Not complete but a good start..

Final Exam Study Guide

Module #1: Intro to nursing Nursing is an art and a science which integrates and assimilates knowledge and skills derived from biological, physical, social, and behavioral sciences. o Science is the knowledge base. Nurses are concerned with the human response to the medical diagnosis. Characteristics of professional nursing: caring, commitment, accountability. Patricia Benner-Novice to Expert o Novice beginner with no experience taught general rules to help perform tasks o Advanced Beginner Demonstrates acceptable performance Has gained prior experience in actual situations to recognize recurring meaningful components. Principles, based on experiences, begin to be formulated to guide actions. o Competent Typically a nurse with 2-3 years experience on the job in the same area or in similar day-to-day situations More aware of long-term goals Gains perspective from planning own actions based on conscious, abstract, and analytical thinking and helps to achieve greater efficiency and organization o Proficient Perceives and understand situations as whole parts More holistic understanding, improves decision making Learns from experience what to expect in certain situations and how to modify plans o Expert No longer relies on principles, rules, or guidelines to connect situations and determine actions Much more background of experience Has intuitive grasp of clinical situations Performance is now fluid, flexible, and highly-proficient

Module #2: Health Care Systems

4 Components: People, Settings, Regulatory Agencies, Health Care financing Mechanisms Peopleo Participants in the health care system RNs, LPNs, Medical doctors, pharmacists, dentists, dietitians, physical, respiratory, and occupational therapists, assistive personnel. Settingso Where health care is provided Hospitals, homes, skilled nursing facilities, assisted living, community/health departments, adult day care centers, schools, hospices, providers offices, ambulatory care clinics, occupational health clinics. Regulatory Agencieso Where regulations for practice are enforced US Department of health and human services US food and drug administration State and local public health agencies State licensing boards To ensure that health care providers and agencies comply with state regulations The Joint Commission To set quality standards for accreditation of health care facilities Professional Standards Review Organizations Utilization Review Committees To monitor for appropriate diagnosis and treatment of hospitalized clients. Health Care Financing Mechanisms o Federally funded programs: Medicare-65+ or permanent disabilities. Insurance program-Reimburses providers based on DRGs. Managed care organizations (MCOs)-Enrolled clients receive comprehensive care overseen by a primary care provider. Medicaid-clients with low incomes. Federally funded. State regulated. o Private plans: Traditional insurance reimburses for services on a fee-for-service basis. Managed Care Organizations-Comprehensive care is overseen by a primary care provider and focuses on prevention and health promotion.

Preferred provider organizations-The client chooses from a list of contracted providers. Using non-contracted providers increases the clients out of pocket costs. Exclusive provider organizations-The client chooses from a list of providers within a contracted organization. Long-term care insurance-This provides for long-term care expenses not covered by Medicare.

Primary Care (Health Promotion) o Prenatal care o Well-baby care o Nutrition counseling o Family planning o Exercise classes Preventive Care Blood pressure and cancer screening Immunizations Poison control information Mental health counseling and crisis prevention Community legislation (seat belts, air bags, bike helmets) Secondary Care (problem trying to solve) o Emergency care o Acute medical-surgical care o Radiological procedures Tertiary Care (specialized facility) o Intensive care o Subacute care Restorative Care (bring back to what might have been) o Cardiovascular and pulmonary rehabilitation o Sports medicine o Spinal cord injury programs o Home care Continuing Care o Assisted living o Psychiatric and older adult day care

EX. A nurse has volunteered to give influenza injections at a local clinic. What level of care is he demonstrating? Primary

Module #3 & 4: Health Care Policy & Quality Improvement Health Care Economics: How healthcare is financed o Payment Sources o Commercial Insurance Plans o Prospective payment systems Healthcare regulation: Used to promote and improve the quality of healthcare o Accreditation: Joint Commission o Federal Regulation/Licensure: OSHA, CMS, QIO, HIPAA o State Regulation/Licensure: DHHS, DHSR o Utilization Review Committees-monitor appropriate diagnosis and treatment of hospitalized clients

Sentinel evento an unexpected occurrence (or risk of) involving death or a serious psychological injury o called sentinel because they signal the need for immediate investigation and response o purpose: monitor trends Role of nurse in quality improvement: o Communication o Safety-keeping current o Reporting any errors or sentinel events

Module #5: Safety Patient Safety Goals:

Patient-Inherent Accidents- seizures, choking, burns Procedure-Related Accidents- Medication errors, infiltrations, improper applications Equipment-Related Accidents-Cords, malfunction, disrepair, misuse

Patient Practice Act- To ensure safe and competent care. 7 legal tips for safe nursing practice: o Communicate effectively o Document in an accurate, timely manner. o Administer medications appropriately. o Monitor for and report deterioration. o Delegate Responsibly o Know and follow facility policies and procedures. o Use equipment properly. Risks to safety related to developmental age. (Ex. Infants-oral, toddlers-falls, drowning, preschoolers-drowning, poisoning)

Module #6: Collaboration Definitionso Cooperative effort that focuses on a win-win strategy o Working together for the common good o Working as a group utilizing individual skills and talents to reach the highest of patient care standards Factors encouraging effective collaborationo Communication o Understanding roles of interdisciplinary team o Effective problem solving skills. Barriers to effective collaborationo Lack of communication o Lack of understanding roles o Lack of trust and respect for or in others o Lack of confidence o Bad listener o Controlling o Time Management Chain of command-report to manager o EX. Who would you report to when you notice a nurse is not performing her assessments but charting them as complete? Manager

Module #7: Legal Issues Key points: o Nurses are legally responsible for the care they deliver o Knowledge of the law helps maintain standards of practice and protect the nurse from liability o Nursing practice is regulated primarily at the state level, through licensing, legislation (nurse practice act), and accreditation The whole point of licensure: o To protect public from harm NC Board of Nursing: o To protect the public by ensuring the provision of safe nursing care to the people of North Carolina through the regulation of nursing practice. o Functions: To regulate the practice of nursing To license registered nurses and licensed practical nurses. To approve educational programs leading to licensure. To issue interpretations of the Nursing Practice Act To maintain a registry of nurse aide To investigate complaints against nurses Document Meticulously: o Factual Accurate Complete Current Organized Informed consento A persons agreement to allow something to happen based on a full disclosure of facts needed to make an intelligent decision. Must include information about procedure/treatment and why it is needed, risks involved, benefits, alternative treatment options, and consequences of refusal. It is required for surgery, certain diagnostic and medical treatments and research involving clients. o Physician is responsible for explaining the need for the procedure, nature of the procedure or treatment, risks, complications, other treatment options, consequences if procedure or treatment not done, etc. o Nurse is responsible for obtaining and witnessing the patients signature and act as a patient advocate if s/he does not understand or has questions Legal requirements o person signing must be A&O x 3 (not under the influence of sedatives/narcotics) o must be18 years old or an emancipated minor; parents sign the form for children under 18 o telephone or faxed consent is acceptable o if patient is unable to write a signature, an X must be witnessed by 2 people o patients cannot be coerced, manipulated or forced to give consent o physicians can assume responsibility in emergency situations without a signed consent form o date and time of signing must be identified

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no medical abbreviations can be used no blank spaces can be left on form physicians full name must be legible (No initials) patients signature or legal guardian and relationship must be obtained witnesses signature (usually nurse)(student nurses do not witness)

HIPAAo Health Insurance Privacy Accountability act o Maintains privacy Nurse Practice Acto Nursing is a dynamic discipline which includes the assessing, caring, counseling, teaching, referring and implementing of prescribed treatment in the maintenance of health, prevention and management of illness, injury, disability or the achievement of a dignified death. It is ministering to, assisting, and sustained, vigilant, and continuous care of those acutely or chronically ill; supervising patients during convalescence and rehabilitation; the supportive and restorative care given to maintain the optimum health level of individuals, groups, and communities; the supervision, teaching, and evaluation of those who perform or are preparing to perform these functions; and the administration of nursing programs and nursing services. o The practice of nursing by a registered nurse consists of the following ten components: Assessing the patient's physical and mental health including the patient's reaction to illnesses and treatment regimens. Recording and reporting the results of the nursing assessment. Planning, initiating, delivering, and evaluating appropriate nursing acts. Teaching, assigning, delegating to or supervising other personnel in implementing the treatment regimen. Collaborating with other health care providers in determining the appropriate health care for a patient but, subject to the provisions of G.S. 90-18.2, not prescribing a medical treatment regimen or making a medical diagnosis, except under supervision of a licensed physician. Implementing the treatment and pharmaceutical regimen prescribed by any person authorized by State law to prescribe the regimen. Providing teaching and counseling about the patient's health. Reporting and recording the plan for care, nursing care given, and the patient's response to that care. Supervising, teaching, and evaluating those who perform or are preparing to perform nursing functions and administering nursing programs and nursing services. Providing for the maintenance of safe and effective nursing care, whether rendered directly or indirectly.

Module 8 & 9: Ethics & Accountability Definition: o The practices or beliefs of a certain group. Ethical Principles: o Autonomy-people have the right to make decisions. They have the right to refuse. o Beneficence-doing or promoting good; basis for all healthcare o Nonmaleficence-to avoid doing harm; prevent harm or remove from harm o Justice-involves fair treatment of all individuals with equal allocation of resources o Fidelity-keep promises and dont make promises you cant keep o Veracity-tell the truth. Be honest with patients, families, and peers o Accountability-take responsibility for your own actions o Confidentiality-keep information private Ethical Dilemmas: o A problem that is unable to be solves solely through a review of scientific data. Frequently occurring ethical dilemmas: End of life care Non-response by a physician Unsafe nurse-patient ratio Refusal of treatment Fertility Issues Stem-cell research Use of scarce resources Incompetent health care providers

Accountability The responsibility that nurses assume for their nursing practice and the obligation to report and account for their actions to: themselves, the institution, the profession, the public. Student nurses as well as licensed nurses are accountable for their actions. Students must always function within the scope of the student nurse role. Ex. The students responsibility in the clinical environment is: o To take responsibility for assignments assigned by CIs. Continued competence in nursing in NC is: An evaluative process carried out by the nurse, employer, and BON. A self-directed and ongoing process carried out by the individual nurse for the purpose of licensure renewal Based on a reflective model (Benner: Novice to expert) How is it done? Assess practice Based on standards Collect feedback Develop a learning plan

Module #10 Advocacy: Advocacy requires accepting and respecting the patients right to decide, even if the nurse believes the decision to be wrong. The advocate must be careful to be objective and not convey approval or disapproval of the patients choices. It is the nurses responsibility to ensure the patient has access to health care services that meet health needs.

Vulnerable populations that may need advocating for: Physically, mentally or emotionally disabled or challenged Children or elderly Dying, sedated, or unconscious Institutionalized or incarcerated Pregnant women and fetuses Nurses are advocates when they: Inform patients of their rights Provide patients with the information they need to make informed decisions Support patients to get additional info from others Support patient decisions, giving them full, or at least mutual responsibility in decision making when they are capable of it.

Module # 11: Managing Care

The nurse as a manager: o Someone who is given authority, power, and responsibility for planning, organizing, coordinating, and directing the work of others, and for establishing and evaluating standards. o Nurse manager strives to meet goals and objectives. Leadership: o Autocratic- leader makes all the decisions o Democratic- group is involved in decision making o Lassez-Faire-non-directive, permissive leader. Nursing care delivery modelso Functional Nursing Task focused not patient focused o Team nursing Staff assigned to group of patients organized by geographical location RN is team leader o Modular nursing or care partners Form of team nursing RN cares for patient assisted by CAN o Total patient care RN responsible for all aspects of care Shift-based focused Critical care setting o Primary nursing RN autonomous-responsible for caseload of patients Develops a 24 hr nursing care plan Ensures quality of care o Case management Coordinates care for patients Does not give direct care Facilitates referrals, testing, discharge, etc. o EX. ____ nursing is when all care is by a registered nurse. Primary Nurse aide I & II tasks.

Module # 12 & 16 Health team communication: Informatics The nurse understands: o Patients have the right to read their record. Functions of automated patient record: o Communications pertinent pt. information o Provides the legal record of care o Support clinical decision making o Captures costs for billing, costing, and/or accounting purposes o Provides a retrievable database for administrative queries, quality assurance, and research o Supports data exchange with internal and external systems. Purposes: o Legal documentation o Communication o Financial Billing o Education o Research o Auditing or monitoring standards of care Acuity records: o Determine the staffing to patient ratio Incident/variance report: o Sentinel events are not charted. Not a part of patients permanent record. Telephone reports: o Always repeat information back Situation Background Assessment Recommendation Repeat Ex. Pts. Forearm is red what would you do first. Assess pt. first.

Module # 13: Evidence Based Practice Evidence based practice is essential to provide competent, safe nursing care. Five steps: o o o o o o Ask the clinical question Collect the best evidence Critique the evidence Integrate the evidence Evaluate the practice decision or change 6th step- communicate your results

Module # 14: Health, Wellness, Illness Just because you arent sick doesnt mean you are health. High level wellness The awareness and ability to apply wellness habits Levels of prevention Primary-Preventive screening, immunizations Secondary-Diagnosis and treatment Tertiary-Rehabilitation, optimal management of chronic conditions and functions 8 ways to stay healthy Maintain a healthy weight Exercise regularly Dont smoke (Cut down if you do.) Eat a healthy diet Drink alcohol only in moderation Protect yourself from the sun Protect yourself from sexually transmitted diseases Get screening tests Stages of health behavior change Precontemplation- Not intending to change anytime soon Contemplation-Considering Change Preparation-making small changes for action plan Action-Actively engaged in plan Maintenance-Sustained change, possible relapses Termination-Previous behavior no longer pleasurable Health People > 5 fruits and vegetables a day Exercise > 12 times/month Maintain healthy weight Moderate alcohol consumption No Smoking

Module # 15: Teaching-Learning Learning theories Behaviorismo Learning that occurs in response to environmental stimuli Cognitiveo Learning is a mental or thinking process in which the learner structures/processes information. Three areas of domain: Cognitive, psychomotor, affective Humanismo Learning focuses on self-development/achieving full potential. Learner identifies learning needs and takes responsibility for meeting them

Learning Domains Cognitiveo Includes all intellectual behaviors and requires thinking Psychomotoro Requires the integration of mental and muscular activity. (Thinking and doing) Affectiveo Deals with expression of feelings/acceptance of attitudes, opinions, and values.

Ex. Client is providing ostomy care without contaminating hands is an example of which learning domain? Psychomotor Factors that inhibit learning Emotions Physiological Psychomotor ability Language barriers Cultural barriers

Factors that facilitate learning Motivation of learner Readiness of learner Active involvement of learner Relevance of the content to the learner Feedback that is meaningful to the learner Nonjudgmental support Simple to complex Repetition Timing Environment

Ex. Of a patient showing readiness to learn: o Teaching must be: o o o o o Sequencing: Start with something pt. is concerned about Review what the patient knows, then proceed to new material Address early any area that is creating anxiety Teach the basics first before teaching variations or adjustments (Simple-complex) Schedule time for review and questions Purposeful Interactive Goal oriented Individual or group Planned or spontaneous Im not sure Ill be able to do this at home

Suggestions for effective teaching Assess for readiness to learn Be trustworthy and consistent Respect patient Involve pt. in planning Seize the teachable moment Use vocabulary the pt. understands Do not overwhelm with information Communicate clearly and concisely Use agency materials if available Allow ample practice for psychomotor learning Relate learning to something the pt. values

Module # 17 & 18: Self & Family Self-concept An individuals conceptualization or image about himself or herself. It is a subjective sense of the self and a complex mixture of unconscious and conscious thoughts, attitudes, and perceptions. Ex. Empty nest syndrome may alter self-concept. Eriksons Psychosocial Theory of Development Trust vs. mistrust (0-1 year) Autonomy vs. shame (1-3 years) Initiative vs. guilt (3-6 years) Industry vs. inferiority (6-12 years) Identity vs. role confusion (12-20 years) Intimacy vs. isolation (mid 20- mid 40 years) Generativitiy vs. self-absorption (mid 40- mid 60) Ego integrity vs. despair (late 60-death) Nuclear family Husband, wife, children Extended family Relatives (grandparents, aunts, cousins) in addition to nuclear family Single-Parent family Formed when one parent leaves the family unit Single person decides to adopt or have a child Blended family Formed when parents bring unrelated children from prior or foster parenting relationships into a new, joint living situation

Module # 19: Stress and Coping Distress-harmful to individuals health Eustress-positive stress General Adaptation Syndrome Alarm o The bodys first response, which involves mobilization of the bodys defenses. Fight or flight response. Resistance o The body stabilizes. Vital signs and hormone levels return to normal. If adaptation does not occur the person moves to exhaustion. Exhaustion o Illness or death may occur. Anxiety A universal human experience. It is a feeling of apprehension, uneasiness, uncertainty, or dread from a real or perceived threat. May be manifested by physiological, behavioral, or psychological symptoms. It is assess on a continuum from mild to panic level. Mechanisms of defenseConcepts: IDPrimitive instinctual drives Seeks gratification I want what I want when I want it. EgoMediates demands of the environment and the demands for instinctual satisfaction Ego functions: o Perception of reality o Perception of others o Judgment o Control of thoughts, feelings and actions o Thinking and cognition SuperegoStrives for perfection and morality Know defense mechanisms.* Ex. A nurse is reprimanded by her manager and tells the NA to do her job. Displacement

Module 23 Caring Interventions SwansonDefines caring as a nurturing way of relating to a valued other, toward whom one feels a personal sense of commitment and responsibility. Knowing Being with Doing for Enabling Maintaining belief

Touch o Provides Comfort o Creates a connection Contact toucho Hand shake Noncontact touch o Eye contact Protective touch o Used to protect nurse and/or client to prevent an accident Task-oriented touch o Any time going into room to do something to patient

Module 25: Cognition Definition A complicated process by which an individual learns, stores, retrieves, and uses information. Cognitive processing supports reasoning, problem solving, remembering, interpreting, and communicating

Paigets stages of cognitive development Sensorimotor phase: Birth-2 years o Peek a boo Pre-operational phase: 2-7 years o Thinks a tall skinny glass holds more than a short wider glass Concrete operational phase: 7-11 years Formal Operational phase: 11 years to adult o A stitch in time saves nine Cognitive development across the lifespan: Newborn o Require sensory stimulation Infant o Learn by experiencing and manipulating the environment Toddler o Increased ability to remember events and put thoughts into words Pre-schooler o Aware of cause and effect relationships School-age Children o Begin to use logical thought processes Adolescents o Make decisions through logical operations Young adults o General life experiences and occupational opportunities dramatically increase cognitive skills Middle adults o Cognitive changes are rare, except with trauma or illness Older adults o Decline in the ability to: Perform information processing Divide attention between tasks Switch attention rapidly from one auditory input to the other Maintain sustained attention or perform vigilance tasks Filter out irrelevant information Perform word finding Perform abstraction tasks Maintain mental flexibility

7 steps to a positive approach Come from front Go slow Side Low Hand Use preferred name Wait for response Delirium Acute, confused, reversible Dementia Chronic, degenerative Somatic delusion Belief that ones body is changing in an unusual way

Module # 26: Sensory/perception Interventions for hearing loss: Get attention Face client Clean glasses Speak slowly Normal tone Rephrase rather than repeat Visible expressions Talk towards best ear Use written info Avoid eating, chewing, smoking, while speaking Avoid walking away/speaking from another room Ex. Pt shouts and nods and smiles-hearing deficit Sensory deprivation-lack of meaningful stimuli Excessive yawning, drowsiness, decreased attention, difficulty concentrating, confusion, crying, depression, somatic complaints Sensory overload-Unable to process or manage amount of intensity stimuli Unable to selectively ignore stimuli, restlessness, overwhelmed, not in control, fatigue, cognitive overload Sensory deficit- impaired reception, perception or both of one or more senses

Module # 27: Comfort Addiction- characterized by impaired control over drug use, compulsive use, continued use, despite harm and craving Pseudoaddiction- iatrogenic syndrome created by undertreatment of pain, staff suspects addiction Distinguished from true addiction in behaviors resolve when pain is effectively treated Tolerance- state of adaptation in which exposure to drug results in a decrease in one or more drug effects over time Physical dependence- Withdrawal syndrome, cant function without it Withdrawal syndrome-N&V, cramping, muscle twitching, profuse perspiration, delirium, convulsions When to assess pain 5th vital Each report of pain Before and after an intervention Unexpected intense pain Noted changes in pt. behavior Ex. Pt reports pain, first thing to do is: assess pain. Provocative/palliative factors Quality Region/radiation Severity Timing How pain is affecting you Acetaminophen60-75mg/kg for children < 50kg 4gm for adults Is 200mg every 4-6 hours a safe dose for a child that weighs 10kg? NO! NSAIDS- mild-moderate pain Do not give to pt. with a peptic ulcer! Give pt. oxycodone for less side effects. Pain is whatever the patient says it is. Pt. should know you believe them about their pain. PCA pump-only pt. can push. Encourage the patient to press the button when she feels discomfort. Anticoagulants would contraindicate an epidural catheter for pain management. When going into pts. Room to give meds -you DONT take vitals every time or look up side effects every time.

Module # 28 & 29: Oxygenation & Perfusion Murmur valvular dysfunction causes backflow or regurgitation of blood through the incompetent valve, makes whooshing sound mitral murmurs best heard at the apex of the heart Bruit (pronounced brew-ee) when the lumen of a blood vessel is narrowed, this disturbs blood flow causing a blowing or swishing sound. Edema alterations in cardiac function (congestive heart failure or hypertension) pts. often have pedal or lower extremity edema

Left sided heart failure=crackles in lungs. Right sided heart failure=rest of body. DVT- nurse anticipates anticoagulation therapy. Non modifiable risk factors: age, gender, ethnic background, family history of heart disease Modifiable risk factors: smoking history, sedentary lifestyle, obesity/diet, psychological variables Diabetes significantly increases risk of death from stroke & heart disease

Hypoxia- s/s

Oxygenation history Workplace, home environment, pollution, dust or fumes Prescription & OTC drugs, alternative medicine, past illnesses Smoking history in Pack Years Travel, allergies, nutrition, family history Hemoglobin: 12-16g/dL females; 14-18g/dL males Hematocrit: 37-47% females; 42-52% males RBC: 4.7-6.1 Male; 4.2-5.4 Female White Blood Cell Count: 5000- 10,000 Neutrophils: 55-70 Lymphocytes: 20-40

Sodium: 136 - 145 Potassium: 3.5 5.0 BUN: 10 - 20 Creatinine: 0.5 - 1.1 mg/dL Female; 0.6-1.2 mg/dL Male Glucose: 70-110 Chloride: 98-106 pH: 7.35 -7.45 Pco2: 35 - 45 Po2: 80 100 HCO3: 21-28 O2 Saturation: 95%-100% Medications that promote oxygenation-bronchodilaters Medications that promote perfusion-anticoagulants Coumadin (warfarin)-antidote Vitamin K

Module # 30-33: Inflammation, tissue integrity, Infection, thermoregulation Stages of inflammation 1. Vascular and cellular responses 2. Exudate production 3. Tissue repair-damaged cells replaced with new Serous-clear fluid Sanguineous-bloody Seroussanguineous-pinkish Purulent-yellow, indicates puss-infection Local Edema Erythema Warmth Pain or tenderness Loss of function to affected body part Systemic Local plus: T >100.4F or < 96.8F Leukocytosis > 12,000 Tachycardia, Tachypnea Malaise Anorexia, N/V Enlarged lymph nodes Organ failure

Appropriate interventions for contact dermatitis: Teach the importance of not itching it so it will not spread.

Primary intention Clearly incised & re-approximated Healing occurs without complications Secondary intention Healing occurs in open wounds Wound edges are not approximated and it heals with formation of granulation tissue, contraction and eventual spontaneous migration of epithelial cells Tertiary intention delayed primary Occurs when a wound is allowed to heal open for a few days and the is closed as if primary Pre-albumin is the most important protein when it comes to wound healing. o Hyperthermia Pyrexia, fever Body temperature above normal range Illness: viral or bacterial infections, cancer, etc..

Heat exhaustion or stroke Impaired hypothalamic thermoregulation Hypothermia Core body temperature falls below 35C (95F) Excessive heat loss Inadequate heat production to counteract heat loss Impaired hypothalamic thermoregulation

To prevent shearing: turn patient on side. Know stages of pressure ulcers. To see if pressure ulcer is tunneling: probe with sterile cotton swabs. Indications of dvt-swollen leg Pt. has a broken arm: priority assessment is neurosensory/circulation assessment.