NR224 / NR 224: Fundamentals Exam 2 (Latest 2020 / 2021) Chamberlain College of Nursing

Chapter 15 CRITICAL THINKING Basic critical thinking : limited experience, based on the rules Complex critical thinking : increase knowledge & intuition Committtment : making choices with full responsibility Chapter 16 NURSING ASSESSMENT Nursing process  critical thinking for the client individually Assess: Gathering all of the information about patients condition -observe Data collection Diagnosis : Identify the Problem Planning: Evidence Based practice Establish priorities  optical outcomes Implementation: Provide care based on assessment Use critical thinking Evaluation: Determine if the plan was effective or needed to change Nursing process Assessment -investigate, immunization, vaccinations, systems, travel history -recognize risk factors -medical therapy -appearance -laboratory data (WBCS) Diagnosis - risk for infection (2 part diagnosis) - imbalanced nutrients - risk for impaired skin integrity - social isolation HIGH FLYER - impaired tissue - readiness for enhanced immunizations Planning HIGH FLYER -smart goals, realistic -preventing exposure to infectious organism -control or reduce extent to infection -verbalizing understanding of infection prevention and control (hand watching) Implementation -health promotion (prevention of development) -acute care Critical thinking : collect/verify data analyze data Sources of date: Patient (interview, observation physical exam) BEST SOURCE!! -use own words & use quotation marks Family & SO (agreement first) Health care team Medical records Scientific literature HIPAA- indivuadlly information in verbal and electronical CHAPTER 26 DOCUMENTATION AND INFORMATICS CHAPTER 27 PATIENT SAFETY CHAPTER 28 IMMOBILITY DVT: unilateral edema, pain, redness in one leg/calf -elevate affected leg, admin anticoagulants -increase activity (every 2 hours) and change positions -SCD cuffs, compression stockings -NO PILLOW AT KNEES Cane: 2 points of support, position cane on stronger unaffected side, move cane forward, move weaker leg to leg, stronger leg past the cane Walker: advance walker 12 inches, advance affected leg, then unaffected forward Crutches: adjust 3 finger widths, elbows flexed @ 30 degrees Tripod position, move unaffected leg forward above crutches Sitting/rising: on unaffected side HIGH FLYER Up stairs: step up with unaffected leg , bring injured leg and crutches up and a bove Integumentary: skin lack of circulation  pressure ulcers Protein, move every 15 mins, 1 hr in chiar, Q2 turns, Metabolic: maintain metabolism  I&O, wound healing, high calorie, oral intake Elimination: urinary/bowel  I&O, bowel sounds, color, odor, amount, frequency Hydration, stool softner, perineal care, straight cath, high fiber Respiratory: maintain airway  observe chest wall, ascultate , productive cough? Incenintive spiraometer Cardiovascular: circulatory in the heart  ascultate for S3, palpate for edema, pulses -avoid valsalva maneuver , heparin, Bp MUSCOLOSKELETAL AND PSYCH CHAPTER 29 INFECTION CONTROL Native immunity – restricts entry , immediate response Passive—antibodies produced by external source (skin) Specific- producing antiboties against direct antigen The highest risk of spreading  health care providers Hand washing!! Incubation – interval b/w time of interest and symptoms Prodromal – malaise (nonspecific), pathogen multiplying Illness – sign and symptoms specific Convalescence – days to two months of recovery Infectious agent does not mean an infection will occur – if chain stays intact Causative agent -bacteria -viruses -fungi -protozoa reservoir – multiply waiting for a host -health care workers HANDS! -equipment -animals -foods port of exit – leaving the host -respiratory -blood -skin -mucous membrane