NUR 155- Final Exam

health promotion- 3 levels - ANS-primary, secondary, tertiary primary - ANS-prevention secondary - ANS-identification/early intervention tertiary - ANS-rehabilitation and restoration What is Maslow's highest priority? - ANS-physiological needs (food, clothing, shelter) Does the highest priority of needs start at the top or the bottom of the period in Maslow's? - ANS-starts at bottom of the pyramid What kind of open therapeutic communication should we use as nurses? - ANS-open ended statements and questions What does being a role of advocacy mean as a nurse? - ANS-argues or pleads on behalf of what is best for the patient, even if the patient cannot speak for themselves, the RN must be an advocate for their patients What kind of relationships do we want with our patients? - ANS-trusting Differ between assertive and non-assertive communication techniques. - ANS-Assertive: uses "I am" statements Aggressive: uses "You should" statements What does SBAR stand for and what is it? - ANS-Situation, Background, Assessment, Recommendations SBAR is a communication tool used for health care members, it is professional, it is organized What data from SBAR does current vital signs fall under? - ANS-Assessment data NOT background *a lot of people get this confused Specific details for each category of SBAR S: situation - ANS-what is the situation you are calling about? provide your name, health care agency, patient name, brief info about the problem. p. 433 in text Specific details for each category of SBAR B: background - ANS-provide info pertinent to the current situation, admitting dx, date of admission, important clinical info that relates to patient Specific details for each category of SBAR A: Assessment - ANS-refers to the current condition of the patient- ex. include current vital signs, O2 level, pain scale, LOC, any change in assessment since the previous communication, also indicate the severity of the problem Specific details for each category of SBAR R: recommendation - ANS-what is your recomendation for resolving the problem? what do you need from the Dr.; some example include: come see patient, transfer to diff. unit, order a med, etc. What is the Nursing Process and what does it stand for? - ANS-The nursing process is a systematic, rational method for planning and providing nursing care. Page: 156 ADPIE stands for: Assessment, Diagnosis, Planning, Implementation, Evaluation Can the nursing process contain a medical diagnosis? - ANS-No- only a nursing diagnosis-- if we choose to talk about a medical diagnosis in our care plan, we have to explain the medical diagnosis without stating what the medical diagnosis is Subjective vs. objective information - ANS-subjective: symptoms, can be described ONLY by the patient i.e. itching, pain, feeling worried Objective: signs the RN observes i.e. they can be seen, heard, felt, smelled, and are observed when the RN assesses p. 160-161 When do we document a task as a nurse? - ANS-AFTER we have done the task Document example: Patient fell on the floor. The nurse did not see the patient fall. What would they document? - ANS-They would document something like, "Pt found on the floor." We would NOT document: "Pt fell" unless we watched them fall with our own eyes. As nurses we have to be explorers... explain what this means - ANS-We need to ask ourselves, Do we have the info we need or do we still need to gather some more data to form our thoughts Legal Aspects Chapter Terms Fidelity beneficence autonomy veracity - ANS-Fidelity: a moral principle that obligates the person to be faithful to agreements and responsibilities one has undertaken beneficence: moral obligation to do good or to implement actions that benefit the patient and their support people autonomy: state of being independent and self-directed; without outside control; to make ones own decisions veracity: a moral principle that holds that one should tell the truth and not lie *found in glossary of text electrolytes: know lab values sodium potassium magnesium calcium - ANS-sodium: 135-145 potassium: 3.5-5 magnesium: ___________ calcium: 9-10.5 what is a tort? know the difference between intentional and unintentional tort - ANS-a civil wrong committed against a person or a person's property Normal BUN and Creatinine levels What do the BUN and Creatinine labs check for? - ANS-BUN- 10-20 Creatinine: Male: 0.6-1.2 mg/dL Female: 0.5-1.1 mg/dL BUN/Creatinine test kidney function Know the difference between medical asepsis and surgical asepsis - ANS-surgical asepsis: is the same as sterile technique, this has ZERO spores or microorganisms-- EX) surgery medical asepsis: confines a microorganism to a specific area, limiting growth EX) clean technique p. 603 Types of Isolation - ANS-Airborne Droplet Contact Airborne Isolation Examples What do you wear? - ANS-N-95 Mask Gloves Place patient in a room with negative airflow EX) TB, measles, varicella Droplet Isolation Examples What do you wear? - ANS-Surgical mask EX) Flu, diptheria, pneumonia, pertussis Contact Precautions Examples What do you wear? - ANS-gloves gown EX) VRE, MRSA Continously