Foundations of Nursing Exam #1

ICN definition

Promotion of health, prevention of illness, and collaborative care

ANA definition

Social policy statement

Blended Competencies

Cognitive, technical, interpersonal, ethical (legal)

QSEN Competencies

Patient-centered care, teamwork and collaboration, quality improvement, safety, evidence-based practice, informatics

Nursing aims

Promote health, prevent illness, restore health, facilitate coping disability or death

Nursing Practice Acts

define the legal scope of nursing practice and create a state board of nursing to make and enforce rules and regulations

Nursing Process Essentials

Assessing, diagnosing, planning, implementing, and evaluating

Signs of burnout

Compassion fatigue, burnout, and secondary traumatic stress

Vital Signs Method to Combat Burnout

BP - Be Present T - tracking P - practicing health and wellness behaviors R - refueling

Guidelines for Nursing practice

Standards of nursing practice, nurse practice acts and licensure, nursing process

Infectious agents

Bacteria, fungi, viruses

Reservoir

Natural habitat of an organism Food, soil, water and surfaces

Means of transmission

Direct contact, indirect contact, airborne contact

Portal of entry

Point at which organisms enter a new host

Examples of portal of entry

GI, GU, surface of skin, blood, and inhalation

Susceptible host

Must overcome resistance mounted by host's defenses

Bacteria

Most significant and most prevalent in hospital settings

Virus

Smallest of all microorganisms

Fungi

Plant-like organisms present in air, soil, and water

Factors affecting organism's potential to produce disease

number of organisms, virulence, immune capabilities, length of contact between person and organism

Possible reservoirs for microorganisms

other people, animals, soil, food, water, milk, and inanimate objects

Common portals of exit

respiratory, GI, GU, breaks in skin, blood, tissue

Stages of infection

Incubation, prodromal stage, full stage of illness, convalescent period

Incubation period

Organisms grow and multiply

Prodromal stage

Person is most infectious, vague and nonspecific signs of disease

Full stage of illness

Prescence of specific signs and symptoms of disease

Convalescent period

Recovery from infection

Factors affecting host susceptibility

Age, sex, race, hereditary factors, normal pH levels, etc.

Cardinal signs of acute infection

Redness, swelling, heat, pain, loss of function

Normal WBC count

5,000 to 10,000 mm3

WHO Hand Hygiene, how many moments are there?

5 moments

Moment 1

Prior to touching patient

Moment 2

Before a clean or aseptic procedure

Moment 3

After a body fluid exposure risk

Moment 4

After touching a patient

Moment 5

After touching patient surroundings

Bacterial flora locations

Transient and resident

Transient flora

Attached loosely to skin and removed with relative ease

Resident flora

Found in creases in skin, requires friction with brush to remove

Categories of Hospital-Acquired Infections

Catheter-associated urinary infection (CAUTI), surgical site infection (SSI), central line associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP)

What determines the body's defense against infection

Body's normal flora, inflammatory response, and immune response

List of PPE equipment used

Gloves, gowns, masks, protective eyewear

Aseptic technique

Activities performed to break the chain of infection

Categories of aseptic technique

Medical asepsis and surgical asepsis

Medical asepsis

Clean technique - soap and water are adequate

Surgical asepsis

Sterile technique - scrubbing sponge, sterile gloves, 2 min hand washing, etc.

Factors to consider when examining skin

Cleanliness, color, temperature, turgor, moisture, sensation, vascularity, and evidence of lesions

Assessment of oral cavity

Examine lips, buccal mucosa, color and surface of gums, teeth, tongue, hard and soft palates, oropharynx

Hygiene deficit categories for patients

Feeding, bathing, hygiene, dressing and grooming, and toileting

Times of care provided

Early morning care, morning care (AM care), afternoon care (PM care), hours of sleep care (HS care), as needed care (PRN care)

Physical assessment of teeth

Denture fit or loose teeth

Physical assessment of cheeks

Edema or swelling, dry mucosa

Physical assessment of tongue

Color and symmetry, texture, movement, lesions

Assessment of hard and soft palate

Discolorations, patches, lesions, and petechiae

Assessment of oropharynx

Tonsil swelling and uvula movement

Assessment of lips

dry or chapped, discoloration, peeling

Oral problems to assess for

Dental carries, periodontal disease, etc.

Assessment of eyes

Position, alignment, general appearance, redness, swelling, and discharge

Assessment of ears

Cerumen build up, dryness, crust, hearing aid placement

Assessment of nose

nostril patency, dryness, or bleeding

Assessment of hair

Texture, cleanliness, oiliness, dandruff, hair loss, texture, hair removal practices, infestations (lice), lesions on scalp, inflammation or redness

Assessment of feet and nails

Asses nails for color and shape, intactness, and cleanliness, tenderness Assess feet for lesions or breaks in skin, turgor, color, temperature, and integrity

Ensuring bedside safety steps

Bed in lowest position, position is safe for patient, bed controls are functioning, call light is functioning and within reach, side rails are raised if needed, wheels are locked

Vital Signs (abbreviated)

T, P, R, BP

What is the 5th vital sign?

Pain

Normal oral temperature (C and F)

36 to 38.2 C or 98.6 to 100.4 F

Normal pulse rate

60 to 100 bpm

Normal respirations

12 to 20 breaths per min

Normal blood pressure

120/80 mmHg Systolic - 100 to 140 Diastolic - 60 to 90

When to assess VS

On admission, institutional policies, change in condition, loss of consciousness, after surgical procedure, after ambulation, before administering cardiac medications

Factors affecting VS

Diagnosis, co-morbities, types of treatments received, patient's level of activity

Types of fever

Intermittent, remittent, sustained or continuous, relapsing or recurrent

Intermittent fever

Temp returns to normal at least once every 24 hours

Remittent fever

Temp does not return to normal and fluctuates a few degrees up and down

Sustained or continuous fever

Temp remains above normal with minimal variations

Relapsing or recurrent fever

Temp returns to normal for one or more days with one or more episodes of fever, as long as several days each

In what areas could body temperature be taken?

Rectal, oral, tympanic, axillary, and temporal

What area is the most accurate for temperature?

Rectal

When should you not use a rectal temp on a patient?

If the patient has neutropenia or thrombocytopenia

Normal rectal temp (C and F)

37.1 to 38.1 C or 99.5 F

Normal axillary temp

35.9 to 36.9 C

Normal tympanic temp

36.8 to 37.8 C

Normal temporal temp

37.1 to 38.1 C

Ways heat can be transferred out of body

Radiation, convection, evaporation, and conduction

Factors affecting body temperature

Circadian rhythms, age, gender, physical activity, state of health, and environmental temp

Pulse rate

number of contractions over a peripheral artery for 1 min

What regulates pulse

ANS through the SA node

PNS stimulation causes

Decreased HR

Sympathetic stimulation causes

Increased HR and force of contraction

Characteristics of pulse

Rate, amplitude, quality, rhythm, and volume of blood ejected with each heartbeat

Peripheral pulse points

Temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial

Pulse amplitude (0 to 3)

0 - absent and unable to feel 1 - diminished and weak 2 - brisk and expected (normal) 3 - bounding

When is apical pulse used?

In infants less than 2 yrs of age, if peripheral pulse is weak or irregular, if patient is on cardiac medications

Normal SpO2

92% to 100%

Hypertension Stage 1 reading

Systolic - 130 to 139 mmHg Diastolic - 80-89 mmHg

Hypertension Stage 2 reading

Systolic - greater than or equal to 140 mmHg Diastolic - 80-89 mmHg

Hypertensive crisis reading

Systolic - greater than 180 mmHg Diastolic - greater than 120 mmHg

Hypotension reading

Less than 90/60 mmHg

What sounds are listened to when taking BP?

Korotkoff sounds

Five types of nursing assessments

Comprehensive initial, focused, emergency, time-lapsed, and assessment of communities and special populations

Characteristics of nursing assessments

Purposeful, prioritized, complete, systematic, factual and accurate, and recorded in a standard manner

Comprehensive initial assessment

Performed shortly after admittance, establishes a baseline for problem identification and care planning

Focused assessment

Performed to gather data about a specific problem already identified or to identify new or overlooked problems

Emergency assessment

Performed when a physiological or psychological crisis presents, quick and simple to know how to intervene to help the patient

Time-lapsed assessment

Performed to compare a patient's current status to baseline data obtained earlier, used to compare progress of patient

Medical Assessment

Target data pointing to pathological conditions

Nursing assessment

Focus on patient's response to health problems

Objective data

Observable and measurable data that can be seen, heard, or felt by someone other than the patient

Examples of objective data

Elevated temp, skin moisture, vomiting

Subjective data

Information perceived by only the patient

Examples of subjective data

Pain, dizziness, anxiety, etc.

Sources of data

Patient, family, patient record, medical history, consultations, etc.

Phases of a nursing interview

Preparatory phase, introduction, working phase, termination

Purpose of a nursing assessment

Appraisal of health status, identification of health problems, establishment of database for nursing interventions, methods

Ques

Subjective and objective data

Inferences

Judgement about que, must validate

Phases of clinical assessment

Assessment, clinical reasoning, diagnosis

Medial

In or towards midline of the body

Lateral

Further from midline

Purpose of the heart

Pump blood to extremities, oxygenated blood supplies tissues and organs

What does LOC stand for

Level of consciousness

What does ABCD stand for

Airway, breathing, circulation, and disability

Orthopnea

Dyspnea when laying down

Paroxysmal Nocturnal Dyspnea

Waking during deep sleep being extremely short of breath or hypoxic

Heart Failure

Heart fails to pump blood due to fluid accumulation in lungs and periphery

Edema Scale Grading

1+, 2+, 3+, 4+

1+

2 mm indentation

2+

Indentation in between 2 and 4 mm

3+

Indentation greater than 6 mm

4+

Indentation greater than 8 mm

Edema treatment

Skin integrity, movement, elevation, and skin hygiene

Hemoglobin normal (female and male)

Female - 14 plus minus 2 Male - 16 plus minus 2

Hematocrit normal (male and female)

Female - 37 to 47% Male - 42 to 52%

What is hematocrit?

Percentage of blood volume made up of RBCs

S1 sound (LUB)

Closure of mitral and tricuspid valve, best heard at heart apex

S2 sound (DUBB)

Closure of aortic and pulmonic valves, best heard at base

Systole

Contraction of heart

Diastole

Heart relaxation and refilling

S3 heart sound is heard when

Too much blood is in the atrium, ventricle is forced to dilate beyond normal

S4 heart sound is heard when

Ventricle is stiff and noncompliant

When do murmurs occur?

Valve stenosis, incompetency or regurgitation, obstructed blood flow