Flashcards in Exam 1 Deck (143):
Theory-based nursing practice helps you to?
design and implement nursing interventions that address individual and family responses to health problems.
Nurses develop theories to explain?
relationships among variables by testing the theory through research and applying it in practice. Throughout this process new information often comes to light that indicates the need to revise a theory, and the cycle repeats
Novice: Beginning nursing student or any nurse entering a situation with no previous experience. Learns via set of rules/procedures that are step wise and linear.
Advanced beginner: Some experience may only be observational, able to identify meaningful aspects or principles of nursing care.
Competent: Been in same position for 2-3 yrs. Able to anticipate nursing care & establish long range of goals. Experience w/all psychomotor skills
Proficient: More than 2-3 yrs. Perceives patient clinical situation as whole, able to assess entire situation, readily transfer knowledge gained from mult. previous experiences. Focused on managing care.
Expert: Diverse experience, intuitive grasp of clinical problem. Zero in on problem & mult. dimensions. Skilled at identifying both patient-centered problems & problems related to the health care system.
A theory: Helps explain an event by
- Defining ideas or concepts
- Explaining relationships among the concepts
- Predicting outcomes
ANA Standards of nursing practice
3) Outcomes identification
a. coordination of care
b. health teaching and health promotion
d. prescriptive authority and Tx
ANA Standards of Professional Performance
3) Evidence-based practice and research
4) Quality of practice
8) Professional Practice Evaluation
10) Environmental Health
4 core roles for Advanced practice registered nurse (APRN)
1) Clinical nurse specialist (CNS)
2) Nurse practitioner (NP)
3) Certified nurse midwife (CNM)
4) Certified registered nurse anesthetist (CRNA)
Affects how health care is paid for and delivered
ACA Affordable Care Act
Quality of care is achieved by?
Implementing evidence-based practice
Involve family and friends in care. Elicit patient values and preferences. Provide care with respect for diversity of the human experience. This is an example of?
Recognize the contributions of other health team members and patient's family members. Discuss effective strategies for communicating and resolving conflict. Participate in designing methods to support effective teamwork.
Teamwork and collaboration
Quality and Safety Education for Nurses (QSEN)
Encompasses the competencies of patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
-(KSA) each one has targeted knowledge, skills, and attitudes
Touch is relational and leads to a?
connection between nurse and patient. It involves contact and noncontact touch. Contact touch involves obvious skin-to-skin contact, whereas noncontact touch refers to eye contact.
Knowing the context of a patient’s illness helps you?
choose and individualize interventions that will actually help the patient. Striving to understand an event as it has meaning in the life of the other and knowing the patient are essential when providing patient-centered care. Two elements that facilitate knowing are continuity of care and clinical expertise.
Instilling hope and faith helps increase an individual’s?
capacity to get through an event or transition and face a future with meaning.
Asking permission demonstrates to the patient and family that the nurse?
respects the patient's rights. Respecting and protecting patient rights is part of "doing for" and "being with" the patient.
Providing presence is a person-to-person encounter conveying closeness and a sense of caring. It involves?
“being there” and “being with.” “Being there” is not only a physical presence, but also includes communication and understanding. Presence is an interpersonal process that is characterized by sensitivity, wholism, intimacy, vulnerability, and adaptation to unique circumstances.
Factors that may affect vital signs
temp. of environment, patient's physical exertion, the effects of illness
When vital signs appear abnormal what should the nurse do?
1) Have another nurse/health care provider repeat the measurement to verify readings.
2) Inform the charge nurse/health care provider immediately
3) Document findings in your patient's record
4) Report vital sign changes to nurses during hand off communication
Acceptable Ranges for Adults: Temperature Range
- Average temp. range: 36-38 C (96.8-100.4 F)
- Average oral/tympanic: 37 C (98.6 F)
- Average rectal: 37.5 C (99.5 F)
- Axillary: 36.5 C (97.7 F)
Acceptable Ranges for Adults: Pulse
60-100 beats/min, strong and regular
Acceptable Ranges for Adults: Pulse Oximetry (SpO2)
Normal: SpO2 > or equal to 95%
Acceptable Ranges for Adults: Respirations
Adult: 12-20 breaths/min, deep and regular
Acceptable Ranges for Adults: Blood Pressure (BP)
Systolic <120 mm Hg
Diastolic <80 mm Hg
Pulse pressure: 30-50 mm Hg
Acceptable Ranges for Adults: Capnography (EtCO2)
Normal: 35-45 mm Hg
When to measure vital signs
- On admission to a health care facility
-When assessing a patient during home care visits
- In a hospital on a routine schedule according to the health care provider's order or hospital standards of practice before, during, and after a surgical procedure or invasive diagnostic procedure
- Before, during, and after a transfusion of blood products
- Before, during, and after the administration of medication or therapies that affect cardiovascular, respiratory, or temperature-control functions
- When a patient's general physical condition changes (e.g before a patient previously on bed rest ambulates or before a patient performs range of motion exercises)
- When a patient reports nonspecific symptoms of physical distress (e.g. feeling "funny" or "different")
Body tissues and cells function efficiently w/in a narrow range
From 36-38 C (96.8-100.4 F), but no single temp. is normal for all people
Site of temp. measurement
- Tympanic membrane
- Temporal artery
- Pulmonary artery
- Urinary bladder
Are all just one factor that determines a patient's temp.
In the elderly population the average core temp. ranges from?
35-36.1 C (95-97 F) as a result of decreased immunity
What are considered core temperatures
Invasive measurements such as with a pulmonary artery catheter
Controls body temperature
The hypothalamus located between the cerebral hemispheres.
-The hypothalamus senses minor changes in body temp. -The anterior hypothalamus controls heat loss, and the posterior controls heat production.
-When nerve cells in the anterior become heated beyond the set point, impulses are sent out to reduce body temp.
If it senses the body temp. is lower than the set point, body initiates heat conservation mechanisms.
-Vasoconstriction (narrowing) of blood vessels reduces blood flow to skin/extremities.
-Compensatory heat production is stimulated through voluntary muscle contraction and muscle shivering.
-When vasoconstriction is ineffective in preventing additional heat loss, shivering begins.
-Disease or trauma to hypothalamus or the spinal cord, which carries hypothalamic messages, causes serious alterations in temp. control.
Heat production occurs during?
Rest, voluntary movements, involuntary shivering, nonshivering thermogenesis
Occurs primarily in neonates, because neonates cannot shiver, a limited amount of vascular brown tissue, present at birth, is metabolized for heat production.
The transfer of heat from the surface of one object to the surface of another w/out direct contact between the two
The transfer of heat from one object to another w/direct contact.
Factors affecting body temp.
-Temperature alterations (fever, hyperthermia, heat stroke, heat exhaustion, hypothermia)
Newborn's body temp. is usually w/in
35.5-37.5 C (95.9-99.5 F)
The older adult has a narrower range of body temps.
-Oral temp.: 35 C (95 F)
-Average body temp: 35-36.1 C (95-97 F)
Bacteria and viruses that elevate body temperature
If the body cannot meet the demand for additional oxygen what happens?
Cellular hypoxia (inadequate oxygen) occurs
Myocardial hypoxia (inadequate oxygen) produces?
Angina (chest pain)
Cerebral hypoxia produces
Interventions during a fever include?
Oxygen therapy & maintaining optimum fluid volume
When water loss through increased respiration and diaphoresis is excessive, the patient is at risk for?
Fluid volume deficit
A serious problem for older adults and children with low body weight and experiencing a fever
Patterns of fever:
Sustained: A constant body temp. continuously above 38 C (100.4 F) that has little fluctuation
Intermittent: Fever spikes interspersed with usual temp. levels (temp. returns to acceptable value at least once in 24 hours)
Remittent: Fever spikes and falls w/out a return to acceptable temp. levels
Relapsing: Periods of febrile episodes & periods w/acceptable temp. values (febrile episodes & periods of normothermia are often longer than 24 hrs)
Classifications of hypothermia
Mild: 34-36 C (93.2-96.8 F)
Moderate: 30-34 C (86.0-93.2 F)
Severe: <30 C (<86 F)
Fever is an upward shift in the set point, hyperthermia results from?
An overload of the thermoregulatory mechanisms of the body.
A hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs
Body temp of 40 C (104 F) or more
Patients at risk of heat stroke include
- very young or very old
- those who have cardiovascular disease
- those who take medications that decrease ability of the body to lose heat (e.g. phenothiazines, anticholingergies, diuretics, amphetamines, beta adrenergic receptor antagonists)
- those who exercise or work strenuously ( athletes, construction workers, farmers)
Signs and symptoms of heat stroke
- excessive thirst
- muscle cramps
- visual disturbances
Vital signs of heat stroke
- body temp of 45 C (113 F)
- increased HR
- Lowered BP
- most important sign is hot, dry skin because they can't sweat due to severe loss of electrolytes and hypothalamic malfunction
Nursing diagnostic process: ineffective thermoregulation related to aging and inability to adapt to environmental temperature
Assessment activities & defining characteristics
This is an example
1) Assessment: Obtain vital signs, including temp., pulse, respirations, SpO2
Defining characteristics: Increased body temp. above usual range, tachycardia, tachypnea, hypoxemia
2) Assessment: palpate skin
Defining characteristics: warm, dry skin
3) Assessment: Observe patient's appearance and behavior while talking and resting
Defining characteristics: restlessness, confusion, flushed appearance
4) Review medical history
Defining characteristics: found in unventilated apartment during heat wave; 85 yrs old with history of dementia
Nursing interventions for patients with a fever
Interventions (unless contraindicated)
- Obtain blood cultures (before beginning antibiotics) if ordered. Obtain blood specimens to coincide w/temp. spikes when the antigen-producing organism is most prevalent
- minimize heat production: reduce frequency of activities that increase oxygen demand such as excessive turning and ambulation; allow rest periods; limit physical activity
- maximize heat loss: reduce external covering on patient's body w/out causing shivering; keep patient, clothing, and bed linen dry
- satisfy requirements for increased metabolic rate: provide supplemental oxygen therapy as ordered to improve oxygen delivery to body cells; provide measures to stimulate appetite and offer well-balanced meals; provide fluids (at least 8-10 8oz glasses for patients w/ normal cardiac & renal function) to replace fluids lost through insensible water loss and sweating
- promote patient comfort: encourage oral hygiene because oral mucous membranes dry easily from dehydration; control temp. of the environment w/out inducing shivering; apply damp cloth to patient's forehead
- identify onset and duration of febrile episode phases: examine previous temp. measurements for trends
- initiate health teaching as indicated
- control environmental temp. to 21-27 C (70-80 F)
Acceptable ranges of heart rate
1) infant 120/16 beats/min
2) toddler 90-140
3) preschooler 80-110
4) school-aged child 75-100
5) adolescent 60-90
6) adult 60-100
Abnormally elevated HR, above 100 beats/min
A slow HR, below 60 beats/min
An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site. The difference between the apical and radial pulse rates is the pulse deficit
The movement of gases in and out of the lungs
The movement of oxygen and carbon dioxide between the alveoli and the red blood cells
The distribution of red blood cells to and from the pulmonary capillaries
Factors influencing character of respirations
-Exercise: increases rate and depth to meet the need of the body for additional oxygen and to rid the body of CO2
-Acute pain: pain alters rate and rhythm of respirations; breathing becomes shallow. Patient inhibits or splints chest wall movement when pain is in area of chest or abdoment
-Anxiety: increases respiration rate and depth as a result of sympathetic stimulation
-Smoking: chronic smoking changes pulmonary airways, resulting in increased rate of respirations at rest when not smoking
-Body position: a straight, erect posture promotes full chest expansion. A stooped or slumped position impairs ventilatory movement. Lying flat prevents full chest expansion
-Medications: Opioid analgesics, general anesthetics, and sedative hypnotics depress rate and depth. Amphetamines and cocaine sometimes increase rate and depth. Bronchodilators slow rate by causing airway dilation
-Neurological injury: injury to brainstem impairs respiratory center and inhibits respiratory rate and rhythm
-Hemoglobin function: decreased hemoglobin levels (anemia) reduce oxygen-carrying capacity of the blood, which increases respiratory rate. increased altitude lowers amount of saturated hemoglobin, which increases respiratory rate and depth. abnormal blood cell function (e.g. sickle cell disease) reduces ability of hemoglobin to carry oxygen, which increases respiratory rate and depth.
Acceptable ranges of respiratory rate
Infant (6 months) 30-50
Toddler (2 years) 25-32
Alterations in Breathing Pattern
- Bradypnea: Rate of breathing is regular but abnormally slow (less than 12 breaths/min
- Tachypnea: Rate of breathing is regular but abnormally rapid (greater than 20 breaths/min)
- Hyperpnea: Respirations are labored, increased in depth, & increased in rate (greater than 20 breaths/min) (occurs normally during exercise)
- Apnea: Respirations cease for several seconds. Persistent cessation results in respiratory arrest
- Hyperventilation: Rate & depth of respirations increase. Hypocarbia sometimes occurs.
- Hypoventilation: Respiratory rate abnormally low, depth of ventilation is depressed. Hyperccarbia sometimes occurs.
- Cheyne-Stokes respiration: Respiratory rate & depth are irregular, characterized by alternating periods of apnea & hyperventilation. Respiratory cycle begins w/slow, shallow breaths that gradually increase to abnormal rate/depth. The pattern reverses; breathing slows & becomes shallow, concluding as apnea before respiration resumes
- Kussmaul's respiration: Respirations abnormally deep, regular, & increased in rate
- Biot's respiration: Respirations abnormally shallow for two to three breaths, followed by irregular periods of apnea
Average optimal blood pressure for age
Newborn: 40 mean
1 Month: 85/54
1 Year: 95/65
6 Years: 105/65
10-13 years: 110/65
14-17 years: 119/75
18 years and older <120/<80
Classification of blood pressure for adults ages 18 older
Stage 1 hypertension: >or equal to 140/>or equal to 90
Stage 2 hypertension: >or equal to 160/>or equal to 90
Factors influencing blood pressure
-Activity and weight
When is Prehypertension diagnosed in adults?
When an average of two or more readings on at least two subsequent visits is between 120 and 139 mm Hg systolic and 80-89 mm Hg diastolic
Antihypertensive medications: Diuretics
Lowers blood pressure by reducing resorption of sodium and water by the kidneys, thus lowering circulating fluid volume
Antihypertensive medications: Beta-adrenergic blockers
Combines with beta-adrenergic receptors in the heart, arteries, and arterioles to block response to sympathetic nerve impulses; reduces heart rate & thus cardiac output
Antihypertensive medications: Vasodilators
Acts on arteriolar smooth muscle to cause relaxation and reduce peripheral vascular resistance
Antihypertensive medications: Calcium channel blockers
Reduces peripheral vascular resistance by systemic vasodilation
Antihypertensive medications: Angiotensin-converting enzyme (ACE) inhibitors
Lowers BP by blocking the conversion of angiotensin I to angiotensin II, preventing vasoconstriction; reduces aldosterone production and fluid retention, lowering circulating fluid volume
Angiotensin II receptor blockers (ARBs)
Lowers BP by blocking the binding of angiotensin II, which prevents vasoconstriction
Hypotension, hypertension, orthostatic hypotension, and narrow or wide pulse pressures are defining characteristics of certain nursing diagnoses, including the following
-Decreased cardiac output
-Deficient/Excess fluid volume
-Risk for injury
-Ineffective peripheral tissue perfusion
Describe the benefits and precautions involving self-measurement of blood pressure.
Advantages: The patients are able to monitor their BP more often which helps with adherence to treatment
Disadvantages: They may be taking it wrong, risk of inaccurate reading and may inappropriately self-adjust medications
Signs and symptoms of hyperthermia
Decreased skin turgor; tachycardia; hypotension; concentrated urine
Developmental tasks for older adults
-Adjusting to decreasing health and physical strength
-Adjusting to retirement and reduced or fixed income
-Adjusting to death of a spouse, children, siblings, friends
-Accepting self as aging person
-Maintaining satisfactory living arrangements
-Redefining relationships w/adult children and siblings
-Finding ways to maintain quality of life
Nursing assessment takes into account three key points to ensure an age-specific approach
1) The interrelation between physical and psychosocial aspects of aging
2) The effects of disease and disability on functional status
3) Tailoring the nursing assessment to an older person
Risk factors for urinary incontinence include?
Roles & responsibilities of nurses
-Autonomy and accountability
The development of a care plan
Take the nursing process ADOPIE & applying it to the patient understanding that every care plan needs to be individualized and focused on our specific patient and their needs
Differences between abuse and neglect in older adults
There is a difference between physical and emotional abuse. Usually you can see signs of physical abuse (e.g bruising, broken bones) emotional abuse you will see a withdrawal of some kind.
Neglect will usually be some kind of hygiene issue or underweight (malnutrition)
Taste buds atrophy and lose sensitivity, and appetite may decrease. As a result, which is the older adult less able to discern?
1 Spicy and bland foods
2 Salty, sour, and bitter tastes
3 Hot and cold temperatures
4 Moist and dry food
2 Salty, sour, and bitter tastes
As people, age, salivary secretion is reduced, and taste buds atrophy and lose sensitivity. The older adult is less able to differentiate among salty, sweet, sour, and bitter tastes. Often an adult uses heavy spices because of the inability to taste food. Older adults maintain their ability to differentiate between hot and cold temperatures, and moist and dry food.
When a patient experiences kyphosis, which should the nurse recognize as a future risk?
1 Decreased bone density in the vertebrae and hips
2 Increased risk for pathological stress fractures in the hips
3 Changes in the configuration of the spine that affect the lungs and thorax
4 Calcification of the bony tissues of the long bones such as in the legs and arm
3 Changes in the configuration of the spine that affect the lungs and thorax
Kyphosis is a curvature of the thoracic spine, which can affect the patient’s ability to breath deeply and cough effectively. Although kyphosis may be cause by osteoporosis, the primary concern is the impact on the lungs. Decreased bone density, increased risk for stress fractures, and calcification of the bony tissues of the long bones may coexist with osteoporosis.
An older patient presents to the nurse with impaired vision, nocturia, and agitation. Which risk is most likely to occur in this patient?
3 Heart disease
4 Chronic lung disease
Impaired vision, nocturia, and agitation may increase the risk of falls in the patient. Diabetes mellitus, hypertension, and hyperlipidemia are the risk factors for stroke. Obesity, stress, and stroke are risk factors for heart disease. Smoking tobacco is a risk factor for chronic lung disease.
1) Presbycusis is characterized by the presence of a loss of acuity for high-frequency tones and conversational speeches due to aging. It is a physiological sensory change that may occur in the ears with aging.
2) Sensory changes in the eyes include yellowing of the lens and altered color perception.
3) A sensory change in taste is often characterized by fewer taste buds.
4) A sensory change in the touch might be caused by decreased skin receptors.
Decreased mobility of the ribs is cause due to?
calcification of the costal cartilage. This occurs with aging.
The curvature of the thoracic spine is known as?
Dorsal kyphosis and is due to vertebral change.
Decrease in the respiratory muscle strength and increase in the anteroposterior diameter of the thorax are?
Age-related problems due to configurational changes in the thorax.
Auditory changes are often subtle in older adults, and are often unidentified and untreated. A 68-year-old patient with presbycusis may have?
Impacted cerumen, which is a common cause of diminished hearing acuity.
Kyphosis occurs in the older adults due to?
Osteoporosis, which leads to curvature of the thoracic spine.
Irregular, round or oval, brown, and watery lesions usually found on an older adult’s skin due to aging.
A visual acuity defect in older adults that occurs due to retinal damage, reduced pupil size, development of opacities in the lens, or loss of lens elasticity. Presbyopia leads to progressive decline of the eyes to accommodate vision. Therefore, an older adult patient with presbyopia may not able to differentiate dark colors such as black and blue.
Specialists in the field of gerontology consider older adults to have?ence.
An optimistic outlook on life, tolerance for others, and good memory recall. The United States census bureau states that only 9.5 percent of older adults are poor and most of them are well-cared for, protected, and financially happy. It is a myth that most older adults are mentally instable. Most older adults have an intact memory even up until the end of life. Some stereotypes consider older adults as worthless after leaving the workforce, but they are actually the ones with more knowledge and experience.
Production of sperm declines during the?
fourth decade of a man’s life; that is, it declines at 40 years of age. With increasing age, sexual desire also decreases. A characteristic feature of reproductive change in women is decreased production of estrogen and progesterone. Decreased estrogen and progesterone may cause decreased lubrication of the vaginal mucosa, leading to irritation. Vaginal irritation, which occurs due to lack of lubrication, may result in pain during sexual activity.
Acute confusional state, a potentially reversible cognitive impairment that often has a physiological cause.
-often presenting symptom for pneumonia or UTI
-a medical emergency that requires prompt assessment and intervention
A generalized impairment of intellectual functioning that interferes with social and occupational functioning.
-includes Alzheimer's disease, Lewy body disease, frontal-temporal dementia, vascular dementia
-decline in ability to perform ADLs and IADLs
-gradual, progressive, irreversible cerebral dysfunction
-nurse assessment: always consider the safety & physical/psychosocial needs of the older adult and family
Older adults sometimes experience late life depression, but it is not a normal part of aging.
-most common, undetected/untreated, impairment in older adulthood
Assessment of safety: safety in the home
-Water heaters set at hot temps
-slippery floor surfaces
The concurrent use of many medications. It increases the risk for adverse drug effects (ADE)
Cataracts normally result in?
blurred vision, sensitivity to glare, and gradual loss of vision
Alterations in the lower gastrointestinal tract lead?
diarrhea, flatulence, and constipation. Due to aging, peristalsis movement becomes slow, and alterations in secretions occur.
Vitamin A promotes?
epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation.
Vitamin C acts as an?
A sudden fall in blood pressure, increase in pulse, and change in consciousness in a postoperative patient indicate?
Internal hemorrhage which is a complication following the resection of the intestines and should be attended to immediately.
When seeking truth from a patient, the nurse should?
be honest, use tact, and ask objective questions.
A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of:
Applying ethical criteria
The use of ethical criteria for nursing judgment allows a nurse to focus on a patient’s values and beliefs. Clinical decisions are then just, faithful to the patient’s choices, and beneficial to the patient’s well-being.
By using known criteria in conducting an assessment such as reviewing with a patient the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude?
Discipline is being thorough in whatever you do. Using known criteria for assessment and evaluation, as in the case of pain, is an example of discipline.
Be objective in asking questions of a patient.
Be tolerant of the patient's views and beliefs
Anticipate how a patient might respond to a treatment.
Organize assessment on the basis of patient priorities.
The nurse observes a student nurse caring for a patient with diarrhea. Which quality in the student nurse reflects cognitive maturity?
Considering multiple solutions for the patient’s condition
-Nursing requires critical thinking, and critical thinking requires cognitive maturity. Maturity can be demonstrated by considering multiple solutions to a patient’s condition, including the suggestions of others, and choosing the appropriate action.
Which technique should the student nurse follow to develop critical thinking skills and bring theory into practice?
- Reflective journaling involves recollecting daily incidences and writing them down for further reference. This helps improve critical thinking skills and clarifies concepts for further reference.
Which components can restrict the student nurse’s ability to move from a basic level to a complex level of critical thinking? Select all that apply.
Inexperience, Inflexible attitude, Weak competency
- Student nurses mostly apply the basic level of critical thinking in practice because they are still learning and are task oriented. The student’s inexperience due to less exposure, inflexible attitude due to less practice, and weak competency due to less exposure can restrict the ability to move from a basic level to a complex level of critical thinking in practice.
The nurse is caring for a patient with diabetes mellitus. The nurse uses diagnostic reasoning to determine the patient’s health problems. Which parameters should the nurse include when using diagnostic reasoning for this patient?
-Risk of hemorrhage
A basic critical thinker always has?
faith in the experts. The learner tends to consult books or experts before making a decision or performing a task.
A complex critical thinker?
analyzes a situation before making a decision.
In commitment thinking, the person?
makes decisions without any assistance and is accountable for the decision made.
According to Paul, there are 14 intellectual standards that are universal for critical thinking:
clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for purpose), and fair. These are guidelines or principles to enhance rational thinking that can be used in daily nursing practice.
Self-regulation is a critical thinking skill applied by the nurse while making?
complex decisions about a patient and care. Based on patient outcomes, the nurse chooses an alternative way to achieve better outcomes. This enables the nurse to attain success and satisfaction in clinical practice.
Interpretation is the skill applied by the nurse while?
collecting and organizing the patient data in a systemic manner.
Inference is the skill applied by the nurse in order to find?
a relationship between assessment findings of the patient.
Health perception-health management pattern
Describes patient's self-report of health and well-being, how patient manages health (e.g. frequency of health care provider visits, adherence to therapies at home), knowledge of preventive health practices
Describes patient's daily/weekly pattern of food/fluid intake (e.g. food preferences or restrictions, special diet, appetite), actual weight, weight loss or gain
Provokes: precipitating and relieving factors: what causes symptom? What makes it better or worse? Are there activities that affect it?
Quality: What does the symptoms feel like? If patient cannot describe, offer proves such as "is it sharp, dull, burning?"
Radiate: Where is the symptom located? Is it in one place? Does it go anywhere else? Have patient be as precise as possible
Severity: Ask a patient to rate the severity of a symptom on a scale of 0-10. This gives you a baseline with which to compare in follow-up assessments
Time: Assesses onset and duration of symptom. When did it start? Does it come and go? If so, how often & for how long? What time of day or day of the week?
The nurse is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths per minute. He lost his wife just a month ago. The nurse’s knowledge about this patient would result in which type of assessment approach at this time? Select all that apply.
-A problem-focused approach
-A structured, comprehensive approach
-Using multiple visits to gather a complete database
-Focusing on the functional health pattern of role-relationship
-Scheduling a single, extensive, structured interview to gather a detailed assessment
- A problem-focused approach
- Using multiple visits to gather a complete database
The nurse should use a focused approach initially to determine the patient’s respiratory status. However, to gather an admission assessment, multiple visits are necessary because of the patient’s age and level of physical distress. A structured, comprehensive approach is not appropriate for this acute situation. Eventually the nurse will want to assess the patient’s role-relationship health pattern because of his wife’s death. However, it is not appropriate at this time.
comparing data with another source
Chain of infection
-An infectious agent or pathogen
-A reservoir or source for pathogen growth
-A port of exit from the reservoir
-A mode of transmission
-A port of entry to a host
-A susceptible host
Modes of transmission: Direct
Person-person (fecal, oral) physical contact between source and susceptible host (e.g. touching patient feces and then touching our inner mouth or consuming contaminated food)
Modes of transmission: Indirect
Personal contact of susceptible host w/contaminated inanimate object (e.g. needles or sharp objects, dressings, environment)
Modes of transmission: Droplet
Large particles that travel up to 3 feet during coughing, sneezing, or talking and come in contact w/susceptible host
Modes of transmission: Airborne
Droplet nuclei or residue or evaporated droplets suspended in air during coughing or sneezing or carried on dust particles
Modes of transmission: Vehicles
-Food (improperly handled, stored, or cooked; fresh or thawed meats)
Modes of transmission:Vector
-External mechanical transfer (flies)
-Internal transmission such as parasitic conditions between vector and host such as: Mosquito, louse, flea
1) Incubation period: Interval between entrance of pathogen into body and appearance of first symptoms (e.g. chickenpox, 14-16 days after exposure; common cold, 1-2 days; influenza, 1-4 days; measles, 10-12 days; mumps, 16-18 days; Ebola 2-21 days)
2) Prodromal stage: Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to more specific symptoms. (During this time microorganisms grow & multiply, and patient may be capable of spreading disease to others.) For example, herpes simplex begins w/itching & tingling at the site before the lesion appears
3) Illness stage: Interval between patient manifests signs and symptoms specific to type of infection. For example, strep throat is manifested by sore throat, pain and swelling; mumps is manifested by high fever, parotid and salivary gland swelling
4) convalescence: Interval when acute symptoms of infection disappear. (Length of recovery depends on severity of infection and patient's host resistance; recovery may take several days to months
The nurse is teaching student nurses about the inflammatory response to an injury. Arrange the events in the order of their occurrence in a response to injury.
1) Rapid vasodilation at site of injury
2) Accumulation of fluid at site of injury
3) Formation of exudate at site of injury
4) Formation of granulation tissue