HESI FUNDAMENTALS study Guide

5/21/2018 Hesi Fundamentals - 1. Nightingaletheory Patient's environment is arrange to facilitate the body's reparative processes.Lady with the lamp 2. Dorothea Orem Self-Care Deficit Theory Focuses on activities that adult individuals perform on their own behalf to maintain life, health and well-b 3. Malpractice Professional negligence; failure to meet a legal duty, thus causing harm to another. 4. Negligence The commissioning (doing) of an act or the omission (not doing) of an act that a reasonable prudent person would have preformed in a similar situation, thus causing harm to another. 5. Abandonment of Care Wrongful termination of providing patient care. 6. HIPAA Health Insurance Portability and Accountability Act of 1996 (HIPAA) set rules and limits on who can look and receive health care information. 7. Confidentiality duty to protect information about a patient 8. Invasion of privacy Person right to be left alone or anonymous if she or he chooses 9. Erickson's Developmental Stages 1. Infancy/0-1/Basic trust vs. Mistrust 2. Toddler/1-3/Autonomy vs. Shame and Doubt 3. Preschool/4-6/Initiative vs. Guilt 4. School Age/7-11/Industry vs. Inferiority 5. Adolescence/12-19/Identity vs. Role confusion 6. Young Adulthood/20-44/Intimacy vs. Isolation 7. Middle Adulthood/45-65/Generativity vs. Stagnation 8. Late Adulthood/65+/Ego Integrity vs. Despair 10. Maslow's Hierarchy of Needs 5: Self-Actualization 4: Self-Esteem 3: Love and Belongingness 2: Safety and Security 1: Physiologic 11. Verbal communication techniques  Closed questioning -Focuses and seeks a particular answer  Open-ended question -Does not require a specific response and allows the patient to elaborate freely  Restating - Caregiver repeats to the patient what the caregiver understands to be the main point  Paraphrasing -Restating the patient's message in the nurse's own words to verify that the nurse's interpretation is correct  Clarifying -Restating the patient's message in a manner that asks the patient to verify that the message received is acc  Focusing - Used when more specific information is needed to accurately understand the patient's message  Reflecting -Assists the patient to "reflect" on inner feelings and thoughts - Stating observation -Validates the accuracy of observation Offering information -Nurse should make this interaction two-way  Summarizing -Review of the main points covered in an interaction 12. Nonverbal Communication Non verbal cues such as tone, rate of voice, volume of speech, eye contact, physical appearance, gestures, posture and use of touch. hesi fundamentals Study online at 5/21/2018 Hesi Fundamentals - 13. Nonverbal Communication Techniques  Listening -Most effective methods but also most difficult -Conveys interest and caring - Active listening (Requires the caregivers fullattention) -Passive listening (Caregiver attends nonverbally to what the patient is saying through eye contact and nodding, or verbally through encouraging phrases such as "uh-huh" or "I see.")  Silence - Requires skill and timing - Can convey respect, understanding, caring, support; often used with touch -Gives you time to look at nonverbal responses  Touch -Must be used with great discretion to fit into sociocultural norms and guidelines -Can convey warmth, caring, support, and understanding -Nature of the touch must be sincere and genuine -If the caregiver is hesitant or reluctant to touch, it may be interpreted as rejection 14. non- English communication Language Barriers. Interpreter if available; messages must be kept simple 15. Alternative Methods of Communication  Lip reading  Sign language  Paper and pencil/magic slate  Word or picture cards  Magnetic boards with plastic letters  Eye blinks  Computer-assistedcommunication  Clock face communicator 16. Nursing Process A Nice Delicious PIE A= Assessment ND = Nursing diagnosis P= Plan I= Interventions E= Evaluation 17. Assessment * Subjective:Verbal statements provided by the patient *Objective:Observable and measurable signs,Can be recorded 18. Head to Toe Assessment Begin with neurological assessment, the skin, hair, head, neck, eyes, nose and mouth. The chest, back, a and, perineal area, legs and feet in that order. 19. Physical Assessment Techniques Inspection Palpation Auscultation Percussion 20. Adventitious Abnormal breath sounds 21. Normal Lung Sounds Just hear air moving 22. Crackles or Rales Produced by fluid in bronchioles and alveoli heard on inspiration 23. Wheezes Musical quality sounds and are produced by air flowing through narrowed airways 24. Fine Crackles High pitched, discrete, discontinuous crackling sounds heard during the end inspiration; not cleared by 25. Medium Crackles Lower, more moist sound during mid-stage of inspiration not cleared by cough. 26. Coarse Crackles loud bubbly noise heard during inspiration; not cleared by cough. 27. Rhonchi (sonorous wheeze) Loud, low coarse sounds like a snore, most often heard continuously during inspiration or expiration coughing may clear sound (usually means mucous accumulation in trachea or large bronchi) 28. Wheeze (Sibilant Wheeze) Musical noise sounding like a squeak; most often heard continuously during inspiration or expiration; us louder during expiration 5/21/2018 Hesi Fundamentals - 29. Pleural Friction Rub dry, rubbing, grating sound, usually caused by inflammation of pleural surfaces; heard during inspiration or expiration; loudest over lateral anterior surface. 30. Pitting Edema Scale 1+ Trace- barely perceptible pit (2mm) 2+ Mild- a deeper pit(4mm), with fairly normal contours, that rebounds in 10-15 secs 3+ Moderate- A deep pit (6mm); lasts for 30 secs to more than one min 4+ Severe- an even deeper pit (8mm), with severe edema that possibly lasts as long as 2 to 5 mins before rebounding 31. Record Ownership and Access -The original health care record or chart is the property of the institution or physician. -The patient usually does not have immediate access to his or her full record -Patients have gained access rights to their records in most states, but only if they follow the established polic each facility. - A lawyer can gain access to a chart with the patient's written permission 32. Confidentiality -Health care personnel must respect the confidentiality of the patient's record. -The Patient's Bill of Rights and the law guarantee that the patient's medical information will be kept private unless the information is needed in providing care or the patient gives permission for others to see it. -The nurse should not read a record unless there is a clinical reason and should hold the information regarding the patient in confidence. 33. KUBLER-ROSS- STAGES OF GRIEVING/DYING 1. Denial I feel fine."; "This can't be happening, not to me."--- 2. Anger ("Why me? It's not fair!"; "How can th happen to me?"; '"Who is to blame?) --- 3. Bargaining (""I'll do anything for a few more years."; "I will give m savings if...") --- 4. Depression (m so sad, why bother with anything?"; "I'm going to die soon so what's the point?") --- 5. Acceptance (It's going to be okay."; "I can't fight it, I may as well prepare for it."). 34. PASS Pull, Aim, Squeeze, Sweep 35. RACE rescue the pt alarm confine the fire extinguish or evacuate 36. ROM (range of motion) -any body actin involving the muscles and joints in natural directional movements 4 TYPES: 1. passive 2. active 3. active assisted 4. passive assisted -patient needs some type of exercise to prevent excessive muscle atrophy and joint contracture -minimum of 2hrs per day divided into 20 min sessions -each movement should be repeated 5 37. passive ROM exercise is performed by caregiver 38. active ROM exercise is performed by patient 39. Using Appropriate Body Mechanics -Maintain a wide base of support. - Bend the knees and hips rather than the back. - Stand in front of the object. -Adjust the working level to one of comfort. - Carry objects close to the midline of the