Nursing fundamentals: Final Study guide PDF

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FUNDAMENTALS FINAL EXAM NOTES...

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1. Definition of Nursing: -To promote better health, prevention of illness, collaborative care. Patient is the central focus of all definitions. Includes: physical, emotional, social, and spiritual dimensions. NURSING IS AN ART AND SCIENCE!!! 2. Aims of Nursing- {4 aims} promote health, prevent illness, restore health, and facilitate coping with death and disability. 3. The 4 aims of nursing interrelate by the nurse using: cognitive, technical, interpersonal, ethical/legal abilities or skills. 4. Nurse Role: [health and illness]: Nurses emphasize health promotion activities, wellness-enhancing strategies, and illness prevention activities as important forms of health care because they assist patients in maintaining and improving health. 5. The Nursing Process: -Assessment: collecting comprehensive data about the clients health -Diagnosis: analyze the assessment data to determine the dx or issue -Planning: develop a plan that prescribes strategies and alternatives to attain expected outcomes -Implementation: implements the identified plan -Evaluation-evaluate progress 6. Benner’s stages of Nursing proficiency: –Novice” has no prior experience” –Advanced beginner” new graduation working at his or her first nursing Job” –Competent “develops within 2-3 years of experience on the same job” –Proficient “ Holistic “This nurse has learned from experiences what to expect in certain situations and how to modify plans” –Expert “The Expert operates from a deep understanding of the total situation” uses intuitive grasp of each situation. 7. Historical Perspective/ Pre- Civilization •Belief that good and evil spirits bring health or illness •Physician as medicine man: a member of an indigeneous society who is knowledgeable about the magical and chemical protencies of various substances and skilled in the rituals through which they are administered. •Early Christian period: {nursing has formal and more clearly defined role; deaconesses made visits to the sick during this period[ + leadership. women

made the first visits to sick people, male gave nursing care and buried the dead. Nursing became a respected vocation •Temple and church are used for patients’ care •Characteristic of the 16th century: shift from a religious orientation to an emphasis on warfare, exploration, and expansion of knowledge during this time period. Nursing had a poor reputation; nurses received low pay and worked long hours in unfavorable conditions during this time period. •Historical Perspective/World War II: large numbers of women worked outside the home and became more independent and assertive. Explosion in medicine and technology broadened the role of nurses. Growth of nursing as a professional discipline. •Florence Nightingale: founder of modern nursing, Florence Nightingale established the first nursing philosophy based on health maintenance and restoration. Also wrote books about health care and nursing education. Challenged prejudice against women and elevated the status of all nurses. 8. What are the Models of Health and Illness? •Health Belief Model (Rosenstoch's 1974) –Addresses the relationship between a person’s beliefs and Behaviors •Health Promotion Model (Pender) –Directed at increasing a patient’s level of well-being 9. Healthy People 2020 Goals Looking at the goals, How do you see your role as a nurse? -Attain high-quality longer lives free of preventable disease, disability, injury, and premature death -Achieve health equity, eliminate disparities, and improve the health of all groups -Create social and physical environments that promote good health for all -Promote quality of life, healthy development, and healthy behaviors across all stages 10. Health Promotion, Wellness, and Illness Prevention a. Immunization Programs b. Routine Exercise, Good Nutrition c. Physical Awareness Stress management, Self-responsibility

11. Levels of Preventative Care •Primary Prevention –True prevention that lowers the chances that a disease will

Develop •Secondary Prevention –Focuses on those who have health problems or illnesses and are at risk for developing complications or worsening Conditions •Tertiary Prevention –Occurs when a defect or disability is permanent or Irreversible 12. What is Illness: •A state in which a person’s physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired •Acute Illness –Short duration and severe •Chronic Illness –Persists longer than 6 months 13. Maslow’s Hierarchy of Needs -step 1: Physiological Needs: Includes the need for air, water, food, and sex -step 2: Safety Needs: Includes the need for safety, order, and freedom from fear or threat -step 3: Love & Belonging: love, affection, feelings of belonging, and human contact -step 4: Esteem Needs: self-respect, self-esteem, achievement, and respect from others -step 5: Self-Actualization Needs: need to grow, to feel fulfilled, to realize one’s potential 14. Vital Signs (know all the CONTRAINDICATIONS for all vital signs) - Temperature: [normal: 96.8-100.4] but average is 98.6 - Oral: 96.8-100.4 [average 98.6] - Rectal: ⇡1 degree higher [99.6] - Temporal: ⇡higher [99.6] - Axillary: ⇣lower 0.9-1 [97.6] - Tympanic: 98.6 [same as oral] ------------------------------------------------------*Pulse [average 60-100 bpm] in adults -abnormalities: bradycardia [pulse < 60 bpm] tachycardia [pulse > 100 bpm]

Arrhythmia [irregular pulse rate] -------------------------------------------------------*Respiration: normal [12-20 in adults] -------------------------------------------------------*Blood Pressure -normal 120/80 -abnormal: 220/40 -elevated: 120-129 sys/ 80 or less diastolic ↳stage 1 high BP: 130-139/80-89 ↳stage 2 high BP: 140↑/90↑ ---------------------------------------------------------15. When do we assess vital signs? - Admission - Home visit - Routine schedule - Before & after surgical procedure - Before and after medication administration - When pt reports specific symptoms of physical distress 16. Maintenance of Body Temperature: {ch 30-funds} ↳Thermoregulation: controlled by hypothalamus / “set point” for comfortable temp ↳Anterior hypothalamus controls heat loss -ex: sweating, vasodilation, inhibit heat production ↳ Posterior hypothalamus controls heat production -ex: initiates heat conservation mechanism (vasoconstriction to reduce low to extremities) 17. Heat Production in the Body: ↳ heat produced by the body is a by product of metabolism -ex: food, more food = more heat production ↳ BMR= heat produced by the body at rest -affected by thyroid hormone -male testosterone increases BMR -movement voluntary -shivering 18. What are the Factors Affecting Body (influence normal body temp) A. Individual metabolism differs. An increase in the emotional state of the pt may increase the temperature B. Body temperature is usually lowest in the morning and highest in

the late afternoon or evening. C. Normal temperature for infants and children is usually higher than the normal adult temperature. At birth, heat-regulating mechanisms are not fully developed, so a marked fluctuation in body temperature may occur during the infant’s first year of life. D. In some women, ovulation may be signaled by a slight drop in body temperature 12 to 24 hours before a post ovulation rise in temperature of about 0.4 to 0.8 F. 19. Body Temperature Regulation ↳Neural and vascular control: ↳Heat production: thru metabolism of food (chemically). Food is used as energy by muscle and glands to generate most of the heat in the body. Heat is also gained (physically) from the environment. ↳Heat Loss : cold, shock, and certain drugs, which depress the NS, decreases heat production -radiation- body heat warms surrounding air which rises and is replaced by cooler air -conduction- direct physical contact with an object -convection- when body heat warms surrounding air which rises and is replaced by cooler air -evaporation- perspiration that is removed from the body surface by change from a liquid to vapor ↳ Skin Temperature regulation ↳Behavioral Control: when a person becomes angry or excited, the adrenal glands become very active and the body warms as a result of the action of certain body chemicals such as epinephrine. 20. Risk for Imbalanced Body Temperature: ↳Hyperthermia: overheating of the body, possibly due to extreme weather conditions. Example: heat stroke, heat exhaustion, heat rash, cramps, fainting ↳Hypothermia: the condition of having an abnormally low body temperature, typically one that is dangerously low. ↳Ineffective Thermoregulation: a state in which an individual’s temperature fluctuates between hypothermia and hyperthermia. Damage to the hypothalamic center / seen in pt with spinal cord injury,

traumatic brain injury, stroke, and other conditions that cause damage to the brain stem. 21. Types of Health Assessments •Comprehensive –Conducted upon admission to healthcare facility •Ongoing partial –Conducted at regular intervals •Focused –Conducted to assess a specific problem •Emergency –Conducted to determine fatal conditions 22.Cultural Sensitivity •Culture influences a patient’s behavior •Consider: –Health beliefs –Use of alternative therapies –Nutritional habits –Relationships with family –Personal comfort zone - Avoid stereotyping 23. Techniques of Physical Assessment: [define and give example] -Inspection: critical observation *always first* Ex: observe eyes, ears, nose, look at color, shape, symmetry, odors, skin, etc -Palpation: light and deep touch Ex: back of hand to assess skin temp, fingers to assess texture, moisture, tenderness, sie shape, consistency of legions and organs (deep 5-8 cm/2-3’); Light = 1 cm deep -Percussion: sounds produced by striking body surface ex : produces different notes depending on underlying mass (dull, resonant, flat, tympanic) Used to determine the size and shape of underlying structures by establishing their borders and indicate if tissue is air-filled, fluid-filled or solid, action performed in the wrist. -Auscultation: listening to the sounds produced by the body

Ex: bell picks up low pitched sounds such as heart murmurs 24. CRANIAL NERVES -12 pairs -Originate in the brain -Take impulses to and from the brain -Some are sensory nerves, motor nerves or both 25. Testing of Cranial Nerves •Can I – Olfactory (sensory) Smell and smell interpretation •CN II- Optic Nerve (sensory) Vision, visual acuity, peripheral vision •CN III- Oculomotor (motor) eye movement (EOM) Pupil constriction and eyelid raising •CN IV-Trochlear ( Eye motor) •CN VI – Abducens (motor) –EOM: lateral –Test •6 cardinal fields of gaze •CN VII – Facial (sensory and motor) –Sensory: taste –Motor: facial expression –Test•Ask patient to smile, frown, show teeth, puff cheeks, raise eyebrows CN VIII – Vestibulocochlear/Acoustic (sensory) –Hearing and equilibrium –Test •Weber and rinne •CN IX – Glossopharyngeal (sensory and motor) –sensory: pain, touch, temp –Motor: swallowing –Test •Open mouth and say “AHH” 25. Nursing Process -Assess: Gather information about the client’s condition -Diagnose: Identify the client’s problem -Plan and Identify Outcomes: Set goals of care and desired outcomes and identify appropriate nursing actions -Implement: Perform nursing actions identified in planning -Evaluate: Determine if goals and expected outcomes are achieved 26. Objective Data vs. Subjective Data Objective data –Observable and measurable data that can be seen, heard, or felt

by someone other than the person experiencing them –For example, elevated temperature, skin moisture, vomiting •Subjective data –Information perceived only by the affected person –For example, pain experience, feeling dizzy, feeling anxious 27. Types of Pain -Acute/transient pain ↪protective, identifiable, short duration; limited emotional response -Chronic/Persistent noncancer ↪Is not protective, has no purpose, may or may not have an identifiable cause -Chronic episode ↪occurs sporadically over an extended duration -Idiopathic ↪chronic pain without identifiable physical or psychological cause What is the difference between Urinary retention, Urinary tract infection & Urinary incontinence? ↳ Urinary retention ⇒ the ability to partially or completely empty the bladder ↳ Urinary Tract infection ⇒ an infection that characterized by burning or pain with urination (dysuria), urgency, frequency, foul smelling urine, or hematuria. ↳ Urinary incontinence ⇒ the complaint of any involuntary loss of urine What is the characteristic of urine? ↳ Color ⇒ pale straw color to amber ↳ Clarity ⇒ transparent ↳ Odor ⇒ ammonia odor How does the nurse assess the patient for urinary retention? ↳ by palpating the bladder What is the nurse role after testing? ↳ perineal care, follow up on the lab result How do the nurse collect a sterile sample? ↳ Foley ⇒ clamp the tube below the port, come back in about 15-20mins, clean the port of the foley catheter with antimicrobial swab, insert a syringe and draw about 3 to 5ml of urine, and transfer to the specimen container. ↳ Clean catch urine ⇒ wipe from front to back, urinate and catch the urine midstream into specimen container

How does the nurse teach the patient to reduce the risk of Urinary tract infection? ↳ educate to wipe from front to back ↳ if patient has a foley catheter, educate about foley care ↳ increase fluid intake ↳ do not hold pee ↳ urinate after sex Components of Nutritional Assessment ↳ History taking ↳ Dietary, medical, socioeconomic data ↳ Physical assessments ↳ Anthropometric and clinical data ↳ Laboratory data ↳ Protein status, body vitamin, mineral, and trace element status What is the calorie-dense nutrient for each of the nutrient's elements? ↳ Carbohydrates 4 ↳ Protein 4 ↳ Fat 9 What is the percentage of water in the body? ↳ 60%. Water 2/3 of the body content & more water in the vascular system.

What are the water soluble & fat-soluble vitamin? ↳ Water Soluble B, C ↳ Fat Soluble A, D, E, K What organization published the Dietary Guidelines? ↳ USDA (United States Department of Agriculture) What is the BMR? ↳ Basal Metabolic Rate ⇒ the energy needed at rest to maintain life sustaining activities (breathing, circulation, heart rate and temperature) Metabolism, Catabolism & Anabolism ↳ Metabolism ⇒ all biochemical reactions within the cells of the body ↳ Anabolism ⇒ building of more complex biochemical substances by synthesis of

nutrients ↳ Catabolism ⇒ breakdown of biochemical substances into simpler substances; occurs during physiological states of negative Why do the patients receive TPN? ↳ Patients unable to digest or absorb enteral nutrition or are in highly stressed physiological states such as sepsis, head injury or burns. What is the main nutrients in TPN? ↳ major electrolytes ↳ Vitamins ↳ mineral How do we monitor TPN? ↳ Assess for initial placement (X-rays) ↳ Assess for nutritional needs using lab Value ↳ Pharmacy will deliver the TPN ↳ Verify patients equipment and tubes & labels ↳ Use aseptic technique to connect and dressing change for central lines or pick line per facility protocol or PRN ↳ Monitor for complications ↳ TPN is adjusted according to lab values (weekly) How is TPN administer? ↳ Peripheral or central line Exercise and activity ↳ Friction ⇒ force that occurs in a direction to oppose movement ↳ Exercise and activity ↪ Activity tolerance ↪ Isotonic exercises ↪ Isometric exercises ↪ Resistive isometric exercises Voluntary movement is a combination of isotonic and isometric contractions Isotonic exercise ↳ Exercise when a contracting muscle shortens against a constant load, as

when lifting a weight. Isotonic exercise is one method of muscular exercise. Examples of isotonic exercise include squats, stair climbing, bicep curls and push-ups. Benefits ↳ Increased muscle strength and size ↳ Adding mass by using heavy weights and increasing resistance over time ↳ Improved range of motion in functional movements ↳ Training your body in movements required for daily activities Isometric exercise ↳ are contractions of a particular muscle or group of muscles. Benefits ⇒ Can be performed with little or no equipment ⇒ Can build muscle size when performed with weights ⇒ Builds strength in specific muscle groups ⇒ Aids in rehabilitation & Improves joint flexibility ⇒ May be performed seated, making exercises beneficial for the elderly and others with mobility challenge What are the factors influencing sleep? ↳ Drugs and substances (Rx meds, L-tryptophan in milk) ↳ lifestyles (rotating work shifts) ↳ usual sleep patterns (sleep deprivation, jet lag) ↳ emotional stress (Nursing school, exams, personal issues) ↳ environment (Noise, construction, alarms, equipments) ↳ exercise and fatigue (Exercising 2 hours or or more before bedtime) ↳ food and calorie intake (Eating a large, heavy, and/or spicy meal at night, caffeine, alcohol, nicotine) Stages of the Adult Sleep Cycle: ↳ NREM stage 1: few minutes, lightest level of sleep, easily awakes ↳ NREM stage 2: lasts 10 to 20 min, relaxation, body function continue to slow ↳ NREM stage 3: 15-30 min, initial stage of deep sleep. Vital sign declines, hard to wake ↳ NREM stage 4: 15-30 min. Deepest stage of sleep ↳ REM sleep: 90 minutes after sleep has begun, duration increase w/each cycle and average 20min. Dreaming occurs, rapid eye movement.

Sleep disorders: ↳ Insomnia (difficulty sleeping) ↳ sleep related breathing disorder (primary & obstructive sleep apnea) excessive daytime sleepiness ↳ hypersomnolence (excessive sleepiness) ↳ narcolepsy (Cataplexy passing out asleep) ↳ parasomnias (sleep walking) What is the nursing care of sleep disorders: ↳ sleep apnea - lifestyle changes, encourage to see Sleep Specialist for treatment ↳ insomnia - assess the patients sleeping pattern and help to develop a sleeping plan. Provide a dark, quiet, and comfortable environment for the patient to sleep in. ↳ narcolepsy - scheduling daytime naps ↳ parasomnias - encourage to sleep downstairs What are the factors affecting bowel elimination? ↳ Age (Infants w/ small intestine, older individuals have difficulty swallowing) ↳ diet (Fiber and veggies) ↳ fluid intake (Fluid intake affects characteristics of feces) ↳ physical activity (Promotes peristalsis) ↳ psychological factors (Depression affects peristalsis) ↳ personal habits ↳ position during defecation ↳ Pain ↳ pregnancy ↳ surgery & anesthesia ↳ medications What are the common problems for bowel elimination? What is the management? ↳ constipation, impaction, diarrhea, incontinence, flatulence, hemorrhoids problems because of physiological changes in the GI tract such as abdominal surgery, inflammatory disease, medications, emotional stress, environmental factors. ↳ management; bowel training, fluid and food intake, regular exercises What are the safety guidelines for nursing skills in bowel elimination and ostomy care? ↳ self administer enema to use side-lying position. CAN be delegated

to NAP, but nurse is responsible to assess pt for positioning, comfort, stable vital sign procedures. ↳ if patient has cardiac disease or is taking cardiac or hypertensive meds, obtain a pulse rate, because manipulation of rectal tissue stimulates the vagus nerve and sometimes causes a sudden decline in pulse rate. ↳ ostomy care: empty @ ⅔ - ½ full, change 3-7 days, assess color (pink or red) What is the nurse role in the process of inserting and maintaining a nasogastric tube? ↳ Only the RN may insert and maintain the NG tube however, RN may delegate the CNA or others to point out signs of discomfort or help with bed position. ↳ Check for residual ↳ Withhold feeding if GRV is 250-500

What is sensory deprivation? ↳ Sensory Deprivation - Reduced sensory input from the internal/external environment What is the plan of care for a patient who suffers from Aphasia? Pg. 252 (ATI) ↳ Aphasia - Loss of ability to understand/express speech, caused by brain damage. --------GOAL: pt communicate nonverbally-----IMPLEMENTATION: use pen/paper Care for patient who has: ↳ Sensory deprivation or sensory overload - Minimize overall stimuli & provide meaningful stimulation ↳ Hearing impairment - Use flashing lights instead vs. a warning sound for alarms & doorbells ↳ Visual impairment - Remove rugs - Walking pathways clear - Stairways well lit with secure handrai...