Nurse 120 - (Continuation) Test2

Front 1

Guidelines for conducting a health assessment

Back 1

Establish rapport
Encourage honest communication
Make eye contact
Listen carefully
Be aware of your own nonverbal communication
Avoid technical terms - communicate in a way that is easily understood
Consider educational & cultural background and any disabilities pt may have

Front 2

The Assessment Database (data collection) includes:

Back 2

The initial interview
Nursing health history
Physical examination
Results of lab/diagnostic tests

Front 3

FIRST step on the beginning of data collection is:

Back 3

Client's interview

Front 4

Definition of Interview

Back 4

Organized conversation with client to obtain client's health history and info about current illness

Front 5

Phases of Interview

Back 5

Orientation Phase
Work Phase
Termination Phase

Front 6

Interview's opportunities

Back 6

1. To be introduced to client, explain role, and the role of others during care
2. To establish sense of caring for pt
3. To establish therapeutic relationship
4. To gain insight about pt's concerns/worries
5. To determine client's goals/expectations of healthcare system
6. To obtain cues of data collection needing further in-depth investigation

Front 7

Orientation Phase

Back 7

Begins with nurse's introduction (name, position, explanation of purpose of interview: e.g., for nursing history or focused assessment)
State confidentiality of info obtained
Establish trust and confidence with client (allows pt to feel more comfortable)
Lays groundwork for nurse to know pt's needs
Assure pt that interviews are confidential
Be professional and convey competence
Set interview time with pt

Front 8

Working phase

Back 8

Gather information about client's health status
Use interview techniques to gather comprehensive/complete database
Initial interview usually most extensive

Front 9

Termination phase

Back 9

Ideally client should be given a clue that interview is coming to an end
Example "There are just two more questions." or "We'll be finished in 5 to 6 minutes."

Front 10

Four(4) Interview Techniques (in order)

Back 10

Open-ended questions
Back Channeling
Problem-seeking
Closed-ended questions

Front 11

Open-ended questions

Back 11

Prompts clients to describe situation in more than one or two words

Front 12

Back Channeling

Back 12

(active listening technique) Indicates nurse has heard what pt says and encourages even further elaboration. "all-right" "go on" "uh-huh"

Front 13

Problem-seeking

Back 13

Focus on the symptoms that the client mentions to fully describe/identify specific problems

Front 14

Closed-ended questions

Back 14

Limit client's answers to one or two words: "yes" or "no" or a number or frequency of a symptom
Example: "How often does the diarrhea occur?"

Front 15

Components of Health History

Back 15

Biographical data (pt profile and cultural considerations)
Chief complaint
Present health concern (or present illness)
Past history
Family history
Environmental history
Psychosocial history
Spiritual environment
Review of systems

Front 16

Review of systems (Textbook, pg. 292, Box 15-4)

Back 16

1) general presentation of symptoms: fever, chills, malaise, pain, sleep patterns, fatigability
2) diet: appetite, likes/dislikes, restrictions, written diary of food intake
3) skin, hair, nails
4) musculoskeletal
5) head and neck
6) endocrine and genital/reproductive
7) chest and lungs
8) heart and blood vessels
9) gastrointestinal
10) genitourinary
11) neurological
12) psychiatric

Front 17

Ethical/Legal use of History or Physical Exam Data

Back 17

Data are recorded in a clear, concise manner using appropriate terminology

Front 18

Functional Assessment







Functional Assessment (continued)

Back 18

Self-esteem/Self-Concepts
Cognitive function
Nutrition and Metabolism
Activity and Exercise
Sleep and Rest
Elimination
Coping and Stress Tolerance
Sexuality
Interpersonal relationships and resources
Spirituality

Front 19

Areas of Concern (Functional Assessment)

Back 19

Physiologic function
Cognitive function
Psychosocial needs
Nutrition
Sleep and Rest
Elimination
Activity and exercise
Sexuality
Meeting developmental tasks

Front 20

Physiologic function

Back 20

Nursing action:
-Maintain physiologic reserves
-Maintain ongoing assessments for early detection of problems
-Review perceptions of current health status,problems, and prescribed or over-the-counter meds
-Include nursing care that maintains physical status (e.g., skin care, planned rest and activity)

Front 21

Cognitive function

Back 21

Nursing Action: Slow pace of activity and wait for responses.
Be sure eyeglasses and hearing aids are used.

Front 22

Psychosocial needs

Back 22

Nursing Action: Be aware that illness, hospitalization, or changes in living arrangements are major stressors.
Assess and support sources of strength, incl. cultural and spiritual values and rituals.
Encourage use of support system.
Set mutual goals and encourage pt's role in making decisions about care.
encourage life review and reminiscence.
Encourage self-care.
Consider pt's background, interests, capabilities, values, culture, and lifestyle when planning care.

Front 23

Nutrition

Back 23

Nursing Action: Assess for lost or damage teeth; ensure dentures fit properly.
Assess ht,wt,eating patterns, food choices.
If wt is being lost, assess income, storage, and transportation.
Assess swallowing ability.

Front 24

Sleep and Rest

Back 24

Nursing Action: Discourage excessive napping.
Assess normal bedtime, time for rising,bedtime rituals, effects of pain, medications, anxiety, and depression.

Front 25

Elimination

Back 25

Nursing Action: Assess frequency of bladder elimination (incontinence).
Assess normal times for bowel movements.
ensure floor is uncluttered, toilet is accessible, lighting is adequate,and privacy is provided.
Review diet for necessary fluid and fiber content.

Front 26

Activity and exercise

Back 26

Nursing Action: Assess ability to walk.
Consider effects of illness, surgery, medications, and changes in diet and fluid intake on strength and motor function.
Ensure uncluttered environment with good lighting.
Slow pace of care, allowing extra time to carry out activities

Front 27

Sexuality

Back 27

Nursing Action: Assist as necessary with hygiene, hair care, oral care, clean clothing and bedding, makeup, and shaving.
Maintain clean, odor-free environment.
Demonstrate genuine caring (e.g., ask preferred name)
Discuss safer sex, if appropriate.
Discuss water-soluble lubricants with women; refer men for evaluation if erectile dysfunction is a concern.

Front 28

Meeting developmental tasks

Back 28

Nursing Action: Promote continued development and maintenance of functional health by identifying unmet tasks, feelings of isolation, and physical or sensory limitations.
Assist in finding creative solutions to developmental tasks.
Collaborate with other healthcare providers to provide info and referral to community resources for the pt and family.

Front 29

Topic: Infection Control

Back 29

Topic: Infection Control

Front 30

Chain of infection (definition)

Back 30

infectious agent (bacteria, viruses, fungi, protozoa)

Front 31

Reservoir (definition)

Back 31

place where pathogen can survive (but doesn't "stay"); Survival based on food, oxygen, water, temperature, light

Front 32

Portal of Exit (definition)

Back 32

how pathogen gets out of initial host: skin, respiratory tract, urinary tract, gastrointestinal tract, reproductive tract, blood

Front 33

Six(6) Modes of Transmission (definition)

Back 33

How organism gets from one host to another.
1. Direct contact
2. Indirect contact
3. Droplet
4. Air
5. Vehicles
6. Vectors

Front 34

Direct contact (definition)

Back 34

person to person, blood and body fluids, touch

Front 35

Indirect contact (definition)

Back 35

needle sticks, surfaces (depends, blood pressure machine)

Front 36

Droplet (definition)

Back 36

sneezing, coughing

Front 37

Air (definition)

Back 37

carried on dust particles or suspended in air

Front 38

Vehicles (definition)

Back 38

contaminated items, water, drugs, solutions, blood, food.

Front 39

Vectors (definition)

Back 39

External (flies).
Internal (mosquito, louse, flea, tick)

Front 40

Portal of Entry (definition)

Back 40

how organisms enter human body, same as portal of exit

Front 41

Susceptible Host (definition)

Back 41

very old, very young, depends on nutritional status, disease process, functioniung immune system, mental and physical overall

Front 42

Infection control measures to reduce reservoirs of infection (pg. 789 of textbook)

Back 42

Bathing.
Dressing changes.
Contaminated Articles in proper disposal.
Contaminated needles in puncture-proof container.
DO NOT RECAP contaminated NEEDLES.
Bedside Unit: Keep table surfaces clean and dry.
Bottled solutions: do not leave open for prolonged periods, keep tightly capped, date bottles when opened and discard according to policy.
Surgical wounds: Keep drainage tubes and collection bags patent to prevent accumulation of serous fluid under skin surface.
Drainage Bottles and Bags: empty and dispose of drainage suction bottles, empty all drainage systems each shift (unless otherwise ordered by MD). Never raise a drainage system (e.g., urine bag) above level of the site being drained, unless it is clamped off.

Front 43

How we defend against infections (3 ways)

Back 43

1- Inflammatory response
2- Normal flora
3- cellular response defenses

Front 44

Inflammatory response

Back 44

Protective reaction that neutralizes pathogens and repairs body cells.
Vascular and cellular.
Formation of inflammatory exudate.
Tissue repair.

Front 45

Normal Flora

Back 45

-does not cause disease, we all have normal flora
-does not like to mix with non-normal flora
-everywhere, from head-to-toe, but can be disrupted easily

Front 46

Defenses: cellular response

Back 46

-dilation through inflammatory response which allows more circulation
-chemical mediators allow more fluid to flow, leads to localized edema (this is protective during injury only)
-White Blood Cells (WBCs) arrive at injured site, leads to process that eats and destroys microorganisms (Phagocytosis)
-Inflammation becomes systemic which leads to more WBCs being produced and circulating

Front 47

White Blood Cells (WBCs) NORMAL (adult) RANGE

Back 47

5000-10,000.

-Increased in acute infection.
-Decreased in certain viral or overwhelming infections.

Front 48

Success Against Infections

Back 48

Know when something is CLEAN, DIRTY, STERILE

Front 49

PUTTING ON protective wear (page 799 in textbook):

Back 49

In this order:
MASK
GOWN
GLOVES

Front 50

TAKING OFF protective wear:

Back 50

In this order:
GLOVES
MASK
GOWN

Front 51

Assessment of LAB VALUES

Back 51

-WBCs: 5000-10,000
-Erythrocyte sedimentation rate (ESR): 20 mm/hr (women), 15 mm/hr (men)
-Differential count
-Neutrophils: 55-70%
-Lymphocytes: 20-40%
-Monocytes: 2-8%
-Eosinophils: 1-4%
-Basophils: 0.5-1%
-Iron level: 60-90 g/100 ml
-Cultures

Front 52

Infection - Nursing Diagnosis
Decide/Critical Thinking Exercise

Back 52

Nursing Diagnosis: Risk of Infection for complaint of "HOPELESSNESS" not for "Activity Intolerance"

Front 53

Infection - Nursing Diagnosis
Decide/Critical Thinking Exercise

Back 53

Nursing Diagnosis: Risk of Infection for "TOTAL INCONTINENCE" not for "risk for trauma"

Front 54

Infection - Nursing Diagnosis
Decide/Critical Thinking Exercise

Back 54

Nursing Diagnosis: Risk of Infection for both "TISSUE PERFUSION" and "TISSUE INTEGRITY"

Front 55

Nursing diagnoses that may apply to Infection (pg. 783 of textbook):

Back 55

- Disturbed body image
- Risk for infection
- Risk for injury
- Imbalanced nutrition: less than body requirements
- Impaired oral mucous membrane
- Risk for impaired skin integrity
- social isolation
- Impaired tissue integrity

Front 56

Infection - Planning

Back 56

-goals directed towards prevention and controlling or eliminating risks
-goals directed towards actual treatment
-realistic, measurable, take home lessons for patient. Upon discharge: make sure pt has supplies and knows how to clean wound.

Front 57

Infection - Implementation

Back 57

-Interventions for healthcare personnel (not just nurses) make sure promotes infection control.
-Make sure gets body able to fight and internally prevent infection (nutrition, control immunosuppression through stress reduction)
-Be mindful of what's clean, dirty, and sterile

Front 58

Infection control measures:

Back 58

asepsis, sterilization, disinfection, OSHA and CDC guidelines, gowning, gloving

Front 59

Asepsis (medical asepsis):
(page 786 of textbook)

Back 59

Absence of pathogens. Medical asepsis is also called "clean technique".
Principles of medical asepsis are commonly followed in the home, as in washing hands before preparing food.

Front 60

Sterilization:

Back 60

complete elimination or destruction of ALL microorganisms

Front 61

Disinfection

Back 61

think Purell

Front 62

Infection Control Measures

Back 62

-Hand hygiene: friction, friction, friction
-Isolation measures (airborne, droplet, contact)
-wound care
-sterile dressing change
-sterile gloving

Front 63

Infection - Evaluation

Back 63

-Documentation
-Reassessment
-Teaching
-Prevention of "frequent flyers"
-Follow-up phone calls

Front 64

Example of Test Question:
When is environment: clean?

Back 64

Clean: use of standard precautions (hand washing, using clean gloves to prevent direct contact with blood or bodily fluids, cleaning the environment routinely)

Front 65

Example of Test Question:
When is environment: dirty?


Example of Test Question:
When is environment: dirty?

Back 65

Dirty: anything that is contaminated by bodily fluids or suspected of containing pathogens

Front 66

Example of Test Question:
When is environment: sterile?



Example of Test Question:
When is environment: sterile?

Back 66

Sterile: (pg.802) during procedures requiring perforation of client's skin (insertion of IV catheters or administration of injections)
When skin integrity is broken as a result of a trauma surgical incision or burns.
During procedures that involve insertion of catheters or surgical instruments into sterile body cavities.

Front 67

Example of Test Question:
Contamination: What is it? and What do you do about it?

Back 67

(Page 786): After an object becomes unsterile or unclean, it is considered contaminated.

(pg.787): if object is disposable, usually it is discarded unless policy/procedure is in place to reprocess the object. Reusable objects must be cleaned thoroughly before reuse and then either disinfected or sterilized according to manufacturer's recommendations.

Front 68

Purposes of Teaching & Learning

Back 68

To help patients & families develop the self-care abilities (knowledge, attitude, & skills) that enable them to maximize their functioning and quality of life (or dignified death)
Promote health
Prevent illness
Restore health
Facilitate coping

Front 69

Teaching

Back 69

Informal- Unplanned teaching
Immediate learning needs
May lead to planned teaching
Formal - Planned teaching done to fulfill learner objectives

Front 70

Differences in Children vs. Adults

Back 70

Children
Concept of self: Dependent
Previous Experience: Not a resource / Building a body
Readiness to learn: Uniform by age
Orientation to learning: Subject centered;Use later
Motivation: External rewards

Front 71

Differences in Children vs. Adults

Back 71

Adult
Concept of self: Independent
Previous Experience: Serves as a resource
Readiness to learn: From life tasks, roles, problems
Orientation to learning: Task centered; Use immediately
Motivation: Internal incentives & curiosity

Front 72

Psychomotor Learning

Back 72

When a physical skill has been acquired
Example objective:
The patient demonstrates how to change dressings using clean technique.

Front 73

Affective Learning

Back 73

Involves changes in attitudes, values, and feelings
Example objective:
The patient expresses renewed self-confidence following physical therapy

Front 74

Verbs that can be used when writing Learner Objectives (Cognitive Domain):

Back 74

Cognitive Domain:
--Compares -- Prepares
Defines -- Plans
Describes -- Solves
Designs -- States
Differentiates -- Summarizes
Explains
Gives examples
Identifies
Names

Front 75

Verbs that can be used when writing Learner Objectives (Affective Domain):

Back 75

Affective Domain:
Chooses -- Shares
Defends -- Uses
Displays -- Values
Forms
Gives
Helps
Initiates
Justifies
Relates
Revises
Selects