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68 Cards in this Set

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Hygiene
describes activities involved in maintaining personal cleanliness and grooming
What does personal hygiene contribute to?
our physical and psychological well-being
Activities of daily living (ADLs)
such as taking a bath or shower, washing our hair, or brushing and flossing our teeth promote comfort, improve self-image, and decrease infection and disease
What does self-care in ADL promote?
increased activity, independence, and self-esteem
factors influencing hygiene
1. body image
2. knowledge
3. socioeconomic status
4. cultural variables/social practices
5. personal preferences
6. physical condition
Describe cultural and other psychological factors that influence a client's hygiene practice.
Some cultures do not mind body odor and may bathe less frequently and not use deodorant. Some religions will not allow personal care by someone of the opposite sex.
Describe the components that comprise total personal hygiene.
Total personal hygiene includes taking a bath or shower, washing our hair, brushing and flossing teeth. Hair, skin, nails, teeth, and perineum
Discuss the role of the nurse in maintaining the client's personal hygiene.
The nurse’s roll is to provide privacy, maintain safety, maintain warmth, and promote client independence. Providing privacy, pulling the curtain, keep client warm, care for feet and nails, wash them, brush teeth, perineum care, do anything they cannot do for themselves and set up time and space if they can perform their own hygiene. The main responsibility is maintenance and prevention.
Discuss the principle and guidelines used when providing and/or assisting the client with hygiene practice.
Ask what they would usually do, let them do anything on their own that they can, provide privacy.
Discuss the relationship between skin integrity and hygiene.
Hygiene improves and promotes skin integrity. If skin is not kept clean it will break down.
Describe the type and purpose of therapeutic baths.
Therapeutic baths can have a medication in them and be used to treat things like eczema, itchy skin, hives, ect. Can be oatmeal, saline, sodium bicarbonate.
Implement the nursing process in promoting or maintaining total personal hygiene.
Assess the ability to tolerate care, the physical condition of the skin, developmental changes and self care ability. Diagnoses include self care deficits of bathing/hygiene, dressing/grooming, and toileting and risk for impaired skin integrity. The plan should include the method, client’s preference, client’s condition, and time. Intervention is cleansing or therapeutic baths. Evaluate.
Identify the client’s developmental level according to Erickson.
Trust vs Mistrust- birth to 12-18 months
Autonomy vs Shame and Doubt- 18 mos to 3 years
Initiative vs Guilt- 3-6 years
Industry vs Inferiority- 6-12 years
Identity vs Role Confusion- 12-18 years
Intimacy vs Isolation- 19-40 years
Generativity vs Stagnation- 40-65 years
Ego Integrity vs Despair- 65 years and older
Discuss the influence that a client’s growth and developmental stage would have on a nursing plan of care designed specifically for that client.
The needs of a client, especially the psychosocial, will be affected by the developmental stage. The care plan will be designed to meet those specific needs, including counseling and activities if necessary.
Identify common myths and stereotypes about older adults.
Common myths and stereotypes about the older adult include poor health, disabled and unattractive, senile or demented, live in nursing homes, cannot make decisions, and they are unable to learn new things.
Assess the older adult and identify and address changes related to the aging process.
Changes in the older adult include trophy of body fat and loss of muscle mass leading to a bony appearance, height may decrease, skin, nails, hair, sweat glands, decrease in turgor and elasticity, skin is thinner, dryer, and more fragile making it more prone to breakdown, circulatory changes delay wound healing, pigment changes, calcification of the rib cage and coastal cartilage, chest wall is more rigid and less compliant, Lung tissue looses elasticity, lungs exhale less effectively, more susceptible to infection, loss of elasticity in blood vessels, increase in blood pressure, orthostatic hypotension (dizziness, low BP when sitting up), varicosities, dry mouth, dysphagia (difficulty swallowing), diminished gag reflex, decreased peristalsis, increased indigestion, teeth age, decreased renal blood flow, men have an enlarged prostate, women have decreased sphincter tone, incontinence, loss of bone mass, decrease in muscle tone and strength, less elastic ligaments and tendons, stiffness, decreased range of motion, muscle weakness caused by inactivity, increased neurological response time, decreased cerebral blood flow, decrease in the number of neurons, changes in reflex, changes in balance, delirium, dementia, and depression.
Identify the learning needs of the older adult
The older adult is ready to learn, you should face the person, speak slowly and clearly, present one idea at a time, give time for them to process the information, enhance the learning environment, get feedback by having them show you how to do it, and promote self esteem.
Discuss health promotion and maintenance behaviors for the older adult.
Health promotion includes activity and regular exercise, weight reduction, good nutrition, management of hypertension, smoking cessation, and immunizations.
Identify nursing diagnosis relevant to clients with sensory alterations.
Disturbed sensory perception (specify), Acute confusion, chronic confusion, impaired environmental interpretation syndrome, impaired memory, risk for peripheral vascular dysfunction, unilateral neglect
Identify interventions for preventing sensory deprivation and controlling sensory overload.
Sensory deprivation can be prevented by supporting the sense by providing glasses or hearing aids, providing orientation by providing a calendar and activity board, and by providing stimuli through regular contact, television and radio, pet therapy, smells, and reminiscence therapy. Sensory overload can be treated by minimizing stimuli by allowing less light and noise, less television and radio, using a calm tone, reduce noxious odors, provide rest, and teach stress reduction
Identify nursing measures to reduce the risk of falls in the older adult and Identify ways to maintain a safe environment for the older adult experiencing physical and sensory changes.
Provide a clear path, good lighting, assistive devices like mobility aids, caregiver assistance, supervision, backings for door mats and area rugs, grab bars in the tub and shower, smoke detectors, the call light, a safe chair, and a safe bed position
Define communication
A process by which people affect one another through the exchange of information, ideas, and feelings
Discuss factors that influence communication
Communication is influenced by perception, values, beliefs, environment, distractions, timing, and relevance, pace, intonation, vocabulary, verbal, nonverbal, and paraverbal.
Describe the elements of the communication process
Sender encodes and sends message through a channel and it is filtered and received and decoded by the receiver.
Discuss the role of communication and the nursing process.
Communication is used in the therapeutic use of self, can decrease anxiety, can discover parts of a problem and treat some psychosocial issues.
Describe the basic techniques for facilitating effective communication.
Speaking at the correct pace, be simple, brief, and direct, maintain eye contact, use a relaxed posture, lean forward, nod in acknowledgement, share observations, use silence, share hope, humor and feelings, provide information, self disclosure, empathy, and open ended questions.
Recognize ineffective verbal and nonverbal communication behaviors.
Ineffective communication behaviors include giving personal opinions which can be interpreted as professional advice and can have legal implications, changing the subject which blocks further communication, false reassurance, asking for explanations which sound like accusations, approval and disapproval which imposes your own attitudes or beliefs, defensive responses, arguing, giving advice, being judgmental, asking why and expressing sympathy
Describe the therapeutic benefit of listening to clients.
Communication is therapeutic because it allows the client to express themselves and allows you to understand their problems and how they are feeling
Differentiate helping from social relationships.
In helping relationships the client needs are met, the purpose is to enhance client growth, interactions are goal directed and planned, the communication is therapeutic, includes periodic evaluation of goal achievement, and has a defined end. In a social relationship mutual needs are met, the purpose is friendship, socialization, enjoyment or accomplishment of a task, interactions are spontaneous, communication may include giving advice, has little to no emphasis of the evaluation of the interaction, and it has no defined end
Discuss effective communication techniques for clients with special needs.
Effective communication techniques for clients with special needs include listening carefully or asking them to write it down if they have speaking difficulties, looking at them or writing it down if they are hearing impaired, continue trying to communicate with the cognitively impaired and unresponsive clients, and get a translator for non English speaking client.
Describe the essential components of the client’s records or chart.
Includes the admission data, advance directives, history, doctor’s orders, diagnostic tests, interdisciplinary section, checklists, I/O records, medication records, progress notes, and plans of care
Discuss the purpose of the client’s health care record.
The health care record is used for communication, education, legal documentation, quality assurance, reimbursement, and research
Describe the characteristics of proper documentation.
Proper documentation should be accurate, concise, complete, specific, and timely. You should chart basic assessment, in depth assessment, nursing actions taken, patient response, patient progress toward goals, education provided and discharge needs, care or instruction. Documentation should be done when you perform it or shortly thereafter and you should document what you see and do. Make sure you write legibly, spell correctly, use black ink, use proper terms and grammar, finish a partially full line with a line across the line, and only use hospital approved abbreviations. Record facts and specific times, objective observations, document all actions taken and add quotes of specific communications
Discuss legal guidelines for documentation.
For legal reasons make sure you spell correctly, chart objectively, do not include opinions, do not include if an incident report was filed, if an error is made draw a single line through it, write mistaken entry, initial and date. Don’t use negative language, record staffing problems, staff conflicts, use words associated with errors, name a second patient, or chart casual conversations with co-workers. Do not leave the chart in a public area, do not remove client information from the facility, do dispose of confidential papers properly
Maintain confidentiality of records and reports.
Do not share your password or share information with anyone that does not need to know
Develop ______ related to the needs of the older adult.
sensitivity
What should you start to use when communicating?
Begin to use correct medical terminology.
Describe five quality guidelines for documentation and reporting.
Good charting should be accurate, concise, complete, specific, and timely
Discuss issues related to computerization in documentation.
With computerized charting be sure to not display data where others can see it, correct errors per protocol, do not leave the terminal unattended after you log on, and do not give your password to anyone
Describe different documentation systems for recording client data.
Narrative charting
Block charting
SOAP
PIE
FOCUS/DAR
Charting by exception
Narrative charting
easy to learn, adjust to and explain in detail; it is time consuming, difficult to retrieve information, and may be unfocused or disorganized
Block charting
document in paragraph form everything for the entire shift, focuses on important aspects of care, inadequate in events that require timing
SOAP
focused around client problems, interdisciplinary, and easy to track progress, but it is difficult to master, has a specific focus and is lengthy and time consuming
PIE
plan of care incorporated into progress notes, outcomes included, daily review to determine progress, less redundancy, and easily adaptable to automated charting. Disadvantages are you must read the progress notes to determine the plan of care, if the problem is not identified it can be difficult to chart, and it is not multidisciplinary
FOCUS/DAR
broad view, you can chart on any significant area, concise, flexible, works well in LTC, mental health settings, or ambulatory care. Not muiltidisciplinary, difficult to identify chronological order, and the progress notes may not relate to the plan of care
Charting by exception
efficient, use of flow sheets permits rapid detection of changes, can take the place of a care plan. Disadvantages are it is expensive to institute and train staff, it is not prevention focused, and it is not appropriate for LTC or ambulatory care
Describe the purpose and content of a change-of-shift report.
Report provides for continuity of care, it is a regularly scheduled, structured exchange of information, and is a summary of individual client progress. It should include the name, age, sex, room number, attending physician, diagnosis, surgical procedures, pertinent assessment data, events form the last 24 hrs including changes in orders, changes in condition, lab studies, diagnostic tests, and specimens, patients response to care, any unfinished nursing activities, any special equipment needed, pertinent interdisciplinary care, and personalization of nursing care
Discuss common myths and misconceptions about the pain experience.
Myths about pain is that comfort is a absence of pain, that pain is universal, pain is objective (you can’t see it!), that if a patient is in pain you will know it, and that because pain is subjective there is no good way to assess it
The component of pain experience-- transmission
Transmission- peripheral nerves carry the pain message to the dorsal horn of the spinal cord using A delta fibers which are large diameter myelinated fibers transmitting fast pain impulses and C fibers which are smaller unmyelinated fibers carrying slow pain impulses
The component of pain experience-- perception
Perception- recognition and definition of pain in the frontal cortex
Acute pain
sudden, short lived onset (less than 6 months), the purpose is to alert you to tissue damage, the location is well identified, the clinical signs are activation of the fight or flight response shown with dilated pupils, increase in pulse, respiration, and blood pressure, eventually there will be complete relief
Chronic pain
duration of greater than 6 months, there is no purpose to the pain as it is no longer warning of tissue damage, it can be persistent or intermittent, general localization, no clinical signs, complete relief is not possible
Discuss factors that influence that client's reaction to pain.
Reaction to pain is influenced by age, emotions, sociocultural factors, and communication and cognitive impairments
Assess the client experiencing pain.
Done on a scale, usually numerical or could be the faces chart, the FLACC pain scale of the NIPS scale for newborns
Discuss the interventions to assist the client to achieve comfort.
Interventions include gate control using heat, cold, and touch, relaxation and distraction, acupressure, biofeedback, TENS, visualizations, guided imagery, meditation, and medications which include non-opioids (acetaminophen, aspirin, NSAIDS), opioids (Morphine, Oxycodone, Hydromorphone), and adjuvants (antiemetics, antihistamines, ect)
What kind of care plan should you implement for pain?
Implement a nursing care plan for the client experiencing pain in simulated and/or selected clinical experiences.
Anuria
absent production of urine
Polyuria
excessive passage of urine
Oliguria
decreased production of urine
Dysuria
painful urination
Hematuria
blood in the urine
Urgency
sudden, almost uncontrollable urge to urinate
Frequency
need to urinate at short intervals
Hesitancy
involuntary delay in initiating urination
Dribbling
small amounts of released urine
Incontinence
loss of control of urine or feces
Describe common urinary alterations.
Normal output is 1500 mL but it could vary from 1000-2000 mL.
Assess urinary output.
Normal amount per day is 1500 mL, or 30-50 mL/h, it should be translucent with no crystals or sediment or blood. Normal color is pale yellow to amber.