NUR2115- Fundamentals of Professional Nursing Final Exam Review

NUR2115- Fundamentals of Professional Nursing Final Exam Review *The final exam will cover your required readings from the following chapters: 1, 2, 3, 4, 5, 6, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, 26, 27, 31, 32, 33, 34, 36, 37, 38, 40 and 41. All Modules Review various nursing diagnoses related to specific patient problems Module 1-3 Concepts: Review importance of documentation of patient assessments Accurate documentation of this data is important to provide a baseline for later comparisons as the patient's condition changes.The patient record is the only permanent legal document that details the nurse's interactions with the patient and is the nurse's best defense if a patient or patient surrogate alleges nursing negligence. Review types of nonverbal behavior which could promote improved communication Body language Gestures, movements, touch, appearance, adornments Personal appearance May express culture, religion, group associations, self-concept Posture and gait Erect vs slouched posture Facial expression The most expressive part of the body! Review the importance of QSEN in nursing education To prepare nurses who combine the highest level of scientific knowledge and technologic skill with responsible, caring practice. To challenge students to identify and master the cognitive and technical skills as well as the interpersonal and ethical/legal skills they will need to effectively nurse the patients in their care. Review what a sentinel event is An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. An error that causes serious harm to a client and singles out the need for investigation. Review examples of health promotion activities for primary, secondary and tertiary Primary-Directed toward promoting health and preventing the development of disease processes or injury. Ex: Immunization clinics, family planning services, providing poison-control information, accident prevention education, teaching about a healthy diet, health-risk assessments. Secondary-Focus on screening for early detection of disease with prompt diagnosis and treatment. It identifies an illness, reverse or reduce its severity or provide a cure, and thereby return the person to maximum health as quickly as possible. Ex: Assessing children for normal growth and development and encouraging regular medical, dental, and vision examinations; screenings for BP, cholesterol, and skin cancer; routine GYN exams and mammograms; teaching testicular self-exams to men; administering medications; caring for wounds. Tertiary- Begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning. Maintaining and preventing progression of severe diseases, dying with dignity, assisting to cope with impending death. Ex: Teaching a diabetic patient how to recognize and prevent complications; using PT to prevent contractures in a patient who has had a stroke or spinal cord injury; referring a woman to a support group after removal of a breast because of cancer. Review use of ISBARR model of communication ISBARR is an easy to remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician's immediate attention and action. It allows for an easy focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety. Introduction Situation Background Assessment Recommendation/Request Read-back of orders or Response Review teaching for a patient on anticoagulant therapy- safety considerations Use electric razors to shave Age related safety concerns Infant- Falls, SIDS (must lay on back to sleep), Injury from toys, Burns, Suffocation and choking Electrocution, Ingestion of foreign bodies, Child mistreatment (nurse obliged to report to DCF) **Need rear facing car seat Toddler: Falls Cuts, Drowning, Concussions, Guns and weapons (locked and unloaded), Escape from home Poison (Poison Control # on fridge), Suffocation and choking, Child mistreatment (nurse obliged to report to DCF), **Front facing car seat in the BACK seat School Age Children- Sexual abuse, Burns, Broken bones, Concussions Drowning, Guns and weapons, Use of Internet, Sports injuries (cognitive rest), Abduction, Bullying (cyberbullying), Child mistreatment (nurse obliged to report to DCF) **Back seat until age 13 Teenagers: Piercing & Tattoos, Driving (distracted driving)..texting especially, Firearms, Suicide, Drugs and Alcohol and Tobacco, Sexuality and STIs, Sexual abuse, Use of Internet, Risk taking (diving into unfamiliar water), **Seat belt and driving Adults: Stress, Domestic Violence, MVA, Industrial accidents and exposure, Drugs and alcohol abuse Elderly: Falls #1, Elder abuse and neglect, MVA, Sensorimotor changes, Fires (candles, heaters)..forgetfulness, Burns (electric blankets, hot water, heating pads) Accidental overdosing and polypharmacy Developmental theories: focus on Erickson’s Trust vs. mistrust (infancy) Autonomy vs. shame and doubt (toddler) Initiative vs. guilt (preschool) Industry vs. inferiority (school age) Identity vs. role confusion (adolescence) Intimacy vs. isolation (young adulthood) Generativity vs. stagnation (middle adulthood) Ego integrity vs. despair (later adulthood) Musculoskeletal: Review education on crutch walking Education: Remind the patient that the support of body weight should come primarily on the hands and arms while using the crutches, not in the axillary areas, where pressure may damage nerves and cut off circulation. Also, the crutches should not be forced into the axillae each time the body moves forward. Positioning-Prevent pressure on the axillae. Keep elbows close to sides. Prevent crutches from getting closer than 12 inches to your feet. To rise for a chair with crutches-Slide forward to the edge of the chair. Extend the injured leg to prevent any weight bearing. Place crutches on unaffected side, lean forward, and push off using the crutches. To climb stairs with crutches: Advance unaffected leg past crutches, then place weight on unaffected leg. Advance affected leg and then crutches to the step. Continue with this order until top of stairs is reached. To descend stairs with crutches: Move crutches and affected leg first, followed by the unaffected leg. Review safety precautions when repositioning patient in bed If the patient is unable to assist with movement, a full-body sling and two or more caregivers are required. When turning the patient, the bed should be at the height of the caregivers' elbows to ensure a comfortable working height. If the patient is fully able to assist in moving up in the bed, allow the patient to complete the movement independently, with safe supervision. The patient assists movement either by pushing with the feet flat against the bed or by using an overbed trapeze. If only partially able, encourage the patient to assist using a positioning aid or cues. If the patient is less than 200 pounds, use a friction-reducing device and two to three caregivers. If the patient is over 200 pounds, use a friction- reducing device and at least three caregivers. If the patient is not able to assist, use a full-body sling lift and two or more caregivers. Friction- reducing sheets or other devices should be used to minimize shearing forces and work effort Review nursing interventions which would be included in caring for a patient with contractures Encourage continuation of daily routines and activities. Maintain exercise program to tone and strengthen unaffected muscle groups without fatiguing affected muscles. Range-of-Motion (ROM) exercises; first Active ROM, then passive. Ensure proper positioning, no pressure on bony prominences. Deep tissue massage to relax contractures. Review the difference between active and passive range of motion Active: The patient independently moves joints through their full range of motion (isotonic exercise). In active ROM, the nurse may provide minimal support. Passive: The patient is unable to move independently, and the nurse moves each joint through its range of motion. Vital Signs: Review the assessment of obtaining all vital signs including BP, HR, respirations, temperature and pulse ox Assessing Oral Temperature: When selecting the oral site, the patient must be able to close his or her mouth around the probe. The probe must remain in the sublingual pocket for the full period of measurement. If a patient has had either hot or cold food or fluids or has been smoking or chewing gum, the general recommendation is to wait 15 to 30 minutes to allow the oral tissues to return to normal temperature. Don't take an oral temp on patients receiving oxygen by mask. Assessing tympanic membrane temperature- Pull pinna UP and back for adults, DOWN for children. The thermometer does not touch the tympanic membrane. This site allows easy and safe measurement of temperature and is readily accessible. Should not be used for patients who have drainage from the ear, ear pain, ear infection, or scars on the tympanic membrane. Assessing temporal artery temperature: When taking a temporal artery temperature assess for head coverings. Anything covering the area— such as a hat, hair, wigs, or bandages—would insulate the area, resulting in falsely high readings. If a patient is lying on the side, measure only the side of the head exposed to the environment. Do not measure temporal artery temperature over scar tissue, open lesions, or abrasions. Move the thermometer across the forehead slowly and remain in contact with the skin to ensure accurate results. Assessing an axillary temperature: The axillary site may be used when both oral and rectal sites are contraindicated or when these sites are inaccessible. Place the probe in the center of the axilla. Hold the patient's arm by the patient's side until the measurement is complete. Assessing rectal temperature: The rectal temperature, a core temperature, is considered to be one of the most accurate routes. The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal surgery or have a disease of the rectum. Because the insertion of the thermometer into the rectum can slow the heart rate by stimulating the vagus nerve, assessing a rectal temperature for patients with heart disease or after cardiac surgery may not be allowed in some institutions. Assessing a rectal temperature is contraindicated in patients who are neutropenic (have low white blood cell counts, such as in leukemia) and in patients who have certain neurologic disorders (e.g., spinal cord injuries). Do not insert a rectal thermometer into a patient who has a low platelet count. The rectum is very vascular, and a thermometer could cause rectal bleeding.