RN31 Final Exam – Study Guide

RN31 Final Exam – Study Guide 1. Definition of nursing and the implementation of the nursing process Nursing is Caring: a compassion, a respect for each client’s dignity Four Broad Aims of Nursing Practice: 1. To promote health 2. To prevent illness 3. To restore Care 4. To facilitate coping with disability or death Definition: The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations Nursing process: systematic, rational method of planning and providing individualized nursing care Assessment Diagnosis Planning Implementation Evaluation 2. Difference between the Nurse Practice Act and Standards of Practice The Nurse Practice Act is the most important law affecting the nursing practice. Each state has a nurse practice act that protects the public by broadly defining the legal scope of nursing practice. Obtain a copy from your state’s BRN. Each nurse is expected to care for patients within defined practice limits. Practicing beyond those limits can put the nurse at risk for violating the state nurse practice act. Voluntary standards, developed and implemented by the nursing profession itself are not mandatory but are used as guidelines for peer review. Professional organizations reassess the functions, standards, and qualifications of their members. Examples of voluntary standards: American Nurses Association (ANA) standard of practice, professional standards for accreditation of education programs and service organizations, standards for certification. Legal standards: developed by legislature and implemented by authority granted by state to determine minimum standards for nursing education, licensure requirements, determining when a license should be suspended or revoked. 3. The health illness continuum A model that helps with understanding a person’s level of health. Views health as a constantly changing state with high-level wellness and death at opposite ends of the continuum. It illustrates the ever-changing state of health as a person adapts to changes in internal and external environments. ex: patients w/cancer may view themselves at different points on the continuum at any given time, depending on how well they are functioning with the illness. (Fig 3-3, pg. 60) 4. Know the “chain of infection” and the inflammatory process Chain of Infection · Infectious agent - (the microorganism itself) Some of the more prevalent agents that cause infection are bacteria, viruses, and fungi · Reservoir - (where the organism lives) The reservoir for growth and multiplication of microorganisms is the natural habitat of the organism. Possible reservoirs that support organisms pathogenic to humans include other people, animals, soil, food, water, milk, and inanimate objects. · Portal of exit -(how the microorganism exits the reservoir - ex: sneezing, coughing) The portal of exit is the point of escape for the organism from the reservoir. The organism cannot extend its influence unless it moves away from its original reservoir. · Means of transmission- An organism may be transmitted from its reservoir by various means or routes. Some organisms can be transmitted by more than one route. Organisms can enter the body by way of contact transmission, either directly or indirectly. o Direct ▪ person to person, Ex: kissing, hugging, touching o Indirect ▪ vehicle born - ex: objects, food, water ▪ vector born- ex: animals, insects o Airborne ▪ through droplets in the air · Portals of entry- (How does the microorganism get into the host? ex: mouth, eyes, nose, blood, impaired skin.) The portal of entry is the point at which organisms enter a new host. The organism must find a portal of entry to a host or it may die. The entry route into the new host is often the same as the exit route from the prior reservoir. · Susceptible host- Microorganisms survive only in a source that provides shelter and nourishment (a host), and only if the microorganisms overcome any resistance mounted by the host’s defenses. Susceptibility is the degree of resistance the potential host has to the pathogen. Break the chain: · Handwashing (breaks the portal of entry) · Clean surfaces (method of transmission) · Nutrition/Vaccine/Sleep/Exercise (susceptible host) · Antibacterial cleanse ( reservoir) The Inflammatory Process The inflammatory response is a protective mechanism that eliminates the invading pathogen and allows for tissue repair to occur. Signs of acute infection are redness, heat, swelling, pain, and loss of function, usually appearing at the site of the injury/invasion. The body’s response occurs in two phases that are responsible for these signs: Vascular Phase · Small blood vessels constrict in the area followed by vasodilation of arterioles and venules that supply the area. · This increase in blood flow results in redness and heat in the area. · Histamine is released, leading to an increased permeability of vessels, which allows protein-rich fluid to pour into the area. · At this point, swelling, pain, and loss of function can occur Cellular Phase · White blood cells (leukocytes) move quickly into the area. · Neutrophils, the primary phagocytes, engulf the organism and consume cell debris and foreign material. · Exudate composed of fluid, cells, and inflammatory byproducts is released from the wound. The exudate may be clear (serous), contain red blood cells (sanguineous), or contain pus (purulent). The amount of exudate depends on the size and location of the wound. · The damaged cells then are repaired by either regeneration (replacement with identical cells) or the formation of scar tissue 5. How does the respiratory tract defend against infection? · The first line of defense starts with the nasal passage where hairs at the entrance of the nares trap large particles in the air. · The second line of defense is the Pharynx shared with naso/oropharanyx which is richly supplied with lymphoid tissue that traps and destroys pathogens · The third line of defense is the larynx. It is important for providing airway patency and protecting the lower airway from foods and liquids · The fourth line of defense is the bronchi and trachea which are lined with mucosal epithelium. the mucus traps pathogens and microscopic particulate matter. · The cough reflex which is triggered by irritants in the larynx, trachea or bronchi 6. Implementation of the different isolation procedures Standard Precautions · Perform hand hygiene before and after every pt contact · Use PPE when risk of body fluid exposure · Use and dispose of sharps safety · Perform routine environmental cleaning · Clean and reprocess shared patient equipment · Follow respiratory hygiene and cough etiquette · Handle and dispose waste and used linen safely Contact - C-Diff, MRSA (diarrhea, wounds that have cultured positive) Precautions in addition with standard precautions Before entering room: Leaving room: · Perform hand hygiene Dispose of gloves · Put on gown or apron Perform hand hygiene · Put on gloves Dispose of gown or apron Perform hand hygiene Droplet - Rubella, Mumps, whooping cough, pertussis, COVID-19 Precautions in addition with standard precautions Before entering room: Leaving room: · Perform hand hygiene Dispose of mask · Put on a surgical mask Perform hand hygiene Airborne - Measles, TB, Varicella, Influenza, Anthrax, Smallpox Precautions in addition with standard precautions Before entering room: Leaving room: · Perform hand hygiene Dispose of mask · Put on N95 or P2 mask Perform hand hygiene · Perform a fit check of the mask 7. Difference between medical and surgical asepsis MEDICAL: Clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Ex: hand hygiene, wearing gloves. Areas are considered contaminated if visibly soiled, suspected of having pathogens. SURGICAL: Sterile technique, includes practices used to keep objects/areas free from microorganisms(all microorganisms, pathogens, & spores have been destroyed). Ex: inserting indwelling catheter or inserting IV catheter, dressing changes, preparing injectable meds. 8. Know the effects of immobilization (pg. ) Lack of exercise, inactivity, or immobility related to illness or injury place a person at high risk for serious health problems, with the potential for complications in every body system. It’s been linked to chronic health problems with complications that vary upon age and overall health status. Immobility & Cardiovascular System: · Increased cardiac workload, orthostatic hypotension, and venous stasis ulcers, w/resulting venous thrombosis. Immobility & Respiratory System · Related to decreased ventilatory effort and increased respiratory secretions. Causes decrease in depth and rate of respirations, may result in atelectasis. Results in poor gas exchange of CO2 and O2, leading to acid-base imbalance. Immobility & Musculoskeletal System · Rapidly seen in pts. confined to bed, leading to atrophy (decreased muscle size), decreased tone & strength, decreased joint mobility & flexibility, bone demineralization, limited endurance, resulting in problems w/ADL’s Immobility & Metabolic System · Resting body needs less energy→ cellular demand for O2 is decreased, leading to decreased metabolic rate. During chronic illness, trauma, or poor nutrition, metabolic demands for the body increase catabolism (protein stores breakdown to make energy for the body). If left unchecked-results in muscle wasting and negative Nitrogen balance Immobility & Gastrointestinal System · Disturbances in appetite, decreased food intake, altered protein metabolism, and poor digestion & utilization of food. Increased food intake while decreasing energy expenditure = weight gain. · GI tract slows down in a immobile pt. that results in constipation, poor defecation reflexes, and inability to expel feces & gas adequately. Immobility & Urinary System · immobile pt’s kidneys & ureters are level and urine remains in the renal pelvis for a longer period of time. Urinary stasis favors the growth of bacteria that could cause UTI. Poor perineal hygiene, incontinence, decreased fluid intake, or indwelling urinary catheter can increase risk for UTI, · Immobility put pt. at risk for kidney stones or renal calculi (due to high levels of urinary calcium). Immobility & Skin · Impaired circulation due to immobility may result in serious skin breakdown or pressure injuries. Immobility & Psychosocial Outlook · Sense of self threatened due to dependence on self-care activities from others. Prolonged immobility can lead to feelings of worthlessness and diminished self-esteem.