Fundamentals of Nursing - Final Exam Review

Fundamentals of Nursing – Final Exam Review Make sure you review your vocabulary words. You are expected to know them, even if they are not included in this study guide. (Please review those words included on the vocab tests that we did not have. All those words are included in the chapters we went over, so you must know them) Chapter 4 – Legal Aspects of Nursing  Selected legal aspects of Nursing practice 53-58 o Informed consent—agreement by a client to accept a course of treatment or a procedure after being provided complete information, including the benefits & risks of treatment o Express consent—either an oral or written agreement o Implied consent—individual’s nonverbal behavior indicates agreement o Delegation—process of nurse to direct another person to perform nursing tasks & duties Chapter 10 – Critical Thinking & Clinical Reasoning  Purpose of Critical Thinking – pg 144 o Nurses use knowledge from other subjects and fields o Nurses deal with change in stressful environments o Nurses make important decisions  Creativity: thinking that results in the development of new ideas & products  Attitudes that Foster Critical Thinking – pg 148 o Independence o Fair-mindedness o Insight into Egocentricity o Intellectual Humility o Intellectual Courage to Challenge the Status Quo and Rituals o Integrity o Perseverance o Confidence o Curiosity Chapter 11 – Assessing  Collecting Data – pg 159 o Types of Data – pg 160  Subjective – symptoms/states Objective – signs/see Types of Assessments – Table 11-3 (p. 161)  Examples of Subjective and Objective Data – Table 11-4 (pg 163) Sources of Data – p. 161 o Client; best source, unless ill, young, or confused o Support people; family members, friends & caregivers o Client records; documented by various healthcare professionals o Healthcare professionals; verbal reports from other health care professionals o Literature; professional journals & reference texts   Read ALL red Clinical Alert! Boxes   Validating Data – 171 o Validation: act of “double-checking” or verifying data to confirm that it is accurate and factual o Cues: subjective or objective data that can be directly observed by nurse; that is, what the client says or what the nurse can see, hear, feel, smell or measure o Inferences: nurses’ interpretation or conclusions made based on the cues (nurse observes the cue that an incision is red, hot, swollen; the nurse makes inference that incision is infected) Chapter 12 – Diagnosing  NANDA Nursing Diagnoses  Definitions – 175 o Diagnosis: statement or conclusion regarding the nature of a phenomenon  Diagnostic label (the standardized name from the NANDA book – this is the patient’s PROBLEM)  Etiology (causal relationship – related to statement; the cause of the problem)  Nursing Diagnosis (the nursing diagnosis is the entire 3 part statement)—causal relationship between a problem & its related or risk factors   Status of the Nursing Diagnoses Components of a NANDA Nursing Diagnosis o The Problem (diagnostic label from the o  NANDA book) The Etiology – the cause of the PROBLEM  The Defining Characteristics – your “As evidenced by” statement. This comes from the data (objective and subjective) you collected. This is where you tell me how you know the patient has that PROBLEM  Your Nursing Diagnosis Statement will be formatted like this: The problem (diagnostic label) related to (etiology) ----- as evidenced by (defining characteristics)--- Differentiating Nursing Diagnoses from Medical Diagnoses – 177 o Independent functions : areas of healthcare that are unique to nursing & separate & distinct from medical management o Dependent functions : nurses obligated to carry out physician-prescribed therapies & treatments Chapter 13 – Planning  Types of nursing interventions – 200 o Independent Interventions : activities that nurses are licensed to initiate on the basis of their knowledge & skills o Dependent interventions : activities carried out under the orders or supervision of a licensed physician or other health care provider authorized to write orders to nurses o Collaborative interventions : actions the nurse carries out in collaboration with other health care teams Chapter 14 – Implementing and Evaluating  Evaluating (DID IT WORK, NEED IMPROVEMNET/CHANGE, GOAL MET) o You must have an understanding of the Evaluation phase of the nursing process in order to provide the best care for your patient. Review this entire section “Evaluating” on pg 210-214.  Relationship of Evaluating to other nursing process phases – p. 211 o Assessment data must be accurate and complete so that the nurse can formulate appropriate nursing diagnosis and desired outcomes  Process of Evaluating client responses o Collecting data—using the clearly stated, precise, and measurable desired outcomes as a guide, the nurse collects data so that conclusions can be drawn about whether goals have been met. //Necessary to collect both objective and subjective o Comparing data with desired outcomes—if two parts of the evaluation process have been carried out effectively, it is relatively simple to determine whether a desired outcome has been met//both the nurse and client play an active role in comparing client’s actual responses with desired outcomes o Relating nursing activities to outcomes— determining whether nursing activities has any relation to outcome o Drawing conclusions about problem status —uses the judgement about goal achievement to determine whether the care plan was effective in resolving, reducing, or preventing client problems o Continuing, modifying, or terminating the nursing care plan—nurse modifies care plan as indicated Chapter 15 – Documenting and Reporting  Ensuring Confidentiality of Computer Records – 222 A personal password is required to enter and sign off computer files. Do not share this password with anyone, including other health team members. o After logging on, never leave a computer terminal unattended. o Do not leave client information displayed on the monitor where others may see it. o Shred all unneeded computer-generated worksheets. o Know the facility’s policy and procedure for correcting an entry error. o Follow agency procedures for documenting sensitive material, such as a diagnosis of AIDS. o Information technology (IT) personnel must install a firewall to protect the server from unauthorized access. SOAP notes – pg 225—subjective data, objective data, assessment & planning o Subjective data consists of information obtained from what the client says o Objective data consist of information that is measured or observed by use of the senses o Assessment is the interpretation or conclusions drawn about the subjective and objective data o Planning is plan of care designed to resolve the stated problem o   General Guidelines for Recording – understand your legal obligation for recording information into the patients record (p. 232-236) o Date & Time—essential legal reasons & client safety o Timing—documenting done ASAP, after an assessment or intervention—no recording done before providing nursing care o Legibility—must be legible and easy to read to prevent interpretation errors o Permanence—dark ink so that record is permanent, and changes can be identified Chapter 19…. See end of this document Chapter 29 – Vital Signs  Assessing body temperature – 481 o Body temperature reflects the balance between the heat produced and the heat lost from the body, and is measured in heat units called degrees. o There are two kinds of body temperature:  core temperature: temperature of deep tissue of the body, such as abdominal cavity & pelvic cavity  surface temperature: temperature of the skin, subcutaneous tissue, & fat The most common sites for measuring body temperature are oral, rectal, axillary, tympanic membrane, and skin/temporal artery. Assessing the Pulse – 488 o  o A pulse is commonly assessed by palpation (feeling) or ausculta- tion (hearing). 1. Temporal, where the temporal artery passes over the temporal bone of the head. 2. Carotid, at the side of the neck where the carotid artery runs between the trachea and the sternocleidomastoid muscle. 3. Apical, at the apex of the heart. 4. Brachial, at the inner aspect of the biceps muscle of the arm or medially in the antecubital space. 5. Radial, where the radial artery runs along the radial bone, on the thumb side of the inner aspect of the wrist. 6. Femoral, where the femoral artery passes alongside the inguinal ligament. 7. Popliteal, where the popliteal artery passes behind the knee. 8. Posterior tibial, on the medial surface of the ankle where the posterior tibial artery passes behind the medial malleolus. 9. Dorsalis pedis, where the dorsalis pedis artery passes over the bones of the foot, on an imaginary line drawn from the middle of the ankle to the space between the big and second toes.  Assessing respirations – 497 Resting respirations should be assessed when the client is relaxed because exercise affects respirations, increasing their rate and depth. o The rate, depth, rhythm, quality, and effectiveness of respira- tions should be assessed.  Assessing Blood pressure – 501 o Blood pressure is measured with a blood pressure cuff, a sphygmomanometer, and a stethoscope.  Table 29-1 Advantages and disadvantages of sites used for body temperature measurements (p 481)  Pulse sites – Figure 29-13  Table 29-3 Reasons for using specific pulse sites (p. 488)  Skill 29-2 Assessing a peripheral pulse (p. 489)  Skill 29-6 Assessing a blood pressure Chapter 30 – Physical Assessment  General Survey 519-522 o Health assessment begins with a general survey that involves observation of the client’s general appearance, level of comfort, and mental status, and measurement of vital signs, height, and weight Skill 30-6 Assessing the eye structures and visual acuity (p. 534) Skill 30-7 Assessing the ears and hearing (p. 540) Skill 30-11 Assessing the thorax and lungs (p. 556) o    Cardiovascular and peripheral vascular systems – Heart sounds (p.561), Table 30-9 Normal heart sounds o S1 (AV valve close) “lub” & S2 (semilunar valve close) “dub”  Skill 30-12 Assessing the heart and central vessels (p. 562)  Skill 30-13 Assessing the peripheral vascular system (p. 566)  Skill 30-14 Assessing the breasts and axillae (p. 568)  Skill 30-15 Assessing the abdomen (p. 573) – [don’t forget the proper order of assessment for the abdomen]  Skill 30-17 Assessing the neurologic system (p. 582) Chapter 31 – Asepsis  Asepsis definitions - 603 o Asepsis, medical asepsis, clean, dirty, surgical asepsis, sepsis  Asepsis: freedom from diseasecausing microorganisms  Medical asepsis: all practices intended to confine a specific microorganism to a specific area  Clean: absence of all microorganism  Dirty: soiled, contaminated, likely to have microorganism, some of which may be capable of causing infection  Surgical asepsis: practices keep area or object free of all microorganism; includes practices that destroy all microorganisms & spores  Sepsis: acute organ dysfunction occurs secondary to infection  Nosocomial and Health Care Associated Infections – 604 o Nosocomial infection: hospital acquired o Including Table 31-2  Chain of Infection - 604 o Understand the links in the chain of infection and the order in which they occur  chain of infection— etiologic agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host  Isolation Practices - 620 o Use of PPE – gloves, gowns, masks, eyewear  Isolation Precautions – Box 31-1 pg 619 o Standard precautions—use of hand hygiene, PPE, & environmental controls o Airborne precautions—known to have or suspected of having serious illnesses transmitted by airborne droplet nuclei smaller than 5 microns o Droplet precautions—know to have or suspected of having serious illness transmitted bu particle droplets larger than 5 microns o Contact precautions—known to or have suspected of having serious illness easily transmitted by direct contact or by contact with items in clients environment  Infection prevention for health care workers p. 636 o Needlestick injury o Exposure to bloodborne pathogens Chapter 32 – Safety  Skill 32-3 Applying Restraints 663  Preventing Specific Hazards – p. 650-659 o Falls, seizures, scalds and burns, fires, agency fires, home fires, poisoning, carbon monoxide, suffocation or choking, excessive noise, electrical hazards, firearms, radiation, bioterrorism attack  Falls—leading cause of injuries among older adults  Seizures—single temporary event consists of uncontrolled electrical neuronal discharge of the brain that interrupts normal brain function  Scalds—burn from a hot liquid or vapor, such as steam  Burn—excessive exposure to thermal, chemical, electric, or radioactive agents o Fires—occurs healthcare setting & homes  RACE (rescue, alarm, confine, extinguish)  PASS (pull, aim, squeeze, sweep)  Poisoning—inadequate supervision & improper storage of many household toxic substances  Carbon monoxide—odorless, colorless, tasteless gas that is very toxic  Suffocation OR choking—lack of oxygen due to interrupted breathing  Excessive noise—causing hearing loss  Electrical hazards—must be properly grounded  Firearms—needs to teach safety rules anyone presence of firearm  Radiation—overexposure to radioactive materials used in diagnostic & therapeutic procedures  Bioterrorism—plan & prepare for the known  Table 32-2 pg. 651 Chapter 34 – Diagnostic Testing  Blood Tests -719 o CBC – WBC, RBC, Hgb, Hct, Plt – also know normal values  RBC (MEN: 4.6-6.0 / WOMEN: 4.0-5.0), WBC (4,400-11,000), Hgb, (MEN: 13.5-18 /WOMEN: 12-15) Hct (MEN: 40-54% / WOMEN: 36-46%),Plt (150,000400,000) (See Table 34-1) o Table 34-1 CBC w/ clinical implications o Serum electrolytes – Na, K, Cl, Mg, Gluc, Phosphate, Calcium – See Box 34-1  Sodium (135-145)  Potassium (3.5-5.3)  Chloride (95-105)  Magensium (1.5-2.5)  Phosphate (1.8-2.6)  Calcium (4.5-5.5)  o Blood Chemistry – 723 A number of other tests may be performed on blood serum (the liquid portion of the blood) o Know how to obtain a capillary blood specimen to measure blood glucose. See skill 34-1 o Know how to collect a clean catch specimen. See skill 34-2 Chapter 35 – Medications This section should be a review of what you learned in Pharmacology. I’ve included only the basics!  Read all CLINICAL ALERT! & Safety Alert ! boxes       Effects of Drugs – 752-754 Therapeutic effect (desired effect)—reason drug is prescribed Side effect—secondary effect, unintended Adverse effect—reactions, may justify discontinuation of drug Drug toxicity—harmful effects of a drug on an organism or tissue, results from overdosage, ingestion of a drug intended for external use, or buildup of the drug in the blood because impaired metabolism or excretion (cumulative effect) Drug allergy—immunologic reaction to a drug Routes of Administration – 758  Oral, sublingual, buccal, parenteral, topical o Oral—most common, least expensive, and most convenient for most clients   o Disadvantage; unpleasant taste, irritation of gastric mucosa, irregular absorption from the GI tract, slow absorption & some cases harm teeth Drug is swallowed Sublingual—drug placed under the tongue where it dissolves  Relatively short-term, drug largely absorbed into blood vessels on the underside of the tongue  o  o NOT be swallowed Buccal—pertaining to cheek Held in the mouth against the mucous membranes of the cheek until drug dissolves Parenteral—route defined other than through alimentary or respiratory tract; that is by needle  Subcutaneous (hypodermic)—into subcutaneous tissue, just below the skin  Intramuscular (IM)—into muscle  Intradermal (ID)—under the epidermis (into the dermis)  Intravenous (IV)—into the vein  Intra-arterial (into an artery)  Intracardiac (into heart muscle)  Intraosseous (into the bone)  Intrathecal or intraspinal (into spinal canal)  Intrapleural (into pleural space)  Epidural (into epidural space)  Intra-articular (into joint) Essential Parts of a Medication Order – 760 1. Full name of client 2. Date & time the order is written 3. Name of drug to be administered 4. Dosage of the drug 5. Frequency of administration 6. Route of administration 7. Signature of person writing order Administering Medications safely – 767  Read this section and pay special attention to the part about getting the patients medication history  Medication Administration Errors – 768 o Occur during administration stage  Prescription drugs (wrong drug or dose)   o Transcription/interpretation error (misinterpretation of abbreviations)  Preparation errors (calculation error)  Administration errors (wrong dose, wrong time, omission, or additional dose) Medication Reconciliation – 769 o Medication reconciliation—process of creating the most accurate list possible of all medications a client is taking, including drug name, dosage, frequency & route. Comparing that list against physician’s admission, transfer, and/or discharge orders, w/goal of providing correct medication to clients at all transition points within the hospital Practice guidelines – Administering Medications p. 769 Process of administering medications – 771  The 5 rights of medication administration (Box 355)- 772  Box 35-6 Ten rights of Medication administration  Oral Medications – 775  Client can swallow & retain the drug in the stomach, route of choice  Contraindicated, client is vomiting, has gastric or intestinal suction, unconscious & unable to swallow  NPO—nothing by mouth   o Skill 35-1 Administering oral medications - 775 Lifespan Considerations – Administering Oral Medications – Older adults – 779 o Physiological changes associated with aging influence medication administration an o o effectiveness; many of these changes enhance the possibility of cumulative effects & toxicity Older adults usually require smaller dosages of drugs, especially sedatives & other central nervous system depressant Older adults are mature adults capable of reasoning; nurse needs to explain reasons for & effects of clients medication Socioeconomic factors—lack of transportation & decreased finances Increase in marketing & availability of vitamins, herbs, & supplements— medication hx  Nasogastric and Gastrostomy Medications – 780  Nasogastric tube—inserted by way of nasopharynx & placed into client’s stomach for purpose of feeding the client or to remove gastric secretions  Gastrostomy tube—surgically placed into client’s stomach & provides another route for administering medications & administration  Parenteral Medications – 780  Equipment 780-784 o Syringes o  Preparing Injectable medications 784-787 o Ampules—glass container usually designed to hold a single dose of drug o  Needles Vials –small glass bottle with a sealed rubber cap  Single-dose vial—contains only one dose of medication & only used once  Multidose vial—bottle of liquid medication that contains more than one dose, such as insulin or vaccination vials Skill 35-2 Preparing medications from ampules -787 Skill 35-3 Preparing medications from vials – 788  Skill 35-4 Mixing Medications using one syringe – 790 Intradermal injections – 791  Intradermal (ID) injection—administration of drug into the dermal layer of the skin just beneath the epidermis o Allergy testing o Tuberculosis screening (TB) evidence of a clinical infection, purulent drainage   Types of wounds – Table 36-1 o Incision—sharp instrument o Contusion—blow from blunt instrument o Abrasion—surface scrape, either unintentional or intentional o Puncture—penetration of the skin, either intentional or unintentional o Laceration—tissue torn apart, often from accidents o Penetrating wound—penetration of the skin and underlying tissues, usually unintentional  Pressure ulcers – pg 829 o Risk factors– these are things that contribute to the formation of pressure ulcers:  Friction—force of acting parallel to skin surface  Shearing—combination of friction and pressure  Skill 35-5 p.792 Subcutaneous injections – 791  Common sites for subcutaneous injections are the outer aspect of the upper arms & the anterior aspect of thigh Skill 35-6 Administering a subcutaneous injection – 794 Intramuscular Injections – 797  Skill 35-7 Administering an intramuscular injection - 801 Chapter 36 – Skin Integrity and Wound Care  Types of Wounds - 829  Clean, contaminated, clean-contaminated, dirty or infected o Clean wounds—uninfected wound in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are not entered. Primarily closed o Clean-contaminated wounds—surgical wounds in which the respiratory, gastrointestinal, genital, and urinary tracts have been entered. No evidence of infection o Contaminated wounds—open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. Evidence of inflammation o Dirty or infected wounds—wounds containing dead tissue and wounds with  Stages of pressure ulcers – see Figure 36-1 Wound Healing 832 Types of wound healing – 834 o Primary intention, secondary intention, tertiary intention, APPROXIMATED***  Primary intention healing— occurs where the tissue surfaces have been approximated (CLOSED) and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring  Secondary intention healing— wound that is extensive and involves considerable tissue loss, and in which the edges o         cannot or should not be approximated Tertiary intention—wounds left open for 3 to 5 days allow edema or infection to resolve or exudate to drain and are the closed with sutures, staples, or adhesive skin closures Types of wound exudate o Serous exudate—consists chiefly of serum, (clear portion of blood), pinkish, watery and has few cells o Sanguineous—red cells, bloody discharge w/pus (open wounds) o Serosanguineous—less blood (clear), watery (heel blister) o Purulent—thicker pus consists of leukocytes Complications of wound healing - 836 Hemorrhage, infection, dehiscence, evisceration o Hemorrhage—massive bleeding o Infection—microorganisms colonizing the wound multiply excessively or invade tissues o Dehiscence w/ possible evisceration**  Dehiscence—partial or total rupturing of a sutured wound//abdominal wound in which the layers below the skin also separate  Evisceration—protrusion of the internal viscera through an incision //obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, and dehydration Skill 36-1 Obtaining a wound drainage specimen for culture - 840 Implementing – 842—nursing interventions for maintaining skin integrity and wound care    involving supporting wound healing, preventing pressure ulcers, treating pressure ulcers, dressing and cleaning wounds, supporting and immobilizing wounds, and applying heat and cold Preventing pressure ulcers 843-846 o Providing nutrition—nutritional supplements o Skin Hygiene—reassess daily in hospital and weekly at home o Avoiding Skin Trauma—providing smooth, firm, and wrinkle-free foundation on which to sit or lie helps prevent o Providing Supportive Devices—turning, positioning and use of pressure-reliving surfaces Treating Pressure Ulcers & dressing wounds 846-851—follow agency protocols and primary care providers orders o RYB Color Code  RED; late degenerative phase of tissue repair  YELLOW; liquid to semiliquid “slough” often accompanied by purulent drainage or previous infection  BLACK; thick necrotic tissue requires debridement The purposes for dressing wounds o Protect wound from mechanical injury o Protect wound from microbial contamination o provide or maintain moist wound healing o provide thermal insulation o absorb drainage or debride a wound or both o prevent hemorrhage (when applied as a pressure dressing or with elastic bandages) o  splint or immobilize the wound site and thereby facilitate healing and prevent injury Heat and Cold applications – 856 o Local effects of cold—lowers the temperature of the skin and underlying tissues and causes vasoconstriction  Vasoconstriction reduces blood flow to the affected area and thus reduces the supply of oxygen and metabolites, decreases the removal of wastes, and produces skin pallor and coolness o Local effects of heat—heat causes vasodilation and increases blood flow to the affected area, bringing oxygen, nutrients, antibodies, and leukocytes//promotes soft tissue healing and increases suppuration Table 36-6 Physiological effects of heat and cold - 857 Chapter 37 – Perioperative Nursing  Potential postoperative problems o See Table 37-4 p. 884 Chapter 38 – Sensory Perception  Factors affecting sensory function - 905 o Developmental stage, culture, stress, medication and illness, lifestyle and personality Chapter 44 – Activity and Exercise  Effects of immobility – p. 1021  Musculoskeletal system  Osteoporosis, atrophy, contractures, foot drop, ankylosed o Osteoporosis: demineralization of bones; loss of calcium o Atrophy: wasting away; decrease in size of organ or tissue (e.g. muscle) o Contractures: permanent shortening of a muscle o Foot drop: plantar flexion contracture o Ankylosed: permanently immobile joints   Cardiovascular system Cardiac reserve, Valsalva maneuver, orthostatic (postural) hypotension, vasodilation and stasis, edema, thrombus formation o Cardiac reserve: o Valsalva maneuver: forceful exhalation against a closed glottis, which increases intrathoracic pressure, and this interferes with venous blood return to the heart o Orthostatic (postural) hypotension:  Vasodilation: increase in diameter of blood vessels  Stasis:  Edema: presence of excess interstitial fluid on the body that makes skin appear swollen, shiny, and taut, and tends to blanch in color  Thrombus formation: solid mass of blood constituents in the circulatory system; a clot (plural: thrombi)  Respiratory system o Decreased respiratory movement, pooling of secretions, atelectasis, hypostatic pneumonia  Decreased respiratory movement:  Pooling of secretions:  Atelectasis: collapse of air sacs  Hypostatic pneumonia:   Positioning Clients – 1035-1038 Fowlers (semi-fowlers, high- fowlers), orthopneic, dorsal recumbent (supine), prone, lateral, sims o See associated figures o Fowler’s position, (semi sitting position) —bed position in which the head and 