1st step. Collect data, use evidence-based assessment techniques, document relevant data
What is the assessment stage of the nursing process?
Compare clinical findings with normal/abnormal variation & developmental events, interpret data, validate diagnoses, document diagnoses
What is the diagnosis stage of the nursing process?
Data collecting
A patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient, the nurse is using the process of:
Decision making
The nursing process organizes your approach to delivering nursing care. To provide care to your patients, you will need to incorporate nursing process and:
clinical judgment about the patient in response to an actual or potential health problem
Nursing diagnosis:
identification of a disease or condition based on specific evaluation or signs and symptoms
Medical diagnosis:
establish priorities, develop outcomes, set timelines for outcomes, culturally appropriate, realistic and measurable, include a timeline
What is the planning stage of the nursing process?
Physiological, Safety, Belongingness and Love, Esteem, and Self-Actualization
Levels of Maslow's Hierarchy of Needs in order
Specific, Measurable, Attainable, Realistic, and Timed
When writing goals, use the SMART acronym. What does SMART stand for?
in a safe & timely manner, use evidence-based interventions, collaborate w/ colleagues, use community resources, coordinate care delivery, provide health teaching & health promotion, document implementation and any modification
What is the implementation stage of the nursing process?
reassess the patient
Any time a nurse interacts with their patient, they should always:
progress towards outcomes, conduct criterion-based evaluation, include pt. and significant others, use ongoing assessment to revise diagnoses, outcomes, plan, disseminate results to pt. and family
What is the evaluation stage of the nursing process?
Document the following activities or findings at the time of occurrence:
Vital signs
Pain assessment
Administration of medications and treatments
Preparation for diagnostic tests or surgery, including preoperative checklist
Change in patient status and wh
How to documentation:
Do not erase, apply correction fluid, or scratch out errors made while documenting
Do not leave blank spaces or lines in a nurses note.
Record all legibly and in black ball point pen.
No critical comments, No personal opinions
Correct errors promptly
Reco
Rules of documentation:
True
True or False: Falls at the age of 65 or older are the leading cause of fatal and nonfatal injuries.
a history of falling, being age 65 or older, reduced vision, orthostatic hypotension, lower-extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications.
Factors that increase a pt risk of fall include:
Adequate lighting- orient to surroundings
Remove obstacles from halls and traffic areas
Throw rugs
Necessary patient items on bedside table within reach
Nonessential items away to decrease clutter
No scatter rugs at home or be sure secure with non-skid ba
What are some fall interventions?
all other alternatives did not work.
Restraints are only used if:
MD must order them based on face-face assessment, must specify duration and circumstances, specific time frame based on facility policy, can not be ordered PRN
Restraint Orders:
alarms, side rails; 4 side rails up = restraint,
Alternatives to use before using restraints:
Any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move arms, legs, body, or head.
Restraints are:
long term facilities
Restraints are used in hospitals, but are not used in
pressure ulcers, pneumonia, constipation, death, loss of self-esteem, incontinence
Restraints can cause:
To prevent a patient from falling, prevent interruption of therapy, prevent patients who are confused from removing life support
Why are restraints used?
swelling, heat, redness, tenderness, loss of function
What are the signs of inflammation/infection?
Age- related deterioration of the immune system function (immune senescence)
Decrease capability of producing lymphocytes to fight infection
Poor nutrition, unintentional weight loss, lack of exercise, low serum albumin increase risk of infection
Should g
Why are people, 65+, more at risk for infection?
WASH HANDS!! Get vaccines
What are some interventions to prevent infection?
Skin and shedding = barrier and removes organisms
Mouth and saliva= mechanical barrier and washes away
Eye (tearing and blinking)= reduce entry, wash away organisms
Resp. tract= cilia traps microbes outward to mucus
Urinary tract= washes microorganisms aw
How does the body defend against infection?
pressure ulcers, orthostatic hypotension, thrombus, atelectasis [pneumonia], muscle atrophy, loss of endurance, osteoporosis, joint abnormalities, urinary stasis, renal calculi, altered endocrine metabolism, fear, anxiety, isolation, sensory alterations,
Complications of immobility
Emotional status, Health promotion practices, Health care education needs
Hygiene assessment includes:
bed linens kept dry and free of wrinkles
monitor temp of bath water
Try to maintain patients normal routine
Patients with limited mobility or cognitive impairment need increased skin assessment
Partial bed baths / complete bed baths/Sponge baths/tub bath/
Hygiene interventions include:
a universal phenomenon that influences the way we think, feel, and behave
Define caring in relations to nursing:
Caring helps a nurse provide patient centered care, caring determines what matters to a person, caring is primary
How is caring used in nursing?
decreased elasticity, pigmentation changes, less oil production, slower nail growth, thinning of blood vessel walls, decreased cough reflex, increased systolic BP, decreased peristalsis and intestinal motility, decalcification of bones, loss of ear wax, s
What are some common changes in older adults?
Changes in ADLs. These changes are usually linked to illness or to disease and degree of chronicity.
What are some functional changes in older adults?
generalized impairment of intellectual functioning that interferes with social and occupational functioning. This is a slow onset, develops over months to years. The recent and remote memory are impaired. Difficulty with thinking, answering questions, wor
Define dementia:
1/3 of older adults experience this. Can exist with chronic illness, lasts at least 6 weeks.
People with depression could experience selective disorientation, disturbed sleep-wake cycle, decreased affect, mood changes, give up easily, answers "i don't kno
Define depression:
Sudden abrupt-short duration less than one month. Attention orientation and consciousness is impaired. Recent memory is impaired. Caused by systemic infections, sensory deprivations, unfamiliar surroundings, sleep deprivation, electrolyte imbalance, and m
Define delirium:
4%
What percent of adults live in long-term care facilities?
Does not look like a hospital. Have the patient and family physically go to the nursing home to see it in person. Make sure it is medicare and medicaid certified, has qualified staff, welcomes family visits, clean with no odors, active communication from
When selecting a nursing home it is important to choose one that:
An individual has the opportunity to define the care they want if an illness occurs. Execution of these is dependent on many situations.
What is a living will?
Do not resuscitate (comfort care). A person receives standard medical care until the time he or she experiences a cardiac or respiratory arrest.
What is DNR CC
All extensive measure to resuscitate a person are taken, such as CPR
What is a Full Code status mean?
Situation, Background, Assessment, Recommendation.
What does SBAR stand for?
SBAR is a technique that can be used to facilitate, prompt, and appropriate communication about patients between health care providers.
When is SBAR used?
Is a loss when a person can no longer feel, hear, or know a person or object
What is an actual loss?
A loss that can cause a person to undergo some type of change. When the loss occurs, it is replaced with something better.
What is a necessary loss?
A type of necessary loss that and includes changes that occur across a life span. Ex. a child leaving her mother to go to college.
What is a maturational loss?
A loss that is sudden and unpredictable. Ex. a man in the army having to get his legs amputated.
What is a situational loss?
A loss defined by the person experiencing the loss. It is a less obvious loss to others but is real to that person.
What is a perceived loss?
Denial- a person is not able to accept a loss
Anger- resistance and anger with God and others.
Bargaining- trying to prevent the event from happening, making promises with God
Depression- Overwhelming sadness, hopelessness. Person says "if only I" a lot.
What are the dying stages of Kubler-Ross?
increased periods of sleep, coolness and color change in extremities, bowel or bladder incontinence, decreased urine output, restlessness and disorientation, increased pulmonary secretion, altered breathing patterns, weakness and fatigue
Signs and Symptoms of Death and Dying:
Listen carefully to the patients perceptions
Use culture-specific understanding/developmental stage for appropriate care
Use Professional Standards
Nursing Code of Ethics
Dying Person Bill of Rights
ANA Scope and Standards of Hospice and Palliative Nursin
Overall care of death and dying:
Documentation of death provides legal record of the event. Follow policies and procedures carefully to provide accurate and reliable medical record. Physicians or coroners sign some medical forms such as request for autopsy, but RN gathers and records the
Documentation after death:
Organ and tissue donation- person requesting provides the information about, you can legally give consent, and now donation affects burial or cremation. Nurses provide support and reinforce explanations. Laws govern who to approach for organ donation may
Organ and Tissue Donation after death:
Autopsy- a surgical dissection of the body after death to determine the exact cause and circumstances of death or to discover the pathway of disease.
Family members can consent
Law may require that an autopsy be performed when death is result of foul play
What is an autopsy?
Respect and dignity
Physical changes happen quickly so should be done ASAP
Confirm certified Time of death
Determine if autopsy/organ donation
Identify pt with two identifiers
Elevate HOB to prevent discoloration of the face
Collect ordered specimens
Ask
How to do post-mortem care:
Always through the patient's eyes, ask level of pain on a scale of 0-10, Use PQRSTU. Beware of possible errors in pain assessment, patient's expression of pain, pain is INDIVIDUALIZED to patient.
Pain is characterized by timing, location, severity, and lo
How to assess pain:
Cognitive and behavioral approach, Relaxation and guided imagery, Distraction, Music, Cutaneous stimulation, Cold and heat application, Transcutaneous electrical nerve stimulator (TENS), Sends stimulus right where pain is to block impulse, Herbals, Reduci
Non-pharmaceutical pain interventions/treatment include:
Analgesics- drug acting to relieve pain
Nonopioids- used to treat mild or moderate pain
Tylenols, motrins, nsaids
Opioids-compound that binds to one or more of the three opioid receptors of the body
Narcotics- a drug or other substance affecting mood or b
Acute care for pharmacological pain:
Acute pain is pain experienced for less than 6 months.
Chronic pain is pain experienced for 6 months or more.
Difference between chronic pain and acute pain
Smoking, age, nutrition, obesity, obstructive sleep apnea, Immunosuppression, Fluid and electrolyte imbalance, post operative N&V, venous thromboembolism
Surgical risk factors include:
informed consent, confidentiality, preoperative teaching, preoperative routines, when and where family will be there, explain surgical procedure, confirm they understand the procedure, how long and what expectations are for recovery
Surgical interventions include:
Pain-relief measures, education, Rest, Feelings regarding surgery, Acute care, Minimize risk for surgical wound infection, Antibiotics, Skin antisepsis, Clipping instead of shaving hair, Maintaining normal fluid and electrolyte balance, Fasting before sur
Assessment and interventions for surgical procedures:
A registered nurse that assists with procedures, monitors sterility, and verifies surgical count. Duties are carried out, outside of the sterile room.
What is a circulating nurse?
A registered nurse that maintains sterile field during surgery and assists with procedures, setting up the room before the operation, working with the doctor during surgery (passing instruments) and preparing the patient for the move to the recovery room.
What is a scrub nurse?
pain, fever, hypothermia, vomitting, flatulence, urinary retention, urinary infection, hypoventilation, airway obstruction, pneumonia, hemorrhage, hypertension, infection, hematoma, fluid overload/fluid deficits, electrolyte imbalances
Post-operative complications:
inadequate quality or quantity of stimulation, such as sight or sound for an extended period of time. Being in a hospital can lead to this with cognitive effects.
What is sensory deprivation?
reduced capacity to learn, inability to think, poor task performance, increased need for socialization, boredom, panic, anxiety, changes in visual/motor coordination, reduced color perception, changes in ability to perceive size and shape
What are the effects of sensory deprivation?
blank looks, decreased attention span, no reaction to loud noises, increased volume of speech, head positioning, lip reading.
Behaviors indicating a hearing deficit:
A progressive hearing disorder in older adults.
What is Presbycusis?
Buildup of wax in ears.
What is Cerumen Accumulation?
Malfunctioning biological or psychological processes.
Define disease:
The way that individuals and families react to disease.
Define illness:
Describes and defines the legal boundaries of nursing practice in each state.
The Nurse Practice Act of each state defines the scope of nursing practice and expanded nursing roles, sets education requirements for nurses, and distinguishes between nursing
What is The Nurse Practice Act?
results from judicial decisions concerning individual cases. Most of these revolve around negligence and malpractice.
Define common law:
Protect the rights of individuals and provide for fair and equitable treatment when civil wrongs or violations occur
The consequences of civil law violations are damages in the form of fines or specific performance of good works such as public service.
Nu
Define Civil Law:
Also known as administrative law
Defines your duty to report incompetent or unethical nursing conduct to the Board of Nursing.
Need to give report, cant abandon assignments
Define regulatory law:
Legal guidelines for defining nursing practice and identifying the minimum acceptable nursing care
Best known comes from the American Nurses Association (ANA)
Set by state and federal laws that govern where nurses work
Joint Commission requires policies a
Define Standards of Care:
Legal document to designate a person to make health care decisions when they are not able to
Has to be enacted
Dr. has to say pt. is no longer able to make decisions for themselves
When people have dementia or cognitive impairment, durable power of attorn
What is Durable Power of Attorney?
Civil wrong made against a person or property
What is a tort?
may be actual or it may result from a threatened action such as giving a person an injection or threatening to restrain a patient who refused a procedure
What is assault?
the intentional touching without consent
What is battery?
conduct that falls below the standard of care
What is negligence?
type of negligence and often referred to as professional negligence- when nursing care falls below the standard of care nursing malpractice results
What is malpractice?
A system of ensuring appropriate nursing care that attempts to identify potential hazards and eliminate them before harm occurs
What is risk management?
Ask patient questions about what they consider their normal and abnormal BM to look like. Patient's patterns and habits related to bowel elimination. Ask them about their diet history, exercise, and daily fluid intake. Exam the patients mouth, abdomen, an
Bowel elimination assessment:
Self care ability, patterns of elimination, ask questions about problems urinating, difference in urination during day and night, any burning or urgency, medications patient takes, odor of urine, leakage, how much fluid do they drink.
Urinary elimination assessment:
An awareness of one's inner self and sense of connection to a higher being, nature or some purpose greater than oneself
Define spirituality:
A state of suffering related to the impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself
Define spirituality distress:
Acute illness, chronic illness, terminal illness, near death experiences.
What causes spiritual distress?
Establishing presence, Supportive healing relationship
Mobilize hope, Provide interpretation of suffering that is acceptable to patient., Help patient use resources. Diet therapies, support systems, prayer, meditation, restorative care.
Spiritual care interventions:
involves giving attention, answering questions, having an encouraging attitude, and expressing a sense of trust; "being with" rather than "doing for
Define establishing presence:
therapies used in addition to conventional treatment (aka integrative therapies)
Advances health and well-being through caring-healing relationships
Uses evidence to inform traditional and emerging interventions that support whole-person/whole-systems hea
What is complementary therapy?
Foreign object retained after surgery
Air embolism
Blood incompatibility
Pressure Ulcer Stage III or IV
Falls and trauma
Catheter associated UTI
Vascular catheter-associated infection
Manifestations of poor glycemic control
Surgical site infections follow
What are "Never-Events"?