Nursing Fundamentals Exam 1 Study Guide PDF

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Exam 1 Study Guide Fall 2020

Nursing Fundamentals

[Mark S. (1,2) Katrina P (3), Nick W(4), Maddy M (5,6), Helena Y.X.(7,8),

Katherine C(9), Angelica A(10), Vivian N(11,12), Devan W(13,14), Elizabeth B(15,16), Michelle A(17,18), Gladys A(19,20), Arianna T(21,22), Breann J(23,24), Jared J(25,26), Briana V(27,28), Katia G(29,30), Alejandra L(31,32), Angie V(33,34), Bao Y-C(35,36), Kassandra A(37,38), Lorena D(39,40), Joselyn M(41), Michelle A(42), Samir W(43,44), Lizbeth R(45), Diana N(46)]

1.

Know what to do if your glove gets a tear while you are rendering care ● Take off contaminated pair, perform proper hand hygiene and put on new pair of gloves using proper technique. Put the glove on the dominant hand 1st and then 2nd. 2. Know what it means to prepare a sterile field and what you should keep in mind ● Sterile field: an area free of microorganisms and prepared to receive sterile items (1-in border within sterile field is considered non-sterile). ○ Example: opening sterile packs. ■ Use ABHR or wash hands with soap and water before opening pack. ■ Clean surface to establish sterile field and keep above waist level. ■ Check pack for sterility (expiration date, if intact, any tears, pack should be dry). ■ Open pack from the top and pull to the sides or open away and then towards you, depending on packaging (make sure it is within sterile field). ● Also make sure arm is not above sterile field. ● Make sure to only touch the 1 in tips of the pack/drape. ● Requires a work area in which objects can be handled with minimal risk of contamination. ● A nurse can never turn their back on a sterile field or a sterile tray or leave it unattended.

3.

Know what the chain of infection is and why it is Important to know.

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Chain of Infection Infectious agent or pathogen Reservoir- a place where microorganisms survive and multiply. - Human reservoir (2 types) - 1. Those with acute or symptomatic disease - 2. Those who show no signs but are carriers. Portal of exit Mode of transmission Portal of entry Susceptible host

* A presence of a pathogen does not mean that an infection will occur* * It is important to know because t o prevent germs from infecting more people, we must break the chain of infection. EX) Hand Hygiene. 4. Review communication strategies Verbal - Vocabulary - avoiding medical jargon. Use a translator if needed. If speaking to a child, or teenager, be aware how their vocabulary may vary - Denotative and Connotative meaning - select words carefully so they are not misinterpreted - Pacing - mind your pace, it can affect how the words are interpreted - Intonation - your tone - Clarity and brevity - be concise, speak slow, be clear in your meanings. Don’t say “you know” - Timing and relevance - when you deliver a message is nearly as important as what the message is Non-Verbal - Personal appearance - Posture and Gait - Facial expression - Eye contact - varies by culture - Gestures - Sounds - Territoriality and personal space

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6.

Know what subjective data and objective data are ● Objective data: “what the nurse observes” observable and measurable data that can be seen, heard, or felt by the nurse (ex. temp, BP, or HR) ● Subjective: “what the patient says” information perceived only by the affected patient (ex. pain, feeling dizzy, feeling anxious)

Know Florence Nightingale’s Environmental Theory ● Known as the first nursing theorist; described nursing as a profession that requires its own knowledge (as opposed to medical knowledge) ● Theory founded on belief that nursing could improve a PTs environment to facilitate recovery ● Environmental factors that affect health: fresh air, pure water, sufficient food, efficient drainage, cleanliness of PT and environment, and light (sunlight) 7. Know when you would administer a partial bed bath ● When patient have an accident in bed ● Partial Bed bath that consists of bathing only body parts that would cause discomfort if left unbathed, such as the hands, face, axilla, and perineal area. Partial bath also includes washing back and providing back rub. Dependent patients in need of partial hygiene or self-sufficient bedridden patients who are unable to reach all body parts receive a partial bed bath. 8. Know the concepts of the nursing metaparadigm

● The nursing metaparadigm includes the four concepts of person (or human beings), health, environment/situation, and nursing. ○ Person is the recipient of nursing care, including individual patients, groups, families, and communities. The person is central to the nursing care you provide. ○ Health has different meanings for each patient, the clinical setting, and the health care profession. It is a state of being that people define in relation to their own values, personality, and lifestyle. It is dynamic and continuously changing. ○ Environment/situation includes all possible conditions affecting patients and the settings where they go for their health care. There is acontinuous interaction between a patient and the environment. This interaction has positive and negative effects on a person’s level of health and health care needs. Factors in the home, school, workplace, or community all influence the level of these needs. ○ Nursing includes “care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people” 9.

Know the various types of isolations

•Contact precautions: require a gown and gloves •Droplet precautions: require the wearing of a surgical mask when within 3 feet of the patient, proper hand hygiene, and some dedicated-care equipment •Airborne precautions: requires a specially equipped room with a negative air flow referred to as an airborne infection isolation room . •All health care personnel wear an N95 respirator every time they enter the room

10. Know what interventions should be done for a patient who is in bed and feeling short of breath *use critical thinking skills* (ch 29 pg 483 for a more in depth nursing process) (chapter 41, oxygenation, pg 3092 ) Assessment: Identify pt’s recurring & present signs & symptoms with impaired oxygenation, Determine presence of risk factors for alterations, Know patient’s medications, Know patient’s baseline range of vital signs. Assess the patient’s respirations (rate, rhythm, depth), respirations are tied to numerous functions in the body so consider all possible changes, assess diffusion and perfusion by measuring O2 saturation in the blood (pulse oximeter) and exhaled CO2 throughout exhalation (capnography) Factors influencing oxygenation: physiological (respiratory vs cardiac disorders, hypovolemia, anemia, musculoskeletal abnormalities, obesity, trauma, neuromuscular diseases, etc.), developmental (infants and toddlers at risk for URI, choking hazards, older adults undergo changes: calcification of heart valves, atherosclerotic plaques, vascular stiffening, increased left ventricular wall thickness, few SA nodes, costal cartilage stiffening, etc.), lifestyle (nutrition, hydration, exercise, smoking, substance abuse, stress, etc.), environmental (workplace/occupational pollutants, rural vs urban area living, COPD higher in rural areas, etc.) Diagnosis: Use assessment data to determine the patient’s problem. Possible problems: impaired airway clearance, impaired breathing, impaired gas exchange, environmental irritations, allergic reaction, pulmonary embolism from immobility, impaired cardiac output, activity intolerance, risk for activity intolerance, acute pain Planning/Implementation: develop a plan of care for each nursing diagnosis, set realistic expectations, measurable outcomes (SMART goal). Pts with impaired oxygenation require specific expected outcomes directed toward oxygenation needs (ex. Pt’s respiratory rate between 12-20 breaths/minute, pt achieves bilateral lung expansion, pt breaths without use of accessory muscles) Provide the patient with supplemental oxygen (oxygen  may be given without a physician’s order), sit the patient up in a semi fowler or high fowler position to allow for optimal lung expansion, clear any airway obstructions (example: suction secretions - yankauer), administer bronchodilators if indicated, treat acute pain if causing SOB. Collaborate/consult with physicians, respiratory therapists, other professionals as needed Evaluation: Evaluate effectiveness of interventions implemented and the patient’s response (improve? Worsen? Stayed the same?) Consider physiological changes expected from interventions provided and reassess if indicated

11. Know when different types of hand hygiene are required A. When hands are visibly soiled, wash hands with soap and water B. If hands are not visibly soiled, use alcohol-based hand product or wash hands with soap and water C. Before and after treating each patient e.g. before and after gloving D. After touching instruments, equipment, and other objects that are likely to be contaminated by blood, saliva, or secretions with bare hands E. Before and after leaving a patient’s room F. Before and after using the bathroom G. Before and after eating and drinking 12. Know what HIPAA is and what types of behavior may cause a violation A. Health Insurance Portability and Accountability Act of 1996 (HIPAA)  set standards for the protection and confidentiality of patient's personal health information. B. You can’t share information about a patient’s medical condition or personal information with anyone who isn’t involved in the care of the patient C. HIPAA’s Privacy Rule requires that disclosure or requests regarding health information are limited to the specific information required for a reason. Ex. if you need a patient’s personal phone # to reschedule an appointment, access to the health record is limited solely to telephone information D. HIPAA’s Security Rule specifies administrative, physical, and technical safeguards in place for protected health information (PHI) in electronic form. You must ensure that any electronic written materials in your practice do not include patient identifiers such as name, room number, DOB, demographic info E. Do not print material from an electronic health record (EHR) for personal use. Information that’s printed must be for professional use only and should not include identifiable information F. You can review patient health records only for information required to provide safe and effective patient care ex. You’re assigned to a patient and need to review the patient’s health record and plan of care. Do not share this information with classmates and do not access other patients’ health records on the unit 13. Know what is documented when assessing a patient’s breathing/respirations - Respiratory rate, heart rate, and pulse are documented

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Also document how the person is breathing, is it labored? Are their lips pursed out? Are they wheezing? 14. Know how to provide basic hygiene for the eyes - Like physical assessment, the bath is given from head to toe. The first area to be washed is the inner canthus of each eye; the neck area is the face and neck, after which the bath is given downwards towards the toes. -

When washing the eyes, wash from the corner out NEVER wash from out to in as it will cause irritation and increase likelihood of bacteria getting into the eye leading to an infection. - You can use two seperate wipes for the eyes so that you are not using the same wipe for each eye to reduce spreading any bacteria. 15. Know the principles of assessment, palpation, inspection, percussion and auscultation Inspection- Close, careful scrutiny, first of individual as a whole and then of each body system ● Inspect each area for size, shape, color, symmetry, position, and abnormality ● REQUIRES good lighting, adequate exposure, occasional use of instruments Auscultation- to listen to sound produced by the body ● REQUIRES stethoscope ● Frequency ● Loudness ● Quality ● Duration Palpitation- use of touch to gather information ● Start with light palpation, end with deep palpation Percussion- to tap to produce a vibration o Sound determines location, size, density of structures, and detects superficial abnormal mass 16. Know what to do to get a patient out of bed if the patient has not gotten up for several days ● Assess the patient to see what activities they can physically perform & the skin ● Plan for some ROM activities ● Allow legs to hang over the bed to increase circulation to the feet ● Take patient for a short walk w/ a gait belt ● Evaluate for effectiveness 17. Know the signs and symptoms of localized and system infection ● Systemic ○ Affects entire body instead of just one single organ ○ Can become fatal if undetected and untreated

○ Fever, fatigue, nausea/vomiting,malaise ○ Enlarged, swollen, tender lymph nodes when palpated ● Localized infection ○ Localized symptoms: pain, tenderness, warmth, redness at wound site ○ Most common in areas of skin or mucous membrane breakdown ■ Surgical and traumatic wounds, pressure injuries, oral lesions, abscesses 18. Know what serous, sanguineous, and serosanguineous, purulent, serous are Serous: clear, watery, like plasma Sanguineous: containing red blood cells purulent : containing white blood cells and bacteria, thick and opaque, pus 19. Review how to write nursing diagnosis PES P- Problem (NANDA-1) Example: Impaired physical mobility E- Etiology or related factor Example: incisional pain S- Symptoms of defining characteristics Example: evidenced by restricted turning and positioning Fully constructed nursing diagnosis: “ Impaired physical mobility related to incisional pain as evidenced by restricted turning and positioning” 20. Know the nursing process ADPIE Assessment- identify area of interest or clinical problem Diagnosis- develop research questions/hypotheses Planning- determine how study will be conducted Implementation- conduct the study Evaluation- analyze results of the study 21. Review the various phases of critical thinking Basic level of critical thinking: •The learner trusts that experts have the right answers for every problem •Thinking is concrete and based on a set of rules or principles. Complex critical thinkers: •Begin to separate themselves from experts and analyze the clinical situation and examine choices more independently; thinking becomes more creative and innovative

•Each solution has benefits and risks that you weigh before making a final decision; there are options •You learn to gather additional information and take a variety of different approaches for the same therapy Commitment level thinkers: •Anticipate when to make choices without assistance from others and accept accountability for decisions made 22. Review body mechanics and how a Patient should be moved in bed

23. Know what areas should be assessed when determining activity tolerance in a patient Activity tolerance is the type and amount of exercise or work that a person is able to perform without undue exertion or injury ● Observe patients after ambulation, self-bathing, or sitting in a chair for several hours and assess their verbal report of fatigue and weakness. ● Do they show difficulty breathing or report being short of breath after exercise? ● Assess heart rate and blood pressure response to activity by comparing with baseline rates at rest. ○ Both heart rate and blood pressure should increase. ● When you care for a patient who is relatively healthy and able to exercise regularly, assess what he or she sets as a target heart rate during exercise. ○ Use this finding to determine whether the patient has set an adequate target rate for exercise training

24. Review how to make an occupied bed

See box 40.15 Procedural guidelines for making an occupied bed. There are 43 steps. To summarize those steps: 1. It can be done by assistive personnel but nurse should instruct AP about: a. Any positive or activity restrictions b. Looking for wound drainage or loosened equipment c. When to obtain help, importance of safe patient handling and supporting patient alignment d. Using special precautions for aspiration precautions of tube feeding 2. Gather the equipment (bottom sheet, top sheet, draw sheet, blank, pillowcases, clean gloves, antiseptic cleaner, washcloth) 3. Review medical record for restrictions 4. Organize supplies and give patient privacy 5. Assess environment 6. Perform hand hygiene 7. Explain procedure to patient 8. Raise bed to comfortable height, lower head of bed as tolerated a. If aspiration precaution or has tube feeding, keep HOB 30 degrees or higher at all times 9. Lower side rail, loosen linen, maintain patient privacy and change out the top blankets 10. Position patient turned onto side and facing away from you, then loosen bottom linen and tuck under patient (remove disposable pads) 11. Apply clean linens to exposed mattress (clean mattress first if necessary)-- hem side of sheets should be down 12. Add pad on top of clean linens 13. Roll patient over while patient is aligned (keeping patient covered) 14. Raise side rail and move to opposite side of bed then lower that side rail 15. Remove soiled linen (clean mattress if required) 16. Pull clean sheets toward you and help patient roll back to supine (reposition pillow) 17. Change blankets and make toe pleat, miter the corners 18. Change pillowcase (do not hold against uniform) 19. As changing linens, inspect skiing for irritation and observe patient for fatigue, dyspnea, pain or other discomfort 25. Know the nursing theories of Orem, King, Henderson & Nightingale (p.46-48;10th edition)

Nightingale Environmental Theory- (Grand Theorist)Focused on the patient's environment. Nurses should manipulate(ventilation, lights, noise levels, hygiene and nutrition) so nature is able to restore a patient to health. Orem’s Self Care Deficit Nursing Model-(Grand Theorist) A nurse continually assesses patients ability to perform self-care and intervenes as needed to ensure that patients meet physical, psychological,, sociological, and environmental needs. Patients who participate in self-care are more likely to improve their outcome.Nursing care becomes necessary when they are unable to complete self tasks. ASSESS, INTERVENE, EVALUATE. Henderson Principles and Practice of Nursing- (Grand Theory) Nurses assist patients with 14 activities( breathing,eating, drinking, eliminating, movement, sleep, clothing, body temp, hygiene, safety, communication,play, practice of faith, learning,) until patient can meet their own needs or help patient have a peaceful death. King’s Goal Attainment- (Grand Theory) Nurses view their patients as part of a system. This system (i.e. the nurse, family and friends) help patients become active participants in their care. Through setting goals that are attainable, the patient can help with restoring and maintaining their own health.

26. Know the parts of the PICOT question PICOT format is used as a part of a step by step system to develop EBP. PICOT format assists you in finding the right evidence to answer a question. The aim is to ask a question that contains as many of the PICOT elements as possible.

27. Know the parts of the nursing process a. Assessment i. Gathering data (objective and subjective) b. Nursing Diagnosis/nursing problem i. Differentiates medical and nursing professions- North American Nursing Diagnosis Association International c. Plan

i. Realistic ii. Communicate the plan with pt and family. iii. S.M.A.R.T. goals: E> Specific (simple, sensible, significant) F> Measurable (meaningful, motivating) G>Achievable (agreed, attainable) H>Relevant (reasonable, realistic and resourced, results-based) I> Time bound (time-based, time limited, time/cost limited, timely, time-sensitive) d.

e.

Implementation i. Carry out the plan ii. Document results Evaluation i. Was the plan accomplished? If not you have to revise your plan!

28. Know what is required for the chain of infection to occur Infection occu...