Exam 1 Review Flashcards
1
Q
What launched the profession of nursing in the United States
A
Civil War
2
Q
The war where Florence Nightingale first came up
A
Crimean War
3
Q
Florence Nightingale’s Notes on Nursing
A
What it is and What it is Not
4
Q
Where was the First professional nursing school established?
A
St. Thomas’ Hospital in London
5
Q
Based on Florence Nightingale’s principles of nursing, where was the nation’s first nursing school opened?
A
Bellevue Hospital, New York City
6
Q
What is first American nursing journal called?
A
The Nightingale
7
Q
Where was the first board of nursing established?
A
North Carolina
8
Q
Name the University that had the first bachelor’s degree in nursing.
A
University of Minnesota
9
Q
Who is the founder of the modern nursing profession?
A
FLORENCE NIGHTINGALE
10
Q
CLARA BARTON
A
Founder and first President of the American Red Cross
11
Q
MARY ELIZABETH MAHONEY
A
First African American to study and work as a professionally trained nurse
12
Q
SUSIE WALKING BEAR YELLOWTAIL
A
Broke barriers for Indigenous women and fought for culturally competent health care
13
Q
LUTHER CHRISTMAN
A
Helped establish the National Male Nurse Association
14
Q
Ildaura Murillo-Rohde
A
helped found the National Association of Hispanic Nurses
15
Q
Anastacia Giron-Tupas
A
helped to develop the first baccalaureate nursing program offered in the Philippines
16
Q
Bestowed with the title of Dame by Queen Elizabeth II for “services to Nursing and to International Humanitarian Aid.”
A
Dame Claire Bertschinger
17
Q
How was nurses viewed before as?
A
Angel of Mercy, Battle-ax, Handmaiden
18
Q
What is the most “trusted” profession?
A
Nurses
19
Q
Nursing ranks low in what?
A
Desirability
20
Q
How is Nursing Currently Defined? (PPFAA)
A
- Protection, promotion, and optimization of health and abilities
- Prevention of illness and injury
- Facilitation of healing
- Alleviation of suffering through the diagnosis & treatment of human response
- Advocacy in the care of individuals, families, groups, communities, and populations
21
Q
Nursing is the _____ and _____ of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.
A
diagnosis, treatment
22
Q
Which nursing role “Address physical, emotional, social, and spiritual needs?”
A
Direct care provider
23
Q
What does a Client/family educator role do?
A
Assess and diagnosis teaching needs
24
Q
What does a Client advocate nursing role do?
A
Support rights and protecting from harm
25
What does a Change agent role do?
Advocate for change to enhance health
26
What is Manager nursing role function?
Coordinate and manage activities of health care team
27
Consumer of research nursing role function?
Apply evidence-based practice (EBP), identify clinical problems, and protect
rights of research subjects
28
What is SENC?
Safe, Effective Nursing Care
29
Nursing Today is based on what?
Safe, Effective Nursing Care (SENC)
30
Two types of SENC Competencies?
1. Institute of Medicine (IOM) Core Competencies or National Academy of Medicine
2. Quality and Safety Education for Nurses (QSEN) Competencies
31
What are the Institute of Medicine (IOM) Core Competencies?
1. Provide patient-centered care
2. Work in interdisciplinary teams
3. Employ evidence-based practice (EBP)
4. Apply quality improvement (QI)
5. Utilize informatics
32
What does the Institute of Medicine (IOM) Core Competencies begin with?
including the patient on the health care team
33
What are the Quality and Safety Education for Nurses (QSEN) Competencies?
1.Patient-centered care
2. Teamwork and collaboration
3. Evidence-based practice (EBP)
4. Quality improvement (QI)
5. Informatics
6. Safety
34
Which nursing theorist described the process by which a nurse acquires clinical skills and judgment via 5 categories
Patricia Benner
35
What model is the most useful framework for assessing nurses’ needs at different stages of professional growth?
Benner's Model
36
What are the 5 categories from Benner's Model? (List from lowest to highest)
1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert
37
What category of Benner's Model is this: Beginners with no experience; rigid adherence to rules; minimal judgement
Novice
38
What category of Benner's Model is this: Provides care drawing from some practical experience; can perform tasks but has difficulty improvising and prioritizing.
Advanced Beginner
39
What category of Benner's Model is this: Enacts intentional short-term and longer term planning for care; efficient and organized
Competent
40
What category of Benner's Model is this: Decision-making and prioritizing come more easily; practice with holistic perspective rather than in steps or parts.
Proficient
41
What category of Benner's Model is this: Has intuitive grasp of broader situations; able to analyze and think critically for creative solutions.
Expert
42
What is defined as the mental process of actively and skillfully perception, analysis, synthesis and evaluation of collected information through observation, experience and communication that leads to a decision for action.
Critical thinking
43
Nursing is more than performing tasks; it requires what?
great critical thinking skills
44
The National Council of State Boards of Nursing integrates what?
critical thinking & decision making
45
What are the Complex Critical-Thinking Processes?
1. Problem-solving
2. Clinical judgement
3. Clinical reasoning
46
Process of synthesizing knowledge and information from numerous sources & incorporating experiences to develop a plan of care for a particular client or case scenario
Clinical reasoning
47
What is the MODEL FOR CRITICAL THINKING called?
Star
48
Star Model
- Contextual awareness
- Using credible sources
- Analyzing assumptions
- Exploring alternatives
- Reflecting & deciding
49
Bloom's Taxonomy
1. create
2. evaluate
3. analyze
4. apply
5. understand
6. remember
50
Types of Nursing Knowledge
1. Theoretical
2. Practical
3. Self-knowledge
4. Ethical
51
Theoretical Nursing Knowledge
knowing why
52
Practical Nursing Knowledge
Knowing what do and how to do it
53
Self-knowledge Nursing Knowledge
to think critically, you must be aware of your beliefs, values, and cultural and religious biases
54
Ethical Nursing Knowledge
knowing your obligation to patients and colleagues is key; you know right versus wrong
55
A systematic, patient-centered, goal-oriented method of caring that provides a framework for nursing practice
Nursing Process
56
What is ADPIE in Nursing Process?
1. Assess
2. Diagnose
3. Plan
4. Implement
5. Evaluation
56
Step in ADPIE that:
- Systematic gathering of information
- uses collecting, validating, and communicating data
- relates to thorough patient evaluation
Assessment/Assess
57
Step in ADPIE that:
- response to health/illness issue
- Form a nursing diagnosis based on the collected data
- instructs the nursing care that the patient shall receive
Diagnosis
58
Step in ADPIE that:
- develop a care plan drawing on information from the nursing diagnosis
- be measurable and goal-oriented
- specifying goals/outcomes and interventions
Planning outcomes
59
Step in ADPIE that:
- measuring extent that goal achieved
- determine if goals met and outcomes achieved
Evaluation
60
Step in ADPIE that:
- the care plan is put into action
- Perform the nursing actions identified in planning
Implementation
61
What are some Data Sources?
- Patient and patient’s behavior
- Physical assessment
- Family and significant other
- Patient record
- Findings of the provider – Physician, APRN, or Physician Assistant/Associate (PA)
- Consultations
- Laboratory & Diagnostic study results
- Other health care professional results
62
What are the 2 types of Data Collection?
1. Subjective data
2. Objective data
63
Subjective data
Information perceived only by the affected person: “I have pain in my left shoulder.
64
Objective data
- Observable (e.g., inability to move a limb)
- Measurable (e.g., vital signs)
- Usually occurs during the physical assessment period
65
- A clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes.
- provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
Nursing Diagnosis
66
NOT a medical diagnosis
Nursing Diagnosis
67
A medical diagnosis is:
- is made by a doctor or advanced health care practitioner
- focuses on the patient’s disease, medical condition, or pathologic state – determining which falls into the expertise of advanced medical practitioners
- Does not usually change. Remains in medical history
68
A statement of client health status that nurses can identify, prevent, or treat independently
Nursing Diagnosis
69
What are the Steps to Writing a NANDA Diagnosis?
1. Pick the diagnostic label
2. Read the definition
3. Identify the related factor(s) or “related to” (r/t)
4. Identify the defining characteristics or “as evidenced by” (AEB)
70
What are the 2 types of Nursing Diagnosis?
1. Risk
2. Actual
71
Only 2 parts:
1.Patient’s problem
2.“related to” (r/t) – related factors
example: Risk for falls related to acute illness
Risk
72
3 parts
1. Patient’s problem
2. “related to” – related factors
3. “as evidence by (AEB)” – defining characteristic(s)
example: Excess Fluid volume r/t excess sodium intake AEB edema (2+ lower extremities)
Actual
73
What model do we use to prioritize patient problem?
Maslow's Hierarchy of Human Needs
74
What are the 5 parts of Maslow's Hierarchy of Human Needs? (list from bottom up)
1. Physiological
2. Safety
3. Need for love, affection, belonging
4. Need for Esteem
5. Need for Self-actualization
75
Maslow's Hierarchy of Human Needs: Physiological examples
- breathing
- food
- water
-sex
- sleep
- homeostasis
-excretion
76
Maslow's Hierarchy of Human Needs: Safety examples
security of the following:
- body
- employment
- resources
- morality
- family
- health
- property
77
2 types of Planning Outcomes
1. Short-term goals
2. Long-term goals
78
Long-term goals
weeks or months
79
Short-term goals
hours or a day or so
80
SMART Goals
S- Specific
M- Measurable
A- Attainable
R-Relevant
T- Timely
81
Always evidence-based
Interventions
82
2 types of Planning Interventions
1. Direct-care interventions
2. Indirect-care interventions
83
Type of Planning intervention that is performed through interaction with the client(s)
Direct-care interventions
84
Types of Nursing Interventions
1. Independent intervention
2. Dependent intervention
3. Collaborative/interdependent intervention
84
Type of Planning intervention that is performed away from the client but on behalf of a client or group of clients (e.g., advocacy)
Indirect-care interventions
85
the authorization for the performance of selected nursing interventions from a licensed nurse to an unlicensed assistive person (UAP)
Delegation
86
Five Rights of Delegating: TCPDS
1. Task (Can I delegate it?)
2. Circumstance (Should I delegate it?)
3. Person (Who is best prepared to do it?)
4. Direction/Communication (What does the UAP need to know?)
5. Supervision/Evaluation (How will I follow up?)
87
conscious internal dialogue, sometimes known as self-talk
Intra-personal Communication
88
communication occurs between two or more people
Inter-personal Communication
89
Nurses use ______ to gather information during assessment, to teach about health issues, to explain care, and to provide comfort and support
interpersonal communication
90
2 Methods of Communication
1. verbal
2. non-verbal
91
Active Listening
SOLER
92
What is SOLER?
S- Sit Straight
O- Open Posture
L- Lean forward
E- Eye contact is maintained
R- Relax
93
- If something doesn’t seem right to you, it’s important to raise your concerns, especially when it comes to patient safety
- You can feel empowered using this tool to point out a problem or a conflict of information without challenging the other person’s authority or coming off as a personal attack
CUS Tool
94
CUS Tool
I am Concerned …
I am Uncomfortable …
This is a Safety Issue
95
a communication tool that helps provide essential, concise information, usually during a crucial situation
SBAR
96
SBAR
S- Situation
B- Background
A- Assessment
R- Recommendation
97
a developmental process in which one achieves increasing levels of awareness, knowledge, and skills along a continuum, improving one’s capacity to work and communicate effectively in cross-cultural situations
Cultural competency
98
often seen as an alternative approach to cultural “competence”
Cultural Humility
99
Cultural Humility
a reflective process of understanding one’s biases and privileges, managing power imbalances, and maintaining a stance that is open to others in relation to aspects of their cultural identity that are most important to them
100
self-awareness, examining personal attitudes to identify bias
Cultural Awareness
101
- Knowledgeable about culture prevalent in their area of practice
- Has more to do with personal attitudes and being careful not to say or do something that might be offensive to someone from a different culture
Cultural sensitivity
102
apply knowledge of client’s culture to their care delivery
Cultural appropriateness
103
impose rules of your own culture onto another person
Cultural imposition
104
we're all influenced by them whether we like it or not
Bias
105
subconscious tendency to seek & interpret information in ways that affirm our existing beliefs, ideas, expectations
Confirmation Bias
105
refers to negative attitudes toward other people based on faulty and rigid stereotypes about race, gender, sexual orientation, and so on
Prejudice
106
refers to the behavioral manifestations of that prejudice
Discrimination
107
the tendency to think that your own group (cultural, professional, ethnic, or social) is superior to others and to view behaviors and beliefs that differ greatly from your own as somehow wrong, strange, or unenlightened
Ethnocentrism
108
the unsubstantiated belief that all people of a certain racial or ethnic group are alike in certain respects
Cultural stereotyping
109
- a social construct
- a form of prejudice and discrimination based on the belief that race is the principal determining factor of human traits and capabilities and that racial differences produce an inherent superiority (or inferiority)
Racism
110
the assumption that members of one sex are superior to those of the other sex
Sexism
111
can involve foreign languages, dialects, regionalisms
Language barriers
112
words or expressions used by a subculture, including medicine
Healthcare Jargon
113
This theory helps distinguish nursing as a separate discipline from medicine and related sciences, and assists nurses in understanding their patients and their needs
Nursing Theory
114
Organized set of related ideas & concepts
Theory
115
Broader & more philosophical than theories
Framework
116
Symbolic representation of framework
Conceptual model – model expressed in language
Model
117
Worldview or ideology
Paradigm
118
Created an environmental adaptation theory
Florence Nightingale
119
Was ahead of her time in recognizing the importance of hygiene and cleanliness in the environment
Florence Nightingale
120
Known as the “mother of psychiatric nursing”
Hildegard Peplau
121
Believed that interpersonal relationships and communication can improve mental health
Hildegard Peplau
122
Her theory was focused on therapeutic relationship using communication and collaboration
Hildegard Peplau
123
The founder of transcultural nursing
Madeleine Leininger
124
According to her theory, the nurse must make cultural accommodations for the health benefit of the client
Madeleine Leininger
125
Called nurses to see the whole of the patterns of people’s lives in relationship to their environment and to respond to what is meaningful
Margaret Newman
126
Her theory asserts finding greater meaning in life
Margaret Newman
127
Maintaining an environment free of negative energy is important
Martha Rogers
128
Proposed noninvasive modalities for nursing. Ex. therapeutic touch, humor, music, meditation and guided imagery, and even the use of color
Martha Rogers
129
Her theory states that a patient is not simply the illness or injury being treated, but an entire person
Betty Neuman
130
Her theory wants patients to be cared for from a holistic perspective in order to ensure they are cared for as people and not simply ailments
Betty Neuman
131
Orem’s Self-Care Deficit Nursing Theory explains what nursing care is required when people are not able to care for themselves
Dorothea Orem
132
Goal is to help client attain total self-care
Orem’s Self-Care Deficit Nursing Theory
133
She created the adaptation model theory
Sister Callista Roy
134
This theory where Nurses assist clients with adaptation
Roy’s adaptation model theory
135
Her theory states Caring promotes health and individual/family growth
Jean Watson
136
What theory states that "Caring promotes health and individual/family growth?"
Science of Human Caring
137
Developed the nursing theory known as the “Science of Human Caring”
Jean Watson
138
SDOH
Social Determinants of Health
139
What are the Social Determinants of Health (SDOH)?
1. Economic Stability
2. Education (Access and Quality)
3. Health Care (Access and Quality)
4. Neighborhood and Built Environment
5. Social and Community Context
140
What are the Ethical Principles?
1. Autonomy
2. Nonmaleficence
3. Beneficence
4. Fidelity
5. Veracity
6. Justice
141
Nurses are Ethical Agents
- Knows the difference between right and wrong
- Apply ethical principles in decision making
- Value neutrality
142
What are the factors in Ethical Decision Making?
1. Values
2. Attitudes
3. Beliefs
143
What is the key point in Ethical Decision Making?
Important to clarify the influence of your values each time you enter a situation in which you are called on to be objective in decision making
144
-Right to choose and ability to act on that choice
-Informed consent
Autonomy
145
To do no harm
Nonmaleficence
146
Promote good
Beneficence
147
Keep promises
Fidelity
148
Tell the truth
Veracity
149
Obligation to be fair
Justice
150
Not legally binding; however, often exceed legal obligation
Nursing code of ethics
151
Nursing code of ethics
Formal statement of group’s expectations & standards for professional behavior
152
Processes for Ethical Practice: MORAL
M- Massage the dilemma
O- Outline the options.
R- Resolve the dilemma.
A- Act by applying the chosen option.
L- Look back and evaluate.
153
Nursing practice is guided by what?
legal principles
154
What is the purpose of laws?
1. Protect clients/society
2. Define scope of nursing practice
3. Identify the minimum level of care to be provided
155
- Failure to care
- Professional held liable
Malpractice
156
- Financially or legally responsible for something
- Nurses are legally responsible for their own actions
Liability
157
- Principal or standard for decision making
- Belief about the worth of something
Values
158
Mental dispositions or feelings
Attitudes
159
Accepts as true
Beliefs
160
Board of Nursing
Govern the activities of administrative agencies
(Administrative Law)
161
HIPAA
Health Insurance Portability and Accountability Act
162
- Protects health insurance benefits for workers
- Standards to protect privacy of health information
HIPAA
163
EMTALA
Emergency Medical Treatment and Active Labor Act
164
Requires health care facilities to provide emergency medical treatment, regardless of ability to pay, legal status, or citizenship status
EMTALA
165
- Right for clients to make decisions regarding his/her/their own health care
- Legal written advance directives
Patient Self-Determination Act (PSDA)
166
2 types of Legal written advance directives (PSDA)
1. Living will
2. Durable power of attorney for health care
167
Provides instructions to the medical team about care choices
Living will
168
Names one or more people to make decisions if that person becomes mentally incapacitated
Durable power of attorney for health care
169
Protection against discrimination of individuals with disabilities
Americans with Disabilities Act (ADA)
170
A law that protects people from legal repercussions when they believe another person is injured and decide to help them out.
Good Samaritan laws
171
What are the State Laws Guiding Nursing Practice?
1. Mandatory reporting laws
2. Good Samaritan Law
3. Nurse practice Acts
172
What is included in the Mandatory reporting laws?
1. Abuse
2. Communicable disease/Infection
173
What are the types of Criminal Law?
1. Misdemeanor
2. Felony
174
Misdemeanor
- Minor crime – relative to felony
- Less than a year in jail
- May lose professional license.
Example: assault, battery, and petty theft.
175
Felony
* More than 1 year in jail
* Lose the right to vote, hold public office, serve on a jury, and possess firearms.
* May also lose any professional licenses.
* Examples: murder, assisted suicide, rape/sexual assault, or stealing drugs and equipment.
176
Dispute between individuals or entities
Civil Law
177
- Written or oral agreements between two parties
- Explicit or implicit
Contract Law
178
- Wrongs done to one individual to another not involving contracts
- Involves claims for damages
Tort Law
179
- Defamation of character
- Slander
- Libel
Quasi-intentional torts
180
Three types of Tort Law
1. Quasi-intentional torts
2. Intentional torts
3. Non/unintentional torts
181
- Assault and battery
- False imprisonment
- Invasion of privacy
- Fraud
Intentional torts
182
- Negligence
- Malpractice
Unintentional tort
183
Negligence
- Failure to perform as a reasonable, prudent person would
- Failure to follow standards of practice
- No intent to harm is present
184
Malpractice
--Four elements necessary
a. Existence of a duty
b. Breach of a duty
c. Causation
d. Damages
185
promote comfort, improve self-image, and decrease infection and disease
Activities of daily living (ADLs)
186
What are the ADLs?
1. Personal grooming
2. Bathing
3. Dressing
4. Feeding
5. Toileting
6. Transferring
7. Walking/Ambulating
187
What are the Nursing Roles?
- Assess self-care abilities
- Provide assistance with ADLs
- Promote self-care in ADLs
- Delegate appropriate parts of hygiene care
188
What are the Factors That Influence Hygiene and Self-Care Practices?
* Personal preferences
* Culture and religion/spirituality
* Economic status
* Developmental level
* Knowledge level
189
What are Types of Scheduled Hygiene Care?
1. A.M. care
2. P.M. Care
3. H.S. Care (Hours of Sleep)
190
comfort rounds or safety rounds frequency
Hourly rounds
191
After breakfast: bathing, toileting, oral care, hair, skin, bed making
A.M. Care
192
Afternoon: toileting, handwashing, oral care, readying for visitors
P.M. Care
193
Prior to sleep: relaxation activities, readying environment to facilitate sleep
H.S. Care
194
When you think about prioritizing who should get a bath, think about what?
“what can cause more harm if I don’t bathe this patient first?”
195
Factors That Influence Hygiene and Self-Care Practices (Physical Status)
1. Pain
2. Limited mobility
3. Sensory deficits
4. Cognitive impairments
5. Emotional disturbances
196
What are the 3 purposes of Bathing?
1. Health Promotion
2. Pleasure or relaxation
3. Social interaction
197
What are the Types of Baths?
1. Assist Bath
2. Complete Bath
3. Partial Bath
198
Bathe areas hard to reach
Assist Bath
199
Bathe the client from head to toe, cleanest areas first
Complete Bath
200
Bathe only those areas absolutely necessary, including perineum
Partial bath
201
- Tends to become agitated when told it is time to bathe
- Provide care in short intervals, but don’t rush
Client who has dementia
202
- A thorough skin assessment is essential, but it is difficult
- Lift folds
Client who is obese
203
Nursing Process: Nail Care
- Trim Nails straight across with a nail trimmer
- just file for patients with diabetes or circulatory problems
204
These patients should seek nail care from a podiatrist
patients with Diabetes
205
What happens if oral care is not implemented well?
The bacteria can travel down to the lungs
206
an inflammation of the oral mucosa
Stomatitis
207
inflammation of the tongue
Glossitis
208
Always use electric razors for which patients?
patients taking anticoagulant
209
Eye care for the unconscious client
comatose or critically ill clients need more frequent eye care
- lost the blink (corneal) reflex
210
What to do to prevent cross-contamination if there is drainage or crusting?
a different wipe should be used for each eye
211
are expensive and often essential to the client, so handle and store them properly; never place in water
Hearing aid care
212
a wax
cerumen
213
visible portion of the external ear
auricles
214
Usually the nose requires no special care
(true or false)
True, except for an unconscious client or patient with NG tube
215
NG tube
Nasogastric tube
216
provide special skin care and a lubricant at the point where the tube touches the nares
Caring for a client with NG tube
217
Nursing Process: Nose - need to provide care for which clients?
1. unconscious patients
2. patients with NG tube
218
Each time you enter a client’s room, you should what?
Scan/Assess the environment
219
Each time you leave the room, ask what?
“What else can I do for you?” This ensures that you have not overlooked anything.
220
What should you Instruct unlicensed assistive personnel (UAP) regarding from?
1. Client’s limitations
2. Amount of assistance needed
3. Use of assistive devices
4. Presence and care of tubes
5. Observations to make during hygiene care
221
Including brushing teeth, combing hair, and/or shaving
Personal grooming
222
Wash face and body in the tub or shower
Bathing
223
Put on clothes and manage one’s appearance
Dressing
224
Consuming meals from plate to mouth using proper utensils.
Feeding
225
Going to and from the toilet to clean oneself
Toileting
226
Moving the body from one position to another (not necessarily just walking)
Transferring
227
Move from one place to another using their legs; also called “ambulating.”
Walking
228
A Factor that influence Hygiene and Self-Care Practices: When to bathe, what products to use
Personal preferences
229
A Factor that influence Hygiene and Self-Care Practices: Beliefs about hygiene and cleanliness
Culture and religion/spirituality
230
A Factor that influence Hygiene and Self-Care Practices: Inadequate bathing facilities and
Monetary constraints
Economic status
231
A Factor that influence Hygiene and Self-Care Practices: influenced by:
Parents, media, peers, age
Developmental level
232
A Factor that influence Hygiene and Self-Care Practices: Client teaching is an important part of your hygiene care because most people will, eventually, take care of their own personal hygiene
Knowledge level
233
- Bathing removes perspiration and bacteria from the skin surface, helping to prevent body odor
- The warmth from the bath solution and the friction of bathing dilates the blood vessels near the surface of the skin, increasing the circulation
- Bathing stimulates depth of respirations and provides sensory input
Health promotion
234
bathing can be a time to strengthen the nurse-client relationship
Social interaction
235
Patient cannot tolerate activity; movement is not a good idea.
Decreased Activity Intolerance
236
Teach foot care, especially what?
nail care
237
(True or false): Remove hangnails by carefully removing them with cuticle clipper.
True
238
(True or False): Clean under the nails with an orangewood stick or other blunt instrument.
True
239
bathing dilates the blood vessels near the surface of the skin, increasing what?
circulation
240
- Removal of food particles and secretions
- Improved appetite
- Reduction of the incidence of pneumonia, especially on a ventilator (want to avoid ventilator assisted pneumonia – VAP)
Oral Care Importance
241
VAP or ventilator assisted pneumonia can happen with improper oral care (True or False)
True
242
To prevent cross-contamination if there is drainage or crusting, what should you do?
a different wipe should be used for each eye
243
use dressing self-care deficit or bathing self-care deficit
when the difficulty with hair care lies with self-care ability
244
NG tube is used to supply what?
Nutrition
245
Nursing Process: Environment Assessment
-Temperature(comfortable?)
- Side rails
- Bed position (not high)
- Wheels locked on bed
- Clean linen
- Call light within reach
- Over-bed table clean and clear
- Uncluttered walking spaces
- No foul odors; remove food tray after meal
246
The pain itself, limited mobility caused by the pain, and drowsiness from analgesics used to manage the pain may all contribute to a self-care deficit
Pain
247
(e.g., from joint and muscle problems, casts or traction, injury, weakness, fatigue, surgery, prescribed bedrest, or pain) makes it difficult to perform hygiene activities.
Limited Mobility
248
diminish a person’s ability to perform hygiene measures safely and independently
Sensory Deficit
249
Cannot determine the need for hygiene
Cannot problem-solve ADL processes
Forgets when last performed hygiene and ADLs
Cognitive impairments
250
Profound lack of energy for ADLs
Altered reality does not include hygiene
Emotional disturbances
251
prior to delegating what should you do?
Assess
252
Infants have fragile, easily injured skin
As a child matures, the skin becomes more resistant to injury and infection, but children need adults to provide or supervise the cleanliness of their skin
Developmental level: Factor Affecting the Skin
253
- Health status
- Dampness
- Dehydration
- Nutritional status
- Insufficient circulation
- Skin diseases
- Jaundice
- Lifestyle and personal choices
-Developmental level
Factors affecting the skin
254
- Prepackaged bathing products
- Basin and water
- Shower
- Tub bath
- Therapeutic bath
Other Types of Baths
255
- Oatmeal bath for specific skin conditions
- Warm sitz to cleanse perineal area
Therapeutic bath
256
The reason for agitation for client who has dementia
usually that the client experiences pain, cold, fear, and loss of control
257
significantly reduce aggressive behaviors of a client with dementia by doing what?
giving a towel bath or bag bath instead
258
- Corn
- Calluses
- Tinea pedis/athlete’s foot
- Ingrown toenail
- Foot odor
- Plantar warts
- Pressure injuries
- Bunion
Common Foot Problems
259
assess the appearance and care of the nails
Assessment: Nursing Process for Nail Care
260
Analysis/Nursing Diagnosis for Nail Care
there are no nursing diagnoses specific for nail care
261
outcomes are more appropriate for circulation
Planning Outcomes/Evaluation: Nursing Process for Nail Care
262
What is the Planning Intervention/Implementation for Nail Care?
teach nail care
