NURS 6001 EXAM 1 with Correct Solutions 100% Score

NURS 6001 EXAM 1 with Correct Solutions 100% Score Types of Assessment ** comprehensive, episodic or problem-focused, emergency comprehensive assessment ** (initial) results in baseline data for problem identification and care planning, time consuming, complete, all aspects of preventive health/physical disease episodic/problem-focused assessment ** based on the patient's health issues, involves one or two body systems. smaller scope, but more in depth What is the nursing process? ** systematic problem-solving approach to identifying and treating human responses to actual or potential health difficulties. patient centered and focuses on problem solving and inhaling strengths. uses ADPIE emergency assessment ** involves life threatening or unstable situation, traumatic injury, uses ABCDE ABCDE ** airway, breathing, circulation, disability, and exposure ADPIE ** assessment of patient, nursing diagnosis, planning care, implementing and then evaluating patients status implementation ** collaboration with other team members, involvement of patient and family, actually doing the phase evaluation ** how effective is nursing care and each phases affects the other nursing diagnosis vs medical diagnosis ** medical focuses on diagnosis and treatment of disease whereas nursing focuses on the human response to actual or potential health problems assessment ** establish baseline, review history, physical assessment diagnosis ** clustering of data to make a judgement or statement about the patient's difficulties or condition Nanda diagnosis for nursing ** a clinical judgement about individual, family, or community responses to actual or potential health difficulties/life processes. Provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable Normal range of blood pressure ** 120/80 normal range of pulse ** 60-100 bpm scale of pulse strength ** 0-4+ scale of 0 pulse ** non palpable or absent 1+ of pulse ** weak, diminished, and barely palpable 2+ of pulse ** normal, expected 3+ of pulse ** Full, increased 4+ of pulse ** Bounding normal oral temperature range ** 97.7-99.5 F normal range for Temporal range ** 98.7-100.5 F five ways to take temperature ** oral, axillary, rectal, tympanic, and temporal normal respirations ** 12-20 normal O2 saturation ** 95-100% Pain scale ** 1-10 COLDERR ** characteristic, onset, location, duration, exacerbation, relief, radiation 6 stages of infection cycles ** infectious agent, reservoir, portal of exit, means of transmission, portal of entry, susceptible host infectious agent ** bacteria, viruses, and fungi reservoir ** place for growth and multiplication of microorganisms is the natural habitat of the organism (other people, animals, soil, food, water, milk and inanimate objects) portal of exit ** point of escape for the organism from the reservoir (respiratory, gastrointestinal, and genitourinary tracts, as well as breaks in the skin and blood and tissue means of transmission ** how an organism is transmitted from its reservoir, through touching, kissing, sexual intercourse, contaminated instrument, blood, food, water, or inanimate objects, vectors like mosquitos, ticks, and lice portal of entry ** point at which organisms enter a new host, same as exit route... urinary, respiratory, and gastrointestinal tracts susceptible host ** source that is acceptable for microorganisms that overcome any resistance mounted by the host's defenses nursing interventions to break chain of infection between susceptible host and infectious agent ** immunizations and screen healthcare staff nursing interventions to break chain of infection between infectious agent and reservoir ** hand hygiene, sterilization, antibiotic/antimicrobials nursing interventions to break chain of infection between reservoir and portal of exit from reservoir ** transmission-based precautions, sterilization or use of disposable supplies nursing interventions to break chain of infection between portal of exit from reservoir and means of transmission ** dry intact dressing, hand hygiene, wear gloves if contact with body fluids, cover nose and mouth when sneezing nursing interventions to break chain of infection between means of transmission and portals of entry ** hand hygiene, use pesticides to eliminate vectors and adequate refrigeration nursing interventions to break chain of infection between portals of entry and susceptible host ** hand hygiene, wear gloves, use masks, and appropriate protective gear, proper disposal of needles/sharps overall way to break the chain of infection ** hand washing, PPE, standard precautions, transmission based precautions, immunizations and cleaning supplies (sterilization) Stages of infection ** incubation period, prodromal stage, full stage of illness, convalescent period incubation period ** the interval between the pathogens invasion of the body and the appearance of symptoms of infection. organisms grow and multiply and length of incubation may vary prodromal stage ** stage where a person is most infectious and show early signs and symptoms of the disease, that are often times vague and nonspecific ranging from fatigue and malaise to low-grade fever (lasts several hours to several days) patient is often unaware of being contagious and as a result infection spreads full stage of illness ** presence of specific signs and symptoms indicates the full stage of illness, this type of infection determines the length of the illness and the severity of the manifestations. localized symptoms ** symptoms that are limited or occur in only one body area systemic symptoms ** symptoms manifested throughout the entire body convalescent period ** recovery period from the infection. signs and symptoms disappear and the person returns to a healthy state, may be a temporary of permanent change in the patient's previous health state body's defense against infection ** body's normal flora, inflammatory response and immune response inflammatory response and 5 cardinal signs of it ** protective mechanism that eliminates the invading pathogen and allows for tissue repair to occur. redness, heat, swelling, pain, and loss of function immune response ** involves specific body responses to an invading foreign protein, like producing an antibody to and antigen or a cell-mediated defense, or cellular immunity (increase in WBCs) factors affecting host susceptibility ** intact skin and mucous membranes, normal pH levels, body's white blood cells, age, sex, race, hereditary factors, immunization (natural or acquired), fatigue, climate, nutritional and general health status, stress, and use of invasive or indwelling medical devices factors predisposing patient's to nosocomial infections ** use of invasive medical devices and antibiotic-resistant organisms developed in hospitals Asepsis/aseptic technique ** All activities done to prevent or break the chain of infection, two categories- medical and surgical asepsis medical asepsis ** reduce the number and transfer of pathogens, clean technique surgical asepsis ** keep objects and areas free from microorganisms. sterile technique number of organisms ** more organisms present the longer it takes to destroy them factors that reduce the incidence of healthcare-associated infection ** asepsis/aseptic technique, nature and number or organisms present, equipment being used, sterilization and disinfection sterilization ** process by which all microorganisms are destroyed, including spores disinfection ** process by which all microorganisms are destroyed, except spores standard precautions ** used in care of all hospitalized patients, applies to blood, body fluids, secretions, excretions, broken skin, mucous membranes transmission based precautions ** used in addition to standard precautions for patients with suspected infection, includes airborne or droplet or contact precautions isolation ** protective aseptic techniques. protective procedure designed to prevent the transmission of specific organisms cdc guidelines ** standard and transmission-based precautions PPE ** gloves, gown, masks, protective eye gear factors that affect safety in an individual's environment ** developmental considerations, lifestyle, mobility, sensory perceptions, knowledge, ability to communicate, physical health state, and psychosocial health state developmental considerations for neonate and infants ** never leave infant unattended, use crib rails, monitor choking hazards and car seats developmental considerations for toddler and preschool children ** childproof home, prevent poisoning, child abuse warnings, car seats developmental considerations for school aged child ** avoid activities that are potentially dangerous, safety at home, school and community. Teach bicycle safety, child abduction, wear seatbelt developmental considerations for adolescents ** teach safe driving, tobacco and alcohol avoidance, and tattoo and piercing safety and about guns and violence developmental considerations for adults ** remind them of the effects of stress, drugs, and alcohol, and counsel about domestic violence (DV) developmental considerations for older adults ** prevent accidents, orient person to surroundings to avoid falls, maintain vehicle in working order, schedule eye exams, keep noise at a minimum. promote safe environment, and use medication trays (avoid poisoning) lifestyle ** occupation, social behavior environment ** unhealthy, unstable substance, community hazards mobility ** limitations make for an unsafe environment. older adults, disabled, mentally ill sensory perception ** impairment in sight, hearing, smell, taste or touch knowledge ** safety and security precautions is crucial communication ** basis to many safety practices physical health state ** physical health can affect safety in the physical environment psychosocial health state ** stress narrows attention span. prone to accidents, depression, isolation DAME ** Drug and alcohol use age related medical problems environment fall risk ** use DAME, main focus is prevention, well lit home, no rugs, bars in bathroom home health ** fire and burn safety, electrical safety, preventing poisoning, falls, firearms, choking safety risk factors for fetus ** abnormal growth and development safety risk factors for neonate ** infection, falls, SIDS safety risk factors for infant ** falls, toy, injuries, burns, drowning, suffocation, choking safety risk factors for toddler ** falls, sharp objects, burns, suffocation, drowning, choking, poison, guns, and weapons safety risk factors for school aged ** burns, drowning, broken bones, concussions, choking, guns, weapons, alcohol and drugs safety risk for adolescent children ** driving accidents, drowning, guns and weapons, choking, STDs, alcohol and drugs safety risk for adult ** stress, DV, industrial accidents risk factor assessments ** falls, fires, poisoning, suffocation, and choking, and firearm injuries factors that contribute to falls ** over 65, history of falls, impaired vision or balance, altered gait or posture, impaired mobility, medication regimen, postural hypotension, slowed reaction time, weakness, frailty, confusion, disorientation, unfamiliar environment three types of restraints ** physical, chemical, seclusion physiological hazards associated with restraints ** suffocation from entrapment, impaired circulation, altered skin integrity, pressure ulcers, diminished muscle and bone mass, fractures. altered nutrition and hydration, aspiration and breathing difficulties, incontinence, changes in mental status types of physical restraints ** wrist, mummy, elbow, papoose board, bed rails, food tray three main classes of medications used to chemically retain a patient ** benzodiazepines, typical or classic antipsychotics, and atypical antipsychotics chemical restraints always require ** doctors orders physical restraint ** physical devices used to limit a patients movements considerations for restraints? ** always a last resort, assessed every hour/psych ever 15 min, document date/time/type/ what was tried first and notify family supine position and associated benefits ** flat on back, helps muscle relaxation prone position and associated benefits ** on abdomen, assess hip and posterior sims position and associated benefits ** lies on either side. lower arm below the body. both knees flexed, partially flexed fowlers position and associated benefits ** sitting. low (15-30 degrees) semi (30 to 45 degrees) fowlers (45-60 degrees) high (85-90 degrees) general consideration for canes ** widen a persons base of support to help with balance. weight evenly. support comes from stronger leg general considerations for crutches ** for patients who have temporary restrictions on ambulation. weight from hands and arms, not axillary general considerations for walkers ** improve balance by increasing base or support. never on stairs three learning domains ** cognitive, psychomotor, and affective cognitive learning domain ** storing and recalling of new info in the brain. strategies: lecture, panel, discovery, written materials affective learning domain ** changing attitudes, values, feelings. strategies role modeling, discussion, audiovisual materials psychomotor learning domain ** learning a specific skill. strategies: demonstration, discovery, printed material TEACH ** Tune in patient Edit patient info Act on every teaching moment clarify often honor the patient as partner in education motivational interviewing ** a collaborative family centered model that focuses on understanding and helping rather than solutions. making the patient interested in helping themselves. HIPAA ** the health insurance portability and accountability act. addresses patients privacy and rights. securing medical info primary level of care ** activities to reduce the probability that a disease will develop secondary level of care ** early detection and treatment of a disease. block progression of disease tertiary prevention ** rehab, therapy. prevent complications. care for dying, hospice. quality improvement (QI) ** the commitment and approach used to continuously improve every process in every part of an organization. with the intent of meeting and exceeding customer expectations and outcomes PDSA ** plan so study act cycle to find improvement for specific processes Change theory ** Lewins change model unfreezing- the need for change is recognized moving-change is initiated after planning refreezing-change becomes operational QSEN ** quality and safety education for nurses. prepare future nurses with knowledge skills and attitudes, patient centered and teamwork team STEPPS ** team strategies and tools to enhance performance and patient safety SBAR ** situation, background, assessment, recommendation CUS ** concerned, uncomfortable, safety DESC ** describe, express, suggest, consequences patient care models ** 1. case method or private duty 2. functional method/task oriented 3. team method with democratic/RN as a team leader 4. primary/24 hour accountability (shift accountability) Case method or private Duty (total patient care) ** RNs are self-employed, patient needs were quickly met, close relationship between the RN and the patient, and cost! RN hella expensive functional method ** very efficient way to deliver care, could accomplish a lot of tasks in a small amount of time staff did what only they were capable to do, no extraneous work was added that could be done by assertive personnel. Care of persons become fragmented. patients did not have one identifiable nurse and the nurse had no accountability, very narrow scope of practice for RNs, lead to patient and nurse dissatisfaction team nursing ** each member's capabilities are maximized so job satisfaction should be high. patients have one nurse (team leader) with access to other providers. requires team spirit and commitment to succeed. RN may be the team leader one day and a team member the next, thus continuity of patient care may suffer. care is still fragmented with only 8 or 12 hour accountability primary nursing ** increased satisfaction for patients and nurses. more professional system: RN plans and communicates with all disciplines. RNs are seen as more knowledgeable and responsible. RNs more satsifed and because they continue to learn as a function of the in-depth care they are required to deliver. intimidating for new graduates who are less skilled and knowledgeable.