Fundamentals Nursing - Exam -2 Questions and Answers

Fundamentals Nursing - Exam -2 Questions and Answers Hypertonic solution 3% NaCl - causes shift of fluid from ICF to ECF - out of the cells into the vessels. Hypertonic solutions have high osmolality - high ability to draw water toward it and draw water out of the cells. Hypotonic solution 0.45% NaCl - causes shift of fluid from ECF to ICF - pushes water from the vessels into the cells. HypOtonic - cells expand with fluid - used for dehydration. Isotonic Solution 0.9% NaCl and Lactated Ringer's solution. Expand the vascular volume without causing a shift in fluids Osmosis movement of water (solvent) across a plasma membrane from a High concentration of water to low concentration of water to achieve equillibrium Diffusion movement of solutes from area of HIGH concentration to LOW concentration Filtration movement of fluid/solutes through membranes by high pressure. High pressure in arteries forces oxygen nutrients into cells. High force in tissue pushes waste/Co2 into veins Active Transport movement of solutes against concentration gradient (from Low to High). Requires ATP (energy) to force molecules against gradient. Ex - sodium/potassium pump What is the ANA? ANA = American Nursing Association. They established Nursing Code of Ethics, Scope of Nursing - Nurse practice acts. Adminstrative Law - enforced state to adhere to Nurse practice acts Documentation "Dos" and "don'ts" Entries should include date, time (military), problem, intervention used and evaluation of outcomes. Proper spelling and terminology should be used. Errors should have strike throughs with "mistaken entry" written with initials, date and time next to it. Documentation should be written in chronological order. When documenting entry out of order, list current time and time that omitted data took place as well as what happened. What is PIE charting? PIE = problem, intervention and evaluation Problem - state the issue/problem that patient is stating or dealing with Intervention - describe how problem was addressed - what was done to fix the problem? Evaluation - what was the outcome of the intervention What is SOAP charting? SOAP = subjective, objective data, assessment, planning What is SOAPIE charting? SOAPIE = subjective data, objective data, assessment, planning, intervention and evaluation What is objective data? objective data = data that can be seen, heard, smelled, felt and validated by the nurse. Inlcudes vital signs and lab reports, x-rays, etc What is subjective data? subjective data = data this is expressed by the patient. Ex - pain, symptoms, feelings, past illnesses (not documented), concerns What is primary data? Data that is obtained directly from the patient what is secondary data? Data that is provided by someone other than the patient. Ex - spouse, old medical record What is the assessment phase? First step in ADPIE - assessment is where nurse collects, organizes, validates and documents data. Goal is to establish complete database of patient information What is the diagnosis phase? Second step of ADPIE - nurse addressess current health problems that patient exhibits and determine issues that patient may be at risk for developing. Help determine problems, strengths and weaknesses of the patient Actual diagnosis problems/issues that the patient is currently exhibiting At-risk dignosis identify problems that the patient may develop based on past or current medical history Wellness diagnosis readiness for enhancement What is the planning phase? Third step in ADPIE - develop a care plan to address nursing diagnosis. Plans should be individualized to each patient. Nurse should establish a goal before determining interventions. Goals should be the opposite of the diagnosis made. Set priorities during the planning phase What is the intervention phase? Fourth step in ADPIE - here, interventions are carried out to address problems identified and accomplish goals created. What are the five steps to the intervention (implementing) phase? 1) reassess the patient before starting interventions, 2) determine if assistance is needed, 3) carry out interventions, 4) supervise delegated tasks, 5) document interventions What are independent interventions? Interventions (activities) that the nurse can carry out without permission or approval from somone else. Inlcude ADLs, ROM exercises, taking vital signs, repositioning, etc What are dependent interventions? dependent interventions (activities) are ones that the nurse needs permission or approval for in order to carry out. Ex - administering medications, oxygen What are collaborative interventions? collaborative interventions are activites that are carried out in collaboration with others What is the evaluation phase? The fifth step of ADPIE - determine if the goals were met. Collect data related to desired outcome and draw conclusions about the problems and treatment Etiology potential causes of the problems/diagnosis - follow the phrase "related to" Signs and symptoms evidence that supports nursing diagnosis - follow the phrase "as evidenced by" Correctly written goal should contain: subject, verb, frequency and time frame. Goal should be the oppositve of the nursing diagnosis Correctly written intervention should contain: verb, frequency and time frame - intervention should directly address the goal and be designed to correct problem identified in diagnosis Contract law contractual obligation between nurse and patient and nurse and employer Nurse practice act is an example of: state legislature American nurses association is an example of: adminstrative law Tort civial wrong against a person or property Negligence misconduct of practice that is below standard expected from ordinary, reasonable person Living will documents letting people know how a person should be cared for to sustain life - if they want life saving measures taken if breathing/heart rate stops, if they want a feeding tube, etc Health Surrogate competent person who is put in charge of making medical decisions for another - usually family member or lawyer Informed consent documentation provided to a patient before consenting to a medical procedure. Obtaining consent is the responsibility of the person performing the procedure. Nurse can act as witness to signing of the consent and to help determine if person is competent enough to understand consequences of procedure Conscience clause can allow individuals (such as physicians and pharmacists) to deny certain medical services based on religious reasons or conscience. These individuals cannot be disciplined or discriminated against for their beliefs Incompetence person is not legally qualified or suited to perform certain tasks Defammation communications that are false Slander defammation in spoken word Libel defammation the is written, in print, photos What is elderspeak? Speaking down to a patient or using "baby talk". Always address patient by last name unless told otherwise. For example - "Mr. Jones". Never use terms like "honey" or "sweety". Always ask if "you" would like to do something, never "we". For example - "are we ready to go". Open ended questions allow for patients to explore their own feelings and expand on their responses Closed ended questions short answer questions - ususally allow for only "yes" or "no" responses reactive hyperemia blood returns to ischemic area - skin blanches when pressed - NOT a pressure ulcer, but may be at risk for impaired skin integrity Stage 1 pressure ulcer reddened area of the skin (epidermis) that does not blanche when pressed - impaired skin integrity Stage 2 pressure ulcer skin breakdown has occured (impaired skin integrity) - involves the epidermis - looks like blister that has popped Stage 3 pressure ulcer epidermis and dermis are affected - may see underlying hypdermis (adipose) tissue, tunneling may also be present. NO BONE, MUSCLE OR TISSUE SEEN Stage 4 pressure ulcer epidermis, dermis, hypodermis affected - can see down to bone, muscle, tendons Unstaggeable pressure ulcer full thickness tissue damage - extent of damage cannot be determined due to presence of escher or slough that covers the base of the wound Examples of Primary care: primary care = routine care with screening. Doctor's office that screens blood work, BP Examples of secondary care: diagnosis and treatment of acute conditions. Ex - emergency room, hosptals, ICU Examples of tertiary care: tertiary care = specialized care. Ex - cancer treatment center Examples of restorative care: restorative = rehabilitation. Ex - rehab facilities, home health care (that are not hospice) Examples of continuing care: care until end of life. Ex - hospice, assisted living facility Examples of preventative care: education to reduce and control risk factors for disease. Ex - immunization programs, nutrition counselor What is COLDERR? during assessment - Character (dull, stabbing, throbbing), onset (when did it start), location, duration (for how long?), exasterbation (what makes it worse), relief (what makes it better), radiation Metabolic acidosis pH of blood is below 7.35 - bicarbonate levels may be decreased below 22 - not due to problem with lungs. Caused by starvation, ketoacidosis Normal pH range of blood 7.35 - 7.45 Normal CO2 range (PaCO2) 35-45 Normal bicarbonate range (HCO3) 22-26 Respiratory acidosis pH of blood below 7.35. Causes include hypoventilation - where CO2 accumulates in blood Conditions that affect cardiac output increased heart rate - decreases cardiac output nursing priority always wash hands before starting intervention or assessment What is DAR and focus charting? DAR = data (data provided by patient), action (what was done to address problem), response (how did the patient respond after the action) Physical therapist works on large muscle groups Occupation therapist helps patient with fine motor skills, performing ADLs, and establish independence Dietician/Nutritionist helps provide patient with knowledge about diet and helps make sure patient is receiving adequate nutrition to promote health/healing Case manager helps clients ensure that they receive adequate care and and fiscally sound Initial assessment takes place when the nurse first meets the client. Ex - upon admission to healthcare facility Problem-focused assessment assessment that addresses a specific issue. Ex - intake and output measurements post-op Emergency assessment takes place during a crisis. Ex - assessment of respirations, circualtion during cardiac arrest Time-lapse assessment assessment that is performed several months after initial assessment and data is compared to baseline Interpersonal communication communication with others - perso to person Intrapersonal communication communication within - self affirmation Intimate zone touching to 1.5 feet