FUNdamentals of Nursing – Exam 1

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What are the most important roles of the nurse (5)
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Caregiver Advocate Educator Researcher Leader
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What are the 5 steps in the nursing process?
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(1) Assessment (2) Nursing Diagnosis (3) Planning (4) Implementation (5) Evaluation *** All of the above require critical thinking!
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Define Assessment
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Collects comprehensive data pertinent to the patient’s health and/or situation. – info medical personnel can look at – begins the moment you walk through the door
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Can the RN provide subjective information about patient?
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NO! Only the patient can give subjective info. OBJECTIVE info is what the RN sees, hears, or smells
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What is the Diagnosis phase?
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Analyze the assessment and make a clinical judgement related to an ACTUAL or POTENTIAL health problem. ** Nurses have to be aware of potential risks based on health problems. ** Also collaborate with other specialists to manage the problem(s)
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What are the three phases of a Nursing Diagnosis?
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First info → Related to → as evidence by WHAT is the problem? WHY is it a problem? WHAT is the evidence of that problem? Ex: “Acute pain → related to surgical incision → as evidence by patient report (or as evidence by crying)”
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What are the OUTCOMES IDENTIFICATION?
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This is the statement of how a patient’s status will change once interventions have been successfully instituted Identify the expected outcomes when planning for the patient’s individual situation. Interventions must be measurable criterion indicating that objectives have been met.
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Define the PLANNING stage of the nursing process
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Develops a plan that prescribes strategies and alternatives to attain expected outcomes. – Prioritize strategies – Goals (statement that describes the aim if the nursing care) should be short term and long term
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Describe IMPLEMENTATION of the nursing process
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The actions to facilitate positive patient outcomes
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What three skills are needed in order to implement goals?
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Cognitive Personal Psychomotor
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Describe the EVALUATION phase of the nursing process
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This describes how well the patients needs were met (or not met). Done through reassessment
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What percentage of all communication is nonverbal?
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90%
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What two characteristics should nurses always exude?
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CARING COMPETENCE
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How is communication used in the Assessment phase of the nursing process?
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Verbal interviewing and history taking Visual and intuitive observation of nonverbal behavior Visual, tactile, and auditory data gathering during physical examination. Written medical records, diagnostic tests, and literature review.
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Define REFERENT
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The referent motivates one person to communicate with another. Examples of referents: sights, sounds, odors, time schedules, messages, objects, emotions, sensations, perceptions, ideas, etc.
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Define SENDER in communication
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The person who encodes and delivers the message. Sender puts ideas or feelings into form that is transmitted and is responsible for accuracy and emotional tone of message content
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What is the RECEIVER in the communication process?
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The person who receives and decodes the message ** senders message acts as a referent for the receiver, who is responsible for attending to, translating, and responding to the message.
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MESSAGE in communication process
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Content of communication…. verbal, nonverbal & symbolic language.
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CHANNELS in communication process
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These are the means of conveying the message through visual, auditory, and tactile senses. Facial expression = visual message Spoken word = auditory Touch = tactile
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FEEDBACK in communication process
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The message that the receiver returns. This indicates if receiver understood meaning of message. Sender can evaluate effectiveness of communication.
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Explain the communication process briefly
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The source has a message and encodes the message. Message is sent through a channel Receiver must first decode the message Before message can be fully received
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What are the 5 levels of communication in nursing?
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Interpersonal Interpersonal Small group Public Transpersonal
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Define Intrapersonal
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a.k.a. SELF-TALK
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Define Intrerpersonal
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Occurs between two people or groups – usually one on one conversation
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Define Small Group Communication
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Committee or a conference
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Public Communication
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Interaction of one person with a group of people
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Transpersonal Communication
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Within a person’s spiritual domain
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Forms of Communication
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Messages conveyed verbally and nonverbally, concretely and symbolically. Expression through: Words, movements, voice inflection, facial expression, and use of space Elements can work in harmony to enhance a message OR conflict with one another to confuse it.
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Example Forms of Communication VOCABULARY What is the role of the nurse?
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Nurse often the interpreter of medical terminology
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Example Forms of Communication DENOTATIVE AND CONNOTATIVE What is the role of the nurse?
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Denotative is the exact meaning Connotative is shades of the meaning Be selective in word choice and avoid easily misinterpreted words.
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Example Forms of Communication PACING What is the role of the nurse?
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Speak slowly and enunciate clearly! Too fast = unintended messages Too slow = impression of hiding the truth
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Example Forms of Communication INTONATION What is the role of the nurse?
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Tone of voice… be careful
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Example Forms of Communication CLARITY & BREVITY What is the role of the nurse?
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Simple – short – to the point & possible repeated
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Example Forms of Communication TIMING & RELEVANCE What is the role of the nurse?
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When it is appropriate to discuss issues & what is most important at that time.
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What are forms of Nonverbal Communication?
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Personal Appearance Posture and gait Facial Expression Eye Contact Gestures Sounds – sighs, moans, groans… Territoriality & Space
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What are the four phases of the Helping (Nurse-Patient) Relationship?
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Pre-interaction Orientation Working Termination
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Describe the PRE-INTERACTION phase of the Helping Relationship.
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This takes place before meeting the patient: – Review available data, history – Talk to other caregivers who have info about patient – Anticipate health concerns or issues that arise – Identify a location or setting that fosters comfortable, private interaction – Plan enough time for initial interaction
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Describe the ORIENTATION phase of the Helping Relationship.
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When nurse and patient first meet and get to know one another: – Set the tone for the relationship by adopting a warm, empathetic, caring manner – Recognize relationship is tentative – Expect patient to test your competence and commitment – Closely observe – Begin to make inference and form judgements about messages and behaviors – ASSESS PATIENT HEALTH STATUS
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Describe the WORKING phase of the Helping Relationship.
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When nurse and patient work together to solve problems and accomplish goals. TEACHING occurs. – Encourage pt. to express feelings about health – encourage pt. w/ self exploration – Provide information – Help pt. set goals – Take action to meet said goals – Use therapeutic comm – Use appropriate self-disclosure & confrontation
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Describe the TERMINATION phase of the Helping Relationship.
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Ending of the relationship – Remind pt. that termination is near – Evaluate goal achievement with pt. – Reminisce about relationship with pt. – Separate from the pt. by relinquishing responsibility for care – Achieve a smooth transition for pt. to other caregivers
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Acronym used for successful communication in the workplace to promote teamwork and safety.
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S – situation B – background A – assessment R – Recommendation
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Characteristics of communication within Caring/Working Relationships:
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Professionalism – appearance, demeanor, behavior Courtesy – hello, good-bye, knock on doors, please, thank you… Use of Names – Always introduce yourself Confidentiality – HIPPA Trust – always honest! Acceptance & Respect – Non-judgmental attitudes Availability – “Anything else I can get you? Socializing – don’t socialize with pt. and don’t socialize with colleagues where pt’s can hear
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What is therapeutic communication techniques?
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Specific responses that encourage the expression of feeling and ideas and convey acceptance and respect.
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Define the therapeutic communication technique of: Active Listening
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Being attentive to what patient is saying both verbally and nonverbally. ** Use SOLER to facilitate attentive listening
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Define acronym SOLER
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S – Sit facing the patient O – Open posture L – Lean toward the patient E – Establish & maintain eye contact R – Relax
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Define the therapeutic communication technique of: Sharing Observations
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Observations/perceptions can help start a conversation, but need to be careful not to anger patient or make assumptions.
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Define the therapeutic communication technique of: Sharing Humor
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Important but often underused resource in nursing interactions. It is a coping strategy that adds perspective and helps adjust to stress.
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Define the therapeutic communication technique of: Using Silence
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Allow patient to break the silence, particularly when he/she has initiated it. Particularly useful when people are confronted with decisions that require thought.
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Define the therapeutic communication technique of: Providing Information
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To help patient understand, but do not preach
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Define the therapeutic communication technique of: Clarifying
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Check that understanding is accurate Restate an unclear message Rephrase to clarify
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Define the therapeutic communication technique of: Focusing
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Centers on key elements of concepts of message Helpful when patient is vague or rambles
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Define the therapeutic communication technique of: Restating
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or Paraphrasing this sends feedback that lets the patient know nurse is actively involved
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Define the therapeutic communication technique of: Open-ended Questions
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Asking relevant questions allows patient to fully respond
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Define the therapeutic communication technique of: Reflection
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Summarizing a concise review of key aspects of interaction. Especially helpful in termination phase
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Other techniques of therapeutic communication are:
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Sharing empathy Sharing hope Use of Touch Sharing feelings Self-Disclosure Confrontation (with sensitivity after trust is established)
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What physical and emotional factors must a nurse assess through communication?
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Developmental – age, physiological status (pain, hunger, weakness) Socioculture Language Gender
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How can you communicate with non-english speaking patient?
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Translator or translator phone
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What are some non-theraputic communication characteristics?
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Inattentive listening use of medical jargon Sympathy Arguing Being defensive
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How does the nurse demonstrate caring in communication?
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Become sensitive to self & others Promote and accept expression of pos & neg feelings Develop helping trust relationships Instill faith & hope Promote interpersonal teaching & learning Provide supportive environment Assist with gratification of human needs Allow for spiritual expression
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What are the Zones of Touch?
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Social zone Consent zone Vulnerable zone Intimate zone
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Social zone of touch is
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Hands, arms, shoulders, back Permission not needed
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Consent zone of touch is
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Mouth, wrists, feet Permission needed
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Vulnerable zone of touch is
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Face, neck, front of body Special care needed
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Intimate zone of touch is
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Genitalia, rectum Great sensitivity needed
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Zones of Personal Space
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Intimate – 0-18″ Personal – 18″ – 4′ Social – 4 -12 ft Public – > 12 ft
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What is Intimate zone of personal space?
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Holding crying infant Performing physical assessment Bathing, grooming, dressing, feeding, and toileting a patient Changing patient dressing
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What is Personal Zone of personal space?
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Sitting at a patient’s bedside Taking patient history Teaching patient Exchanging info at shift change
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What is Social Zone of personal space?
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Making rounds with physician Sitting at the head of a conference table Teaching a class for patients with diabetes Conducting family support
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What is public zone of personal space?
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Speaking at a community forum Testifying at a legislative hearing Lecturing to a class of students
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INFECTION PHYSIOLOGY…….
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SEE NOTECARDS FOR MED-SURG EXAM, PART ONE to review vocabulary and basic understanding. THEN… proceed in this set of flashcards for the Nursing Care of Infections
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Nursing process for Infection: Assessment
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Assess all risk factors: age, nutrition, diagnostic procedures (IV, catheters), occupation, high-risk behaviors, travel history, trauma, stress Nutritional Status – reduction in protein impairs healing Lab Data – WBC count (5000-10000 norm) – Cultures – ESR (up to 15 for men and 20 for women) – Iron level 60-90g/100mL – Differentials Chronic or serious infections/diseases/disorders – COPD → pneumonia – heart failure → skin breakdown – diabetes → venous stasis ulcers * diabetes patients at risk for chronic infections
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Nursing process of Infection: Diagnosis
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⊗ Disturbed body image = look bad, smell bad, etc ⊗ Risk for fall ⊗ Risk for infection = lab results (WBC 5,000-10,000/mm³), review current meds ⊗ Identify potential sites of infection = IV, catheter ⊗ Imbalanced nutrition = protein needed for healing ⊗ Acute pain ⊗ Impaired skin integrity or tissue integrity ⊗ Social isolation
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Nursing process of Infection: Planning
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Goals & Outcomes Setting priorities → Treatment is always a priority Collaborative care
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Nursing process of Infection: Implementation
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Health promotion – break chain of infection Nutrition Hygiene Immunization Adequate rest and regular exercise
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Nursing process for Infection: Evaluation
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Measure the success of infection prevention Measure the patient and family adherence to discharge plans Wound status and healing ** did your patient get better or worse? Did your patient get an infection at hospital?
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Standard precautions taken with ALL patients protect health care workers from:
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Blood Body fluids (except sweat) Excretions Non-intact skin ** These precautions began in the 80’s as a result of HIV/AIDS
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It is required to wash hands with water and soap when:
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Hands are visibly dirty When soiled with blood or other body fluids Before eating After toileting Exposure to spore-forming organisms (c-diff, bacillus anthracis)
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Use of alcohol-based waterless antiseptic agent for routinely decontaminating hands for following situations:
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Hands NOT visibly soiled Before/after/between direct patient contact After contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressing When moving from contaminated to a clean body site during patient care After contact with inanimate surfaces or objects in the patients room Before caring for patients with sever neutropenia or other forms of immunosuppression Before putting on sterile gloves to insert invasive devices After removing sterile gloves
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Nursing process for Infection: Implementation in Acute Care Settings
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Use standard precautions Control or eliminate infectious agents Cleaning Disinfection/Sterilization Control or eliminate reservoirs Control of portals of exit Control of transmission hand hygiene Isolation & barrier protection Protective equipment Proper removal of PPE Role of infection prevent & control Prep for sterile procedures Restorative/long-term care
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What is order of preparing to enter room on isolation?
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Gown Mask or Respirator Eye wear Gloves
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What is order of removal of protective equipment for isolation?
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Gloves Goggles Gown Mask
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Sterile field must have what size border?
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1 inch
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What are the vital signs?
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Pulse Pain Temp BP Respiration Pulse Ox
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When do you take vitals?
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When they first enter Appropriate intervals during stay Just before they leave
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Why must you know the baseline vitals for a patient?
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Any changes in vital signs can help the nurse immensely
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What are guidelines to measuring vital signs?
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Must get baseline by taking when first enter Measure correctly Understood & interpreted Communicated
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Body Temp normal range
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96.4-100.1
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Body temp is affected by heat loss, what causes this?
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Radiation Conduction Evaporation Convection
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What produces heat in the body?
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Cellular Respiration
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What is considered a fever?
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Adult 102.2 ↑ Child 104
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What is pyrexia?
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FEVER
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What is an Antipyretic?
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Medication that brings down fever Ex: Tylenol, NSAIDS
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How is temp measured?
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At the core or the surface by: Electronic Infrared Digital Disposable Chem Dot
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What is pulse?
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Palpable bounding of the blood flow in a peripheral artery
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What are the locations for pulse?
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Temporal Carotid Apical Brachial Radial Ulnar Femoral Popliteal Posterior tibia Dorsalis pedis
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What is Tachycardia
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Pulse faster than 100 bpm
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What is Bradycardia
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Pulse slower than 60 bpm
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What is Blood Pressure
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Ability of the peripheral blood vessels to constrict and dilate that depends on cardiac output, PV resistance, blood volume, blood viscosity, and artery elasticity
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What are the blood pressure variations?
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Hypertension Hypotension Orthostatic hypotension
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Orthostatic Hypotension
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Looking for a drop in blood pressure during a rise in heart rate when person changes from lying to sitting to standing.
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What is the Systolic Pressure?
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Ventricular contraction that forces the blood into the aorta
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What is the Diastolic Pressure
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Minimal pressure exerted against the arterial wall * Pulse pressure is the difference between systolic and diastolic pressures
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Korotkoff sounds of BP
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There are 5 phases, we listen for phase 1 (systolic) and then for phase 4 into phase 5 (diastolic) phase 1 – sharp thump phase 2 – blowing or whooshing sounds phase 3 – crisp intense tapping phase 4 – softer blowing sound that fades phase 5 – silence
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What is respiration?
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the mechanism the body uses to exchange gases among the atmosphere, blood and cells
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What is normal respiration rate?
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12-20 per minute
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Define Eupnea
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Normal breathing
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What is ventilation?
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Physical act of breathing in and breathing out
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What is Pulse Oximetry
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Looking at hemoglobin molecule to determine how saturated it is with oxygen.
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What is a weakness of Pulse Ox measure?
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CO can fake out the pulse oximeter because blood will be saturated with CO, not O₂, but oximeter thinks that it is O₂
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What is apnea?
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Absence of breathing
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How do we naturally release CO₂?
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Sign or yawn up to 15 times an hour
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What is Chain-Stokes Respiration?
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Rhythm of acceleration of respirations followed by deceleration then followed by apnea.
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Why can pulse ox be an indicator of iron deficiency anemia?
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Patient doesn’t have enough red blood cells to carry enough O₂ to meet metabolic needs
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What is a seizure?
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Uncontrolled electrical neuronal discharges from the brain that interrupts normal brain function.
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What causes seizures?
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Brain tumor Brain trauma concussion Infection Metabolic disorders Withdraw from alcohol Idiopathic (no known cause)
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How do you assess a seizure?
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Was seizure seen Precipitating factors Where did it start How did it progress Type of movement in extremities Gaze deviation Incontinence? Mental status How long did seizure last? Mental status after seizure? Motor weakness after seizure Any injury from seizure
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Another term for a seizure?
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Irritable focus -or- Foci
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What is Postictal Phase?
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Altered state of consciousness that a person enters after experiencing a seizure. It usually lasts between 5 and 30 min, and is characterized by drowsiness, confusion, nausea, hypertension, headache or migraine and other disorienting symptoms.
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Nursing Diagnosis for Seizures
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⊗ Risk for injury ⊗ Risk for aspiration – breathing fluid into lungs ⊗ Ineffective airway clearance related to relaxation of tongue and gag reflex secondary to muscle innervation ⊗ Anxiety ⊗ High risk of ineffective therapeutic regimen related to insufficient knowledge
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Nursing plan for Seizures
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Assess and detect signs of seizure Implement seizure precautions Medications as ordered Assess history, serum drug levels, compliance with drug regimen
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Nursing Interventions Before Seizures
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How to call for help Place pads on side rails Bed in low position Access to O₂ & suction
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Nursing Interventions during a seizure
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Attempt to turn patient on side Maintain airway Place O₂ on patient Suction mouth as needed Do not attempt to insert anything into mouth Do not restrain Monitor pulse ox Assess type & length of seizure Administer meds as ordered
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Nursing Evaluation for seizures
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Identify criteria and standards Collect data interpret findings document & notify Revise plan, if needed – are the taking any meds? – if so, is the dosage correct?
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What are the different roles during a CODE?
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Compressor/ventilator Recorder/ time keeper Medication Administrator Defibrillator Traffic Controller
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Code Blue
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Check for responsiveness Assess for breathing 5-10 sec Activate code blue check pulse for 5-10 sec If not pulse, begin CPR
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What does CAB represent?
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Compressions: – compress at least 2 inches – 100 per min – complete chest recoil – correct hand placement Airway – head tilt, chin lift Breathing – 2 breaths every 10 seconds
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What is ACLS?
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Advanced Cardiac Life Support – manual defib – cardiac drugs – advanced airway – lab values
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What are the three layers of the skin
What are the three layers of the skin
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When assessing skin, what alterations in condition are you looking?
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Color Thickness Texture Turgor Temperature Hydration
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Examples of color changes in the skin are:
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Cyanotic – blueish color indicating poor O₂ circulation. Smurf blue – methhemoglobinemia yellow-gray – Dusky (blueish-gray) – Jaundice – accumulation of billirubin Mottled (blotchy – pale/red/blue) – poor perfusion Flush – normal color but face becomes red Pale – lack of blood circulation Ruddy (Erythema) – Redness of the skin. Eschar – Black, necrotic tissue. Petichiae – A small purplish spot on a body surface, such as the skin or a mucous membrane, caused by a minute hemorrhage
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What can thickness changes in skin imply?
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Keloids – Hypertrophic scarring that extends beyond the borders of the initial injury. Langerhans Cells – Attach themselves to antigens that invade damaged skin. Lichenification – Thickening and roughening of the skin with increased visibility of skin furrows from chronic rubbing. Precursor – A substance, cell, or cellular component from which another substance, cell, or cellular component is formed especially by natural processes. Stratum germinativum – Inner cellular keratin layer of the epidermis, that contains melanocytes. Stratum corneum – Outer horny layer of dead keratinized cells ** ONLY THE HEELS & PALMS SHOULD BE THICK
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What does skin Texture imply during assessment?
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Lumpy Smooth Rough Moles, lesions, etc
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How is Turgor assessed and why?
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Grasping the skin on the sternum, forehead, or top of the hand and gently pulling up. After letting go of the skin, the skin should “snap” back into place within three seconds. Skin that remains elevated or “tented” may be due to age related changes, dehydration, or a combination of both
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What is venous thrombosis
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WARM body temperature
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What is arterial thrombosis
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COLD body temperature
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Hydration concerns for the skin
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Normally, your patient’s skin should be dry with only a slight amount of moisture. Overly moist skin may be due to environmental conditions, anxiety, obesity, hyperthyroidism, fever, or diaphoresis
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What is Dependent Rubor?
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A redness or purple color of a leg when it is in the dependent or lowered position. If the leg blanches on elevation it may be a sign of lower leg ischemia
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Why is it important to assess the Nails?
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The appearance of the patient’s nails may provide information about systemic illnesses and yield information about their self care abilities or behaviors: •Clubbed nails may indicate chronic hypoxia. Bases are flat or rounded, not concave. ° Inadequate nutrition – lines (grooves) going across nails horizontally. •Cyanosis: May be present in the nail bed, indicating poor perfusion and possible underlying vascular insufficiency. Nicotine staining can be seen in the nails. Observe for infections of the nails or nail bed
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Condition of what areas greatly impacts patient’s ability for self-care?
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Feet – bear weight or ambulate Hands – dexterity Nails – infection
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What are the purposes of a bath in the hospital?
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Cleanses the skin Acts as skin conditioner Relax the patient Promotes circulation Encourages musculoskeletal exercises Stimulates rate & depth of respirations Promotes comfort through muscle relaxation and skin stimulation Improves self-image Helps build stronger nurse-patient relationship
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What are the types of baths
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Complete bed bath – nurse washes entire body. usually comatose or critical care patients Partial bath – only areas that cause discomfort or odor if left unwashed Sponge bath at sink – pt. sits in chair at sink and nurse helps with areas pt. can”t reach Bag bath – commercially prepared & disposable Shower – full self-care
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Assessment for Hygiene
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Self-care ability * encourage self-care skin feet & nails Oral cavity hair & hair care Eyes, ears & nose
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Nursing diagnosis for Hygiene
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Through assessment hygiene status and patient self-care ability has been identified and it must be determine if patient has an actual problem or is at risk for problem and in need of hygiene diagnosis.
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Common NANDA International diagnostic Identification for patient situation:
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Activity intolerance Ineffective health maintenance Risk for infection Impaired physical mobility Bathing self-care deficit Dressing self-care deficit
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Nursing process: Planning for Hygiene
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Develop individualized plan of care – Techs may be involved in planning Use concept map (may be helpful) Set realistic goals Collaborate with other health care providers -dentistry -podiatry
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Nursing process for Hygiene: Implementation
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Health promotion – teaching patient Reinforce infection control * use a mirror to help patient see
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How can you maintain comfort in patient room?
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Room temp (68°-74°) Clean equipment Water, phone, tissue, & other personal items within reach
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Nursing process in Hygiene: Evaluation
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Observe patient reaction after hygiene measures – comfortable -relaxed Assess condition of skin, mouth, hair after interventions
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What is the hallmark of the Nurse’s role?
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Health Assessment & Physical Examination ** CANNOT delegate assessment to anyone! Nurse should be very proficient in assessment skills
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Reasons for physical examination are:
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– Triage for emergency care (making clinical judgements) ° Gather baseline data – routine screening to promote wellness ° Identify nursing diagnosis – determine eligibility for health insurance, military, new job ° evaluate the outcome of care – admit patient for long-term care
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How can nurse show respect for cultural differences?
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Acknowledge health beliefs (what family can afford too) Use of alternative therapies Nutritional Habits Family relationships (who makes decisions in family) Use of personal space
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What is most important about INSPECTION of a patient?
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PAYING ATTENTION TO DETAIL! – size, shape, color, symmetry, position, abnormalities Make sure lighting is adequate and low level of noises Expose areas you need to examine so that clearly visible while still respecting patient privacy
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When palpating the skin, what should the nurse pay attention to?
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Temperature Moisture Texture Turgor Tenderness Thickness
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When palpating the abdomen, what should nurse examine?
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Tenderness Distention Masses
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Best way to palpate is?
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Lightly – for superficial Deeply – with two hands for deeper findings
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What is percussion?
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Tapping the body with fingertips to produce vibration Nurses typically do not percuss
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What is Auscultation?
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Listening to sounds produced by the body with the aid of a stethoscope. i.e: heart, lungs, GI
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How can sense of Olfaction assist the nurse in assessment?
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Identify nature and source of body odors Help detect abnormalities Used in conjunction with other measurements
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In case of a fire, always remember RACE:
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R = Rescue → remove all patients from danger A = Activate Alarm C = Confine → close doors to confine the fire E = Extinguish → if possible

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