Nur 121 Final Study Guide Unit I: Orientation to Nursing What are the 4 basic skills for nursing

practice? The 4 roles of nursing practice? 1. Cognitive 1. Communicator/Advocate 2. Technical 2. Caregiver 3. Interpersonal 3. Educator/Teacher 4. Legal/Ethical 4. Manager What is the difference between dependent and independent nursing functions? Independent: Does not require a Dr. order to carry out Dependent: Requires a Dr. order to carry out Unit II: Medical Asepsis Describe the steps in the chain of infection? Infectious agent: entity that can cause disease (i.e., biological agent, pathogenic microbes) Reservoir: place where agent can survive (i.e., infected wounds, fecal matter) Portal of exit: how infectious agent leaves the body of its host (i.e., GI tract, Respiratory tract) Mode of Transmission: movement of infectious agent from reservoir to port-of-entry of susceptible host Portal of Entry: how the infectious agent enters the host (i.e., eyes, broken skin, mucous membranes) Susceptible Host: organism that can be affected by an agent What do droplets transmit? Diseases (i.e., Tuberculosis) What do standard precautions include? Hand hygiene, gloves, mask, eye protection, face shield, gown, patient-care equipment, environmental control, linen, occupational health and blood borne pathogens, patient placement What is a nosocomial infection? An infection acquired while receiving care in a health care agency What is the most important thing a nurse can do to protect patients from infection? Wash hands What is the 1st thing one should do following an accidental exposure? Wash exposed area with soap and water What is an effective household disinfectant for viruses? 1:10 chlorine bleach to water Unit III: Personal Care Unit IV: Body Mechanics, Mobility, Safety Who is protected by the nurses use of proper body mechanics? The nurse and the patient Describe and differentiate active and passive range of motion (ROM) Active: used for the patient who independently performs ADLs but for some reason is immobilized or limited in activity or is unable to move one extremity due to injury or surgery. Passive: are performed on the patient who cannot actively move. All muscles over a joint are maximally stretched to achieve or maintain flexibility of the joint. Unit V: Legal & Ethical Concerns Describe and provide examples of invasion of privacy

Occurs when there has been a violation of the confidential and privileged nature of a professional relationship. Occurs when unauthorized persons learn of the patients history, condition, or treatment from the professional caregiver. Describe, differentiate and provide examples of false imprisonment, battery, and negligence False imprisonment: preventing a person from leaving, or restricting his movements in the facility. Battery: the actual physical contact that has been refused or that is carried out against the persons will. Negligence: failing to do something a reasonably prudent person would do, or doing something a reasonably prudent person would NOT do. Describe and provide examples of nursing malpractice and negligence Malpractice: negligence by a professional person. What is the purpose of an incident report? A tool used by the risk management department allowing the facility to note dangerous patterns and/or serves as an immediate recall of an occurrence that may result in injury or damages and future lawsuit. Define informed consent. Informed consent indicates the patients participation in the decision-making process. The person singing must have knowledge of what the consent allows and be able to make a knowledgeable decision What is the purpose of states nurse practice acts? To define the scope of nursing practice, and provide for the regulation of the profession by a state board of nursing. (To protect the public) What role does a client advocate have? One who speaks for and protects the rights of the patient. What do you do if a patient touches you inappropriately? Verbalize to the patient that his action was inappropriate. If it continues, address your supervisor. Unit VI: Communication What is the 1st thing a nurse needs to do in creating a nurse/patient relationship? Introduce yourself What is therapeutic communication and its purpose? Communication that is focused on the needs of the patient. It promotes understanding between the sender and receiver. Unit VII: Documentation Unit VIII: Vital Signs and Pain Management Describe interventions for the management of fever? Encourage a large fluid intake unless contraindicated Lower the room temperature by adjusting the thermostat or opening doors or windows Increase the rate of circulating air with a fan Remove items of clothing or bed covers Control or reduce the amount of body activity Carry out the physicians order for cooling measures and supportive treatment; high-calorie diet and fluids; medications to lower temperature and combat disease. How does sweating lower temperature? Attempts to cool the body by evaporation What does systolic/diastolic blood pressure indicate? Systolic: maximum pressure exerted on the artery during left ventricular contraction Diastolic: lower pressure exerted on the artery when the heart is at rest between contractions

What can elevated B/P and pulse be a sign of? Anxiety, acute pain Is pain objective or subjective? Subjective Differentiate acute, chronic, intractable pain? Acute: usually associated with an injury, medical condition, or surgical procedure. It is of short duration, lasting from a few hours to a few days. Chronic: may continue for months or possibly years. Associated with ongoing conditions, such as arthritis and back problems. Intractable: Intense, usually chronic and unremitting, pain for which no accepted medical intervention has provided relief What is an underlying principle of severe chronic pain management? Treat pain before it becomes excessive What do you do if a clients pain medication is ineffective? Use alternative short term therapy (gateway therapy) and/or obtain an order for an increase in pain meds Describe and differentiate acute and chronic illness Acute: Illness that develops suddenly and resolves in a short time Chronic: Illness that develops slowly over a long period and lasts throughout life How fast should capillary refill be after compression? 3 seconds or less Unit IX: Wellness & Adaptation; Growth and Development (G& D) Wellness: What is homeostasis? A tendency of biologic systems to maintain stability in their internal environment while continually adjusting to changes necessary for survival What does holistic approach to healthcare mean? Considers the biologic, psychological, sociologic, and spiritual aspects and needs of the person Stress: Describe and differentiate Mild, Moderate, and Severe stress Mild: person is alert and perceptual field is increased; can motivate learning and produce personal growth. Moderate: person focuses only on immediate concerns; involves narrowing of the perceptual field. Severe: marked by a reduction in the perceptual field. The person focuses on a specific detail. What is the most common response to emotional stress? Anxiety List an appropriate outcome/goal for a client experiencing anxiety? The patient will demonstrate adaptive ways of coping with stress. Differentiate passive, naturally and artificially acquired active immunity? Passive natural: acquired by the fetus or newborn through its mother, and typically lasts the first six months of the newborn's life. Passive artificial: renders short-term immunization by the transfer of antibodies administered by artificial means, such as human or animal blood plasma or pooled human immunoglobulin administered through intravenous or intramuscular route. Active natural: acquired by experiencing and having recovered from a disease. Active artificial: acquired by vaccination

What are the cardinal signs of inflammation (Local Adaptation Syndrome)? Redness, warmth, swelling, pain, immobility What body systems does General Adaptation Syndrome involve? Autonomic Nervous System and Endocrine System G&D: What is development? How people develop on physical, social, and intellectual levels What is an outstanding characteristic of G & D? The sequence of development is predictable Why is G & D pertinent to nursing? Facilitates interventions at an age appropriate level What characterizes Havighursts six stages of G & D? Developmental Tasks What characterizes Ericksons stages of G& D? What is generatively? Mastering a developmental stage. Communicating ones own values and wisdom to the next generation. What are the 5 levels of Maslows Hierarchy of Needs? Why is this important to nursing? 1. Physiological 2. Safety/Security 3. Love & Belonging 4. Self-Esteem 5. Self-Actualization Unit X: Nursing Theory/ Roys Model of Nursing What is the function of nursing according to Roy? Promote client adaptation within each of the adaptive modes in health and illness Describe the 4 adaptive modes that are the basis of Roys Nursing Theory 1. Physiological 2. Self-Concept 3. Role Function 4. Interdependence Describe and differentiate Roys focal, residual, and contextual stimulus Focal: immediate stimulus confronting a client leading to possible maladaptation Residual: Beliefs and attitudes that effect cognitive response resulting in possible maladaptation Contextual: Stimuli that contribute to a clients possible maladaptation Unit XI: Nursing Process and Patient Teaching What is the nursing process? Systematic approach to client care. (Assessment, Planning, Implementation, Evaluation) What is the purpose of assessment? Identify nursing diagnosis Provide examples of objective and subjective data Objective: information obtained through the senses or measured by instruments Subjective: assessment data experienced and reported only by the patient What occurs during the planning stage of the nursing process? Establish outcomes, long and short-term goals

What are the 3 parts of an actual nursing diagnosis? 1. Diagnosis 2. Etiology 3. Defining characteristics What are the 3 parts of an expected outcome? 1. Measurable 2. Defined timeframe 3. Observable behaviors of the client What is important to remember about nursing interventions? Be specific What are nursing interventions for chronic illness? ADL assistance, environmental modification, emotional support What are nursing interventions to prevent falls in the healthcare and or home setting? Good lighting, unobstructed paths, call lights within reach Why do you continue to collect data following nursing interventions? Evaluate and plan revisions What is evaluation? Judgment of the effectiveness of the intervention or plan What are advantages/disadvantages to standardized nursing care plans? Advantages: They are developed by clinical experts and become the standards of care for clients with

a particular diagnosis; thus, they can be used to educate nurses unfamiliar with certain medical or nursing diagnoses. They reduce the time nurses spend writing nursing care plans; thus, standardized care plans increase the efficiency of nursing care planning.

Disadvantages: They are not individualized or personalized Patient Teaching: What is the first thing a nurse should assess before starting teaching? What the patient needs to learn including how much he already knows about his disease or condition, diet, activity, medications, wound care, treatments, or self-care at home What are effective ways to evaluate patient teaching? Return demonstration or asking questions to obtain feedback Why do you need to document patient teaching? Documentation of patient teaching and the learning achieved is a legal responsibility and should be done consistently.

Unit XII: Nutrition/Fluid & Electrolytes/Acid & Base Balances What is metabolism? The chemical processes that occur within a living organism in order to maintain life. How many kCal in a gram of carbohydrate, protein, and fat? Carbohydrate: 4 cal/gm Protein: 4 cal/gm Fat: 9 cal/gm Why should salt be avoided? Saturated fat? Cholesterol? Salt: Too much can cause retention of fluid and increase blood pressure Saturated Fat: linked to heart disease due to its role in cholesterol production and high calorie content which can lead to obesity Cholesterol: linked to heart disease and hardening of the arteries What is the minimum fluid intake needed on a daily basis to make up for losses? 2500 mL How is skin turgor assessed? What are you testing for? Gently pinching up the skin over the abdomen, forearm, sternum, forehead, or thigh. In a person with normal fluid balance, the skin when pinched will immediately ball back to normal when released. If a fluid deficit is present, the skin may remain elevated or tented for several seconds after the pinch. Are fluid restrictions a dependent or independent function? dependent What medication needs to be supplemented with potassium? loop diuretics Unit XIII: Elimination How is a urine specimen obtained? Clean catch, midstream, specimen to lab in sterile container within 15 minutes or refrigerated How do you calculate output if a urinary catheter is being irrigated? Output amount of fluid used to irrigate How often should a confused incontinent person be reminded to use the restroom? Every 2 hours What is the minimum hourly rate of urine production? 30 mL Unit XIV: Neurological/Endocrine Unit XV: Wound Healing What are the ABCs? Airway, breathing, circulation Describe coughing and deep breathing, what is meant by splinting the incision after surgery? Breathe in through the nose, splint incision with pillow if necessary, exhale through pursed lips Describe/differentiate first (primary), second (secondary), and third (tertiary) intention healing Primary: the edges of the wound approximate and there is only a slight chance of infection Secondary: the edges of the wound do not approximate, and the wound is left open and fills with scar tissue. Because of the longer healing period, the chance of infection is higher. Tertiary: occurs when there is delayed suturing of a wound. Such wounds are sutured after granulation tissue has begun to form. What are Montgomery straps? straps of adhesive tape used to secure dressings that must be changed frequently

Differentiate dehiscence and evisceration? Dehiscence: separation of the layers of the surgical wound: spontaneous opening of an incision Evisceration: extrusion of the viscera through a surgical incision; protrusion of an internal organ through the incision How do you remove a dressing that is adhered to a wound healing by primary (first) intention? Wet with saline to ease removal of dressing Unit XVI: Loss, Grief, and Dying Describe and differentiate Kubler-Ross 5 stages of loss 1. Denial: it can not be true 2. Anger: why me 3. Bargaining: please God if you will just let me live long enough to see then I will 4. Depression: I can not bear to face this 5. Acceptance: I am ready Describe and differentiate Engels stages of loss 1. Shock/Disbelief: refusal to accept loss 2. Developing awareness: anger may be directed at hospitals, nurses 3. Restitution: mourning 4. Resolving the loss: attempts to deal with painful void 5. Idealization: produces image of dead persons that almost devoid of undesirable features 6. Outcomes: importance of the lost object as source of support Differentiate Actual, perceived, and anticipatory loss Actual: recognized by others Perceived: felt by the person Anticipatory: grief felt prior to the loss Who is allowed to request/order an autopsy? Coroner What is the last sense to leave the body? Hearing List 3 interventions and rationale to help maintain a dying patients dignity and self-worth Allow them to make own choices Set timeframes Prioritize the problems of the dying patient (i.e.: elimination, skin integrity, hydration, pain) Pain Define hospice and eligibility for hospice Hospice is a philosophy of care for the dying and their families. It is based on the acceptance of death as a natural part of life and emphasizes the quality of remaining life. The hospice benefit is available to anyone with a life expectancy of six months or less if the terminal illness or disease runs its normal course. The patient, of course, must choose to elect hospice, and the patient's eligibility must be certified by a physician. Differentiate religion and spirituality? Religion: formalized system of beliefs and worship Spirituality: intangible element of religion that concerns the spirit or soul