Final Flashcards

Question

integumentary

Answer 1

Decreased circulation to tissue and increased pressure on skin can lead to pressure ulcers Assess: skin for breakdown and color changes such as pallor or redness. Assess at least every two hours Observe for urinary or bowel incontinence Pressure ulcer Ischemia *** Make sure pt are clean and dry

Answer 2

Decreased fluid intake, poor perineal care and decreased peristalsis: Urinary stasis Renal calculi Constipation/fecal impaction Assess: elimination status on each shift and total intake and output every 24 hours. Bladder distention adequacy of dietary choices, bowel sounds, and the frequency and consistency of bowel movements. *** watch for kidney stones & impacted bowel

Answer 3

Altered sensory perception and ineffective coping: Depression and anxiety Loneliness and social isolation changes in the sleep/wake cycle Assessment: Focus on the patient’s emotional state, behavior, and sleep-wake cycle. Ineffective coping Support systems *** If immobile probably lacking socialization

Answer 4

Prolonged immobility delays gross motor skills, intellectual development, musculoskeletal development. Usually because of trauma or the need to correct a congenital skeletal abnormality.

Answer 5

Delayed in gaining independence and in accomplishing skills | Social isolation can occur

Answer 6

Physiological systems are at risk | Changes in family and social structures

Answer 7

Decreased physical activity Hormonal changes Bone reabsorption

Answer 8

- Impaired physical mobility - Risk for Disuse Syndrome - Ineffective Airway Clearance - Ineffective Coping - Impaired Urinary Elimination - Risk for impaired Skin integrity - Social Isolation - Risk for Falls

Answer 9

``` Goals and outcomes Setting priorities Teamwork and collaboration Make sure immediate needs are met first, prioritize Individualize plan of care Age appropriate ```

Answer 10

Provide high-protein, high-calorie diet with vitamin B and C supplements. If the patient is unable to eat, nutrition can provided parenterally or enterally

Answer 11

Cough and deep breathe every 1 to 2 hours Adequate fluid intake(2,000 mL per day) Reposition every 1-2 hours Monitor ability to expectorate secretions

Answer 12

``` Increase activity as soon as possible: Change positions as often as possible ROM exercises Orthostatic Blood pressure measurement: Lying to sitting to standing ```

Answer 13

- Sequential Compression Devices (SCD): help promote venous return by squeezing leg - TED Hose(anti-embolitic stockings): promote venous return - Medication * ** do these things before there is a problem

Answer 14

ROM exercises Assistive devices(cane, crutches, walker) Change position in bed at least every 2 hours Shift weight when sitting every 15 minutes Assist with ambulation Physical therapy

Answer 15

``` Positioning and Skin Care: Reposition every 1 to 2 hours Use of therapeutic devices to relieve pressure: Trapeze bar Limit sitting in chair to 1 hour Provide skin and perineal care Good skin assessment skills ```

Answer 16

Provide adequate hydration(2,000 mL/day) Serve a diet rich in fluids, fruits, vegetables, and fiber. Medications such as stool softeners, laxatives or enema

Answer 17

``` Routine and informal socialization Involve in daily care activities Help maintain body image Scheduling therapies Encourage visitors Might have a roommate if in rehab ```

Answer 18

Family involvement Provide mental and physical stimulation Play therapist in children's hospitals Teach families activities

Answer 19

Patient outcomes: Evaluate effectiveness of specific interventions Evaluate patient’s and family’s understanding of all teaching provided

Answer 20

The process of sending and receiving messages both verbal and nonverbal Allows for exchange of information, feelings, needs and preferences Goal is to have a mutual understanding of the meaning of the message and receive feedback that indicates the meaning of the message was communicated as intended Communication can result in harm or good Metacommunication: Term that refers to all factors that influence communication

Answer 21

Assessment and communication technique that allows nurses to better understand and perceive the emotions of themselves and others Enables the nurse to use self awareness, motivation, empathy, and social skills to build therapeutic relationships with patients.

Answer 22

Electronic communication is a constantly growing form of communication. Most people use the form of communication numerous times a day thru email, texting, cell phones, etc Nurses need to be able to utilize technology to create ongoing relationships with patients and their health care team(example-nurses using iphones for patient communication, patients being able to view their medical information online) Secure messaging provides an opportunity for frequent and timely communication with a patient’s physician or nurse via a patient portal

Answer 23

Intrapersonal communication-occurs within the individual, inner thought, used to develop self awareness Interpersonal communication-one on one interaction that occurs face to face, used most frequently and is at the heart of nursing practice, meaningful exchange results in an exchange of ideas, problem solving, expression of feelings, decision making, goal accomplishment, team building and personal growth Transpersonal communication-used when addressing spiritual needs, nurses need to assess a patient’s spiritual needs and intervene to meet those needs Small group communication-usually goal directed, working in committees, most effective when they are cohesive Public communication-interaction with an audience

Answer 24

The referent motivates one person to communicate with another. In a health care setting sights, sounds, sensations, perceptions, and ideas are examples of cues that initiate the communication process. The sender is the person who encodes and delivers a message, and the receiver is the person who receives and decodes the message. The more the sender and receiver have in common and the closer the relationship, the more likely they will accurately perceive one another’s meaning and respond accordingly. The message is the content of the communication. It contains verbal and nonverbal expressions of thoughts and feelings. Effective messages are clear, direct, and in understandable language. Communication channels are means of sending and receiving messages through visual, auditory, and tactile senses. Facial expressions send visual messages; spoken words travel through auditory channels. Touch uses tactile channels. Individuals usually understand a message more clearly when the sender uses more channels to send it. Feedback is the message a receiver receives from the sender. It indicates whether the receiver understood the meaning of the sender’s message. Interpersonal variables are factors within both the sender and receiver that influence communication. Perception provides a uniquely personal view of reality formed by an individual’s culture, expectations, and experiences. Each person senses, interprets, and understands events differently. The environment is the setting for sender-receiver interaction. An effective communication setting provides participants with physical and emotional comfort and safety.

Answer 25

Verbal communication-includes use of spoken and written words, can be altered by vocabulary-use of medical terminology, understanding the meaning of the word used(can have more than one meaning), the pace of the conversation, the tone of the message, clarity and timing of the message delivered(if a patient is in pain or emotionally distressed they may not be able to process what is being communicated to them) Vocabulary, timing and relevance is very important for nurses(this takes time and practice to be an effective communicator) Nonverbal-includes the five senses and nonverbal messages can be easily misinterpreted(what does personal appearance say about the nurse or the patient)? Examples-What does showing up in wrinkled clothes say to you patient? What does poor posture and slow slumped gait suggest? Facial expression-face is the most expressive part of the body, people are sometimes unaware of the their facial expressions Nurses need to make sure they are using appropriate eye contact, use of gestures, sounds(such as sighing) and personal space can all impact how the message is received

Answer 26

Nurse-patient-helping relationships are the foundation of clinical nursing practice. Nurse assumes role of the helper and recognizes the patient as an individual with unique health needs, human responses and patterns of living. Therapeutic relationships promote a climate that facilitates positive change and growth Nurse-family-form relationship with the entire family Nurse-healthcare team-communication with the team can affect patient care/safety and the work environment and how to interact with coworkers, accurate communication is essential to preventing errors Nurse-community-communication providing education on health promotion to the community

Answer 27

Preinteraction phase-reviewing patient data including history, previous notes, previous assessments and any other pertinent data Orientation phase-the phase when the patient and nurse get to know each other, initial relationship is superficial, expect the patient to test your competence and commitment Working phase-nurse and patient work together to solve problems, nurses need to encourage expression of feelings and use therapeutic communication Termination phase-ending of the relationship, evaluate goal achievement with the patient, and the nurse relinquishing responsibility of care

Answer 28

Each individual bases his or her perceptions about information received through the five senses of sight, hearing, taste, touch, and smell. An individual’s culture and education also influence perception. People often incorrectly assume that they understand an individual’s culture. They tend to distort or ignore information that goes against their expectations, preconceptions, or stereotypes. Critical thinking helps nurses overcome perceptual biases or stereotypes that interfere with accurately perceiving and interpreting messages from others. By thinking critically about personal communication habits, you learn to control these tendencies and become more effective in interpersonal relationships. You learn to integrate communication skills throughout the nursing process as you collaborate with patients and health care team members to achieve goals.

Answer 29

Professional appearance for a nurse is the expectation to be clean, neat, well groomed, conservatively dressed, and odor free. Professional behavior reflects warmth, friendliness, confidence, and competence. Professionals speak in a clear, well-modulated voice; use good grammar; listen to others; help and support colleagues; and communicate effectively. Professional appearance, demeanor and behavior communicate that you have assumed the professional helping role, are clinically skilled, and are focused on your patient Common courtesy is part of professional communication. To practice courtesy, say hello and goodbye to patients and knock on doors before entering. Always introduce yourself. Failure to give your name and status or to acknowledge a patient creates uncertainty about the interaction and conveys an impersonal lack of commitment or caring. To foster trust, communicate warmth and demonstrate consistency, reliability, honesty, competence, and respect. Autonomy is being self-directed and independent in accomplishing goals and advocating for others. Professional nurses make choices and accept responsibility for the outcomes of their actions. Assertiveness allows you to express feelings and ideas without judging or hurting others. Assertive behavior includes intermittent eye contact; nonverbal communication that reflects interest, honesty, and active listening; spontaneous verbal responses with a confident voice; and culturally sensitive use of touch and space.

Answer 30

Nurses who develop critical thinking skills make the best communicators Integrate knowledge, analyze content and evaluate effect Using critical thinking helps nurse to make decisions about what, when, where, and how to best convey a message Patients are more likely to communicate with a nurse who expresses an interest in them

Answer 31

Psychophsiological context-internal factors that influence communication such as pain, hunger, emotional status, developmental level, unmet needs, perceptions and personalities, self-esteem Relational context- is the nature of the relationship. It is the level of trust and caring expressed, balance of power and control between the nurse and the patient Situational context-is the reason for communication-Is the nurse/patient using it for information exchange, problem resolution, expression of feelings Enviromental context-is the physical surroundings- What is the privacy level, noise level, comfort and safety level, or distraction level Cultural context-what is the education level of participants, language, customs and expectations

Answer 32

pts that are silent, withdrawn or have difficulty expressing feelings pts that are sad or depressed pts with special needs pts that are angry or confrontational pts that are uncooperative pts that are talkative and want someone to be with them all the time pts that are demanding and expect others to meet their requests pts that have difficulty seeing and hearing pts who are confused and disoriented pts with English as a second language pts who are sexually inappropriate pts that are frightened, anxious, and having difficulty coping

Answer 33

Assertiveness allow you to express feelings and ideas without judging or hurting others Increases self esteem and self-confidence, increases the ability to develop satisfying interpersonal relationships and increases goal attainment Make decisions and control their lives effectively Deal with criticism and manipulation, learn to say no, set limits and resist intentionally imposed guilt Responses include “I” messages “I” want, need, think, feel

Answer 34

During the assessment process, thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care. Patient-centered care requires careful assessment of a patient’s values; preferences; and cultural, ethnic, and social backgrounds. If the nurse cannot resolve his or her bias related to a patient, care should be transferred to another individual. Internal and external factors can also affect a patient’s ability to communicate. It is especially important to assess the psychophysiological factors that influence communication. Many altered health states and human responses limit communication. Review of a patient’s medical record provides relevant information about his or her ability to communicate. Aspects of a patient’s growth and development also influence nurse-patient interaction. Adapt communication techniques to the special needs of infants and children and their parents. Age alone does not determine an adult’s capacity for communication. Hearing loss and visual impairments are changes that may occur during aging that contribute to communication barriers. Simple measures facilitate communication with older individuals who have hearing loss. [Review Box 24-7, Focus on Older Adults” Tips for Improved Communication with Older Adults Who Have Hearing Loss] Culture influences thinking, feeling, behaving, and communicating. Be aware of the typical patterns of interaction that characterize various ethnic groups, but do not allow this information to bias your response. [Review Box 24-8, Cultural Aspects of Care: Communication with Non-English-Speaking Patients.] Gender influences how we think, act, feel, and communicate. Men tend to use less verbal communication but are more likely to initiate communication and address issues more directly. They are also more likely to talk about issues. Women tend to disclose more personal information and use more active listening, answering with responses that encourage the other person to continue the conversation.

Answer 35

Intrapersonal analysis of assessment findings Validation of health care needs and priorities during discussion with the patient Focus on the cause of the communication problem Remember that impairment of communication can be physiological, mechanical, anatomical, psychological, cultural, or developmental. The primary nursing diagnostic label used to describe a patient with limited or no ability to communicate verbally is impaired verbal communication. This is the state in which an individual experiences a decreased, delayed, or absent ability to receive, process, transmit, and use symbols for a variety of reasons. The defining characteristics for this diagnosis include the inability to articulate words, inappropriate verbalization, difficulty forming words, and difficulty comprehending, which you cluster together to form the diagnosis. Although a patient’s primary problem is impaired verbal communication, the associated difficulty in self-expression or altered communication patterns may contribute to other nursing diagnoses: Impaired verbal communication Anxiety impaired Social isolation ineffective coping compromised family coping powerlessness

Answer 36

Health care team planning sessions Collaboration with patient and family to determine implementation methods Written documentation of expected outcomes Patient will be able to clearly convey messages with healthcare team- speech therapist or an interpreter.

Answer 37

Delegation and verbal discussion with healthcare team members Verbal, visual, and tactile teaching activities Therapeutic communication techniques are specific responses that encourage the expression of feelings and ideas and convey acceptance and respect. Active listening means being attentive to what a patient is saying both verbally and nonverbally. Use “SOLER”: Sit facing the patient; observe an open posture, lean toward the patient, establish and maintain intermittent eye contact; relax

Answer 38

Promote personal growth and attainment of health-related goals Occurs within a healing relationship between a nurse and a patient Therapeutic interactions are often intense, difficult and uncomfortable Comfort is key to creating a therapeutic environment Assess verbal and nonverbal client communication needs Respect the client’s personal values and beliefs Allow time to communicate with the client Use therapeutic communication techniques to provide client support Encourage the client to verbalize feelings (e.g., fear, discomfort) Evaluate the effectiveness of communications with the client

Answer 39

``` Active listening Sharing Observations Sharing Empathy Sharing Hope Sharing Humor Sharing Feelings Using touch Self-Disclosure Using silence Providing information Clarifying Focusing Paraphrasing Asking Questions Summarizing Validation Confrontation ```

Answer 40

Personal questions-not related to the situation and are to satisfy personal curiosity Personal opinion differs from giving professional advice Changing subject-shows lack of empathy and can stall further communication Automatic responses-stereotyping, being only task oriented False reassurance-”don’t worry everything will be alright” Sympathy-concern or pity, not use of empathy Defensive-implies the other person has no right to their opinion Aggressive-provoke confrontation at the other’s expense Arguing-challenging or arguing can often imply that the other person is lying

Answer 41

Patients who cannot speak clearly Cognitive impairment Hearing impairment Visual impairment Unresponsive Patients who do not speak English (or your language) Patients with impaired verbal communication require special consideration and alterations in communication techniques to facilitate sending, receiving, and interpreting messages.

Answer 42

Show respect to all members, build trust by being honest, genuine and authentic in your relationships, never make promises you can’t keep Never breach privacy Active listening is maintaining eye contact, direct attention Be aware of your verbal and nonverbal communication Show empathy Provide conflict management by using creativity, clarification of feelings, safety Use of humor solicit information offer solutions support child and family educate

Answer 43

CUS protocol C=“ I am concerned about……..” U= “I am uncomfortable with…….” S= “I think we have a safety issue that needs to be addressed…….”

Answer 44

SBAR-Standardized way of communicating for a specific situation Can be used by nurses, doctors, ancillary staff, all health care team members The Situation, Background, Assessment and Recommendation (SBAR) technique has become the Joint Commission's stated industry best practice for standardized communication in healthcare S=Situation B=Background A=Assessment R=Recommendation

Answer 45

You and your patient determine the success of the plan of care by evaluating patient communication outcomes together. You determine which strategies or interventions were effective and which patient changes (behaviors or perceptions) resulted because of the interventions. Evaluation of the communication process helps nurses gain confidence and competence in interpersonal skills. Becoming an effective communicator greatly increases your professional satisfaction and success. There is no skill more basic, no tool more powerful.

Answer 46

Only discuss information with those that need to know HIPAA-legislation to protect patient privacy for health information, governs all areas of patient information and management of that information This includes not reading other charts for which you are not providing care and never using information for personal use-includes looking up your own or family and friends personal information Only members of the health care team who are directly involved in a patient’s care have legitimate access to the medical record. Patients have the right to request copies of their medical records and read the information. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was the first federal legislation providing protection for patient records; it governs all areas of patient information and management of that information. Requires that disclosure or requests regarding health information be limited to the specific information required for a particular purpose. Sometimes nurses use health care records for data gathering, research, or continuing education. As long as a nurse uses a record as specified and permission is granted, this is permitted. You can review your patients’ medical records only for information needed to provide safe and effective patient care. Not only is it unethical to view medical records of other patients, but breaches of confidentiality lead to disciplinary action by employers and dismissal from work or nursing school(It is ok to view records as long as it is being used for educational purposes)

Answer 47

``` pt info and demographic data informed consent for treatment and procedures admission data nursing diagnosis and plan of care record of nursing care treatment and evaluation medical history medical diagnosis therapeutic orders medical and discipline progress notes physical assessment findings diagnostic study results patient education summary of operative procedures discharge plan and summary ```

Answer 48

``` Communication Legal documentation Financial billing Education Research Auditing-Monitoring: used a part of quality improvement programs used for ongoing reviews of patient care, used to determine if standards are being met and can be used to make changes in policy and practice ```

Answer 49

1. Factual-use of descriptive, objective information, avoid terms like appears, seems or apparently(like stating an opinion instead of facts) Use of subjective data should include exactly what the patient says 2. Accurate-use of exact measurements gives clearer picture than non descriptive statements, makes documentation clear and easy to understand, use of approved medical terminology and spelling 3. Complete-must be complete containing all essential information 4. Current-delays in documentation can lead to unsafe patient care 5. Organized-communicate information in a logical order, be clear, concise and to the point

Answer 50

Destroy (e.g., shred) anything that is printed when the information is no longer needed. You need to de-identify all patient data when you write it onto forms or include it in papers written for nursing courses. Historically, the primary sources for inadvertent, unauthorized disclosure of PHI occurred when information was printed from a patient record and/or faxed to other health care providers. Destroy all printed material after faxing. The following are some steps to take to enhance fax security: Confirm that fax numbers are correct before sending to be sure that you direct information properly. Use a cover sheet to eliminate the need for the recipient to read the information to determine who gets it. Authenticate at both ends before data transmission to verify that source and destination are correct. Use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. Use the encryption feature on the fax machine. Encoding transmissions makes it impossible to read confidential information without the encryption key. Place fax machines in a secure area and limit machine access to designated individuals. Log fax transmissions. This feature is often available electronically on the machine.

Answer 51

Nothing documented = nothing done Poorly documented = poorly done Incorrectly documented = fraudulent

Answer 52

time and date: all entries chart: as you make observations and provide care describe: patients behavior; use direct pt quotes when appropriate record: exactly what happens to the pt and interventions given; be factual and complete

Answer 53

Don’t begin charting until you verify the name and identifying number on the patient’s medical record Don’t chart procedures or interventions in advance. Don’t clutter notes with repetitive or frequently changing data already charted in other places. Don’t make an entry for someone else, or change an entry because someone tells you to. Don’t show bias toward patients. Don’t try to cover up a mistake or incident by inaccuracy or omission. Don’t use meaningless words and phrases such as “good day” or “no complaints”.

Answer 54

Several documentation systems for recording patient data- either paper or electronic health record(EHR) Narrative-use of a story like format to document information specific to patient conditions and nursing care-can be time consuming Problem oriented medical record-method of documentation that emphasizes patients problems, data is organized by problem or diagnosis Source records -separate section for each discipline to record data(dr, nurse, cm, etc), doesn’t show how care is related or coordinated to meet the patients needs Charting by exception- focuses on documenting from established norms, reduces documentation time, all standards are met unless otherwise documented Case management plan/critical pathways-interdisciplinary approach to documenting patient care, critical pathways are interdisciplinary approach to care plans that include patient problems, key interventions, and expected outcomes Kardex-contains most basic information at hand for the nurse without having to constantly refer and search through chart Flow sheet -allow information to be entered quickly and easily, can be paper or computerized-ex restraint log Care plan -preprinted established guidelines used to care for patients with similar health problems Discharge -safe, timely discharge with desired outcomes, begins at admission with identifying needs and plans