing Practice Chapter 4 – Theoretical Foundations of Nursing Practice Chapter 5 – Evidence-Based Practice Definition of Nursing- according to the American Nurses Association (ANA), the protection, promotion and optimization of health and abilities o Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities (sick or well) o Promotion of health, prevention of illness, care of ill, disabled and dying people o Advocacy, promotion of safe environment, research, participation in shaping health policy and in patient and health systems management and education Science and Art of Nursing o Scope and Standards of Practice o Standards of Practice → a competent level of nursing care; the nursing process ● Assessment, Diagnosis, Outcome Identification, Planning, Implementation (Coordination of Care, Health Teaching and Health Promotion, Consultation, Prescriptive Authority and Treatment), Evaluation o Standards of Professional Performance → provide a method to assure patients that they are receiving high-quality care, that the nurses must know exactly what is necessary to provide nursing care and that measures are in place to determine whether nursing care meets the standards ● Ethics, Education, Evidence-Based Practice and Research, Quality of Practice, Communication, Leadership, Collaboration, Professional Practice Evaluation, Resources, Environmental Health o Code of Ethics → philosophical ideals of right/wrong that define the principles you will use to provide care to patients o Professional Responsibilities and Roles ● Caregiver ● Advocate ● Educator ● Communicator ● Manager ● Career Development ● Provider of Care ● Advanced Practice Registered Nurses ▪ Clinical Nurse Specialists (CNS) ▪ Nurse Practitioner (NP) ▪ Certified Nurse-Midwife (CNM) ▪ Certified Registered Nurse Anesthetist (CRNA) ● Nurse Educator ● Nurse Administration ● Nurse Researcher o Autonomy and Accountability Historical Highlights o Florence Nightingale: Crimean War, first practicing nurse, was only a nurse for 3 years; developed first organized program for training nurses o Clara Barton: Civil War, founder of the American Red Cross o Mother Bickerdyke: organized ambulance services and walked battlegrounds at night looking for injured soldiers

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Dorothea Dix: organized hospitals, supplies to the troops Lillian Wald & Mary Brewster: opened Henry Street Settlement in NYC, which focused on health of poor people Mary Mahoney: first professionally trained African American nurse Mary Adelaide Nutting: became first nursing professor at Columbia Teacher’s College

Professionalism in Nursing- comportment o Administer quality patient-centered care o Practice in a safe, conscientious and knowledgeable manner o Responsible and accountable to yourself, your patients and your peers o Always performing the way a prudent nurse would → doing the right thing at the right time Needs for the Nursing Profession o Requires basic liberal foundation and extended education o Has a theoretical body of knowledge → defined skills, abilities and norms o Provides a specific service o Have autonomy in decision making and practice o Has a code of ethics of practice ● To be an expert, the nurse must know how to modify the care depending on the pathology and treatment while considering the patient’s unique needs and personality ANA Standards of Nursing Practice → The Nursing Process o Assessment o Diagnosis o Outcome Identification o Planning o Implementation o Evaluation Nursing Education o Registered Nurse → take and pass the NCLEX o Board of Certification o Post grad options o Continuing education Evolving Health Care – Challenges o Decrease costs o Maintain high-quality care more efficiently o Improve access and coverage o Encourage healthy behaviors o Proactive healthcare vs reactive o Health prevention and maintenance Issues and Changes in Health Care Delivery o Nursing shortage o Competency o Quality and safety in health care → patient satisfaction o Quality Improvement Programs ▪ PDSA = Plan, Do, Study, Act o Magnet recognition program o Nursing informatics and technological advancements Evolving Health Care o Health Care Plans o Health Care Services ● Health promotion and prevention → primary care

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● Preventative care → screenings, immunizations ● Secondary acute care → emergency care ● Tertiary care → intensive care ● Restorative care → rehabilitation ● Continuing care → assisted living Community-based health programs ● Healthy People Initiative ● Healthy People 2020 Coordination of care Utilize services appropriately

Public Health Nursing – Vulnerable Populations o Individuals living in poverty o Older adults o Poverty or homeless o Immigrants o Individuals being abused/neglected o Substance abusers o Individuals with severe mental illness Responsibility of the Public Health Nurse o Health promotion for population o Screenings for early detection o Diseases prevention o Pediatric patients o Immunizations o Education o Infectious/communicable diseases Quality and Safety Education for Nurses (QSEN) o Patient-Centered Care o Teamwork and Collaboration o Evidence-Based Practice o Quality Improvement o Safety o Informatics Theory-based nursing practice- important for designing and implementing nursing interventions; describe, explain, predict and/or prescribe nursing care measures; give well-grounded rationales for how and why nurses perform specific interventions and for predicting patient behaviors and outcomes Nursing Theory- contains a set of concepts, definitions and assumptions or propositions that explain a phenomenon o Phenomenon o Concepts o Definitions o Assumptions Nursing Theories o Nightingale’s Environmental Theory → first nursing theory, a patient’s environment, which nurses should manipulate so nature is able to restore a patient to health o Hildegard Peplau’s Interpersonal Theory →nurses help patients reduce anxiety by converting it into constructive actions, develop therapeutic relationships with patients o Dorothea Orem’s Self-Care Deficit Nursing Theory → a nurse continually assess a patient’s ability to perform self-care and intervene as needed to ensure that the patients meets physical, psychological, sociological and developmental needs

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Madeleine Leininger’s Culture Care Theory → need to focus on culture in nursing as she predicted that nursing and health care would become more global

Nursing Theory and Nursing Research o Builds the scientific knowledge base of nursing, which is then applied to practice o The discipline learns to what extent the theory is useful to provide information to improve patient care o Components in a theory drive the research questions and research studies o Sometimes research identifies new theories o Nursing relies on knowledge gained from practice and reflection on past experiences ● More research, the better care we can provide A Case for Evidence o Nurses practice is an “age of accountability” in which quality and cost issues drive the direction of health care o Technology: general public is more informed about a facility’s/provider’s health and medical errors, statistics, outcomes etc. o Evidence-Based Practice: EBP; help guide nurses to be more effective, timely and make appropriate clinical decisions; patient receives the best possible treatment ● Best evidence = best practices at the patient’s bedside ● Problem-solving approach to patient care ● Where do we find the evidence? ▪ Textbooks ▪ Journals → peer-reviewed ▪ Internet ▪ Conduct our own research Challenges of Evidence-Based Research o Very best o Most current o Accurate information o At the right time when needed for patient care o Banishing “sacred cows” → doing it because it’s the way it’s always been done Steps for Evidence-Based Practice o Cultivate a spirit of inquiry o Ask clinical questions o Collect most relevant and best evidence o Critically appraise the evidence o Integrate evidence with your expertise and patient preferences when making a change in care o Evaluate the practice change o Share the outcomes of EBP change with others Chapter 27 – Patient Safety and Quality Safety- the condition of being safe from undergoing or causing hurt, injury or loss; basic human need; nurses attend to safety needs: o Of clients in all health care settings o Of themselves Quality and Safety Education for Nurses (QSEN)- future nurses need knowledge, skills and attitudes to promote safety; “culture of safety”; continuous improvement is essential; QSEN minimizes risk of harm to patients and providers by: o System effectiveness o Individual performance

Environment- factors that affect the life and survival of the patient; safe environment gives protection to patient, staff Basic Human Needs- safety begins by meeting these needs o Oxygen: low/high concentration, carbon monoxide o Carbon Monoxide Poisoning: produced by burning fuel (gas, wood, oil, kerosene) ▪ Prevention: carbon monoxide detector, avoid use of gas oven or range to heat home, avoid indoor use of kerosene, insure adequate ventilation of gas and wood burning appliances, avoid running gasoline powered engines in confined spaces ▪ Treatment: 100% humidified oxygen, hyperbaric oxygen chamber o Nutrition: proper storage/refrigeration, preparation area o Temperature: person’s comfort zone for a room is between 65-75 F, normal, hyperthermia, hypothermia (core body below 95 F) Nutrition- FDA is responsible for enforcement of federal regulations (manufacture, processing, distribution of foods, drugs, cosmetics) o Food poisoning → each year 5,000 people die from foodborne illness in the US o Hepatitis A → spread through feces or blood o Botulism → causes paralysis, bad canning procedures, honey, vegetables Potential Hazards o Lightning → indoors and outdoors o Obstacles → tripping o Bathroom hazards → falls, burns o Security → smoke detectors Transmission of Pathogens- prevent by #1 aseptic practice, #2 immunization Pollution- harmful chemical or waste material discharged into the water, soil or air; air/land/water/noise pollution Bioterrorism- use of biological agents; Ricin, Anthrax; CDC has info and emergency preparedness Factors Influencing Patient Safety- developmental level (ability to understand and follow instructions), sensory state (balance, neuropathy, blindness), cognitive state, lifestyle choices, knowledge of common safety precaution Risks at Developmental Stages o Infant, Toddler, Preschooler: injuries are the leading cause of death in children over age 1 o School Aged Child: strangers, sports safety, bicycle injuries (helmet), traffic accidents o Adolescent: develop a sense of identity, peers have stronger influence, risk takers o Adult: lifestyle habits (drinking, smoking, drugs), stress level (headaches, GI disorders, IVS, infections) o Older Adult: falls, accidents (burns, car accidents) Most Common Causes of Death in US o Heart disease: 597,689 o Cancer: 574,743 o Chronic lower respiratory diseases: 138,080 o Stroke (cerebrovascular diseases): 129,476 o Accidents (unintentional injuries): 120,859 o Alzheimer's disease: 83,494 o Diabetes: 69,071 o Nephritis, nephrotic syndrome, and nephrosis: 50,476 o Influenza and Pneumonia: 50,097 o Intentional self-harm (suicide): 38,364 Safety Hazards in the Health-Care Facility- falls, equipment-related accidents, fires/electrical hazards, restraints, side rails, medication errors (Patient Safety Goals and Standards – developed by The Joint Commission)

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Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Prevent mistakes in surgery o Prevention is Key: fall risk assessment, increase frequency of rounds, orient the person to surroundings, place disoriented patients close to the nursing state, increase toileting of patients, place call bell within reach, keep beds in low position, encourage family members to stay

Safety Hazards in the Home o Poisoning: household chemicals, lead, medicines, cosmetics, prescription drugs o Prevention: cabinet locks, store poison high, keep poison control telephone number available o Treatment: depends on type of poison ingested, antidotes, charcoal o Scalds and Burns: hot water, grease, sunburn, cigarettes o Prevention: guardrails by fireplace, turning pot handles, care with candles, sunscreen, care when warming food in microwave o Fires: cooking fires, smoke inhalation, home heating equipment o Prevention: smoke alarms, caution with cigarettes, fire extinguisher, no candles unattended, safety with holiday lights, care with electrical cords o Falls: prevalent in those >65 years; slippery floors, tubs; low toilet seat, high bed, throw rugs o Prevention: nonskid shoes, tidy clothes, proper lighting, grab bars/rails, no scattered rugs o Firearms Injuries: youth suicides, domestic violence o Prevention: firearms safety education for parents/children, proper locked storage, keep ammo separate from firearms o Suffocation/Asphyxiation: drowning, choking, smoke/gas inhalation; children 0-4 years old high risk o Prevention: watch for small, removable parts, cut food into tiny pieces, attention to mobiles, strings, cords, plastic bags, barrier to pool, know Heimlich maneuver o Hazardous Toxins: transported from the workplace to home; direct skin-skin contact, arthropod vectors, transmission inhaled “Never Events” o The National Quality Forum (2011): list of events health care providers look at for patient safety initiatives, serious reportable events; healthcare-acquired events; never should happen; Medicare will not pay o Surgical Events o Patient-Protection Events o Care-Management Events o Product or Device Events o Environmental Events o Criminal Events o Foreign object left in patient, air embolism, administering wrong type of blood Safety and the Nursing Process o Assessment o Through the patient’s eyes o Patient’s home environment o Assessment questions → activity and exercise, medication history, history of falls, home maintenance and safety o Nursing history o Health care environment → risks in immediate environment, risk for falls, risk for medication errors, disaster preparedness o Diagnosis: gather data from your nursing assessment and analyze clusters of defining characteristics to identify relevant nursing diagnoses; include specific related or contributing factors to individualize your nursing care. nursing diagnoses for patients with safety risk: o Risk for falls

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o Impaired home maintenance o Risk for injury o Deficient knowledge o Risk for poisoning o Risk for suffocation o Risk for trauma Planning: o Goals and Outcomes: prevent and minimize safety threats, are measurable and realistic, may include active patient participation o Setting Priorities o Teamwork and Collaboration: with the patient, the family, and other disciplines such as social work and occupational and physical therapy becomes an important part of the patient’s plan of care Implementation: Prevention o Falls o Fires and electrical hazards → Code Red ▪ RACE ● R = Rescue ● A = Activate ● C = Confine ● E = Extinguish o Avoid using restraints → most invasive, last resort o Hazardous material spills o Violence o Nonskid slippers o Adequate lighting o Clean dry floors o Client and family education o Identify medications that increase the risk of falling o Equipment related accidents → bed alarms fail, infusion pump fail, wheelchairs/bed not locked during transfer of patients o Avoid clutter in patient rooms Evaluation: through the patient’s eyes (are the patient’s /family’s expectations met?), patient outcomes (monitor care by the health care team, measure outcomes for each diagnosis, continually assess needs for additional support)

Falls- a big concern in healthcare facilities (most common incident reported) o Risk factors for falls o Poor vision o Cognitive impairment o Difficulty with walking and/or balance o Orthostatic hypotension o Weakness or dizziness o Drowsiness from medication o Morse Fall Scale o History of falling o More than 1 diagnosis o Use ambulatory aids o IV o Mental status o Hendrick II Fall Risk Scale Restraints- any device that restricts a patient’s voluntary movement or access to his body that can’t easily be removed by the patient; do not use a double knot, use quick release, avoid restraints when possible, must be removed every 2 hours o Types of Restraints

Physical force by another person Mechanic device → side rail, material ▪ Side rails may lead to serious falls/injuries; a full length side rails is considered a restraint when it is used to prevent the patient from getting out of bed ▪ A half or quarter length upper side rail can be an aid to independence o Chemical restraint → medication such as a sedative or psychotropic agents Use of Restraints: The Joint Commission patient safety standards aim to reduce use of restraints; healthcare facilities need to comply with these standard; must comply with agency policy, state laws, doctor’s orders; must be renewed every 24 hours; restraint supervision, monitoring, documentation A restraint must be medically ordered and other less restrictive interventions are attempted before resorting to restraint use Used as safety measure but research has shown that restraints are often a safety hazard → bed alarms are a good alternate o o

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Motor Vehicle Accidents- failure to use seatbelts, use of alcohol/drugs, distractions, pedestrian accidents; leading cause of death in US o Prevention: be a cautious pedestrian, use designated seat belts, proper age-dependent restraints for children Community-Acquired Pathogens o Food-borne (food poisoning) o Prevention: pooper storage, cleaning, and cooking of foods, clean cooking surfaces o Vector-borne o Prevention: drain standing water, insect repellents, protect skin contact with insects, wipe out breeding areas o Water-borne Pathogens o Prevention: sanitation, private wells o Pollution: harmful chemical or waste material discharged into the air, water or soil o Electrical Storms: death from lightning strikes is the most common cause of weather related fatalities o Prevention: lowest spot possible, in large building, away from water, no use of metal objects Hazards to Healthcare Workers o Back Injury: nursing has one of the highest rates of back injuries in all professions, 52% of nurses complain of chronic back pain o Needle stick Injury: increases risk for diseases such as Hepatitis B and AIDs o Radiation Injury: ionizing Radiation used in the Operating Room, CT Scans and other diagnostic studies o Workplace Violence Prevention of Hazards- body mechanics, sharps awareness, proper disposal, radiation precautions, environmental awareness of personal safety, bioterrorist attack o Use proper lifting & body mechanics techniques o Realistic assessment of your ability o Use assistive devices and help from others o ANA position paper (2005) “manual patient handling should be used only in exceptional situations when it cannot be avoided Incident Reports- “occurrence report”; formal record of an unusual occurrence (falls, med errors, needle sticks, behavior by another HCP, non-adherence to protocol, safety issues); used to track problems and identify areas of quality improvement; typically filled out by the person observing the incident or the person discovering problem o Use objective terms o Quote the patient or persons involved if possible o Avoid coming to conclusions or casting blame o Do not document that an incident report was completed. o Fill out in objective manner, state facts only

Chapter 28 – Immobility

Body Mechanics- maintaining balance, posture and body alignment during lifting, bending, moving and performing activities of daily living (ADL’s), maintaining good body mechanics will reduce the risk of injury o Body mechanics is the utilization of correct muscles to complete a task safely and efficiently, without undue strain on any muscle or joint o The wider the base of support, the greater the stability of the nurse o...