NR 224 FUNDAMENTALS EXAM 1
-Nurses should take advantage of educational and self-help
programs for stress management. Programs such as BREATHE
focus on areas of nursing stress that nurses could address either
by changing the way they view stressors, changing how they
respond to stress, or, when possible, changing the stressful
situation.
-Exercises on grieving and coping with the demands of caring for
dying patients can minimize stress and improve overall care of
patients who are terminally or critically ill.
-Nurses should learn assertive communication, conflict resolution,
and problem solving strategies to reduce the stress associated with
different interactions with other nurses or health care providers.
managing stress in nurses
-Collection of information from a primary source (a patient) and
secondary sources (family/caregiver/SO)
-The interpretation and validation of data to determine whether
more data is needed or if the database is complete
steps in the nursing assessment process
-While gathering data form a patient, you synthesize relevant
knowledge, recall prior clinical experiences, apply critical
thinking standards and attitudes, and use prof standards of
practice to direct your assessment in a meaningful and purposeful
way
-Apply knowledge from physical, biological, and social sciences to
ask relevant questions and complete a hx and physical
-Ultimate goal in assessment is to gather all of the information
necessary to reveal a patient's health care needs
,-Decisions made influence their effectiveness in clinical practice
and make an impact on a patient's lives and experiences with HC
in any setting in which they practice
components of critical thinking and the assessment process
primary source for data
patient
secondary source for data
family, care giver, SO
-admission nursing Hx form
-patient care summary
-care plans
-discharge summary
electronic health record forms
completed when pt admitted to a unit, guide for a thorough
assessment to identify relevant nursing diagnoses and problems,
baseline
admission nursing Hx form
summary of care given, pt has right to read and receive copy,
typically handed out at the end of a visit, automatically updates
and provides the most current information, used to give
report/hand off as well
patient care summary
used to facilitate the creation and documentation of a nursing and
interprofessional plan of care for an identified problem, used for
QI audits, update regularly to ensure that the documents are
appropriate, and evidence based
care plans
, begins at admission, identify goals for recovery and identify
potential discharge needs, identify key clinical outcomes and
appropriate timelines for reaching them
discharge summary forms
-Nurses are legally and ethically obligated to keep all pt
information confidential
-Only discuss the pt's status with members of their HC team
-Protected health information
-Can use data for research or continuing education, but need
permission
-Hippa
maintain privacy, confidentiality, security of health care record
-Electronic documentation has legal risks
-Most security for computers involves a combination of logical
and physical restrictions to protect information
-Physical measures include placing computers or file servers in
restricted areas or using privacy filters for computer screens
visible to visitors or others w/o access
mechanism for privacy, confidentiality, and security
-common in areas of the skin/MM break down
-Surgical and traumatic wounds, PIs, oral lesions, abscesses
-Redness, warmth, and swelling caused by inflammation
-Ask about pain/tenderness with site
-Generalized symptoms: fever, fatigue, nausea/vomiting, malaise,
lymph nodes may be swollen
Local infection signs and symptoms
-Can develop after treatment for localized infection has failed
-Be alert for changes in level of activity and responsiveness
-Temp may cause rise in HR and RR, and decrease BP
-Nurses should take advantage of educational and self-help
programs for stress management. Programs such as BREATHE
focus on areas of nursing stress that nurses could address either
by changing the way they view stressors, changing how they
respond to stress, or, when possible, changing the stressful
situation.
-Exercises on grieving and coping with the demands of caring for
dying patients can minimize stress and improve overall care of
patients who are terminally or critically ill.
-Nurses should learn assertive communication, conflict resolution,
and problem solving strategies to reduce the stress associated with
different interactions with other nurses or health care providers.
managing stress in nurses
-Collection of information from a primary source (a patient) and
secondary sources (family/caregiver/SO)
-The interpretation and validation of data to determine whether
more data is needed or if the database is complete
steps in the nursing assessment process
-While gathering data form a patient, you synthesize relevant
knowledge, recall prior clinical experiences, apply critical
thinking standards and attitudes, and use prof standards of
practice to direct your assessment in a meaningful and purposeful
way
-Apply knowledge from physical, biological, and social sciences to
ask relevant questions and complete a hx and physical
-Ultimate goal in assessment is to gather all of the information
necessary to reveal a patient's health care needs
,-Decisions made influence their effectiveness in clinical practice
and make an impact on a patient's lives and experiences with HC
in any setting in which they practice
components of critical thinking and the assessment process
primary source for data
patient
secondary source for data
family, care giver, SO
-admission nursing Hx form
-patient care summary
-care plans
-discharge summary
electronic health record forms
completed when pt admitted to a unit, guide for a thorough
assessment to identify relevant nursing diagnoses and problems,
baseline
admission nursing Hx form
summary of care given, pt has right to read and receive copy,
typically handed out at the end of a visit, automatically updates
and provides the most current information, used to give
report/hand off as well
patient care summary
used to facilitate the creation and documentation of a nursing and
interprofessional plan of care for an identified problem, used for
QI audits, update regularly to ensure that the documents are
appropriate, and evidence based
care plans
, begins at admission, identify goals for recovery and identify
potential discharge needs, identify key clinical outcomes and
appropriate timelines for reaching them
discharge summary forms
-Nurses are legally and ethically obligated to keep all pt
information confidential
-Only discuss the pt's status with members of their HC team
-Protected health information
-Can use data for research or continuing education, but need
permission
-Hippa
maintain privacy, confidentiality, security of health care record
-Electronic documentation has legal risks
-Most security for computers involves a combination of logical
and physical restrictions to protect information
-Physical measures include placing computers or file servers in
restricted areas or using privacy filters for computer screens
visible to visitors or others w/o access
mechanism for privacy, confidentiality, and security
-common in areas of the skin/MM break down
-Surgical and traumatic wounds, PIs, oral lesions, abscesses
-Redness, warmth, and swelling caused by inflammation
-Ask about pain/tenderness with site
-Generalized symptoms: fever, fatigue, nausea/vomiting, malaise,
lymph nodes may be swollen
Local infection signs and symptoms
-Can develop after treatment for localized infection has failed
-Be alert for changes in level of activity and responsiveness
-Temp may cause rise in HR and RR, and decrease BP
