Nursing Fundamentals 101 Final Notes

What is NANDA? North American Nursing Diagnosis Association. A professional nursing organization that provides standardized language to identify patient problems and plan customized care Define beneficence Placing a priority on the needs of others rather than on personal thoughts or feelings Define veracity Being truthful Define: advocacy supporting/promoting the interest of others Define: confidentiality The ethical principal that a healthcare professional will not share patient's information without patient permission Define: justice acting fairly and equitably Define: fidelity keeping promises or fulfilling an agreement made with others Define: accountability being responsible for your actions Define: autonomy freedom to make decisions supported by knowledge and self confidence What is informed consent? Typically a document signed by the patient to give consent for treatment/procedure. The patient must be told of the details of the treatment, necessity of treatment, benefits and risks, and available alternatives What is the physician's role in obtaining informed consent? The physician explains the details of the treatment, necessity, benefits & risks and available alternatives What is the nurses role in obtaining informed consent? Nurse must witness the patient sign the form, verify that the patient is capable of understand and giving consent. Nurse should also make sure the patient received all necessary info and has a chance to ask any questions If the patient is on a high dose of pain meds upon admittance to the ED for a severe trauma (ie: compound femur fracture) are they capable of giving informed consent? No What is involved in psychomotor domain learning style? and give an example movement and motor. An example is teaching a diabetic patient how to self administer insulin What is involved in cognitive domain learning style? and give an example memorization/information retention. An example is giving a patient a list of instructions and their ability to recall it later What is an example of affective domain learning style? and give an example emotional. takes into account the patients feelings, values, motivations, and attitudes. What is formal patient teaching? Printed media, planned educational or group setting, and goal directed meeting in an acute care setting. What is informal patient teaching? Learner directed, ie: when a patient asks a question about a medication or looks up info online Age appropriate teaching: elderly Can have inadequate literacy skills and have issues reading Rx labels. Consider cognitive and sensory alterations (ie: hearing loss) Age appropriate teaching: child requires a parent or caregiver present, but do not exclude the child. Use pictures and simple terms Age appropriate teaching: young adult self motivated and able to participate in planning their health education. may learn independently or need assistance from the nurse. Facts about taking a carotid pulse Located at the neck, only assess one side at a time Define orthopnea Difficulty breathing experienced in positions other than sitting or standing. Commonly seen in heart failure, can be caused by pulmonary edema, left ventricular heart failure, asthma or chronic bronchitis Normal vitals for temp, pulse, respiration, O2 sat, BP temp: 95.9-99.5 pulse: 60-100 respiration: 12-20 O2 sat > 95 BP 90/60 to 120/80 Define spiritual distress. Disruption in belief or value system due to life challenging diagnosis or health crisis. Patient can express anger/depression/neediness/crying. Define: impaired religiosity Difficulty adhering to religious customs and rituals Define: Moral distress Knowing the right thing to do but not agreeing (ie: caring for a patient who is a rapist) Define: Decisional conflict Unsure about what choice or option to choose given the treatment options (ie: what would god want me to do?) What does community health focus on? Individuals or families preventing illness maintain or regain health What does public health focus on? focuses on populations prevent control of diseases threats to human health health protection/promotion/disease prevention What is OSHA? Occupational Saftey & Health Administration -provides employers with guidelines for preventing exposure to hazardous chemicals and hazardous situations and reducing the risk of injury in the workplace. What is CDC? Centers for Disease Control -federal agency that conducts and supports health promotion, prevention and preparedness activities in the United States with the goal of improving overall public health. What is QSEN? Quality & Saftey Education for Nurses goal of preparing nurses of the future with the knowledge, skills, and attitudes needed to advance quality and safety on the job in their health care setting What is NIOSH? National Institute for Occupational Safety & Health -federal agency within the CDC, was established to conduct research and recommend interventions for the prevention of work-related injury and illness. What are the 6 steps in the chain of infection? Infectious agent -> Source -> Portal of exit -> Mode of transmission -> Portal of entry ->susceptible host Side effects and adverse reactions to opiods respiratory depression seizures nausea/vomiting constipation itching urine retention Characteristics of an open wound break in the skin surface -abrasion, puncture wound, surgical incision, pressure wound Characteristics of a closed wound bruising Characteristics of a superficial wound involves only the epidermis Characteristics of a partial thickness wound involves epidermis and dermis Characteristics of a full thickness wound involves epidermis, dermis and subcutaneous later. may involve muscle or bone Characteristics of a clean wound No sign of infection and risk for developing infection is low Characteristics of a clean contaminated wound is similar to a clean wound, but because the surgery involves organ systems that are likely to contain bacteria, the risk for infection is greater. Characteristics of a contaminated wound result from a break in sterile technique during surgery; from the perforation of an organ such as the colon, small bowel, or appendix before surgery, which allows for spillage of bacteria-laden material into the wound; or from certain types of trauma or accidents, such as penetrating trauma or a fall. These wounds have a higher risk of infection than clean contaminated wounds Characteristics of an infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 105 per gram of tissue sampled when cultured Characteristics of a colonized wound ne or more organisms are present on the surface of the wound when a swab culture is obtained but there is no overt sign of an infection in the tissue below the surface. Colonization is common in chronic wounds and may contribute to delayed wound healing. Characteristics of an acute wound A wound that progresses through the phases of wound healing in a rapid, uncomplicated manner How do wounds heal from primary intention? Wounds such as surgical incisions or traumatic wounds in which the edges of the wound can be approximated (brought together) to heal are examples of acute wounds. This type of wound is said to heal by primary intention. Wounds that heal by primary intention tend to heal quickly and result in minimal scar formation How do wounds heal from secondary intention? When a wound heals by secondary intention, new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue. Such wounds are often associated with disease processes such as diabetes or vascular disease or with other factors that have inhibited proper wound healing. How do wounds heal from tertiary intention? when a wound is left open to heal initially (ie: if contaminated during surgery) to drain and then closed at a later time Facts about the elderly and nutrition BMR slows so they needs fewer calories per day. They should focus on eating nutrient dense foods and adequate water take to avoid constipation Aspiration precautions for feeding a stroke patient -oral care before and after feeding -head of bed 30-45 degrees -turn head towards the affected side to protect airway -chin tuck -offer small bites -alternate food and drink Steps in removing NG tube -Raise bed (Fowler's ) -Bedside set up and towel over pt's chest - Disconnect tube from pump -Running? Stop flow, flush tube, disconnect, clamp -Remove tapes -Instruct pt to take deep breath and hold -Pull tube quickly and smoothly and dispose -Mouth care Define depression a mood disorder characterised by sense of hopelessness and persistent unhappiness What are the signs and symptoms of depression? sadness over long period of time, decrease in self esteem, changes in eating patterns, changes in sleeping patterns What are the two types of depression/what causes each? Situational/ Exogenous= triggered by life situations Intrinsic/ Endogenous= chemical changes in the brain Define delirum Rapid onset, & usually reversible w/treatment by eliminating underlying cause, providing counseling, or prescribing antidepressant agents Interventions for patient with sensory overload -Reduce sensory stimuli (dimming unnecessary lights, turning sound down on alarms) - Pt is not constantly disturbed - Pain medication - soothing music, backrub - family member visits - provide soothing, recognizable presence Effects of corticosteroids on the body Increase serum glucose level -inhibits the inflammatory response, which improves respiratory function Risks: increase of bleeding, increase of infection, delays wound healing and immune response Goals