NUR1020C MODS 1&2
Objectives: Session 1.1
 Articulate the
criteria of a profession as applied to nursing.
· Altruism – public service over personal gain
· Accountability – accepting responsibility for actions and omissions
· Autonomy – Make independent decisions within their scope of practice and are responsible
for the results and consequences of those decisions
·
·
·
Advocate
Assertiveness
Ethics – standard of right and wrong behavior
 Discuss
standards of practice and nurse practice acts.
The Standards of Nursing Practice published by the ANA help to ensure quality care and serve as
legal criteria for adequate patient care. ANA standards have two parts. The first part, the
standards of practice, includes six responsibilities for the nursing process: assessment, diagnosis,
outcomes identification, planning, implementation, and evaluation (ANA, 2010).
The second part of Standards of Nursing Practice focuses on professional performance, which
includes ethics, education, evidence-based practice and research, quality of practice,
communication, leadership, collaboration, professional practice evaluation, resource utilization,
and environmental health (ANA, 2010). Nurses who attend continuing education conferences or
further their education; use evidence to guide their nursing practice; or communicate and
collaborate with patients and other professionals are practicing within the standards.
 Discuss
the nurse’s responsibility in making clinical decisions.
assessment, diagnosis, outcomes identification, planning, implementation, and evaluation
 Define and
describe the concept of Health Care Quality.
Health care quality applies within the realm of health care delivery in any public or private
setting. Whatever structures, systems, and processes an organization establishes, it must be
able to show evidence that standards are upheld.
 Identify the context of health care quality in nursing and healthcare practice.
 Define and describe the concept of communication.
 Apply effective communication skills in the context of nursing practice.
Objectives: Session 1.2

Define and describe the concepts of and thermoregulation.
Optimal physiological function of the human body occurs when a near-constant core temperature
is maintained. Normal body temperature ranges from 36.2° to 37.6°C (97.0°–100°F), or an average
of 37°C (98.6°F). Fluctuation outside this range is an indication of a disease process, strenuous or
unusual activity, or extreme environmental exposure. Thermoregulation is defined as the process
of maintaining core body temperature at a near constant value. The term normothermia refers to
the state in which body temperature is within the “normal” range. The term hypothermia refers to
a body temperature below normal range (<36.2°C), and hyperthermia refers to a body temperature
above normal range (>37.6°C). An extremely high body temperature is referred to as hyperpyrexia.
1
1


Notice risk factors that place individuals at risk for thermoregulation problems across the
lifespan.
Define and describe the concept of Functional Ability.
Functional ability refers to the individual's ability to perform the normal daily activities required
to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain
health and well-being. Specifically, it reflects the adaptive dimension of development, which is
concerned with the acquisition of a range of skills that enable independence in the home and in the
community. For the purposes of this concept analysis, functional ability is defined as the cognitive,
social, physical, and emotional ability to carry on the normal activities of life. Functional ability
may differ from functional performance, which refers to the actual daily activities carried out by
an individual. Functional impairment and disability refers to varying degrees of an individual's
inability to perform the tasks required to complete normal life activities without assistance.
4
5





Notice situations that increase the risk for functional impairment.
Recognize when functional impairment exists.
Provide appropriate interventions to optimize functional ability and minimize
complications.
Define and describe the concept of Health Care Quality.
Identify the context of health care quality in nursing and healthcare practice.
Lab Objectives: 1.0




Describe the purpose and components of a health assessment interview.
Describe the purpose and methods of obtaining the vital signs of temperature, pulse,
respiration, and blood pressure.
Demonstrate and document accurate assessments of temperature, pulses, respirations, and
blood pressures
Demonstrate the correct methods and sequence of inspection, palpation, percussion, and
auscultation for all body systems.
Objectives Session 2.1

Define and describe the concept of Gas Exchange.
The process by which oxygen is transported to cells and carbon dioxide is transported from cells.

Notice risk factors for impaired gas exchange.
Chronic Disorder, Congenital Disorder, Lifestyle, Respiratory Defects (COPD, Asthma), Trauma

Recognize when an individual has compromised gas exchange.
Capillary refills >3 seconds, respiration elevated, tachycardia, blood pressure drops
(hypotension), confusion, labored breathing, skin discoloration (cyanosis)

Provide appropriate nursing and collaborative interventions for optimizing gas exchange.
Lifestyle education, medications, turning positions, surgery, appropriate clothing, oxygen
therapy, patient teaching, nutrition/hydration

Define and describe the concept of perfusion.
Circulation of oxygenated blood to the organs and surrounding tissues in the body and the
removal of carbon dioxide and other gases

Notice risk factors for impaired perfusion.
Obesity, Diabetes, Cardiac defects, Trauma, Genetic conditions, Congenital defects, Infection &
Inflammation

Recognize when an individual has compromised perfusion.
Respiratory acidosis, Metabolic acidosis, Increased Respiratory/Heart rate

Provide appropriate nursing and collaborative interventions to optimize perfusion.
Smoking cessation, Pharmacotherapy, Oxygen therapy, Airway Management and Breathing
Support, Chest Physiotherapy and Postural Drainage, Invasive procedures, Nutrition therapy,
Positioning

Describe techniques used during physical assessment.
Pulse Ox, Vital signs, skin discoloration, capillary refill, mental status
Vital Sign Ranges Across the Life Span
AGE GROUP TEMPERATURE
PULSE
(bpm)
RESPIRATIONS
(bpm)
SpO2
BLOOD PRESSURE (mm
Hg)
SYSTOLIC
DIASTOLIC
Newborn
35.5°-37.5° C (96°-99.5° F)
80-160
30-80
>95%
60-90
20-60
1 yr old
37.4°-37.6° C (99.4°99.7° F)
80-140
24-40
>95%
74-100
50-70
6 yr old
36.6°-37° C (98°-98.6° F)
75-110
15-25
>95%
84-120
54-80
15 yr old
36.1°-37.2° C (97°-99° F)
50-90
15-20
>95%
94-120
62-80
Adult
35.5°-37.5° C (95.9°99.5° F)
60-100
12-20
>95%
90-120
60-80
Older adult
35°-37.2° C (95°-99° F)
60-100
15-20
>95%
90-120
60-80
Objectives: Session 2.2

Define and describe the concept of sensory/perception.
Sensory perception can then be defined as the ability to receive sensory input and, through
various physiological processes in the body, translate the stimulus or data into meaningful
information. To describe the concept of sensory perception, it is important first to define
both sensation and perception. Sensation is the ability to perceive stimulation through
one's sensory organs such as the nose, ears, and eyes. This stimulation can be internal,
from within the body, or external, from outside the body, and includes feelings of pain,
temperature, and light. External stimuli are commonly received and processed through
the five senses: vision, hearing, taste, smell, and touch. Perception is defined as the
process by which we receive, organize, and interpret sensation.

Notice risk factors for sensory/perception.
Trauma, All individuals, regardless of age, gender, ethnicity, or socioeconomic status, are at risk
for disturbances in sensation and perception. The population at the highest risk is the elderly
population as a result of changes in sensory perceptual functioning associated with the aging
process.Significant individual risk factors include genetic predisposition, adverse effects of
medications, chronic medical conditions, lifestyle choices, and occupation.

Recognize when an individual has impaired sensory perception.
A comprehensive health assessment is essential to determining current health
status, identifying present health risks, predicting future health risks, and identifying
appropriate health-promoting activities. An assessment includes conducting a history and
examination as well as diagnostic testing when sensory perceptual conditions are suspected.

Provide appropriate nursing and collaborative interventions to sensory perception.
Appropriate nursing skills for sensory perception are required as follows:
• Assessment
• General assessment
• Assessment of senses
• Irrigation of eye and ear
• Medication administration
• Oral hygiene demonstration/teaching
• Prevention strategies for occupational and recreational exposure to hazards
• Eye protection
• Hearing protection
• Other proper protective equipment
• Foreign body removal
• Age-appropriate teaching strategies for safety in the home (e.g., childproof cupboard locks and
hot water heater setting)
• Assistive devices
• Hearing aide
• Eyewear
• Cane/walker/wheelchair
• Prosthetics (e.g., eye and lower limb)
Collaborative interventions for all categorical areas such as vision, hearing, smell and taste, and
touch may incorporate surgical intervention, pharmacotherapy, and adaptive methods in order to
assist the patient.
Lab Objectives: 2.0

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
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
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
Describe and perform assessment of the head and neck including applicable cranial
nerves.
Describe assessment techniques used to assess chest and lungs and describe possible
findings.
Explain normal findings of lungs and give variations in infants, children adults, and aging
adults.
Demonstrate auscultation of the lungs including the posterior, lateral, and anterior areas.
Perform auscultation of the normal heart sounds of S1 and S2.
Describe capillary refill and its relationship to peripheral circulation.
Describe location of arterial pulses in distal extremities of popliteal, posterior tibial and
dorsal pedis, brachial, and radial in infants, children, adults, and aging adults.
Define edema and the four-point grading of edema.
Edema
Module 3 Review Guide
Giddens
Concept 45 Communication
Describe ISBARR (identify self, situation, background, assessment, recommendations, and read
back) as it relates to consistent and accurate communication between professionals.
ISBARR is a system that allows each step to be taken as a structured routine for passing
information between healthcare team members thus ensuring consistency & accuracy. The
approach provides the health care provider with the necessary information to make decisions
about proposed interventions (Nurse consistently identifies him/herself, describes the patient
situation, explains background information relevant to the situation, provides an assessment,
provides recommendations for action & reads back orders)
Concept 48 Technology
Define and describe the concept of Technology and Informatics
Technology describes the knowledge and use of tools, machines, materials, and processes to help
solve human problems. It can be applied to a specific discipline such as education technologies,
medical technologies, or health technologies.
Informatics, like technology, also is a broad term and is derived from the French word
informatique—it is the science that encompasses information science and computer science to
study the process, management, and retrieval of information.
Identify ways that technology and Informatics impact health care.
Over time, health care providers have used technology to gather, process, and manage data and
information about patients in order to provide the best possible care. Technology and
informatics have impacted health care by providing safe, effective, efficient, and quality care.
Define the following terms:
. Computer science
A branch of engineering that studies computation and computer technology, hardware, and
software as well as the theoretical foundations of information and computation techniques.
. Health informatics
A discipline in which health data are stored, analyzed, and disseminated through the application of
information and communication technology.
·
Health information technology
The application of information processing involving both computer hardware and computer
software that deals with the storage, retrieval, sharing, and use of health care data, information,
and knowledge for communication and decision making.
·
Nursing informatics
The science and practice (that) integrates nursing, its information and knowledge, with
information and communication technologies to promote the health of people, families, and
communities worldwide.
Explain the Health Insurance Portability and Accountability Act (HIPAA)
The privacy and security rules issued under (HIPAA) of 1996 along with multiple state laws
create a complex network of laws and regulations that address patient privacy and consent for the
use of identifiable personal health information. In 2013, HIPAA rules were modified to reflect
new technologies and to enhance personalization and the quality of health care. Building and
maintaining the public's trust in health IT requires comprehensive privacy and security
protections that establish clear rules on how patient data can be accessed, used, and disclosed.
Concept 51 Care Coordination
Define and describe the concept of Care Coordination
One definition of coordinated care doesn't yet exist. There are more than 40 definitions.
The American Academy of Pediatrics was the first organization to try and establish a definition.
The definitions differ depending on the focus of care. The general understanding of this is
doctors, nurses, patients, family, and other health care providers working together to establish
goals of optimal health care and optimal patient outcomes.
Identify how care coordination is applied in the context of nursing and health care practice
Describe the target of Care Coordination efforts
There are currently two tiers to coordinated care. First, is the elderly and frail. This would
include children with special health care needs, frail elderly , those in crisis situations or
catastrophic events, and people at end of life care before other high risk populations. The
second tiers people with complex medical or mental health care needs, disabilities, low income
and unstable health insurance coverage.
Concept 52 Caregiving
Define and describe the concept of Caregiving


Caregiving is providing unpaid support and assistance to family members or
acquaintances who have physical, psychological, or developmental needs.
The scope of caregiving ranges from a temporary/limited caregiving role for an
individual with an acute illness or condition to a long-term or permanent caregiving role.
What are caregiver experiences related to the following?
· Caregivers' Perception and Coping


·
Perception is the mental process of viewing and interpreting a person's environment
Coping is how an individual handles and processes a situation; typically stressful. Can
have positive or negative coping skills.
Uncertainties and Inadequate Understanding

Often face uncertainties about the present and future along with an inadequate
understanding of the disease.

Caregivers who do not understand a given diagnosis often can refuse to accept that
certain symptoms are the result of a disease process. This can result in caregivers feeling
guilty.
·
Caregivers' Financial and Social Distress
 Often experience negative financial consequences
 Have to leave work early, come in late, cut back on working
 Grandparents find their retirement funds dwindle rapidly to cover the unexpected costs of
raising their children's children.
·
Changing Family Roles, Relationships, and Dynamics
 Majority of stress falls on head of family, roles change, puts new stress on rest of family
that may not have had those responsibilities previously
 Lack of help from other family members, caregiver receives a lot of criticism but no help;
children “stay busy” due to being upset about a parent being ill
 Lack of communication
 Must work towards family homeostasis to maintain healthy environment
·
Influence of Culture on the Caregiving Experience
 Culture plays a big part in how caregiver perceives role and cares for loved one
 Familism -This value refers to the central role of family in an individual's life and the
individual's reliance on family as a priority. The Hispanic/Latino caregiver relies more heavily
on unofficial sources of support, which include children, family members, and spouses.
Outcomes of Caregiving
 A comprehensive review of quantitative studies reported post-traumatic growth of bereaved
caregivers and a sense of existential meaning associated with the caregiver role, including a
sense of pride, esteem, mastery, and accomplishment.
 Concentrating on the positive aspects can “reframe” their role and help it seem more
manageable and meaningful. It strengthens the bonds between caregiver and care recipient
and elicits feelings of fulfillment at a personal level and satisfaction derived from the act of
assisting others.
 An understanding of the antecedents, attributes, and consequences of family caregiving are
helpful when conducting a family caregiver assessment.
 An understanding of the antecedents, attributes, and consequences of family caregiving are
helpful when conducting a family caregiver assessment.
Identify appropriate interventions to support caregiver for positive outcomes.
 The Alzheimer's Association has developed 10 signs of caregiver stress (Table 52-1).
 Caregivers have been referred to as “hidden patients” because a common characteristic of
caregivers is primarily having concern for their family member and often ignoring their own
needs or being ignored by health care professionals.
 Signs of caregiver stress: denial, anger, social withdrawal, anxiety, depression, exhaustion,
irritability, sleeplessness, lack of concentration, health problems
 Nurses should encourage caregivers to seek and accept the support of family, friends, and
community resources when needed.
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

Nurses can and should act as facilitators who can access and provide information about
local, regional, and national sources of help and resources for caregivers and care receivers.
help them to understand and cope with the stressors of caregiving.
Help care for the caregiver by offering support: mentally, emotionally, socially, cognitively,
spiritually.
Yoost
Chapter 3 Communication
Explain concerns and precautions related to electronic communication.
Special care must be taken to maintain confidentiality while communicating electronically.
Electronic communication in the form of information referencing, e-mail, social networking, and
blogging can quickly contribute to a person's knowledge, providing patients and health care
professionals with vital information. However, the potential for miscommunication exists, in part
because nonverbal cues are not apparent. When communicating verbally by electronic media,
patients and nurses must take time to validate and verify shared information because
misunderstandings can occur if feedback is inadequate
Identify techniques used to enhance therapeutic communication when talking with patients.
Techniques such as active listening, open posture, and reflection used by nurses encourage
patients to explore personal concerns.
The use of therapeutic communication techniques enhances nurse–patient relationships and
helps to achieve positive outcomes. Consistent use demonstrates empathy and concern for
patients. Various techniques greatly assist the nurse in gathering, verifying, and validating
assessment data.
Describe the essential components of the nurse patient relationship for:
· Respect: Respect for patients and their families is conveyed by nurses verbally and
nonverbally. Asking a patient's name preference during initial contact demonstrates respect and
establishes the foundation for a trusting nurse–patient relationship. Ensuring privacy, providing
necessary health care information, and fostering autonomy in decision making are nursing
actions that further strengthen the relationship. Controlling facial expressions and body
language during challenging interactions with patients and health care team members is
essential to consistently demonstrate respect.
· Assertiveness: Assertive nurses communicate with patients, families, and other members
of the health care team regularly and without hesitation. Assertive communication by nurses
demonstrates confidence and elicits respect from patients and colleagues.
· Collaboration: Collaboration with other health care professionals is a key factor in
communicating necessary health care information and providing comprehensive patient care.
Most patients require the collaboration of many different healthcare professionals during
hospitalization or outpatient treatment, and the nurse is often the coordinator of this team.
· Delegation: Delegation is a multifaceted responsibility of the registered nurse. When
communicating during delegation, nurses must show collegiality and respect for all members of
the health care team. It is important to call other health care team members by their preferred
names. Accuracy while communicating helps ensure positive patient outcomes. Receiving
feedback from the person to whom care is delegated is required by law and provides an
opportunity for clarity, which ensures greater accuracy.
Communicating therapeutically with colleagues during the delegation process shows respect
and recognizes the many stressors with which all members of the health care team cope while
providing patient care.
· Advocacy: Patient advocacy is a hallmark of professional nursing. Advocacy involves
defending the rights of others, especially those who are vulnerable or unable to make decisions
independently. To be an effective advocate for patients, the nurse must be knowledgeable,
organized, and able to communicate in a caring manner. Nurses who communicate
therapeutically and assertively are better able to advocate for their patients.
Chapter 5 Introduction to Nursing Process
Define the nursing process.
is the foundation of professional nursing practice. It is the framework within which nurses
provide care to patients in an organized and effective manner. Paul (1988) describes critical thinking as a
complex process during which individuals think about their thinking to provide clarity and increase
precision and relevance in a specific situation while attempting to be fair and consistent. Critical thinking
using the nursing process allows nurses to collect essential patient data, articulate the specific needs of
individual patients, and effectively communicate those needs, realistic goals, and customized
interventions with members of the health care team. Chapter 4 provides additional information on its
importance in nursing.
The term nursing process was first used by Lydia Hall in 1955 (de la Cuesta, 1983). In the late
1950s and early 1960s, other nurses (Johnson, 1959; Orlando, 1961; Wiedenbach, 1963) began using the
term to define the steps used for decision making while initiating and providing patient care. In 1973, the
American Nurses Association (ANA) identified five specific steps of the nursing process in its Standards
of Clinical Practice (1991). These five steps—assessment, diagnosis, planning, implementation, and
evaluation—define how professional nursing practice is conducted. Outcome identification was added as
an essential aspect of the nursing process by the ANA in 1991. Most nursing professionals and educators
recognize outcome identification as part of the planning step of the traditional five-step nursing process.
Describe each step of the nursing process (ADPIE)
· Assessment
is the organized and ongoing appraisal of a patient's well-being. Assessment involves
collecting data from a variety of sources that is needed to care for patients. Data collection
begins at the first direct or indirect encounter with a patient. Specific data are collected during
the patient interview, health history, and physical assessment. Nurses assess the state of a
patient's physical, psychological, emotional, environmental, cultural, and spiritual health to gain
a better understanding of his or her overall condition. This is known as a holistic approach to
patient care.
· Diagnosis
identifies an actual or potential problem or response to a problem (NANDA-I, 2012).
Accurate identification of nursing diagnoses for patients results from carefully analyzing,
validating, and clustering related patient subjective (symptoms) and objective (signs) data. If
data collection includes inaccurate or inadequate information or if data are not validated or
clustered with related information, a patient may be misdiagnosed.
· Planning
the nurse prioritizes a patient's various nursing diagnoses, establishes short- and longterm goals, chooses outcome indicators, and identifies interventions to address patient goals.
Deciding the order in which nursing diagnoses are addressed depends on several factors,
including the severity of symptoms and the patient's preference. Obviously, a patient's ability to
breathe is of greater concern than the need to complete activities of daily living independently.
After emergent needs are dealt with, less critical problems take priority. This aspect of the
nursing process is another indication of its dynamic nature and interrelatedness.
· Implementation
focuses on initiation of appropriate interventions designed to meet the unique needs of
each patient. Interventions may be independent, dependent, or collaborative nursing actions
requiring direct or indirect nursing care. All should be derived from evidence-based practice
standards that have evolved from research conducted to elicit the best patient outcomes
possible.
·
Evaluation
focuses on the patient and the patient's response to nursing interventions and goal or
outcome attainment. Evaluation is not a record of the care that was implemented. Evaluation
must clearly identify the effectiveness of implemented interventions with the patient as its focus.
During the evaluation step of the nursing process, nurses use critical thinking to determine
whether a patient's short- and long-term goals were met and desired outcomes were achieved.
Monitoring whether the patient's goals were attained is a collaborative process involving the
patient.
All goals should be should be patient focused, realistic, and measurable.
Chapter 6 Assessment
Describe the following methods of assessment:
·
·
Observation
 Use the senses of sight, hearing, and smell during the observation
 A nurse can gather significant information about a patient's emotional condition and health
status by observing the patient's
o affect, clothing, personal hygiene, and obvious physical conditions, such as a limp or
an open wound.
o Using the senses of sight, hearing, and smell during the observation phase helps the
nurse gather important patient information, which can guide later aspects of the
assessment process.
Patient Interview
 a formal, structured discussion in which the nurse questions the patient to obtain
demographic information, data about current health concerns, and medical and surgical
histories.

essential for the nurse to gather information regarding developmental, cultural, ethnic, and
spiritual factors that may affect the patient. These factors can significantly influence patient
outcomes and must be considered when developing a patient-centered plan of care.
Describe the following types of assessment:
· Comprehensive
 thorough interview, health history, review of systems, and extensive physical head-to-toe
assessment, including evaluation of cranial nerves and sensory organs, such as with sight
and hearing testing.
o often include a variety of laboratory and diagnostic tests that are ordered by the
primary care provider.
· Focused

·
brief individualized physical examination conducted at the beginning of an acute care–
setting work shift to establish current patient status or during ongoing patient encounters
in response to a specific patient concern.
o may be conducted when signs indicate a change in a patient's condition or the
development of a new complication.
o most common type conducted by a nurse.
o
Vital signs are assessed during each focused examination, which includes
assessment of the pain level and pulse oximetry readings
o
After completion of the basic head-to-toe assessment, attention turns to any health
concerns raised by the patient.
Emergency
 done when time is a factor, treatment must begin immediately, or priorities for care need to
be established in a few seconds or minutes.
 treatment is based on a quick survey of accident or illness onset, followed by a narrowly
focused physical examination of critical injuries or symptoms and signs.
 responsiveness is determined in an attempt to establish the potential extent of injury to vital
organs.
o Attention is paid to the patient's airway, breathing, and circulation.
o noticeable deformities such as compound fractures, contusions, abrasions, puncture
wounds, burns, tenderness, lacerations, bleeding, and swelling.
 nurse may never have time to do a complete assessment and may work to stabilize one
body system at a time.
o must remember to continually reassess every 5 to 15 minutes, depending on the
stability of the patient
 Triage, a form of emergency assessment, is the classification of patients according to
treatment priority.
o classifications in the three-tier system are emergent, urgent, and nonurgent. The fivetier system classifies patients by levels numbered 1 through 5.
TRIAGE TIER DESIGNATION
INDICATIONS FOR CARE
Level 1 Critical: life-threatening condition
Requires immediate and continuous care
• Severe trauma
• Cardiac arrest
• Respiratory distress
• Seizure
• Shock
Requires care within 30 min
• Chest pain
• Major fracture
• Severe pain
Level 2 Emergent: imminently life-threatening
condition
Level 3 Urgent: potentially life-threatening condition
Requires care within 30-60 min
• Minor fracture
• Laceration
• Dehydration
Requires care within 60-120 min
• Sore throat
• Abrasion
Level 4 Nonurgent: stable health condition
Requires care when possible
• Conditions with symptoms for a week or
longer
• Cold symptoms
• Minor aches and pains
Level 5 Fast track: less urgent
Marjory Gordon developed functional health patterns to help nurses focus on patient strengths and
related but sometimes overlooked data relationships.
FUNCTIONAL HEALTH PATTERN
Health perception and health management
Nutrition and metabolism
FOCUS
Patient's perceived level of health
Social habits
Living conditions
Health and safety concerns
Food consumption
Fluid intake and balance
Tissue integrity
Elimination
Excretory concerns
• Bowel
• Urinary
Activity and exercise
Activities of daily living
Exercise and leisure
Cardiac status
Respiratory status
Musculoskeletal status
Cognition and perception
Sensory intactness
Cognitive ability
Level of consciousness
Neurologic function
Sleep and rest
Self-perception and self-concept
Roles and relationships
Sexuality and reproduction
Values and beliefs
Sleep patterns
Rest and relaxation activities
Fatigue levels
Identity
Body image
Self-worth
Self-esteem
Role satisfaction
Role strain
Relationship function or dysfunction
Sexuality patterns
Satisfaction with intimacy
Values
Spiritual beliefs
Cultural patterns
Influences on decision making
Chapter 10 Documentation, Electronic Health Records and Reporting
Identify critical aspects and legal issues of documentation
Critical Aspects - Nursing documentation is guided by the five steps of the nursing process:
assessment, diagnosis, planning, implementation, and evaluation. Expected nursing
documentation includes a nursing assessment, the care plan, interventions, the patient's outcomes
or response to care, and assessment of the patient's ability to manage after discharge.
Use of standardized language provides consistency, improves communication among nurses and
with other health care providers, increases the visibility of nursing interventions, improves
patient care, enhances data collection to evaluate nursing care outcomes, and supports adherence
to care standards. The Joint Commission (2014b) has compiled a list of do-not-use abbreviations,
acronyms, and symbols to avoid the possibility of errors that may be life-threatening. The Joint
Commission supplies a toolkit to help facilities reach compliance in this area, and it recommends
that each facility implement a “spell it out” campaign rather than using risky abbreviations.
Legal Issues - Nurses' notes are legal documents. The medical record is seen as the most reliable
source of information in any legal action related to care. When legal counsel is sought because of
a negative outcome of care, the first action taken by an attorney is to acquire a copy of the
medical record. Documentation that meets specific guidelines can prevent a case from going to
court or can provide protection if a case does go to trial. Every entry into the medical record
should include a date, time, and signature.
Describe the process of accepting verbal and telephone orders
If a verbal or phone order is necessary in an emergency, the order must be taken by a registered
nurse (RN) who repeats the order verbatim to confirm accuracy and then enters the order into the
paper or electronic system, documenting it as a verbal or phone order and including the date,
time, physician's name, and RN's signature. Most facility policies require the physician to cosign
a verbal or telephone order within a defined time period.
What is the purpose of an incident report?
The purpose of this report is to document the details of the incident immediately to ensure
accuracy. Incident reports are factual accounts of an incident involving a patient, visitor, or staff
member that are not part of the medical record.
Chapter 27 Hygiene and Personal Care
Describe the importance of hygiene related to skin, hair, nails, and mucous membranes.
Skin is the body's vulnerable barrier to the outside world, but it is strong, self-renewing, and
easily cleaned. Mucous membranes of the lips, nostrils, anus, urethra, and vagina join seamlessly
with the skin. During hygienic care, the nurse cleanses all areas of the integumentary system to
maintain healthy tissue, reduce body odor, and enhance comfort. Cleansing rids the skin of
microorganisms that can cause infection and odor.. Located in the dermis, sebaceous glands
secrete an oily substance that keeps the hair and skin soft. If left unwashed, hair becomes oily as
a result of these secretions. Nails arise from the epidermis and are composed of keratinized
epithelial cells. They grow from the nail matrix, which is the actively growing portion of the nail.
Nails protect the ends of fingers and toes. Unlike skin, nails do not slough off and must be cut.
Identify how alterations in skin, hair, nails, and mucous membranes affect hygienic care.
Ulcers, Incisions, and Wounds - Any interruption in the skin, which is the body's first line of
defense, may lead to infection. Excessively dry skin can lead to cracks and openings in the
integumentary system. Excoriation (red, scaly areas with surface loss of skin tissue) occurs in
patients whose skin is exposed to bodily fluids such as stool, urine, or gastric juices. Excoriation
also occurs in areas where skin rests on skin, such as in the axilla (armpit); under large,
pendulous breasts; or in abdominal folds.
Decreased Sensation - Damage to peripheral nerves occurs for a variety of reasons. Patients
with neurologic deficits, such as peripheral neuropathy due to diabetes, may not be able to
identify extremes of hot and cold. The nurse should monitor the temperature of bath water for
patients with decreased sensation. Burns may result if skin is exposed to extremely hot water
during bathing.
Alopecia - Patients may have alopecia due to hereditary factors, certain illnesses, or the effects
of drugs such as those used in chemotherapy. This condition may affect the patient's self-esteem.
Special care should be given to the scalp.
Pediculosis - A contagious scalp infection, this disorder is more commonly known as head lice.
Transmission occurs through contact with infested personal items such as combs, hats, or linens.
Symptoms of pediculosis are itching and redness of the scalp. If the condition is untreated,
secondary bacterial infections can occur.
Nails - Fungal, bacterial, and viral infections of the fingernails and toenails occur that cause
discoloration and thickening of the nails. Some patients have a decreased ability to heal due to
poor circulation. Any cut in the skin can lead to an ulcer in these patients. An order from the
primary care provider (PCP) may be necessary for nail trimming, or a podiatrist may be
consulted.
Oral Cavity - Alterations in the health of the oral cavity can affect the patient's ability to chew
or overall health. Sores anywhere in the oral cavity, gingivitis (inflammation of the gums), and
broken or missing teeth create problems with chewing. Certain medications cause the mouth to
be dry, creating discomfort for the patient. Halitosis (unpleasant breath odor) may result from
poor dental hygiene, fungal or bacterial infections, and complications of medical conditions such
as diabetic ketoacidosis or renal failure. Oral health depends on diligent oral hygiene.
Self-Care Alterations - Many hospitalized patients have alterations in self-care abilities due to
illness, recent surgery, immobility, and cognitive dysfunction. Assessing the patient's level of
ability to perform skills such as self-bathing helps the nurse devise an appropriate plan of care
and assist the patient when needed.
Jarvis
Chapter 12 Skin, Hair, and Nails (page 199-225)
Describe the structure and function of skin, hair and nails.
Skin Structure
The skin is the largest organ of the body. It has three main layers, the epidermis, the dermis and
the subcutaneous layer
The epidermis’ major ingredient is the tough, fibrous protein keratin. The melanocytes
interspersed along this layer produce the pigment melanin which gives brown tones to skin &
hair. People of all skin colors have the same # of melanocytes; however, the amount of melanin
they produce vary w/genetic, hormonal & environmental influences. The epidermis is completely
replaced every 4 weeks and is avascular as it is nourished by blood vessels in the dermis
below. Note: Skin color is derived from 3 sources: (1) mainly from the brown pigment melanin
(2) from the yellow-orange tones of the pigment carotene & (3) from the red-purple tones in
underlying vascular bed.
The dermis is the inner supportive layer consisting mostly of connective tissue or collagen
which is the tough, fibrous protein that enables the skin to resist tearing. The dermis has
resilient elastic tissue that allows the body to stretch w/body movements. THe nerves, sensory
receptors, blood vessels & lymphatics lie in the dermis.
The subcutaneous layer is adipose tissue, which is made up of lobules of fat cells. The
subcutaneous tissue stores fat for energy, provides insulation for temperature control & aids in
protection by its soft cushioning effect. The loose subcutaneous layer also gives skin its
increased mobility over structures underneath.
Skin Functions
Protects: minimizes injury from physical, chemical & thermal & light-wave sources
Prevents penetration: Skin is a barrier that stops invasion of microorganisms and loss of water
& electrolytes from within the body
Perception: SKin is a vast sensory surface holding the neurosensory end-organs for touch,
pain, temperature & pressure
Temperature Regulation: Skin allows heat dissipation through sweat glands & heat storage
through subcutaneous insulation.
Indentification: People identify one another by uniques combinations of facial characteristics,
hair, skin color & even fingerprints.
Communication: Emotions are expressed in the sign language of the face and body posture.
Wound Repair: Skin allows cell replacement of surface wounds.
Absorption and excretion: Skin allows limited excretion of some metabolic wastes, by
products of cellular decomposition such as minerals, sugars, amino acids, cholesterol, uric acid
& urea.
Production of vitamin D: The skin is the surface on which UV light converts cholesterol into
vitamin D.
Hair Structure
Hairs are threads of keratin. The hair shaft is the visible projecting part, and the root is below the
surface embedded in the follicle. At the root the bulb matrix is the expanded area where new
cells are produced at a high rate. Hair growth is cyclical, with active and resting phases. Each
follicle functions independently; thus while some hairs are resting, others are growing. Around
the hair follicle are the muscular arrector pili, which contract and elevate the hair so it resembles
“goose flesh” when the skin is exposed to cold or in emotional states.
Hair Functions
Hair functions as a means of regulating body temperature and it acts as a sensory organ. It also
helps to protect the skin from external damage such as sun, wind and foreign particles and acts
as insulation for the body
Nail Structure
The nails are hard plates of keratin on the dorsal edges of the fingers and toes (Fig. 12-2). The
nail plate is clear, with fine longitudinal ridges that become prominent in aging. Nails take their
pink color from the underlying nail bed of highly vascular epithelial cells. The lunula is the white,
opaque, semilunar area at the proximal end of the nail. It lies over the nail matrix where new
keratinized cells are formed. The nail folds overlap the posterior and lateral borders. The cuticle
works like a gasket to cover and protect the nail matrix.
Nail Functions
Nails act as a protective plate and enhances sensation of the fingertip and protects ends of
digits from trauma . They can also help grasp and manipulate objects.
Identify abnormal characteristics of pigmented lesions using the ABCDE method
Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCDE:
Asymmetry (not regularly round or oval, two halves of lesions do not look the same
Border irregularity (notching, scalloping, ragged edges, poorly defined margins)
Color variation (areas of brown, tan, black, blue, red, white or combination)
Diameter greater than 6mm (i.e., the size of a pencil eraser), although early melanomas may be
diagnosed at smaller sizes
Elevation or Evolution
Additional symptoms: rapidly changing lesion; a new pigmented lesion; and development of
itching, burning or bleeding in a mole.
Describe the following skin changes
· Pallor: changes in skin tone or complexion/paleness
Caused by:
Changes in light Skin:
Changes in dark skin:
Anemia or shock
generalized pallor
brown skin appears
yellow-brown, dull: black skin appears ashen gray, dull; skin loses healthy glow
Albinism
Whitish pink
Tan, cream, white
Vitiligo
Patchy milky-white spots, often
Symmetric bilaterally
Same
· Erythema: redness of the skin or mucous membranes
Caused by:
Changes in light Skin:
Changes in dark skin:
Hyperemia
Red, bright pink
Purplish tinge but difficult to
see; palpate for increased warmth w/inflammation, taut skin & hardening of deep tissues
Polycythemia
Ruddy blue in face, oral mucosa,
Conjunctiva, hands & feet
Well concealed by pigment
check for redness in lips
Carbon monoxide
beds,
poisoning
Bright cherry red in face & upper
Cherry-red color in nail
torso
lips & oral mucosa
Venous stasis
palpation
Extremities; a prelude to necrosis
w/pressure sore
Dusky rubor of dependent
Easily masked; use
for warmth or edema
· Cyanosis: the appearance of a bluish discoloration of the skin and/or mucous membranes
due to excessive concentration of deoxyhemoglobin in the blood
Caused by:
Changes in light Skin:
Increased amount of
Dusky blue
only
hemoglobin
apparent
Central- Chronic heart &
conjunctivae,
lung disease cause arterial
Desaturation
Peripheral-Exposure to cold, Nail Beds dusky
anxiety
Changes in dark skin:
Dark but dull, lifeless;
severe cyanosis is
in skin --check
oral mucosa, nail beds
· Jaundice: yellow coloring of the skin or eyes caused by too much bilirubin in the body.
Caused by:
Changes in light Skin:
Changes in dark skin:
Increased serum bilirubin,
Yellow in sclera, hard palate,
Check sclera for yellow near
more than 2-3 mg/100 mL
mucous membranes, then over
limbus, do not mistake
from liver inflammation or
skin
normal yellowish fatty
hemolytic disease such as
deposits in the periphery
after severe burns, some
under the eyelids for jaundice
Infections
Carotenemia
Uremia
; best noted in junction of
hard/soft palate & palms
Yellow-orange in forehead, palms
& soles, nasolabial folds, but no
yellowing in sclera or mucous
membranes
Orange-green or gray overlying
pallor of anemia; may also have
ecchymoses & purpura
yellow-orange tinge in palms
& soles
Easily masked; rely on lab &
clinical findings
· Warts: An example of a papule (can be felt). Raised bumps on the skin
· Bulla/ Bullae (more than one): blisters that occur when fluid is trapped under a thin layer
of skin. Usually larger than 1 cm diameter & shingle chambered (unilocular); superficial in
epidermis & easily ruptures since thin walled. Examples: friction blisters, pemphigus, burns &
contact dermatitis
· Freckles: Small, flat macules of brown melanin pigment that occur on sun-exposed skin
· Papules: Something you can feel (i.e. solid, elevated, circumscribed, <1 cm diameter)
caused by superficial thickening in epidermis. Examples: elevated nevus (mole), lichen planus,
molluscum, wart (verruca).
Chapter 13 Head, Face and Neck, including Regional Lymphatics
Describe Dizziness related to Presyncope, vertigo and disequilibrium
Presyncope, a light-headed, swimming sensation or feeling of fainting or falling caused by
decreased blood flow to brain or heart irregularity causing decreased cardiac output.
Vertigo is true rotational spinning often from labyrinthine-vestibular disorder in inner ear. With
objective vertigo the person feels like the room is spinning; with subjective vertigo the person feels like
he or she is spinning.
Disequilibrium is a shakiness or instability when walking related to musculoskeletal disorder or
multisensory deficits.
Identify cranial nerves involved in sensory and motor function of the face and neck
The human face has many appearances and expressions that reflect mood. The expressions are
formed by the facial 252 muscles, which are mediated by cranial nerve VII, the facial nerve. Facial
muscle function is symmetric bilaterally, except for an occasional quirk or wry expression.
Facial structures are symmetric; the eyebrows, eyes, ears, nose, and mouth appear about the same
on both sides. The palpebral fissures—the openings between the eyelids—are equal bilaterally. Also the
nasolabial folds—the creases extending from the nose to each corner of the mouth—should look
symmetric. Facial sensations of pain or touch are mediated by the 3 sensory branches of cranial nerve V,
the V trigeminal nerve.
The neck is delimited by the base of the skull and inferior border of the mandible above and by
the manubrium sterni, the clavicle, the first rib, and the first thoracic vertebra below. Think of the neck as
a conduit for the passage of many structures that are lying in close proximity: blood vessels, muscles,
nerves, lymphatics, and viscera of the respiratory and digestive systems. Blood vessels include the
common and internal carotid arteries and their associated veins. The internal carotid artery branches off
the common carotid and runs inward and upward to supply the brain; the external carotid artery supplies
the face, salivary glands, and superficial temporal area. The carotid artery and internal jugular vein lie
beneath the sternomastoid muscle. The external jugular vein runs diagonally across the sternomastoid
muscle. (See assessment of the neck vessels in Chapter 19.)
The major neck muscles are the sternomastoid and the trapezius; they are innervated by cranial nerve XI,
the spinal accessory. The sternomastoid muscle arises from the sternum and the clavicle and extends
diagonally across the neck to the mastoid process behind the ear. It accomplishes head rotation and flexion.
The two trapezius muscles on the upper back arise from the occipital bone and the vertebrae and extend
fanning out to the scapula and clavicle. The trapezius muscles move the shoulders and extend and turn the
head.
Describe the function of the Lymphatic system
The lymphatic system is a separate vessel system from the cardiovascular system and a major part of the
immune system, whose job it is to detect and eliminate foreign substances from the body. The vessels
gather the clear, watery fluid (lymph) from the tissue spaces into the circulation. Lymph nodes are small,
oval clusters of lymphatic tissue that are set at intervals along the lymph vessels like beads on a string.
The nodes slowly filter the lymph and engulf pathogens, preventing harmful substances from entering the
circulation. Nodes are located throughout the body but are accessible to examination only in four areas:
head and neck, arms, axillae, and inguinal region. The greatest supply is in the head and neck.
Chapter 14 Eyes (pages 281-312)
Describe eye movement stimulated by
 CN III- oculomotor nerve (CN III) innervates all the rest—the superior, inferior, and
medial rectus and the inferior oblique muscles.


CN VI- The abducens nerve (CN VI) innervates the lateral rectus muscle (which abducts the
eye)
CN IV- trochlear nerve (CN IV) innervates the superior oblique muscle
Six muscles attach the eyeball to its orbit (Fig. 14-4, A) and serve to direct our eyes to points of our
interest. These extraocular muscles (EOMs) give the eye both straight and rotary movement. The
four straight, or rectus, muscles are the superior, inferior, lateral, and medial rectus muscles. The
two slanting, or oblique, muscles are the superior and inferior muscles.
Module 4 Review Guidelines
Giddens
Concept 49 Evidence
Define evidence-based nursing.
The conscientious, explicit, and judicious use of theory-derived, research-based information in
making decisions about the care delivery to individual needs and preferences.
How is evidence used in nursing and health care?
Evidence serves a similar function in health care as it does in the legal system. It provides proof
of the usefulness of an intervention, the projected course of a disease, or the link between
environmental insults and illness.
Concept 40 Clinical Judgement
Define Clinical Judgement.
 Inference or interpretation made in a caregiving setting
 A process resulting in such an inference or interpretation
 The capacity for making inferences or interpretations about patient care.
 Interpretation or conclusion about a patient's needs, concerns, or health problems, and/or
the decision to take action (or not), use or modify standard approaches, or improvise new
ones as deemed appropriate by the patient's response.
Describe clinical judgement as it relates to experience, theoretical knowledge, and expertise.
Clinical judgments require that the nurse recognize the unique situation of the patient,
originating from deep knowledge of a variety of interrelated physiologic and psychosocial
concepts resulting in a profound understanding of the clinical situation.
Explain how each of the following contribute to the development of clinical judgment:
· Knowledge or Deep Understanding
Deep knowledge provides a basis for focused assessments, including salient factors, and for
interpreting findings that lead to appropriate clinical judgments, specific to the patient's needs.
· Learning to Recognize Patterns
Pattern recognition of specific conditions is a significant aspect of noticing and interpreting patient
care needs and leads to a deeper understanding of patient issues.
 Knowing patterns alerts the nurse to note what signs or symptoms may be present or absent
in order to determine an appropriate response.
· Apply Concepts to Nursing Practice
Consider how the context (caregiving situation, your own values, knowing the patient and his or her
specific personal qualities and needs, and your own past nursing and personal experiences with the
concept) impacts the particular caregiving situation.
· Skillful Responding
 Involves setting priorities and modifying them as the situation changes
 Discuss prioritization of care as a part of your daily routine in clinical
 Identify the resources in the clinical setting that support skill-related decision making and
performance, ie procedure references
 Think about what you might expect the patient response to the intervention might be, and
then observe the actual response
·
Reflective Practice
 Helps students to process and consolidate learning about caregiving situations
 Reflection on clinical experiences can support application of theoretical knowledge to clinical
situations and improve prioritization of future nursing care
Concept 43 Patient Education
Define patient education.
Patient education is defined as a process of assisting people to learn health-related behaviors so that they
can incorporate these behaviors into everyday life.
Describe the role of the nurse in patient education.
The nurse facilitates patient educational approaches, which can range from formal educational
programming, such as group lecture settings to informal, individualized one-on-one teaching and to selfdirected learning by the patient.
Define and describe the following learning domains:
·
Affective
Education that is intended to change attitudes, such as viewing the lifestyle modifications associated with
the treatment of coronary artery disease as a positive change rather than a burden.
·
Cognitive
Education intended to increase a patient's knowledge of a subject, for example, is cognitive in nature, and
using methods such as written material, lecture, and discussion is appropriate.
·
Psychomotor domains
Skill teaching or psychomotor teaching requires that the patient have opportunities to touch and
manipulate equipment and practice skills. For example, a patient who must learn to change a dressing
over a wound.
Yoost
Chapter 4 Critical Thinking in Nursing
Define and describe critical thinking and clinical reasoning:
Critical thinking is a complex process that is “the art of thinking about your thinking while
you’re thinking so you make your thinking more clear, precise, accurate relevant, consistent and
fair” Differentiated from trial & error, Nurses make life-and-death decisions on the basis of
critical thinking influenced by scientific research and best practices.
“Critical thinking involves the application of knowledge and experience to identify patient
problems and to direct clinical judgments and actions that result in positive patient outcomes”
Clinical reasoning uses critical thinking, knowledge, and experience to develop solutions to
problems and make decisions in a clinical setting A nurse's clinical-reasoning skills develop over
time with increased knowledge and expertise.
Describe the following components of critical thinking:
Knowledge review:Critical thinking is contextual and requires knowledge of the subject that is
the focus of the thinking. A person can not think critically without knowledge of the subject
matter. (i.e. baseline knowledge & information gathering contributes to knowledge review
Reasoning: logical thinking that links thoughts in meaningful ways and is used in scientific
inquiry, in examining controversial issues, and in problem solving. (inductive & deductive
reasoning is used)
Inference: intellectual acts that involve a conclusion being made on the basis of something else.
Validation: the process of gathering information to determine whether the information or data
collected are factual and true
Attitudes necessary for critical thinking: Critical-thinking attitudes promote learning,
reasoning, and discipline/Attitudes foster critical thinking that focuses on clarity, precision,
clarification, validation, and recognition of bias
Identify essential characteristics or traits of critical-thinking: See Table-3/page 60 which
defines 11 intellectual traits identified as essential for competence in critical thinking
Identify thinking errors: (to avoid) bias, illogical thinking, lack of information, closedmindedness, erroneous assumptions (slide #24 PP)
Describe the process referred to as thinking like a nurse. Because nursing requires the
application of knowledge to make clinical decisions and guide care, it involves active
participation by the nurse. The application of knowledge requires development of a questioning
attitude. This process is sometimes referred to as thinking like a nurse.
Chapter 7 Nursing Diagnosis
Define nursing diagnosis.
Identification of an actual or potential problem or response to a problem
Differentiate between the following:
· Actual nursing diagnosis
Diagnostic label used when there is an increased potential or vulnerability for Pt to develop a
problem or complication.
· Risk nursing diagnosis
Risk nursing diagnosis guide the initiation of treatments to avoid potential problems.
· Health promotion nursing diagnosis
Health-promotion nursing diagnoses identify opportunities for patient improvement
· Medical and nursing diagnoses
Whereas medical diagnoses identify and label medical (physical and psychological) illnesses,
nursing diagnoses are much broader in focus. Nursing diagnoses consider a patient's response to
medical diagnoses and life situations in addition to making clinical judgments based on a patient's
actual medical diagnoses and conditions. Nursing diagnoses take into consideration a patient's
attitudes, strengths, and resources—not just the medical problems identified—which are critical for
planning holistic, individualized care
Describe each of the following components of a nursing diagnosis:
· Diagnosis label
diagnosis label is a concise term or phrase that represents a pattern of related, clustered data
· Related factors and risk factors
Related factors are the underlying cause or etiology of a patient's problem.
Risk factors are environmental, physical, psychological, or situational concerns that increase a patient's
vulnerability to a potential problem or concern.
· Defining characteristics
Defining characteristics are cues or clusters of related assessment data that are signs,
symptoms, or indications of an actual or health-promotion nursing diagnosis.
Describe the process of data clustering.
Clustering involves organizing patient assessment data into groupings with similar underlying
causes. The nurse looks for cues among the data that support the diagnosis of a problem. For
example, objective and subjective data related to mobility can be clustered. Data related to
nutritional status, such as weight, height, and dietary intake, can be clustered.
Chapter 8 Planning
Describe the planning step of the nursing process.
Prioritizes the patient's nursing diagnoses, determines short- and long-term goals, identifies outcome
indicators, and lists nursing interventions for patient-centered care.
Describe how each of the following is used to prioritize care:
· Maslow’s hierarchy of needs
Helps organize the most urgent to less urgent; a patient’s physiological needs must always be
met first.
· Life threatening concerns vs routine care
Use the ABC’s to determine situation.
· Conflicting priorities
Nurse-patient collaboration in the goal-setting process can help to alleviate the incidence of
conflicting priorities.
Define each of the following goal characteristics:
· Realistic
Consider the patient's physical, mental, and spiritual condition in relation to the ability to attain
goals.
· Patient centered
Written specifically for the patient. The goal should specify the activity the patient is to exhibit or
demonstrate to indicate goal attainment. Goals are written to reflect patient, not nursing, activities.
· Measurable
Specific, with numeric parameters or other concrete methods of judging whether the goal was met.
Chapter 13 Evidence-Based Practice
Define each of the following topics:
· Research: a systematic inquiry that uses disciplined methods to answer questions or solve
problems. Also defined as a diligent, systemic inquiry or study that validates and refines
existing knowledge and develops new knowledge
· Nursing Research: a formal, systematic, and rigorous process of inquiry used to generate
and test theories about the health related experiences of human beings within their
environments and about the actions and processes that nurses use in practice
· American Nurses Association Research Standards: Require nurses to use research
findings in practice where two criteria are measured. 1. Nurses need to use the best available
evidence 2. Nurses participate in research activities that are appropriate for their position and
level of education
Chapter 9 Implementation and Evaluation
Define each of the following:
· Implementation
Performing a task and documentation of each intervention.
· Evaluation
Focuses on the patient and the patient’s response to nursing interventions and outcome
attainment.
· Direct care nursing interventions
Interventions that are carried out by having personal contact with patients.
Types: Reassesment, ADL’s, Physical Care, Informal Counseling, Teaching
· Indirect care nursing interventions
Nursing interventions that are performed to benefit patients but do not involve face to face
contact
Types: Communication and Collaboration, Referrals, Research, Advocacy, Delegation,
Prevention-Orientated Interventions
· Independent nursing interventions
Tasks within the nursing scope of practice that the nurse may undertake without a Physician or
PCP order.
· Dependent nursing interventions
Tasks the nurse undertakes that are within the scope of practice but require an order from PCP
to be implemented.
Chapter 20 Health History and Physical Assessment
Describe each of the following:
·
Cranial nerve assessment
A complete cranial nerve assessment involves testing all 12 of the cranial nerves in their numbered order
·
CRANIAL NERVE
ASSESSMENT
I - Olfactory
After assessing patency of both nares, have the pt. close the eyes, obstruct one nare,
and inhale to identify a common scent.
II - Optic
Check visual acuity (have the pt. read article or use a Snellen chart), and test visual
fields for each eye.
III - Oculomotor
Assess pupil size and light reflex; note direction of gaze.
IV - Trochlear
Ask the pt. to gaze downward, temporally, and nasally. (Note: CN III, IV, and VI
are examined together because they control eyelid elevation, eye movement, and
pupillary constriction.)
V - Trigeminal
Motor: Palpate jaws and temples while pt. clenches teeth.
Sensory: With pt. eyes closed, gently touch a cotton ball to all areas of the face.
VI - Abducens
Assess directions of gaze.
VII - Facial
Motor: Check symmetry of the face by having the pt. frown, close eyes, lift
eyebrows, and puff cheeks.
Sensory: Assess the pt. ability to recognize taste (sugar, salt, lemon juice).
VIII - Auditory
(Vestibulocochlear)
Assess the pt. ability to hear a spoken and whispered word.
IX - Glossopharyngeal
Sensory: Assess the pt. ability to taste sour or sweet on last two thirds of tongue.
Motor: Check for presence of the gag reflex by inserting a tongue blade two-thirds
into the pharynx.
X - Vagus
Depress the tongue with a tongue blade, and have the pt. say “ah” or yawn. The
uvula and soft palate should rise and be symmetric. Assess speech for hoarseness.
XI - Accessory
Have the pt. rotate the head and shrug the shoulders against passive resistance.
XII - Hypoglossal
Assess tongue control (e.g., have the patient stick out the tongue and move it from
side to side).
Sensory nerve assessment
The CNS is composed of sensory pathways that detect and conduct sensations of pain, temperature,
vibration, position, and touch. Screening for sensory nerve dysfunction can be accomplished during other
parts of the physical examination, such as during skin assessment. With eyes closed, the patient should
feel dull and sharp sensory stimuli equally on both sides of the body. Ask the patient to describe the
quality of each stimulus, and note the presence or absence of bilateral symmetry when the stimuli are
applied to the patient's extremities and trunk. Compare distal with proximal sensations.
·
Motor nerve assessment
Motor skills are divided into two groups: gross motor skills, which include the larger movements of arms,
legs, or the entire body, and fine motor skills, which include activities using the smaller muscles of the
fingers, hands, or feet and hand-eye coordination.
To test gross motor skills during the assessment, assess the quality of the patient's actions for smoothness
and ease of movement.
To test fine motor skills and function, have the patient perform actions such as transferring an object from
one hand to the other successfully, picking up and holding two or more objects in the same hand, turning
pages one at a time, and writing a signature
Jarvis
Chapter 22 Musculoskeletal System
Define the following terms:
Flexion - Bending movement of a limb at a joint.
Extension - Straightening a limb at a joint, it is the reverse of flexion, and occurs at the same joints.
Abduction - Movement of a limb AWAY from the midline of the body.
Adduction - Movement of a limb TOWARD the midline of the body, it is the opposite of abduction.
Pronation - Refers to the movement of the radius around the ulna, rotating the forearm so that the palm
faces DOWN.
Supination - Refers to the movement of the radius around the ulna, rotating the forearm so that the palm
faces UP.
Circumduction - Moving a limb so that it describes a cone in space eg. moving the arm in a circle around
the shoulder.
Inversion - Special movement of the foot, moving the sole of the foot medially, inwards at the ankle.
Eversion - Special movement of the foot, moving the sole of the foot laterally, outwards at the ankle.
Rotation - The turning of a bone around its own long axis, eg. moving the head around a central axis.
Active and Passive Range of Motion (ROM) - Active range of motion, or AROM, is the range of
flexibility in a joint reached by voluntary movement, eg. when you stretch forward to touch your toes. In
contrast, passive range of motion, or PROM, is the range that can be achieved by external means such as
another person or a device, eg. a trainer pressing into your leg to stretch your hamstring.
Chapter 23
Identify normal findings of cranial nerve 3 to 12, Cerebellar function, Balance function and
Stereognosis.
Normal Findings:
Cranial Nerve III: Oculomotor nerve, Cranial Nerve IV: Trochlear nerve, Cranial Nerve VI:
Abducens nerve/movement of eyeballs
Cranial Nerve V: Trigeminal nerve,/ equal feelings of the temporal and masseter muscles,
inability to separate jaw, person has full facial sensation
Cranial Nerve VII: Facial nerve, /ability to make facial expressions
Cranial Nerve VIII: Acoustic (Vestibulocochlear) nerve/ ability to hear
Cranial Nerve IX: Glossopharyngeal nerve/ uvula and soft palate should rise in the midline and
tonsillar pillars should move medially upon saying 'ahhh” or yawning
Cranial Nerve X: Vagus nerve/ should initiate gag reflex & voice should sound smooth and not
strained
Cranial Nerve XI: Spinal accessory nerve,/ ability to shrug shoulders and move head against
resistance, equal size and strength of muscles bilaterally
Cranial Nerve XII: Hypoglossal nerve,/ voluntary movement of the tongue and ability to
articulate words
Cerebellar function: movements should be smooth & accurate
Balance function: can walk straight & stay balanced
Stereognosis: person can explore familiar items with eyes closed by feeling with fingers and
correctly identify it
Exam: 1/3 rd each subject
1. Safety
2. Legal
3. Abdominal assessment
Safety:
 Joint Commission (makes national patient safety goals)
 QSEN: 6 Competencies
o Patient Centered Care
o Teamwork and Collaboration
o Evidence-Based Practice
o Quality Improvement
o Safety
o Informatics
 Safety concerns in the healthcare field:
o Falls
o
o
o
o
o

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

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


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Restraints
Med administration errors
Radiation
Drug resistant microorganisms (MRSA)
Procedural errors
4 Environmental Health Risk Factors
o Pollution
o Lighting (poor lighting)
o Workplace hazards
o Communicable diseases
Toxin
Bioterrorism
Carbon Monoxide
o Colorless, odorless gas that can cause sudden illness or death
o Symptoms: dizziness, light-headed, nausea, death if exposed long term
o
leading cause of unintentional death in US
Number 1 cause of children poisoning in ages 1-5:
o Lead Poisoning
 Symptoms: developmental delays, weight loss, headaches, sluggishness or
fatigue, vomiting, abdominal pain, irritability
Sentinel events
o Any unanticipated event in a healthcare setting resulting in death or serious
psychological or physical injury to a patient
o #1 sentinel event: falls
RACE
o Rescue, Alarm, Confine, Extinguish
PASS
o Pull, Aim, Squeeze, Sweep
National Safety Goals
o Identify patients correctly
o Use medications correctly/safely
o Improve Staff communication
o Prevent infection
o ID patient risks
o Prevent mistakes in surgery
o Use alarms correctly
o Prevent falls
o Prevent bed sores
Risk Nursing Dx
o

Scopes of Nursing Practice:
o Regulatory or Statutory
o Nurse is responsible for knowing scope of practice
o Know who makes these (government)
o

State Boards make laws
Know what QSEN stands for
o Quality Safety and Education for Nurses
Legal:

Liable
o







written form of defamation of character.
Slander
o verbal defamation of character
Negligence
o creating a risk of harm to others by failing to do something that a reasonable
person would ordinarily do, or doing something that a reasonable person would
ordinarily not do.
Malpractice
o is negligence committed by a person functioning in a professional role.
Regulatory Law
o outline how the requirements of statutory law will be met. Nursing rules and
regulations are categorized as regulatory law. ( Administrative in nature made by
the executive branch of government, and restrictive and impose sanctions upon
people and companies.)
Policy
o a course of principal of action adopted or proposed by a government party,
business, or individual. ( General made by individual organizations and even
governments. Helps organization achieves its goals.)
Assault
o threat to harm another (can be an attempt, written, or spoken threat)
Battery
o actual physical harm to another. (can involve forceful touching of people, their
clothing or anything attached to person; performing procedure w/o consent.)
Legal Documents:
 Advanced directive: consist of three documents: (1) living will, (2) durable power of
attorney, and (3) health care proxy, commonly referred to as durable power of attorney
for health care.
o Living will
 specifies the treatment a person wants to receive in circumstances in
which that person is unconscious or no longer capable of making decisions
independently.
o Durable Power of Attorney
 legal document that allows a designated person to make legal decisions on
behalf of an individual unable or not permitted to make legal decisions
independently. (Health decisions)
o Health care proxy
 specific durable power of attorney for medical care. This document
specifies who is to make health care decisions for an individual who is
unable to comprehend information or communicate his or her wishes for
any reason.



Code status
o Limited code- This is a code “shopping list” pick and choose what you want.
o Full code - do whatever necessary to save life
o AND (Allow Natural Death) AKA “DNR” or “No code”
Power of Attorney
o Make legal decisions for person that is no longer capable; Typically financial
Informed consent
o permission granted by a patient after discussing each of the following topics with
the physician, surgeon, or advanced practice nurse who will perform the surgery
or procedure:
 (1) exact details of the treatment, (2) necessity of the treatment, (3) all
known benefits and risks involved, (4) available alternatives, and (5) risks
of treatment refusal.
 Began when Research Trials came about
Governing Laws
 EMTALA
o A policy that states that a hospital with emergency departments have a duty to
care for those requiring emergency medical assistance whether or not they have
the ability to pay.
 OmNiBus 2007
o Protection of patients in long-term care facilities against chemical and physical
restraints (nursing homes)
 Good Samaritan
o Protects health care professionals from charges of negligence in providing
emergency care in scenes of disaster, emergency, or accident
o Can be suspended for not offering help
 HIPAA
o Established to protect a patient’s privacy and personal information. This includes
accessibility, privacy, security, and confidentiality.



COBRA
o insurance coverage that can be purchased at the end of one policy terminating to
cover until new policy is effective.
Patient Self Determination Act
o requires that health care providers supply all patients with written information
regarding their rights to make medical decisions and implement advance
directives.
AMA
Abdominal Assessment: Jarvis CH21 PP
 Appendix → Cecum → Ascending → hepatic flexure → Transverse → Splenic Flexure
→ Descending → Sigmoid → Rectum
 Normal amount of bowel sounds to hear: 5-30 a minute
 Use Bell when listening for bruits or AV fistula (connection of artery and vein)
 Use Diaphragm to auscultate
 Define what is normal and abnormal
 Know order of examination: slide 82
o Inspect:
o Auscultate: RLQ → RUQ → LUQ → LLQ
o Palpate: lighty ½ inch deep all over each Q, deeper 1-1 ½ inch all over each Q
o Percuss: tympany (sounds)


Abnormal Findings
-Normal finding: 5-30 sounds in 1 min. Listen for 5min each quadrants if no sounds
heard.
-Hypo-active sounds
-Hyper-active sounds
o Obesity
o Air or gas
o Ascites (accumulation of fluid in the peritoneal cavity, causing abdominal
swelling)
o Ovarian cyst
o Pregnancy
o Feces
o Tumor
o Umbilical hernia, Epigastric hernia, Incisional hernia, Diastasis hernia
o Enlarged organs
Types of Contour (4)
o Flat - normal
o Scaphoid - anorexia A scaphoid abdomen is due to malnutrition.
o Rounded - overweight (considered normal as well) after pregnancy, loss of
abdominal muscles.
o Protuberant - Type 2 diabetes, cirrhosis of liver, pregnancy a protuberant
abdomen is caused by one of three things: excess fat stored in the
midsection, a loss of muscle tone, or a buildup of substances inside the
abdominal region (such as in the intestines)
o Six F's of Abdominal Extension
 1. Fetus
2. Flatus
 3. Fecal
 4. Fat
 5. Fluid
 6. Fatal-tumor
Other Testing Info:
Review HTT for ears, eyes, neuro
Organs that are midline
Uterus (only if enlarged)
Aorta
Bladder (only feel if distended)
Organs in RLQ
Appendix
R ovary and tube
R ureter
R spermatic cord
R cecum (small and large intestine meet)
Organs in RUQ
R Kidney
Adrenal gland
Gallbladder
Liver
Ascending colon
Transverse colon
Hepatic flexure of colon
Head of pancreas
Duodenum (first part of stomach)
Organs in LUQ
Left part of liver
Pancreas
L Kidney
Adrenal gland
Splenic flexure of colon (connect transverse to descending)
Part of Transverse and Descending colon
Spleen
Stomach
Organs in LLQ
L ovary and tube
L ureter
L spermatic cord
Transverse colon
Descending colon
Sigmoid colon
Dysphagia- difficulty swallowing
Ascites- accumulation of fluid in the peritoneal cavity causing abdominal swelling
Ecchymosis-blood from intraperitoneal or retroperitoneal hemorrhage may discolor the
abdominal skin (ex: ectopic pregnancy and AAA)
Diastasis Recti-separation between the left and right side of the rectus abdomens muscle (Bulge)
ridge-like in appearance, helps a little if they improve the tone of the abdominal muscles
Cushing Disease -The most common cause is the use of steroid drugs, but it can also occur from
overproduction of cortisol by the adrenal glands.Signs are a fatty hump between the shoulders, a
rounded face, and pink or purple stretch marks.
Loss of salivation is normal as a person ages (dry mouth)
Genital Identification and Health Promotion
Lab Objectives:
a.
b.
.
a.
b.
.
a.
.
a.
.
1. Perform a sequentially correct assessment of the abdomen.
Inspect, Auscultate, Palpate, Percuss
PER BOOK: Inspect, Auscultate, Percuss, Palpate
2. Demonstrate proper auscultation of the aorta, renal and iliacs for bruits.
Aorta: belly button area
Renal: identify location of aorta and auscultate to left and and right of that
Iliacs: below umbilicus, and inward from iliac crest
3. Interpret findings obtained during inspection, palpation, percussion, and auscultation of the
abdomen.
4. Incorporate health promotion concepts when performing an assessment of the abdomen.
5. Describe the structures of the male genitals.
Know basic internal
Know basic external
6. Discuss the importance of teaching testicular self-examination as health promotion during
assessment.
Testicular cancer is common 15-35
Know how to examine and palpate scrotum
7. Describe developmental care for examination of anal, rectal, and prostate structures.
8. Incorporate health promotion concepts when performing an assessment of the anus, rectum,
and prostate.
9. Describe the structures of the internal and external female genitalia.
Look at Jervis slide show
10. Outline the changes observed during puberty.
11. Cite changes found during pregnancy.
.
Cardiac changes
i.
increased HR 10-20bpm
ii.
Increase in blood by up to 50%
a.
Renal changes
b.
Body water metabolism
c.
Respiratory changes
d.
Thyroid changes
e.
Adrenal changes
f.
Glucose changes (gestational diabetes)
g.
Skeletal changes (hips widen, feet flatten)
12. Outline the changes observed during the peri-menopausal period.
13. Incorporate health promotion concepts when performing an assessment of the female
genitourinary system.
14. Differentiate the different types of pain.
15. Compare acute and chronic pain.
.
Acute: 6 months or less
a.
Chronic: 6 months or more
16. Describe developmental care as well as cross-cultural and gender considerations regarding pain.
17. Compare available pain assessment tools.
18. Compare acute and chronic pain behaviors (nonverbal behaviors of pain).
.
objective, vital sign changes
19. Describe the physical changes that may occur because of poorly controlled pain.
20. Demonstrate proper use of personal protective equipment (PPE).
.
1. Gown, 2. mask/respirator, 3. goggles/face shield, 4. gloves
21. Verbalize appropriate PPE to utilize for each isolation category.
.
Gloves and gown are standard precautions
a.
Standard Precaution 2: goggles, mask, or face shield (expecting blood)
b.
Expanded Precautions (Droplet, Airborne, Contact)
.
Airborne: mask, gown, gloves, particulate respirated, negative pressurized isolation room (eg
Whooping cough, Influenza)
i.
Droplet(can travel 3ft): surgical mask within 3ft of pt, gown, gloves
ii.
Contact: gown, gloves
Module 5 Review Guide
Giddens
Concept 47 Safety
Define and describe the Concept of Safety
 Freedom from accidental injury
 ensuring patient safety involves:
o establishment of operational systems and processes that minimize the likelihood of
errors
o maximizes the likelihood of intercepting them when they occur
 Concept of safety is broad and encompasses the ideal of keeping all patients safe to the
unfortunate reality that errors can lead to injury or death
Define and describe the following types of Safety concerns:
· Diagnostic
 The result of a delay in diagnosis



Failure to employ indicated tests
Use of outmoded tests
Failure to act on results of monitoring or testing
· Treatment
 occur in the performance of an operation, procedure, or test
 in administering a treatment
 in the dose or method of administering a drug
 in avoidable delay in treatment or in responding to an abnormal test
· Preventive
 when there are failures to provide prophylactic treatment and inadequate monitoring or
follow-up of treatment
· Communication
 lack of communication or a lack of clarity in communication
Describe the following in the context to nursing and healthcare
· Just Culture
 system's value of reporting errors without punishment
 one in which people can report mistakes or errors without reprisal or personal risk.
 DOES NOT mean individuals are not accountable for their actions or practice
o does mean that people are not punished for flawed systems


promotes sharing and disclosure among stakeholders
balance the need to learn from mistakes and the need to implement disciplinary action.
· Transparency in healthcare
 Hospitals should make available information on a system's performance on safety,
evidence-based practice, and patient satisfaction (HCAHPS)
 also defined as open communication and information sharing with patients and their families
about their care, including adverse and sentinel events.
 Timely, open, honest communication with patients and families about adverse events helps
restore trust
 Michigan Model
Concept 57 Concept of Health Care Policy
Define and describe the concept of Health Policy
Health Policy can be defined as a form of public policy, differentiating it from other kinds of
decision making. A classic and basic definition of public policy is what governments decide to do
or not to do.Public policy can also be defined as the choices made by a society or social entities
that relate to public goals and priorities as well as the choices made for allocating resources to
those goals and priorities. Health policy would therefore be the result of choices and resource
allocation decisions made to support health-related goals and priorities.
Health policy as a concept can first be differentiated by locating it within the realm of public
decision making by political authority including executive order, legislation, judicial process, or
regulatory rulemaking agencies.
The scope of health policy is wide and as varied as the numerous entities responsible for
decisions, funding, enactment, and oversight as well as the many populations and individuals
who are affected by these decisions. Health policy decisions can have both macro-level
(Medicare program funding) and micro-level effects (co-payments for episodes of care) and can
be made on the basis of economics, social justice, political trends, and/or changing social
values. Health policy can also be the source of much political conflict because it has the
potential to affect a large number of people, depending on the health policy goal.
Describe the Scope and Standards of Professional Nursing Practice
The licensing and regulation of health professionals, including nurses, are the responsibility of
state governments. States create laws that establish professional practice acts meant to
regulate health professionals. A state regulatory agency and a politically appointed board of
nursing are tasked with the implementation and administration of nurse practice acts, including
issuing licenses to individuals to legally practice nursing. Some state regulatory boards are
specifically created for nursing and some boards are tasked with regulation of several health
care professions, but all of these regulatory boards establish the scope of legally licensed
practice and minimum standards for professional performance under that license. Regulatory
boards have authority delegated by the state legislature to make rules, and these rules have the
force of law. Professional practice errors that violate the provisions of the practice act are
subject to disciplinary action by boards and are adjudicated by the regulatory agency through
established disciplinary procedures. Boards have the authority to revoke licenses for unsafe
practice as defined by the practice act, including actions or behaviors by the nurse that lie
outside of the scope and standards of practice established by the license.
Concept 58 Concept of Health Care Law
Define and describe the concept of Health Law
Health care law is defined as the collection of laws that have a direct impact on the delivery of health care
or on the relationships among those in the business of health care or between the providers and recipients
of health care. Health care laws represent presciptive (it defines something that must be done) and
proscriptive (it prohibits something from being done) principles.
Explain the Emergency Medical Treatment and Active Labor Act (EMTALA)
The policy which underlies EMTALA is that hospitals that have emergency departments have a duty to
care for those requiring emergency medical services irrespective of patients' ability to pay. Any Medicareparticipating hospital that offers emergency services must provide an appropriate medical screening exam
to any person who presents for treatment of an emergency medical condition and must stabilize any
emergency medical condition before transfer to another facility. At the patient's request, or if the hospital
is unable to stabilize the patient's condition, the hospital can arrange for transfer to appropriate level of
care.
(Basically it is a federal law that requires anyone coming to an emergency department to be stabilized and
treated, regardless of their insurance status or ability to pay.)
Explain the Health Insurance Portability and Accountability Act (HIPAA)
HIPAA was enacted to provide individuals with preexisting medical conditions access to health insurance
specifically if they changed or lost their job. The other element of HIPAA was to prevent health care
fraud and abuse and medical liability reform. The act also included a provision (known as the Privacy
Rule) for health information privacy requirements for individually identifiable health information. The
Privacy Rule protects the confidentiality of health information relating to the provision or payment of
health care for a past, present, or future physical or mental health condition but does permit the
“minimum necessary” use and disclosure of protected health information without patient authorization for
purposes of treatment, payment, and health care operations.
(Basically it is a legislation that provides data privacy and security provisions for safeguarding medical
information.)
Yoost
Chapter 25 Safety
Discuss safety concerns for each of the following
· Home-Poisoning (carbon monoxide, plants, household chems, medications, lead, toxins), fire
and electrical hazards, abuse, bioterrorism, suffocation and drowning
· Community- The same as home
· Health care environments- falls, restains, med administration errors, radiation, drug resistant
microorganism , procedural errors.
List Safety Interventions in the Home and Community- Pt education on safety and prevention.
The nurse should be able to identify possible concerns. Some interventions could include
installation of handles in showers, indoor and outdoor lights, poisoning prevention, fire
prevention, and fall prevention.
List Safety Interventions in the Healthcare Organization
Consistent with the focus of the QSEN project, nurses must possess the knowledge, skills, and
attitudes to maintain safety and prevent patient injury across health care settings. For example,
a nurse must have adequate knowledge of the variety of risk factors for falls, the skill to select
patient-specific interventions to prevent falls, and the attitude that falls can be preventable.
When nurses lack the necessary knowledge, skills, and attitudes to care for the population of
interest, the delivery of competent care is at risk, and legal issues related to patient safety may
result.
List each standard of the National Patient Safety Goals developed by The Joint Commission
• Identify patients correctly.
• Improve staff communication.
• Use medicines safely.
• Use alarms safely.
• Prevent infection.
• Identify patient safety risks.
• Prevent mistakes in surgery.
List the 6 Quality and Safety Education for Nursing (QSEN) competencies
Teamwork and collaboration knowledge are demonstrated when the nurse describes examples
of the impact of team functioning on safety and quality of care.
For a patient with safety concerns, members of the multidisciplinary team together address the
issues associated with safety-related nursing diagnoses. Team members work to accomplish
the goals set forth in what is commonly referred to in hospital settings as an interdisciplinary
plan of care (IPOC). The nurse may implement several safety interventions:
• Educate the patient and family about the role of protective-equipment use in injury prevention
when individuals are engaged in contact sports.
• Collaborate with the social worker to identify community resources for obtaining inexpensive or
free protective equipment.
• Educate the patient and family about the importance of removing clutter, throw rugs, cords,
and obstacles from the floor and the path of the patient.
• Collaborate with the social worker to identify community resources to install appropriate
supportive equipment in the home.
• Educate the patient and family on the importance of and strategies for preventing children from
gaining access to household poisons.
• Collaborate with social services for the scheduling of periodic home safety inspections.
Jarvis
Describe the correct assessment techniques of the abdomen
Inspection: Abdomen flat, symmetric, with no apparent masses. Skin smooth with no striae,
scars, or lesions.
Auscultation: Bowel sounds present, no bruits.
Palpation: Abdomen soft, no organomegaly, no masses, no tenderness.
Percussion: Tympany predominates in all 4 quadrants, liver span is 8 cm in right MCL. Splenic
dullness located at 10th intercostal space in left midaxillary line.
Describe the appropriate assessment techniques for inspection, palpation, percussion, and
auscultation of the abdomen
These should be performed in this order, and follow the route of the colon. You should start in
the in the lower right quadrant(LRQ), upper right quadrant(URQ), upper left quadrant(ULQ), and
than lower left quadrant(LLQ)
Define and compare acute and chronic pain
Acute pain is short term and self-limiting, often follows a predictable trajectory, and dissipates after an
injury heals. Examples of acute pain include surgery, trauma, and kidney stones. Acute pain has a selfprotective purpose; it warns the individual of actual or threatened tissue damage. Incident pain is an acute
type that happens predictably when certain movements take place. Examples include pain in the lower back
on standing or whenever turning a hospitalized patient from side to side.
In contrast, chronic (persistent) pain is diagnosed when the pain continues for 6 months or longer. It
can last 5, 15, or 20 years and beyond. Chronic pain can be divided into malignant (cancer-related) and
nonmalignant. Malignant pain often parallels the pathology created by the tumor cells. The pain is induced
by tissue necrosis or stretching of an organ by the growing tumor. It fluctuates within the course of the
disease. Chronic nonmalignant pain is often associated with musculoskeletal conditions such as arthritis,
low back pain, or fibromyalgia.
Chronic pain does not stop when the injury heals. It persists after the predicted trajectory. It outlasts its
protective purpose, and the level of pain intensity does not correspond with the physical findings. Chronic
pain originates from abnormal processing of pain fibers from peripheral or central sites.
Review Jarvis CH15
Identify structure, function and assessment techniques for the Ears and list lifespan
considerations


sensory organ for hearing and maintaining equilibrium
It has three parts:
o external ear
 called the auricle or pinna
 consists of movable cartilage and skin
o middle ear


o
contains tiny ear bones, or auditory ossicles: the malleus, incus, and stapes.
3 Functions:
 (1) it conducts sound vibrations from the outer ear to the central
hearing apparatus in the inner ear;
 (2) it protects the inner ear by reducing the amplitude of loud sounds;
and
 (3) its eustachian tube allows equalization of air pressure on each
side of the tympanic membrane so the membrane does not rupture
inner ear



embedded in bone
not accessible to direct examination, but can assess its functions
contains the bony labyrinth
 holds the sensory organs for equilibrium and hearing
 within bony labyrinth, the vestibule and the semicircular canals
compose the vestibular apparatus, and the cochlea contains the
central hearing apparatus
Lifespan
Infants and Children
o
o
The inner ear starts to develop early in the 5th week of gestation
In early development the ear is posteriorly rotated and low set;
 later it ascends to its normal placement around eye level. If maternal
rubella infection occurs during the first trimester, it can damage the organ
of Corti and impair hearing.

infant's eustachian tube is shorter and wider, position is more horizontal
o thus it is easier for pathogens from the nasopharynx to migrate through to the
middle ear



The lumen is surrounded by lymphoid tissue, which increases during childhood
These factors place the infant at greater risk for middle ear infections than the adult
The infant's and the young child's external ear canals are shorter and have a slope
opposite to that of the adult's
Adult

Otosclerosis is a common cause of conductive hearing loss in young adults between the
ages of 20 and 40 years
o a gradual bone formation that causes the footplate of the stapes to become fixed in
the oval window, impeding the transmission of sound and causing progressive
deafness.
Elderly

ilia lining the ear canal become coarse and stiff
o this may cause cerumen to accumulate and oxidize, reducing hearing.
o The cerumen itself is drier because of atrophy of the apocrine glands.
o life history of frequent ear infections also may result in scarring on the drum

Presbycusis: type of hearing loss that occurs with 60% of those older than 65 years
o gradual sensorineural loss caused by nerve degeneration in the inner ear that slowly
progresses after the fifth decade.
 first notices a high-frequency tone loss
 harder to hear consonants than vowels
 speech information is lost, and words sound garbled
 ability to localize sound is impaired
Review Jarvis CH16
Identify structure, function and assessment techniques for the Nose, Mouth and Throat and list
lifespan considerations
Nose: figure 16-1 to 16-3
 first segment of the respiratory system
 warms, moistens, and filters the inhaled air
 sensory organ for smell
Only the maxillary and ethmoid sinuses are present at birth.
 maxillary sinuses reach full size after all permanent teeth have erupted
 ethmoid sinuses grow rapidly between 6 and 8 years of age and after puberty
 frontal sinuses are absent at birth, are fairly well developed between 7 and 8 years of age,
and reach full size after puberty
 sphenoid sinuses are minute at birth and develop after puberty
The nose develops during adolescence, along with other secondary sex characteristics. This growth
starts at age 12 or 13 years, reaching full growth at age 16 years in females and age 18 years in
males.
Gradual loss of subcutaneous fat starts during later adult years, making the nose appear more
prominent. The nasal hairs grow coarser and stiffer and may not filter the air as well. The sense of
smell may diminish after age 60 years because of a decrease in the number of olfactory nerve fibers.
Mouth: figure 16-4 and 16-5


the first segment of the digestive system and an airway for the respiratory system
oral cavity is a short passage bordered by the lips, palate, cheeks, and tongue
o contains the teeth and gums, tongue, and salivary glands


mouth contains three pairs of salivary glands
o glands secrete saliva, the clear fluid that moistens and lubricates the food bolus,
starts digestion, and cleans and protects the mucosa.
Adults have 32 permanent teeth—16 in each arch
In the infant salivation starts at 3 months. The baby drools for a few months before learning to
swallow the saliva.
Both sets of teeth begin development in utero. Children have 20 teeth. These erupt between 6 and
24 months of age. All 20 teeth should appear by years of age. The deciduous teeth are lost
beginning at 6 years through 12 years of age. The permanent teeth appear earlier in girls than in
boys, and they erupt earlier in Black children than in White children.
Oral cavity: the soft tissues atrophy, and the epithelium thins, especially in the cheeks and tongue.
This results in loss of taste buds, with about an 80% reduction in taste functioning.
Throat



area behind the mouth and nose
Tonsillar tissue enlarges during childhood until puberty and then involutes
The oral cavity and throat have a rich lymphatic network
Tongue in children are larger than throat
Module 6 Review Guide
Giddens
Concept 44: Health Promotion
Define and describe Health Promotion
Health promotion is defined as the process of enabling people to increase control over, and to
improve, their health. Health promotion requires the adoption of healthy living practices and often
necessitates a change in behavior.Health promotion is viewed broadly as behaviors that promote
optimal health across the lifespan within an individual, family, community, population, and
environment
Describe each of the following health promotion strategies and give examples of each
·
Primary Prevention
Primary prevention refers to strategies aimed at optimizing health and disease prevention. The
focus is on health education for optimal nutrition, exercise, immunizations, safe living and work
environments, hygiene and sanitation, protection from environmental hazards, avoidance of
harmful substances (e.g., allergens, toxins, and carcinogens), protection from accidents, and
effective stress management.
EXAMPLE: Avoiding smoking helps to promote health and reduce the individual's risk for
pulmonary, cardiovascular, and immunologic disease.
·
Secondary Prevention
The goal of secondary prevention is to identify individuals in an early state of a disease process so
that prompt treatment can be initiated. Early treatment provides an opportunity to cure, limit
disability, or delay consequences of advanced disease. Secondary prevention measures typically
involve screening tests
EXAMPLE: Screenings for cancer and sexually transmitted diseases such as HIV.
·
Tertiary Prevention
Tertiary prevention involves minimizing the effects of disease and disability; the focus of tertiary
prevention is restorative through collaborative disease management. The aim is to optimize the
management of a condition and minimize complications so that the individual can achieve the
highest level of health possible.
EXAMPLE: Aerobic exercise is used as a primary prevention strategy to maintain health, but it
may be a specific weight loss intervention for the obese patient or a rehabilitation strategy following
an acute myocardial infarction.
Concept 55: Health Care Organizations
Define and describe Health Care Organizations:
A purposefully designed, structured social system developed for the delivery of health
care services by specialized workforces to defined communities, populations, or
markets.
Explain the difference between Profit and Non-Profit Health Care Organizations: For Profits are
business or investment driven whereas Non-Profits are more service driven, For-profit hospitals
pay property and income taxes while nonprofit hospitals don’t. And for-profit hospitals have
avenues for raising capital that nonprofits don’t have.
List a Health Care Organizations in Florida that are for Profit: Memorial Hospital
List a Health Care Organizations in Florida that are Non-Profit: Florida Hospital
List a Health Care Organizations in Florida that operate by Charity Donations: The Donna
Foundation
List a Health Care Organization in Florida that operate by completely Government funding
What are the major attributes of health care organizations? HCOs are distinguished from other
types of organizations by their unique purpose (to help others by providing health care services),
by their specialized workforce, and by a level of public trust that separates HCOs from other
types of organizations.
What are the minor attributes of health care organizations? The minor attributes of HCOs differ
from major attributes in terms of HCOs' relationship to other kinds of organizations. The major
attributes of HCOs are identified with health care and the health care services sector. The minor
attributes of HCOs are those that define them as forms of purposeful organizations and are
features they share in common with other types of organizations.
List nursing contributions to successful Health Care Organizations: Nursing contributions to
successful HCOs go beyond providing bedside, patient-focused care to include active
management and administration of patient care and patient units, conducting research and
collaborating with other professionals to coordinate and deliver safe and effective patient care.
Nurses work as case managers, infection control specialists, managers of information
technology, human resources specialists, and quality/risk managers. Nurses are also directors
and executives, advanced practice providers, and administrative specialists in HCOs and HCO
networks. Furthermore, professional nurses affect the environments of HCOs by creating
partnerships with other institutions, educating future nurses in universities and community
colleges, and working with public policy decision makers to create policies that enhance health
services environments. It is likely that professional nurses will be associated in some way with
HCOs for most, if not all, of their professional nursing careers.
Concept 56: Health Care Economics
Define and describe Health Economics
Health care economics focuses on how people deal with scarcity and finite resources, it is defined as
a behavioral science that begins with two propositions about human behavior:
1) Human behavior is purposeful or goal directed, implying that persons act to promote their own
interests.
2) Human desires and demands are unlimited, especially for something such as health care.
Health care economics represents the availability (or scarcity) of healthcare resources and
financing, or payment mechanisms, to pay for these resources.
Define and describe each of the following payer systems:
·
Managed Care Organizations
In managed care, health care providers and insurance companies assume a part of the financial
responsibility for health care. Patients pay a monthly premium for health care insurance. Patients
choose from several different plans under the managed care system, including preferred provider
organizations (PPOs) and health maintenance organizations (HMOs). Patients receive health care
from a list of providers who participate in the PPO or HMO.
·
Private or Indemnity Health Insurance
Private health insurance may be purchased on a group basis (e.g., by a firm to cover its employees)
or purchased by individual consumers. Most Americans with private health insurance receive it
through an employer-sponsored program. Nearly 60% of Americans are covered through an
employer, whereas approximately 9% purchase health insurance directly.An example of private
indemnity health insurance that can be purchased either by an employer for its employees or by an
individual is that provided by the Blue Cross Blue Shield Association.
·
Medicare
Medicare provides health care coverage for all people ages 65 years or older, people who are
permanently disabled, and individuals with end-stage renal disease. It is a federal health insurance
program that individuals or their spouses have paid into through employment or self-employment
taxes.Medicare includes hospital insurance (Part A), supplemental medical insurance (Part B),
Medicare Advantage plans (Part C), and outpatient prescription drug coverage (Part D).
·
Medicaid
Medicaid is the nation's major public health insurance program for low-income Americans.
Enacted in 1965, Medicaid has improved access to health care for low-income individuals, financed
innovations in health care delivery, and functioned as the nation's primary source of long-term care
financing. Medicaid is funded by state and federal government sources such as legislative
appropriations, intergovernmental transfers, certified public expenditures, permissible taxes, and
provider donations. Medicaid eligibility is determined by income and need.
Define and explain the Patient Protection and Affordable Care Act (PPACA)
One of the major impacts on health care economics in recent years has been the PPACA. The goal
of the PPACA is to help provide affordable health insurance coverage to most Americans and to
improve access to primary care. The PPACA is expected to cover an estimated 32 million uninsured
Americans. Without the PPACA, the Census Bureau estimates the number of uninsured persons
would reach to more than 60 million or one out of five U.S. residents.The Congressional Budget
Office (CBO) estimates that 95% of legal U.S. residents will be covered under the legislation,
including the aforementioned 32 million who otherwise would have been uninsured. According to
the Kaiser Foundation, the following are some of the law's major provisions:
• The requirement that most U.S. citizens and legal residents have health insurance by 2014
• The creation of state-based exchanges through which individuals can purchase coverage,
with
subsidies available to lower income individuals
• A major expansion of the Medicaid program for the nation's poorest individuals
• The requirement for employers to cover their employees or pay penalties, with exceptions for
employers with few employees
• New regulations on health plans in the private market requiring them to cover all individuals,
regardless of health status
• Establishment of a national, voluntary insurance program for purchasing community living
assistance services
• Increases in payments for primary care services
• Greater support for prevention, wellness, and public health activities
Yoost
Chapter 11: Ethical and Legal Considerations
Define and describe the Concept of Ethics
Compare the following ethical principles or legal issues and give examples of each:
· Deontology vs Utilitarianism Medical ethics is a sensible branch of moral philosophy and
deals with conflicts in obligations/duties and their potential outcome. Two strands of thought
exist in ethics regarding decision-making: deontological and utilitarian. ... In brief, deontology is
patient-centered,will not allow the parents to stay because it is against the rules, whereas
utilitarianism is society-centered. Utilitarians consider consequences to be an important
indicator of the moral value of one's actions
· Beneficence vs Nonmaleficence- Beneficence is the act of doing good. Nonmaleficence is
doing no harm or the least amount of harm.
· Malpractice vs Negligence -negligence is doing something that a reasonable person would
not do, or not doing something that a reasonable person would do. Malpractice is the
negligence on a professional level.
· Battery vs Assault - verbal threats vs actually harming/attacking a person. Assault is pulling a
gun. Battery is shooting or hiting someone with the gun.
· Slander vs Libel - spoken defamation of character vs written defamation of character
Define each of the following ethical principles and give examples of each:
· Fidelity- loyalty, fairness, truthfulness, advocacy, and dedication to our patients. It involves
an agreement to keep our promises
· Justice -giving each person or group what he/she or they are due. It can be "measured" in
terms of fairness, equality, need
· Veracity - being truthful
· Autonomy - making independent decisions in regards to one's own health
· Accountability - accepting responsibility for actions
Chapter 23: Public Health, Community Health and Home Health Care
Define Community Health
Addresses issues of health, disease, and disability found within a defined group of people (or
population) or in a specific person as a member of that community.
Define and describe the focus of each of the following community health systems:
· Public Health Nursing
Examines the greater community as a whole and designs collaborative and interdisciplinary
strategies to keep the population healthy by preventing or controlling disease and threats to human
health.
· Community Health Nursing
Focuses on interventions necessary to help people prevent illness, maintain or regain their health, or
die with dignity while living in a community.
The term client, rather than patient, is commonly used in this area of nursing practice to identify the
person seeking care.
· Home Health Nursing
Promote, maintain, or restore health at an optimal level of functioning and to reduce the effects of
disability and illness for individual clients and their families.
Module 1: Thermoregulation
1. Radiation- heat loss through electromagnetic waves that emit heat from skin to air
Which are modes of heat loss in the newborn? Select all that apply.
a. Radiation
b. Urination
c. Convection
d. Conduction
e. Evaporation
(a,c,d,e)
https://quizlet.com/76385452/nclex-thermoregulation-questions-flash-cards/
2.
Convection- loss of heat by air currents moving across body (wind, fan)
What is the definition of CONVECTION?
a.
When heat transfers through waves.
b.
When heat transfers from objects that are touching.
c.
movement in a gas or liquid in which the warmer parts move up and the colder
parts move down
d.
Heat traveling from the sun
https://quizizz.com/admin/quiz/580a687d14bfe25871d0b884
3.
Conduction- transfer of heat through direct contact of one surface to another (sit on cold
bench) Recall question from first exam about cutting off wet clothes because of hypothermia.
4.
Evaporation- perspiration (sweating)
5.
Respiration- air is inhaled, warmed, exhaled
Risk factors for population:
 Infants (96-99.5)
1 yr old temp range (99.4-99.7)
o Infants lose heat through fontanels; low body mass/surface area; don’t shiver
 Children (97-99)
o Appropriate clothing, playing “sport” outside, risk of dehydration
 Adults (95.9-99.5)
o drug/alcohol abuse, unlining health conditions, work/fun exposure, genetics,
economic status
 Elderly (95-99)
o
loss of sub Q fat, loss of temp sensation, poor perfusion and circulation, reduced
heat production and shiver response
https://quizlet.com/220763862/fundamentals-of-nursing-yoost-chapter-19-vital-signs-flash-cards/
Altruism- Pt comes first.
ANA standards of practice guide and direct the practice of nursing.
State Nurse Practice Acts define nurse’s scope of practice.
Physiological adjustments to body temp are controlled by the hypothalamus
Module 2: Perfusion
Be able to assess heart and lungs
 Heart (auscultate with diaphragm first for S1 and S2, use bell for murmurs)
o Right of Sternum 2nd intercostal- Aortic
o L Sternum 2nd Intercostal - Pulmonic
o L Sternum 4th Intercostal- Tricuspid
o L Sternum, 5th Intercostal Midclavicular- Mitral / Apical
 Lungs ( Listening for adventitious sound everywhere.)
o Anterior: Supraclavicular to 6th intercostal; Bronchovesicular sounds
o Posterior: Starting at the Apices C7 working you way around each shoulder blade
until T10. Listening for vesicular sounds
o Axilla: At the 7th and 8th intercostal space. Listening for vesicular sounds.
( There has been a question about crackles in a newborn baby lungs. This is normal
because of the amniotic fluid being breathed in during pregnancy.)
Poor gas exchange & appearance of patient with conditions
 Gas Exchange: process by which oxygen is transported to cells and CO2 is transported
from cells.
The nurse is caring for a patient who is slow to awaken following general
anesthesia. The patient is breathing spontaneously but is minimally responsive
and having difficulty maintaining a patent airway. Which intervention is the most
appropriate for the patient to improve oxygenation?
a
a.
Insert an oral airway.
b. Lower the head of the bed.

c
c. Turn the patient’s head to the side.
d
d. Monitor the patient’s pulse oximetry.
Disorders: Asthma (acute), Pneumonia, COPD, Emphysema (chronic) [causes: smoking,
family history, air pollution]
Which of the following conditions would be associated with a wheezing
sound on inspiration in a patient's lower posterior chest?
a. Myocardial infarction
b. Congestive heart failure
c. Pulmonary edema
d. Asthma
https://quizlet.com/229315510/chapter-38-oxygenation-and-tissueperfusion-yoost-critical-thinking-flash-cards/

Examples of Deficiencies:
o Hypoxia: insufficient oxygen reaching cells (There was a question on the first
exam about this)
o Anoxia: total lack of oxygen in tissue
o
Hypoxemia: reduced oxygenation of arterial blood
A nurse has assessed a patient's capillary refill, which was 5 seconds. What action by
the nurse is most appropriate?
a. Document the findings and continue the examination.
b. Ask the patient about the use of artificial nails.
c. Ask the patient about his/her occupation.
d. Assess the patient for signs of hypoxia.
Oxygenation
 Perfusion: ability of blood to transport oxygen-containing hemoglobin to cells and return
carbon-dioxide containing hemoglobin to alveoli
The nurse is explaining to a student nurse about impaired central perfusion. The
nurse knows the student understands this problem when the student states,
"Central perfusion
a. is monitored only by the physician."
b. involves the entire body."
c. is decreased with hypertension."
d. is toxic to the cardiac system."
https://quizlet.com/157998015/concept-15-flash-cards/
Pulses & the ranges
 Carotid, Brachial, Radial, Femoral, Popliteal, Dorsalis Pedis, Posterior Tibial, Apical
 Ranges: 0 to +3, Regular or Irregular
Blood flow
 Vena Cava→R Atrium→Tricuspid Valve→R Ventricle→Pulmonic Valve→ Pulmonary
A.→ Lungs→Pulmonary Vein→L Atrium→Mitral Valve→L Ventricle→Aortic
Valve→Aorta to body
5 Rights of Delegation (what you can delegate)
 Task/job
 Person
 Situation
 Directions
 Evaluation
“The Pie Station Deserves Eating”
The Communication Process:
Referent- event or thought initiating conversation
Sender- person who initiates and encodes the communication
Receiver- person who receives and decodes or interprets the communication
Message- information that is communicated
Channel- method of communication (any of the 5 senses can be used to communicate
ex: pt calls for help=auditory, pt’s wound smells=olfactory)
Feedback- the response of the receiver
Edward Hall’s Theory of Proxemics:
 Intimate Space (0 - 1.5 ft)
 Personal Space (1.5 - 4 ft) (Americans)
 Social Space (4 - 12 ft)
 Public Space (12 ft or more)
93% of communication is nonverbal
Module 3: Communication
Know Professional Communication & examples:
Interpersonal: communication between you and another person
Intrapersonal: communication within self
Interdisciplinary: communication between nurse and doctor
Intradisciplinary: communication between nurse to nurse
Transcommunication: spiritual communication
Therapeutic communication: attentive listening, non- judgemental, calm, thoughtful.
Non-Therapeutic communication: Judgemental, opinionated, and aggressive.
Documentation:
Guidelines of documentation
- accessible, accurate, timely, clear, concise, complete and objective
- non-judgemental and factual
- Should be written in order of how events happened
- should occur as soon as possible after event
- Every entry should include date, time, and signature with credentials
(These are all PROBLEM-ORIENTATED examples of documentation)
 SOAP: Subjective (HH), Objective (HH), Assessment, Plan (Nursing Interventions)
 SOAPIE: Subj., Obj., Assessment, Plan, Intervention, Evaluation
 SBAR: (communication w/DR)
Situation- what is happening right now?
Background- what led up to the current situation?
Assessment- what is the identified problem, concern, or need?
Recommendation- what actions or interventions should be initiated to alleviate the
problem
Which note is an example of the S in SBAR?
a. Patient resting; 1 hour after receiving narcotic analgesic pain was rated 3 of 10
b. Patient was admitted on evening shift with a fractured right femur after a fall at home.
c. Patient's pain was rated 8 of 10 before administration of narcotic pain medication.
d. Assess pain every 2 hours, continue pain medication as prescribed, and provide
backrub.


PIE: Problem, Intervention, Evaluation
Narrative: tell a story, includes “patient quotes”
chronologic charting, w/ a baseline recorded on a shift-by-shift basis, time
consuming & includes lengthy notes

DAR: Data, Action, Response
Informatics: Refer to handout from class
Critical Thinking: education, experience, attitude
Learning Requirements: ability, desire, attitude & environment
Module 4:
Nursing Dx:
 Actual Dx
o PES = Problem, Etiology, Signs/Symptoms
o Acute Pain r/t Injury to Femur AEb pain scale 8/10
 Potential/Risk Dx
o PE= Problem, Etiology
o “Risk for” Fall r/t unsteady gait
For a school-age child who enjoys riding a bicycle, which is the priority nursing
diagnosis?
a. Risk for injury
b. Risk for falls
c. Risk for impaired skin integrity
d. Risk for impaired mobility

Health Promotion Dx
o PS= Problem, Signs/Symptoms
o ”Readiness for enhancement”
The nursing diagnosis readiness for enhanced communication is an example of
a(n):
A) Risk nursing diagnosis.
B) Actual nursing diagnosis.
C) Health promotion nursing diagnosis
D) Wellness nursing diagnosis.
A nurse is assigned to a new patient admitted to the nursing unit following
admission through the emergency department. The nurse collects a nursing
history and interviews the patient. Place the following steps for making a nursing
diagnosis in the correct order.
__2___ 1. Considers context of patient's health problem and selects a related
factor
__3___ 2. Reviews assessment data, noting objective and subjective clinical
criteria
__4__ 3. Clusters clinical criteria that form a pattern
__1___ 4. Chooses diagnostic label
https://quizlet.com/162659783/fundamentals-of-nursing-nursing-diagnosis-flash-cards/
https://quizlet.com/224579324/chapter-12-nursing-diagnosis-flash-cards/
https://quizlet.com/188979470/chapter-17-nursing-diagnosis-flash-cards/
Nursing Process:
ADPIE
1. ASSESS: Objective & Subjective Date
2. DIAGNOSIS: Actual- PES; Potential- PE; Health Promotion-PS
3. PLAN: Short Term; Long Terms; S.M.A.R.T Goals
4. INTERVENTION: action taken
5. EVALUATION: Eval if goals were met; met, not met, partially met
The basic guideline used for nursing documentation is(this was similar to what was on a test)
a. HIPAA.
b. the Code of Ethics.
c. the Nursing process (assessment, diagnosis, planning, implementation, and
evaluation).
d. the patient's diagnosis.
ABCDEF & Maslow’s
1. Airways ( There was a question on the last test about a child with an empty bottle of
chemical next to a child. The answer is assess airway.DO NOT CALL POISON
CONTROL FIRST IN THIS CASE)
2. Breathing
3. Circulation
4. Drugs & Diet
5. Emotional Dx, coping mechanisms
6. Family
7.
In adults, healthy lymph nodes can be palpable (able to be felt), in the axilla, neck,
inguinal, arms.
Module 5: Safety
QSEN & The Joint Commission- safety regulation
 QSEN Competencies:
o Patient centered care; Teamwork & Collaboration; Evidence Based Practice;
Quality Improvement; Safety; Informatics.
The three elements of nursing competency described in the Quality and Safety
for Nurses (QSEN) initiative are knowledge, skill, and
a. Accountability.
b. Attitude.
c. Education.
d. Value.
What actions by the nurse are critical to ensure patient safety? (Select all that apply.)
a. Place the call light on the patient's nightstand.
b. Clean up fluid spills on the floor immediately.
c. Instruct the patient to wear socks when ambulating.
d. Keep linens and intravenous tubing off the floor.
e. Return the bed to low position prior to exiting the room.
Factors of safety:
 Environment:
1. Lighting
2. Pollution
3. Workplace hazard
4. Communicable Diseases
PPE:
On: Gown, mask, goggles, gloves
Off: Gloves, goggles, gown, mask
ANA- nursing code of ethics
Legislature makes Statutory Laws → gives state power to make Regulatory Laws
Florida Board of Nursing is regulated by Regulatory Laws in each State
 Outlines scope of practice for nursing
 Gives Licensure
National Patient Safety Goals:
 Identify patient correctly (2 identifiers)
 Use medications safely/Correctly
 Improve Staff Communication
 Prevent infection
 ID patient risks
 Prevent mistakes in surgery
 Use alarms correctly
 Prevent falls (new for 2018)- # 1 sentinel event
 Prevent bed sores (new for 2018)
Safety related test questions:
 The group with the lowest risk of MRSA are food service workers
 Conversations about safe sex are most important to the adolescent population.
 The nurse is taking a patient from the bath and patient starts to have a seizure. FIRST,
you should lower the patient to the floor if standing.
 If you leave equipment outside and have a confused patient in the room, get another
staff member to get the equipment so you don’t have to leave the room.
 “It feels like the room is spinning around me.” Vertigo
 80 yr old patient: not noticing vibrations at ankle, slower gait, impaired tactile sensation normal signs of aging
Cranial Nerves:
Number
What it does
Sensory or motor
1
Smell
Some
2
Optic
Say
3
Movement of eye
Marry
4
Eyes down and in
Money
5
Facial sensory and Jaw
But
6
Side to side move
My
7
Facial
Brother
8
Hearing
Says
9
Speech
Big
10
Gag
Boobs
11
Shoulders
Matter
12
Tongue movement
More
Legal Definitions:
1. Liable- written form of defamation
2. Slander- spoken form of defamation
3. Negligence- creating risk of harm by failing to do job
4. Malpractice- negligence committed by a person functioning in professional role
Example: having sex with a Pt
5.
Regulatory Law- out of how the requirements of Statutory Law will be met
6.
Policy- course of action adopted/proposed by a government party/business/individual
7.
Assault- threatening to harm
8.
Battery- actual physical harm
9.
EMTALA- An emergency room must stabilize you before sending you to a different
hospital regardless of your ability to pay.
10.
OmNiBus- Prevents physical and chemical restraints in your own home. This includes
nursing homes and long term care facilities.There was a question on the last test. I forgot how it
was worded. Just that the answer does not contain COBRA. But is the same as the one that
does say COBRA.
11.
COBRA- an insurance provision allowing you to keep insurance coverage if you leave a
job.
12.
Near miss- Caught the mistake before something bad happened.
13.
Adverse events- Something bad happening because of doing something wrong.
14.
R.A.C.E.- RESCUE the pts. Pull the ALARM. CONTAIN the fire. EXTINGUISH if safe.
15.
P.A.S.S.- PULL the pin. AIM the nozzle. SQUEEZE the handle. SWEEP the base of the
fire. ( spraying the top could cause the fire to spread)
Glasgow Coma Scale (Not a fall scale) Higher number is better
Abdomen: Inspect, Auscultate, Palpate, Percuss
Be familiar with basic organs in abdomen:
LRQ: Appendix, Ovary, Ureter, Spermatic cord
URQ: Kidney/adrenal gland (rests 1-2cm lower), Gallbladder, Ascending/Transverse Colon
LUQ: Kidney/adrenal gland, Liver, Pancreas, Spleen, Stomach, Transverse/Descending Colon
LLQ: Ovary, Ovary, Ureter, Descending/Sigmoid Colon
Dysphagia- difficulty swallowing (G=gag)
Dysphasia- difficulty speaking
https://quizlet.com/182004261/chapter-25-safety-yoost-flash-cards/
https://quizlet.com/142132077/test-1-ethicslegal-giddens-health-law-summer-flash-cards/
Module 6: Ethics
Values- priority that has been instilled by external factors (society, family, friends, cultural) &
adopted within (there was a question on the last test about where there values come from on
the last test)
Ethical Principle- concept used to make decisions; how to apply values
Ethical Dilemma- when 2 ethical principles cause conflict *needs a question still*
involves a problem for which in order to do something right you have to do something
wrong. It is not possible to meet all of the ethical requirements in the situation. For
instance, determining whether aggressive treatment at the end of life will cause more
harm than benefit.
7 Principles
 Autonomy: freedom to make decisions supported by knowledge & self confidence
Test question: Goals must be mutually acceptable to the nurse, patient, and family.




Accountability: willingness to accept responsibility for actions
Justice: acting fairly and equitable (providing fair tx. regardless of race, religion, class)
Fidelity: keeping your promises * needs a question still*
Veracity: being truthful
A male patient suffered a brain injury from a motor vehicle accident and has no brain
activity. The spouse has come up to see the patient every day for the past 2 months. She asks the nurse,
"Do you think when he moves his hands he is responding to my voice?" The nurse feels bad because she
believes the movements are involuntary, and the prognosis is grim for this patient. She states, "He can
hear you, and it appears he did respond to your voice." The nurse is violating which principle of ethics?
a. Autonomy
b. Veracity
c. Utilitarianism
d. Deontology

Non-Maleficence: inflicting least amount of harm possible to reach beneficial outcome
A homeless man presents to the emergency room with hypothermia. He
tells the nurse that he is positive for human immunodeficiency virus (HIV) and sought
revenge by deliberately having sex with his mate, who does not know of his HIV status.
This patient is violating which ethical principle?

Beneficence: doing good despite personal beliefs (ex: treating pt who abused a child)
A nursing student is doing a survey of fellow nursing students. Which ethical concept is
the student following when calculating the risk-to-benefit ratio and concluding that no harmful effects were
associated with a survey?
a. Beneficence
b. Human dignity
c. Justice
d. Human rights



Deontology: follow rules regardless of outcome
Utilitarianism: pick and choose which rules to follow to get desired outcome
Select all that apply
The nurse believes that a patient who states he is in pain is "faking it" and
is hoping to get high. The nurse decides to give the patient a placebo instead of pain
medication that was ordered for the patient. The nurse is violating which principle(s) of
ethics?
Autonomy
Utilitarianism
Beneficence
Veracity
Fidelity
Dentology
https://quizlet.com/236923744/giddens-concept-42-ethics-flash-cards/
https://quizlet.com/217066032/giddens-chapter-42-ethics-flash-cards/
https://quizlet.com/234605004/giddens-42-flash-cards/
https://quizlet.com/232766043/giddens-concept-42-quiz-flash-cards/
https://quizlet.com/147777427/week-2-giddens-concept-42-ethics-flash-cards/
Types of Hospitals:
 For Profit- pay taxes
 Not For Profit - don’t pay property taxes; charity level care


Charity- Bills insurance first, eats rest of cost; pays no taxes; organizes fundraising; Ex:
Shriners, St. Judes
Government- hospitals owned & operated by government; Ex: VA, state mental hospital
Medicare
 65+ age, Disabled, end of life renal failure; must have worked 1/10th of life to qualify;
Income does not matter; Federal care/Acute care
 Government funded
Medicaid
 Any age, low income; “State Funded”; largest population of users are elderly; Acute or
Chronic Care
PPO
 Preferred Provider Option; larger provider network, Private payer option,
Health Maintenance Organization


limited network; pre-arranged copays for services, can’t go to a specialist without a
referral from your primary care provider
Affordable Care Act
 Federally subsidized insurance; Marketplace offers plans
Prevention:
Primary
 Does not have disease; no greater risk than general population
 Taking measures to prevent disease, i.e. diet & exercise, vaccines, washing hands
An example of a primary prevention strategy to prevent obesity is to
1. a. hold an education event about healthy eating habits and exercise. Make this a
mandatory part of a fun education day for students and families.
2. b. screen for BMI and send letters home to parents of identified at-risk children.
3. c. instruct an obese child with type 2 diabetes about diabetes medication and blood
glucose monitoring.
4. d. instruct an obese child with type 2 diabetes about blood glucose monitoring; children
should not handle their own medications.
For the example below the primary prevention would be never smoking in the first place.
Secondary
Screenings are always secondary prevention
 Screening for disease (Screenings DO NOT PREVENT disease, allow for early
detection)
 Controlling disease
 Screen people that are at higher risk than general population
 If you are obese, diet and exercise are secondary because they are preventing diabetes
A 65-year-old male patient has been a one-pack-per-day smoker for 40 years. He was
recently diagnosed with early-stage chronic obstructive pulmonary disease (COPD) and
would like to attend a smoking cessation class. The nurse recognizes smoking
cessation as which level of prevention for this patient?
a. Primary prevention
b. Secondary prevention
c. Statutory prevention
d. Tertiary prevention
Tertiary
 Already has disease, symptoms of disease
 Prevention of additional complications & comorbidities
If we use the same COPD example but this time we would be giving O2 to help him breathe the
answer would be tertiary prevention.
Module 1 Review Guide
Giddens
Concept 45 Communication
Define and describe the concept of communication.
A process of interaction between people in which symbols are used to create, exchange, and
interpret messages about ideas, emotions, and mind states.
linguistic—the verbal exchange of messages through spoken words and written symbols.
paralinguistics—nonverbal exchange of symbols.
Metacommunication—consists of the factors that comprise the context of the message.
Metacommunication factors that affect how messages are received and interpreted include
internal personal states (e.g., disturbances in mood), environmental stimuli related to the setting
of the communication, and contextual variables (e.g., the relationship between the people in the
communication episode).
Explain Communication Competence.
Communication competence in nursing means that communication is both effective and
appropriate.
Effectiveness is achieved when the goals of the communication are met. Appropriate means the
communication has been adapted to the people and situation involved in the act of
communication.
Assertive communication refers to a process in which positive and negative ideas and feeling
are expressed in an open and direct way.
Therapeutic communication is defined as “an interactive process between the nurse and the
client that helps the client overcome temporary stress, to get along with other people, to adjust
the unalterable, and to overcome psychological blocks which stand in the way of selfrealizations.”
Part of an internal perspective, intrapersonal communication takes place within the individual.
Embedded in relationships, interpersonal communication is the verbal and nonverbal interaction
that occurs among human beings. Many types of interpersonal relationships exist, including
friendships, family, romantic, and, in nursing practice, nurse–patient relationships.
Concept 50 Health Care Quality
Define and describe the concept of Health Care Quality.
Health care quality applies within the realm of health care delivery in any public or private
setting. Whatever structures, systems, and processes an organization establishes, it must be
able to show evidence that standards are upheld.
What are the attributes of Health Care Quality.
A fundamental attribute inherent in the concept of health care quality is that you cannot improve
what you cannot or do not measure.
• Safe • Effective • Timely • Patient-centered • Efficient • Equitable
Describe quality in terms of structure, process and outcome.
Avedis Donabedian defined quality as values and goals present in the medical system and
defined outcomes as a validator of the quality and effectiveness of medical care.
Structure is defined as the attributes of settings in which care is delivered. These include the
adequacy of facilities, equipment, supplies, staff training, provider knowledge and attitudes, and
supervision.
Process dimensions include the services offered; the technical quality of the services (i.e., the
staff and providers perform the technical aspects of the task or job)
Outcomes are the impact of structure and process on the patient's satisfaction; perceptions of
quality, knowledge, attitudes, and behavior; and health outcomes.
Concept 2 Functional Ability
Define and describe the concept of Functional Ability.
Functional ability refers to the individual's ability to perform the normal daily activities required to
meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain
health and well-being. Specifically, it reflects the adaptive dimension of development, which is
concerned with the acquisition of a range of skills that enable independence in the home and in
the community. For the purposes of this concept analysis, functional ability is defined as the
cognitive, social, physical, and emotional ability to carry on the normal activities of life.
Identify situations that increase the risk for functional impairment (risk recognition).
Functional impairment and disability refers to varying degrees of an individual's inability to
perform the tasks required to complete normal life activities without assistance.
There are multiple risk factors for impaired functional ability because of the multiple variables
that impact function, including developmental abnormalities, physical or psychological trauma or
disease, social and cultural factors including beliefs and perceptions of health, and physical
environment.
Explain functional ability in terms of basic activities of daily living (BADL) and instrumental
activities of daily living (IADL).
ADLs as indicators of functional ability evolved in the late 1950s with the identification of a
group of basic physical activities, the performance of which was to be used to evaluate the
success of rehabilitation programs. A decade later, IADLs were identified as indicators of ability
to live independently in the community. This led to the use of ADLs as a measure of need and
eligibility for long-term care and other support services and to the development of an array of
assessment tools.
Describe aspects of a functional assessment.
Comprehensive functional assessment is a time-intensive, interprofessional effort requiring use
of multiple assessment tools. Comprehensive functional assessment is indicated under specific
circumstances.
The two basic types of assessment tools are self-report and performance-based. Self-report tools
provide information about the patient's perception of functional ability, whereas performancebased tools involve actual observation of a standardized task, completion of which is judged by
objective criteria. Performance-based assessments are preferred because they avoid potential for
inaccurate measurement inherent in self-report.
What does care delivery involves in terms of functional ability?
Functional level determines the patient's need for assistance as well as the type and amount of
assistance required.
Functional Assessment Components: vision, hearing, mobility, fall history, continence, nutrition,
cognition, affect, home environment, social participation, ADLs.
No assistance, partial assistance, or total assistance are examples of common options related to
dependency used when scoring functional assessment tools. Common scoring options related to
difficulty are some, a lot, or unable to perform.
Concept of Thermoregulation
Define and describe the concept of thermoregulation.
Thermoregulation is defined as the process of maintaining core body temperature at a near
constant value.
Normothermia refers to the state in which body temperature is within the “normal” range. The
term hypothermia refers to a body temperature below normal range (<36.2°C), and hyperthermia
refers to a body temperature above normal range (>37.6°C). An extremely high body
temperature is referred to as hyperpyrexia.
Identify factors that place individuals at risk for thermoregulation.
Risk factors that affect thermoregulation include age, environment, and physiological condition
of the individual.
Individuals with impairments in cognition, surgeries, preexisting medical conditions, genetics,
recreational or occupational exposures, persons under influence of alcohol or drugs, poor
nutrition.
Identify assessment findings for hyperthermia and hypothermia.
When an individual has hyperthermia or hypothermia, the most reliable means available for
assessing core temperature is a rectal temperature.
Hyperthermia: Vasodilation occurs, causing the skin to appear flushed and warm or hot to touch.
If the sweat mechanism has been activated, the individual will be diaphoretic. Patients will often
present with dry skin and mucous membranes, decreased urinary output, and other signs of
dehydration and electrolyte imbalance. Seizures may occur and the patient's cognitive status may
range from slightly confused or delirious to coma.
Hypothermia: Peripheral vasoconstriction causes the skin to feel cool and have slow capillary
refill; skin color is pale and becomes cyanotic. Muscle rigidity and shivering is typically present
in an effort to generate heat. The shivering response diminishes or ceases when the core
temperature decreases to 30°C. Cognition is affected because of a gradual reduction in cerebral
blood flow. A person may experience poor coordination and sluggish thought processes at 34°C;
this progresses to confusion and eventually stupor and coma by the time the temperature
decreases to 30°C. Dysrhythmias (e.g., atrial and ventricular fibrillation) may occur due to
myocardial irritability. As hypothermia progresses, the metabolic rate declines and perfusion of
blood is significantly reduced, leading to diminished urinary function, coma, and cardiovascular
collapse.
Describe clinical management in terms of primary prevention, secondary prevention and
collaborative interventions.
Primary: prevention through education and planning ahead. Primary prevention measures
include environmental control and shelter, appropriate clothing for different conditions, and
physical activity.
Secondary: the goal of secondary prevention refers to the detection of a disease or condition.
Collaborative: (Hyperthermia) The underlying cause of the elevated body temperature should be
identified. The goal is to minimize cardiovascular and neurologic complications associated with
excessive body temperature.
The goal of managing hypothermic patients is to increase the body temperature to the normal
range. An initial step is to remove the individual from the cold.
Yoost
Chapter 1
What is the criteria of a profession as applied to nursing?
Altruism, Accountability, Autonomy, Advocate, Assertiveness, Ethics
The study of nursing requires a broad base of knowledge from the physical and behavioral
sciences, humanities, nursing theories, and related non-nursing theories.
Functions/Roles: care provider, educator, advocate, leader, change agent, manager,
researcher, collaborator, delegator.
Provide an overview of the following nursing theorist:
Florence Nightingale - Nightingale is considered the founder of modern nursing and is known for
her care of the sick in the Crimean War. Her contributions influenced developments in the field
of epidemiology by connecting poor sanitation with cholera and dysentery. Her role in nursing
included establishing nursing as a respected profession for women that was distinct from the
medical profession. She founded a nursing school and stressed the need for university-based and
continuing education for nurses. Her concept of the environment emphasized illness prevention,
clean air, water, and housing. Her nursing theoretical work discussed environmental adaptation
with appropriate noise levels, hygiene, light, comfort, socialization, hope, nutrition, and
conservation of patient energy.
Linda Richards - America's first trained nurse, graduating from Boston's Women's Hospital in
1873.
Dorothea Dix - the head of the U.S. Sanitary Commission, which was a forerunner of the Army
Nurse Corps.
Lena Higbee - superintendent of the U.S. Navy Nurse Corps, was awarded the Navy Cross in
1918.
Clara Barton - practiced nursing in the Civil War and established the American Red Cross.
Jean Watson - theory is based on caring, with nurses dedicated to health and healing. The nurse
functions to preserve the dignity and wholeness of humans in health or while peacefully dying.
The caring process in a nurse-patient relationship is known as transpersonal caring and includes
carative factors that satisfy human needs. Additional concepts include the caring moment or
occasion, caring or healing consciousness, and clinical caring processes such as sensitivity and
mindfulness.
Imogene King - developed a general systems framework that incorporates three levels of
systems: (1) individual or personal, (2) group or interpersonal, and (3) society or social. The
theory of goal attainment discusses the importance of interaction, perception, communication,
transaction, self, role, stress, growth and development, time, and personal space. In this theory,
the nurse and the patient work together to achieve the goals in the continuous adjustment to
stressors.
Explain how Maslow hierarchy of needs is used in nursing practice.
The nurse's understanding of these factors helps with formulating nursing diagnoses that address
the patient's needs and values. Needs at the lower levels of the pyramid-shaped hierarchy must
be met before needs at higher levels are addressed.
Physiological Needs, Safety and Security, Love and Belonging, Self-Esteem, Self-Actualization
What are the functions of the following organization?
Quality and Safety Education for Nurses (QSEN) - adds safety as a competency. The six QSEN
competencies are patient-centered care, teamwork and collaboration, evidence-based practice,
quality improvement, safety, and informatics.
Institute of Medicine (IOM) - outlined five core areas of proficiency for students and
professionals: delivering patient-centered care, working as part of an interdisciplinary team,
practicing evidence-based medicine, focusing on quality improvement, and using information
technology.
Describe the National Patient Safety Goals.
• Identify patients correctly • Improve staff communication 18 • Use medicines safely • Use
alarms safely • Prevent infection • Identify patient safety risks • Prevent mistakes in surgery
Explain the following terms:
· Altruism – public service over personal gain
· Accountability – accepting responsibility for actions and omissions
· Autonomy – Make independent decisions within their scope of practice and are responsible
for the results and consequences of those decisions
·
·
·
Advocate
Assertiveness
Ethics – standard of right and wrong behavior
Describe the standards of practice and the nurse practice act.
The Standards of Nursing Practice published by the ANA help to ensure quality care and serve as
legal criteria for adequate patient care. ANA standards have two parts. The first part, the
standards of practice, includes six responsibilities for the nursing process: assessment, diagnosis,
outcomes identification, planning, implementation, and evaluation (ANA, 2010).
The second part of Standards of Nursing Practice focuses on professional performance, which
includes ethics, education, evidence-based practice and research, quality of practice,
communication, leadership, collaboration, professional practice evaluation, resource utilization,
and environmental health (ANA, 2010). Nurses who attend continuing education conferences or
further their education; use evidence to guide their nursing practice; or communicate and
collaborate with patients and other professionals are practicing within the standards.
Chapter 3
Define the following terms:
· Rationalization
· Suppression
· Sublimation
· Displacement
· Denial
· Regression
· Referent
· Feedback
· Collaboration
· Respect
· Assertiveness
· Delegation
· Message
· Suppression
· Displacement
What is the goal of the nurse patient relationship?
Describe nonverbal communication in terms of body language.
Describe verbal communication in terms of setting, context, content, written and electronic.
Explain the focus of the four basic types of professional communication:
· Intrapersonal
· Interpersonal
· small-group
· public communication
Identify each phase of the nurse-patient relationship and the focus of each phase.
Differentiate between social, therapeutic and nontherapeutic communication
What is the focus of therapeutic communication and techniques used to by the nurse to promote
open dialogue.
What are the special communication considerations for patients who are hearing and visually
impaired?
Chapter 19
Define the following terms:
· Afebrile
· apical pulse
· apnea
· core temperature
· fever
· hypertension
· hyperthermia
· hypotension
· hypothermia
· orthostatic hypotension
· pulse deficit
What is the purpose of obtaining vital sign?
Describe each of the following:
· Baseline Vital Signs
· Frequency of Vital Signs
· Interpretation of Vital Signs
What are situations that require vital sign assessment?
Normal vital sign parameters for:
· Temperature
· Pulse
· Respirations
· Blood Pressure
Practice techniques to obtain temperature, pulse, respirations, blood pressure (Yoost – skills
19.1, 19.2, 19.3, 19.4, 19.5
Chapter 26
What is the purpose of hand hygiene?
Practice hand hygiene technique (Yoost – skill 26.1)
Practice procedure for applying personal protective equipment (Yoost - 26.3)
Jarvis
Chapter 4
Describe each part of a health history
Biographic Data - name, address, and phone number; age and birth date; birthplace; gender;
marital partner status; race; ethnic origin; occupation; language
Source of History - Record who furnishes the information; Judge how reliable the informant
seems and how willing he or she is to communicate; Note if the person appears well or ill
Reason for Seeking Care* - brief, spontaneous statement in the person's own words that
describes the reason for the visit
Present Health or History of Present Illness - For the well person, this is a short statement about
the general state of health: “I feel healthy right now.” For the ill person, this section is a
chronologic record of the reason for seeking care, from the time the symptom first started until
now.
-location, character/quality (descriptive terms), timing, setting, aggravating/relieving factors,
associated factors, patients perception.
Past Health - Past health events are important because they may have residual effects on the
current health state. Childhood illnesses, accidents/injuries, serious/chronic illnesses,
hospitalizations, operations, obstetric hx, immunizations, last exam date, allergies, current
medications.
Family Health - accurate family history highlights diseases and conditions for which a particular
patient may be at increased risk.
Review of Systems - The purposes of this section are (1) to evaluate the past and present health
state of each body system, (2) to double-check in case any significant data were omitted in the
Present Illness section, and (3) to evaluate health promotion practices.
-
General overall health state, head to toe assessment.
Functional Assessment - Functional assessment measures a person's self-care ability in the areas
of general physical health or absence of illness; ADLs such as bathing, dressing, toileting, eating,
walking; instrumental ADLs (IADLs) or those needed for independent living such as
housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances;
nutrition; social relationships and resources; self-concept and coping; and home environment.
subjective data—what the person says about himself or herself.
objective data—what you observe through measurement, inspection, palpation, percussion, and
auscultation.
10- Math
5-7 Pharm 3 packet
Majority Urinary system
Normal urine Output: 1500mL per day. (I have seen some stuff today that says 1500mL)
1st sign of renal failure: protein in urine (losing muscle)
Kidneys and Liver are biggest component in filtration in the body.
Should not be in urine:
 WBC- sign of UTI
 Protein - is a sign of kidney or liver disease,
 Blood- hematuria- could be because of trauma or illness
 Sugar- sign of renal failure or diabetes
Sugar must be over 250 in order to show up in urine. Level should be 80-130 two hours after
eating with insulin patients.
Kidneys produce 30mL per hour. Normal adult Output is 60mL per hour.
Labs (normal & lethal levels):
 BUN- Blood Urea Nitrogen - this is a blood test. It is often used with creatinine to
measure kidney function. Normal BUN is 7-20 mg/dl.
o Cause of Decrease: Malnutrition, excessive intake of fluids, decreased intake of
proteins
 Creatinine - for women normal is 0.6-1.2 mg/dland for men the normal is 0.8-1.4mg/dl , a
high creatinine level is indication of kidney damage or disease.It is a blood test with a
timed urine is the waste product cleared through the kidneys. When the kidneys begin
to fail creatinine levels rise. “Generally 1.0 mg/dl is normal”
 UA- checks for several things, this is a clean catch and a sterile container needs to be
used, refer to yoost for the steps to a “clean catch” “midstream” collection.
o Color - should be a amber-yellow
o Odor- similar to ammonia
o pH- should be slightly acidic with a pH of 6
o Specific gravity- 1.005-1.030
o Glucose - negative (kidney failure or diabetes)
o Ketones - negative (formed by improper protein break down)
o Protein- negative ( kidney failure, if preg this is used to check for preeclampsia)
o Bilirubin- negative (sign of liver issues)
o Cast- negative
o Bacteria- none (UTI)
o Hemoglobin- negative (trauma or illness)
o Myoglobin- negative
o Culture for organisms- none
 Culture & Sensitivity - sterile techniques used to collect sample if pt is cathed, the pt
should use a clean catch midstream collection, checking for growth of bacteria, if
bacteria is found the sensitivity is used to find the best treatment ( If C&S is done on
urine it is checking for a UTI)
Diagnostics:
Know purpose of exam
Know if used- dye, anesthesia, NPO/Special Diet
 Colonoscopy- You are put into kind of a twilight, it make you lose your memory and tell
truth w/o being prompted. A camera is passed through the rectum to view the large
intestine(colon). Biopsies and polypectomies can be performed with this procedure
o Before





Cleansing
Liquid diet 24 hours before (no red,orange,or purple liquids)
Some meds may need to be withheld
NPO 4-6 hours before



Moderate sedation
May get meds to relax smooth muscle
After
o
o
o
o
o



Monitor vitals
Bed rest till alert
Monitor bowel sounds
Passing gas, abdominal fullness, and mild cramping are normal
Report bleeding
Flexible Sigmoidoscopy
Occult Blood/Guiac/Hemoccult
Endoscopy - sedated- a camera is passed down the esophagus to view the gastric wall,
sphincters, and duodenum, tissue samples can be taken.
o Before
 NPO for 8 hours
 Spray or gargle used to numb the area
 Meds to reduce secretions and maybe relax smooth muscle
 Position pt on left side to help with saliva drainage
 Monitor airway and O2 stats

After
o
o
o
o
o







Monitors vitals
NPO until gag reflex return
Monitor signs of perforation
Bed rest till alert
Lozenges , saline gargle, oral analgesics for throat pain
Bladder Scan - nothing is needed for this. It is a simple scan done an emergent situation
just to tell if there is fluid in the bladder.
Bladder Ultrasound - non invasive way of measuring how much fluid is in the bladder b/c
of frequency, inability to urinate, and amount of residual fluid.
Upper GI (check for shellfish allergy)- this is the same reason you check for a CT
w/contrast, The contrast is produced with Iodine. Shellfish produces iodine. Same thing
as endoscopy
Barium Swallow- exam done using a fluoroscopy and the pt drinks barium sulfate.Upper
GI tract study
o Before- do not eat for 8 hours before the test,
o After 
may need a laxative
 Increase water to help pass barium
 Stool may be white as barium passes
Colostomy o
There are 4 types of colostomies
 D escending- Left side of the abdomen - poop is starting to firm
 A scending - right side of the abdomen - watery and foul smelling
 T ransverse - midline upper quadrants- still lose but firmming
 S igmoid-left lower quadrant - firm like “normal” stool
Ileostomy- this is to bring the small intestine to the surface of the abdomen to divert
stool. It is placed in the left lower quadrant at the ileocecal valve.
Urinary Diversion




Stool for O&P
Urine or Stool for C&S
MRI
CT Scan
o Blockage
o NPO 12hrs prior
o Laxatives, sedatives
 IVP
 Cystoscopy- Checks the mucosa in the bladder, it is looking for inflammation, tumors, or
calculi, If there is no biopsy planned then there doesn’t need to be any prep,
o After
 May have burning on urination, pink or tea colored urine, frequent
urination
 Increase fluids
 Deep breathing exercises to relieve bladder spasms
 PRN analgesics(pain meds)
 Sitz or tub bath for pain
 Leg cramps are common b/c of lithotomy position
 Check for bright red urine or clots, fever, increase WBCs could be
infection
o NPO 8-12hrs prior
o Difficulty urinating after, urine may be red or pink
 24- hour urine - does not have to be sterile this test does not check for the presents of
bacteria. It can check things like cleared creatinine, levels of hormones, protein, glucose
and other chemical compounds. This is a 24 hour collection, it doesn't matter what time it
is started, you MUST void the first elimination, then collect for 24 hours, at the 24 hour
mark the pt should void one last time and then turn it into the lab, Each test require
different storage instructions; such as testing for protein should be kept cold.
The stomach produces and secretes
 Hydrochloric acid - breakdown food & kills harmful bacteria ingested in foods
 Pepsin - enzyme produced to degrade protein
 Intrinsic factor - protein produced for the intestines to absorb vitamin B12
 Mucus - protects the stomach mucosa
Medication Administration: (Rev. ch 34&35)
 6 Rights of Medication
 Types of needles
 Length of needles in table
 Volume & Location in table
 Pinch or Z-track method
o Sub Q- is pinch
o IM - is Z-track- helps lock the injection into the muscle
 Slide the tissue to the side, give injection, release tissue
o ID- stretch the skin using thumb and forefinger


Bevel up or down
o Sub Q - up
o ID - up
IM and SubQ


Location of injections in chart
Angles of injections
o Sub Q Pinch and inch = 90° angle
 Otherwise it will a 45° angle
o ID 5 - 15° angle
o IM- 90°
Non-parenteral Med Administration:


G tube/ Peg tube - liquids and crushed meds
J tube - liquids only
Know Medication Rounding Rules:
 Leading by 1, go to tenth only: 1.5
 Leading by 0, go to hundredth: 0.55
 ALWAYS go to hundredth for weight- kg : 22.55lbs
How to calculate I & O:
 INPUT- convert all liquids and IV into mL
 Subtract Output from Input.
 Within 500mL difference is healthy. Over 500mL is not healthy.
Catheters:
 Locations
o Indwelling catheters have a high chance of infections
 Susceptible to infections
Know -ostomy
 Ascending colostomy: fecal output is liquid in consistency, with a pungent odor, and the


stoma is located in the upper right quadrant of the abdomen
Descending colostomy: produce increasingly formed stool; located on left side of the abdomen
Ileostomy: produce liquid stool but with less odor because enzyme activity is not present;
located at the end of the Ileum and bypasses the large intestine
Colon job: absorb water/ fluid balance
Intestines: digestion
Basic Urinary Anatomy
Vocabulary:
 Anuria: Output of 50-100mL in 24hrs
 Nocturia: Excessive urination at night








Dysuria: Painful urination
Enuresis: The involuntary passing of urine
Oliguria: Output of 100-500mL in 24hrs
Hematuria: Blood in the urine
Polyuria: Excessive production and excretion of urine (2500mL urine per day)
Stress Incontinence: Loss of urine control during activities that increase intraabdominal
pressure
Overflow Incontinence: A constant dribbling of urine or frequency in urination
Urge Incontinence: Sudden strong desire to void, followed by rapid bladder contraction
Urine Color Changes:






Tea-colored or brown: Metronidazole (Flagyl), Liver disease, Hepatitis, Cirrhosis
Blue-green: Tagamet, Indocin, Promethazine (Remsed, Phenergan), Asparagus
Orange: Rifadin, Warfarin (Coumadin), Phenazopyridine (Pyridate, Pyridium)
Red or Pink: diet including beets or blackberries and if blood is present in the urine, which may
be secondary to an enlarged prostate or kidney stones
Clear: overhydrated
UNIT 1 & 2: Development, Inflammation, Immunity, Infection
https://quizlet.com/207293410/nurse-360-chapter-18-human-development-young-adult-toolder-adult-flash-cards/
Erikson's Theory (8 Stages): psychosocial development of an individual across the lifespan
1. Trust versus Mistrust: Birth to 18 mo. ---- Caregiver must meet all needs of the child
Could develop trust issues later in life if they do not have a consistent caregiver.
2. Autonomy versus shame and doubt: 18 mo to 3 yr---- Child strives to make decisions for
himself or herself. Restrictive parents can cause children to develop shame and doubt. Give
choices within boundaries.
3. Initiative versus guilt: 3 to 6 yr---- Child explores his or her world and abilities (running,
jumping, throwing).
Restricting play or imagination can cause development of guilt.
4. Industry versus inferiority: 6 to 12 yr---- Child refines skills acquired previously and
develops a peer social network that exerts great influence on him or her.
Develop inferiority due to high expectations of self: real or imaginative.
5. Identity versus role confusion: 12 to 18 yr---- Adolescent explores and integrates multiple
roles: student, athlete, child, adult. Emotional fluctuation and stress are common as the
adolescent struggles to sort out his or her identity.
Education, sexual, occupational- result in confusion.
6. Intimacy versus isolation: 18 to 35 yr---- Person searches for a partner who supports and
complements him or her. Starting a family is common.
Fail to find partner results in isolation.
7. Generativity versus stagnation: 35 to 55 yr---- Person seeks involvement in creative and
meaningful work and transmits culture and values to younger generations. To be successful in
this stage of life people must reach beyond their families, There community and social become
more important to them. Becoming involved with volunteering and outreach programs would be
an example of meeting your milestone at this age group.
8. Integrity versus despair: 55 yr and beyond---- Person reviews life events and accepts the
finality of death.
If feeling of failure, it can affect sense of integrity, regret.
Piaget's Theory of Cognitive Development(4 Stages): how children innately organize their
world and learn to think.
1. Sensorimotor: (Birth to 2 yr ) The child explores the environment by using the senses.
2. Preoperational: (2 to 7 yr) The child begins to use images and symbols to represent
the world; is still unable to repeat mentally what he or she can do physically.
3. Concrete operational: (7 to 11 yr) Logical reasoning gradually replaces intuitive
thought.
4. Formal operational: (11 yr & beyond) The person refines his or her ability to think
logically; is capable of abstract thought.
3 MONTHS
7 MONTHS
12 MONTHS
Raises head and chest when prone
Rolls from front to back and from back to
front
Gets to sitting position without assistance
Brings hands to mouth
Sits with support and then without it
Crawls forward on belly, using arms and legs to
push
Follows a moving object with eyes
Transfers object from one hand to another
Assumes hands-and-knees position
Smiles at the sound of caregiver's
voice
Responds to own name
Uses pincer grasp
Smiles socially
Uses voice to express pleasure
Says “da-da” and “ma-ma”
Babbles
Finds partially hidden objects
Tries to imitate words

Maslow’s Hierarchy of Needs
ABC’s- Airway, Breathing, Circulation - if asked what intervention or assessment to complete
first think ABC
Health Belief Model
 3 primary components
1. Perception of susceptibility
2. Perception of the seriousness of the illness
3. Probability that the individual will act to prevent “ avoidable health risk”

main constructs influences. Models suggest that people are more motivated to take action
if they have certain beliefs or experiences:
1. They are susceptible to the condition ( Perceived susceptibility)
2. Condition has a serious consequences ( Perceived severity)
3. Taking action would reduce the susceptibility or severity (Perceived benefit)
4. They are exposed to factors that prompt action, such as media campaigns, postcard
reminders, and advice from others ( Cues of action)
5. They have confidence in their ability to perform an action ( Perceived self-efficacy)
Informatics:
EHR: Electronic health record. Life long record that follows patient.
EMR: Electronic medical record. Record of specific visit.
HIPAA
PHARM 1 & 2 PACKET
 Therapeutic index- The safety margin for a drug.
 Hepatic first pass - This is the amount of the drug that is absorbed by the stomach and small
intestine.
 Bioavailability- how much of the drug reaches circulation. Only drugs given through IV are
100% bioavailable
 Half-life - the amount of time it takes for half of the drug to be eliminated by your body
 Pharmacodynamics- what a drug does to a pt body after the other 2 phases have been completed.
o Onset, Peak, Duration, Trough, Loading Dose
Rights of drug Administration
1. Patient
2. Drug
3. Dose
4. Route
5. Time
Routes of Meds1. Parenteral ( By injection or infusion)
a. IV
b. IM (intramuscular)
c. ID (intradermal)
d. Sub-q
2. PO- orally - by mouth
3. Suppository -rectally
4. Buccal- against the cheek
5. Sublingual - under the tongue
6. Topical- on skin or mucous membrane
7. Inhaled - inhalers
All medication orders must have
1. Date
2. Time
3. Drug name
4. Dose
5. Route
6. Frequency
7. Duration
8. EVERY order must be signed by the ordering health care provider.
Before giving a med you should always ask 5 questions
1.
2.
3.
4.
5.
Name
DOB
Allergies?
Have you had this med before
If it was an injection where?
Anti Inflammatories
a.
Inflammation is cause by tissue damage (injury/pathogen) that release chemical mediators
i.
Histamine- Arrives first, causes dilation of arterioles and redness ( think allergic reaction)
ii.
Kinis - causes pain
iii.
Prostaglandins - vasodilation and fever at site
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COX-cyclooxygenase- is an enzyme, it converts arachidonic acid into prostaglandins
causing pain and inflammation, there are 2 types
o Cox-1 - protects the stomach and regulated the platelets.
o Cox-2 - promotes inflammation and causes pain
 All 1st gen NSAIDS are non-selective meaning they are COX-1 and
COX-2
 Only 2nd gen NSAIDS(Celebrex) are selective to COX-2 (platelets and
stomach lining are unaffected)
NSAIDs- nonsteroidal anti-inflammatory drug - will inhibit COX
o Elderly are PRIME USERS of NSAIDs
Anti Infectives- C&S must be done before first dose is given.
o Penicillins (PCN) - derived from fungus/molds, This classification has the most allergic
reaction. Bacteria produce an enzyme called beta-lactamase or penicillinase to destroy
PCNs, there are 4 types.
 Natural (penicillin G)- oldest, used more b/c they are better
 Aminopenicillins- $$$ but more effective, are not penicillinase resistant. Most
common is Amoxicillin
 penicillinase -resistant penicillins - used on staph infections (methicillin) only
since they are not killed by the penicillinase enzyme. Become resistant to it with
MRSA, given IV or IM
 Extended spectrum penicillins- works on hard to treat G- bacteria. Mainly
pseudomonas, not penicillinase resistant Ex:piperacillin and ticarcillin.
 Cephalosporin ( Keflex, Rocephin,Mefoxin)- similar molecular structure as PCNs. Watch for
nephrotoxicity, pseudomembranous colitis and seizures

Macrolides ( Zithromax, Erythromycin)- go to drug for pt w/PCN allergies. Erythromycin is
destroyed by stomach acid, salt is added to aid in absorption, they are harsh on the GI system.
Both can cause problem with Kidney and auditory sense, Monitor BUN& Creatinine and whisper
test.
Chronic Infections
 HIV: mutation that occurs during cell replication. It is the CD-4 cells.
 Symptoms- tired, malasis, flu like symptoms, they are very non descriptive could be
taken as symptoms for just about anything else.
 HAART meds
 3 modes of transmission
Know Isolation types
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Contact:
Dropet:
Airborne:
CDiff:
HIV:
Aseptic: clean
Sterile: surgical
MRSA
flu
TB
wash hands with soap and water
only passed through saliva, blood, breast milk, vaginal/genital secretions
Chain of Infection
-broken by washing hands
1. Infectious agent ( pathogen)
2. Susceptible host
3. Reservoir
4. Portal of exit- feces, saliva, blood
5. Mode of transmission
6. Portal of entry- broken skin, sex
https://quizlet.com/212565487/isolation-flash-cards/
https://quizlet.com/167924282/the-chain-of-infection-flash-cards/
PPE ON:
1. Wash hands
2. Gown
3. Mask
4. Goggles
5. Gloves
PPE Removal:
1. Gloves
2. Goggles
3. Gown
4. Mask
R.I.C.E for inflammation (Rest, Ice, Compress, Elevate)
Most effective within 24-48hr period after injury
No more than 20 mins at a time
Diagnostic Testing
CBC (Complete Blood Count)- Infection. include the RBC count, hemoglobin level, hematocrit, RBC
indices, WBC count, and differential WBC count.
normal range is 4,500 to 10,000 cells per microliter (cells/mcL).
WBC(white blood count): infection Normal is less than 4500 cells per microliter
Culture & Sensitivity: identifies invading pathogen and how to treat it
C-reactive protein (CRP): detects elevated C-reactive protein (a substance produced by the liver in the
presence of inflammation in the body) Normal is less than 1.0 mg/L, Anything over that increases risk of
heart disease.
MRI:
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can give a better visualization of blood vessels and joints without radiation exposure.
Can detect inflammation in soft tissues, such as inflammation of pancreas.
Nothing metal can go inside room/machine
CT Scan: provides cross sectional images of organs. Can detect appendicitis and inflammation in colon.
Inflammation- not all inflammation has infection but all infection has inflammation.
o 5 cardinal signs of inflammation
1. Redness (histamine)
2. Heat (prostaglandins)
3. Swelling (histamines)(prostaglandins)
4. Loss of movement/function (kinins) (prostaglandins)
5. Pain (kinins)
 A temp for infection will not show up for 36 - 48 hours after surgery/ invasion.
 Inflammation is secondary response to infection
UNIT 3: Elimination
https://quizlet.com/209855953/chapter-40-bowel-elimination-flash-cards/
https://quizlet.com/209975024/chapter-41-urinary-elimination-flash-cards/
Labs
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BUN- often used with creatinine to measure kidney function. Normal BUN is 7-20 mg/dl.
Creatinine - women: 0.6-1.2 mg/dl; men:0.8-1.4mg/dl. high creatinine level is indication of
kidney damage or disease.
UA- clean catch and a sterile container needs to be used
o Color - amber-yellow
o Odor- similar to ammonia
o pH- 6
o Specific gravity- 1.005-1.030
o Glucose - negative (kidney failure or diabetes)
o Ketones - negative (formed by improper protein break down)
o Protein- negative ( kidney failure, if preg this is used to check for preeclampsia)
o Bilirubin- negative (sign of liver issues)
o Cast- negative
o Bacteria- none (UTI)
o Hemoglobin- negative (trauma or illness)
o Myoglobin- negative
o Culture for organisms- none
Culture & Sensitivity - sterile technique. use a clean catch midstream collection, checking for
growth of bacteria, if bacteria is found the sensitivity is used to find the best treatment ( If C&S is
done on urine it is checking for a UTI)
24 hour urine - checking input and output. 1st urine in toilet; time starts at 1st urine. 2nd urine 24 hour period is collected. Anyone can take to lab. Ensure no paper in container. Remember to
discard first void when starting the time. Failure to collect one sample result in restarting the test.
STOOL IS NOT STERILE- does not need to be in sterile container
Colon job: absorb water/ fluid balance
Small Intestines: digestion/ absorption of nutrients
Stomach: breaks down the food to allow the small intestine to digest it.
Vocabulary:
 Anuria: Output of 50-100mL in 24hrs
 Nocturia: Excessive urination at night
 Dysuria: Painful urination
 Enuresis: The involuntary passing of urine
 Oliguria: Output of 100-500mL in 24hrs
 Hematuria: Blood in the urine
 Polyuria: Excessive production and excretion of urine (2500mL urine per day)
 Stress Incontinence: Loss of urine control during activities that increase intraabdominal pressure
 Overflow Incontinence: A constant dribbling of urine or frequency in urination
 Urge Incontinence: Sudden strong desire to void, followed by rapid bladder contraction
Normal output: 1500mL
Nonsensical fluid loss
Fluid lost through feces: 200mL
Fluid loss from respiration/sweating: 500mL
Diagnostics
Catheters:
 Locations
o Indwelling catheters have a high chance of infections
 Susceptible to infections
 Condom catheter is not sterile- do not need sterile gloves
IVP - Intravenous pyelogram ( can also be called Intravenous Urography)
A radiological procedure use to look for abnormalities in the urinary system ..( X-rays)
There is contrast so you will want to ask for allergies before the test.
May need to use an emema or laxative before.
May be food or fluid restrains (when I had one I did not )
There is information on page in Saunders it is called a Intravenous Urography
Know -ostomy
 Ascending colostomy: fecal output is liquid in consistency, with a pungent odor, and the stoma is
located in the upper right quadrant of the abdomen
 Descending colostomy: produce increasingly formed stool; located on left side of the abdomen
 Ileostomy: produce liquid stool but with less odor because enzyme activity is not present; located
at the end of the Ileum and bypasses the large intestine
 D descending
 A ascending
 T transverse
 S sigmoid
Ememas:
1. Cleansing- empty bowel, remove feces through fluid; peristalsis stimulation
2. Hypertonic: osmotic pressure draws out fluid in interstitial spaces
3. Isotonic: expands colon and promotes peristalsis
4. Oil retention: oil/lubricate the rectum and colon
5. Medication: used to treat infections
6. Carminative: provide relief from gastric distension
7. Return-flow: provide relief from gastric distension
Nursing Diagnoses
• Impaired Urinary Elimination related to microorganisms in the urinary tract as evidenced by
urgency, frequency, and reports of burning with urination
(Although not directly related to urinary elimination, associated nursing diagnoses such as Risk for
Impaired Skin Integrity, Risk for Infection, Disturbed Body Image, Ineffective Coping, and Pain
may be appropriately assigned to patients experiencing urinary elimination concerns.)
• Urinary Retention related to post anesthetic state as evidenced by absent urinary output, lower
abdominal distension, and residual urine evident on bladder scan
• Toileting Self-Care Deficit related to neuromuscular impairment as evidenced by right-sided
paralysis, inability to perform proper toileting hygiene, and inability to manipulate clothing
during toileting
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Overflow urinary incontinence -characterized by the involuntary release of urine from an
overfull urinary bladder, often in the absence of any urge to urinate.
Reflex urinary incontinence-occurs when the bladder muscle contracts and urine leaks
(often in large amounts) without any warning or urge. This can happen as a result of
damage to the nerves that normally warn the brain that the bladder is filling.
Stress urinary incontinence -happens when physical movement or activity — such as
coughing, sneezing, running or heavy lifting — puts pressure (stress) on your bladder.
Urge urinary incontinence -is a sudden and strong need to urinate. You may also hear it
referred to as an unstable or overactive bladder, or detrusor instability, nocturia is often
seen with this,
Bowel elimination Nursing Diagnosis
Risk for constipation
Risk for Diarrhea
Risk for bowel incontinence
Goals for the resolution of elimination problems are structured around maintaining normal
elimination patterns, returning to previous levels of function, preventing associated risks, or coping
with an altered pattern. The nurse and the patient should work collaboratively to create
individualized goals specific for the diagnosis and prioritized according to the patient's need, which
may initially have a psychosocial focus. Expected outcomes are related to satisfactory management
of incontinence, complete emptying of the bladder, and independent management of toileting
tasks.
Short-term goals may include:
• Patient will report resolution of UTI symptoms within 5 days of taking prescribed antibiotic
treatment.
• Patient will spontaneously empty bladder completely without assistance within 12 hours after
surgery.
• Patient will effectively wipe self with left hand after urination within 5 days.
Long-term goals associated with urinary elimination concerns may include:
• Patient will perform self-catheterization without developing a UTI for 6 months after urinary
diversion surgery.
• Patient will demonstrate care of urinary diversion before discharge from the hospital.
• Patient will demonstrate ability to safely perform toileting tasks without assistance within 9
months of developing left-sided weakness secondary to a severe cerebrovascular accident.
Interventions that assist the patient in achieving the goals, including, but not limited to,
continence, complete emptying of the bladder, and self-care in toileting. The focus of each goal
is directly related to the identified nursing diagnosis, which in turn determines what
interventions are most appropriate for each patient. The nurse must focus on activities that will
help the patient with compromised urinary elimination return to the normal state of function or
adapt to changes in the state of function. Nursing interventions to help patients achieve urinary
continence and complete emptying of the bladder and independent toileting include promoting
adequate fluid intake, teaching self-care activities, and assisting with voiding. Collaborative
interventions require the assistance of the PCP or other professionals, such as a physical
therapist or nutritionist. Ongoing assessment and follow-up are needed to ensure quality in the
care provided and to determine need for further nursing interventions. Patient education is
crucial for maintaining urinary tract health. Before leaving the acute care facility, the patient
needs to demonstrate understanding and competency in assessment of the qualities and
characteristics of urine, home catheterization, toileting, fluid intake, and preventing UTIs.
MOD 3 PHARM
Diarrhea
 BRAT Diet- Bananas, Rice, Applesauce, Tea/Toast
Constipation
 Increase fluid intake
 Increase fiber in diet
 Increase activity
 Give laxatives as last resort
o Osmotic: pulls water into colon. Used for bowel prep (Milk of Mag)
o Stimulant: irritates intestinal wall (ExLax)
o Bulk-forming: absorbs water in intestine & increases peristalsis. Mix with full glass of
water, drink an additional glass- can cause intestinal obstruction. (Metamucil)
o Emollient: soften stools and lubricates for easier elimination (good for pts with Hx of
heart attack)
Contraindications for laxatives:
1. Inflammatory disorders of GI tract
2. Appendicitis
3. Diverticulitis
4. Ulcerative colitis
5. Spastic colon
6. Bowel obstruction
7. Can induce labor
UNIT 4 & 5: Fluid and Electrolyte Imbalance, Perfusion, Pain
Sodium (Na+): 135-145
Potassium (K+): 3.5-5.5 (cardiac)
Calcium (Ca+): 8.5-10.5 (cardiac)
Magnesium (Mg+): 1.3-2.1
Chloride (Cl-): 95-105
Paired Electrolytes
Sodium likes Chloride
Magnesium is antagonist to Calcium
Potassium follow Magnesium
Phosphorus and calcium are always opposite
Sodium like potassium
Chloride and Calcium
Chloride and potassium
https://quizlet.com/42013572/electrolytes-flash-cards/
https://quizlet.com/209715829/chapter-39-fluid-electrolytes-and-acid-base-balance-flash-cards/
Indication of imbalance: unexplained vomiting, diarrhea
Nursing Diagnosis for electrolyte/fluid imbalance
 Risk for electrolyte imbalance ( as related to diarrhea or vomiting)
 Readiness for enhanced fluid balance
 Deficient fluid volume (Dehydrated not drinking enough)
 Risk for deficient fluid volume
 Excess fluid volume (Fluid overloaded, pul edema, edema,overhydration )
 Risk for imbalanced fluid volume
Pain
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Referred: pain felt in another part of the body other than actual source
Psychogenic: pain that is perceived but has no physical cause
Radiating: pain that travels the length of the nerve
Somatic: injury to skin, bone, joints
Visceral: pain coming from an organ
Phantom: pain that occurs when the brain receives messages from an area of amputation
• Medication administration may not be delegated.
• Unlicensed assistive personnel (UAP) should report the following to the nurse:
• Changes in vital signs or any patient complaints or discomforts
• Medications found in the patient's room
• Patient questions regarding medications
• Collaborate with the pharmacist about medication questions before administration.
CAM
 Alternative - Alternative therapies take the place of pharmacologic interventions, and
complementary therapies are implemented to enhance the effect of pharmacologic treatment.
During the assessment process, nurses should inquire about the patient's use of herbal remedies to
avoid potential medication interactions if analgesics are included in the plan of care.

Complementary- Music therapy, massage therapy, physical therapy, and the services of health
care providers specializing in pain management provide exercise, muscle manipulation, and other
complementary therapies to manage pain in addition to medication.
 Modalities
a.
Physical based modalities- any therapeutic medium that uses the transmission of energy to or
through the pt, physical force such as heat, cold, pressure, water, light, sound, or electricity to help control
pain, not supposed to replace medical or other interventions, help the overall outcome
b.
Biologically based modalities- substance found in nature herbs, food, and vitamins.
c.
Mind-body based modalities -Acupuncture, massage,therapy, meditation, relaxation techniques,
spinal manipulation, and yoga, tia chi
d.
Multimodalities - therapies combined to treat pt.
UAP Delegation: The nurse can delegate unlicensed assistive personnel to perform nonpharmacologic
pain management techniques, such as administering back rubs, repositioning the patient, performing oral
hygiene, changing the linens, talking to the patient, and darkening the room, to help make the patient
more comfortable and assist in decreasing pain.
https://quizlet.com/237018966/cam-flash-cards/
https://quizlet.com/133569577/pain-and-communication-quiz-flash-cards/
Sleep
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Dyssomnia:
o Insomnia( Trouble getting to sleep), jet lag, obstructive sleep apnea, narcolepsy, restless
leg syndrome
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Parasomnia: nocturnal enuresis (bed wetting), sleep terrors (do not wake up), bruxism (teeth
clenching at night)
Nursing Diagnosis Related to Sleep
 Risk for insomnia
 Risk for sleep deprivation
 Risk for disturbed sleep pattern
https://quizlet.com/203624366/chapter-33-sleep-questions-flash-cards/
UNIT 6: Culture, Healthcare Quality, Communication, Informatics
I am not really sure what they are going to be asking on the test but I thought these links may be a good
place to start.
https://quizlet.com/195555830/fundamentals-of-nursing-yoost-chapter-21-ethnicity-and-culturalassessment-flash-cards/
https://quizlet.com/209561700/nurse-360-chapter-3-communication-flash-cards/
Race -is a socially constructed concept that tends to group people by common descent, heredity,
or physical characteristics.
Ethnicity - is the person's identification with or membership in a particular racial, national, or
cultural group and observation of the group's customs, beliefs, and language.
Culture - a pattern of shared attitudes, beliefs, self-definitions, norms, roles, and values that can
occur among those who speak a particular language or live in a defined geographical region.
Enculturation - the process by which a person learns the norms, values, and behaviors of a
culture, similar to socialization. Culture is passed from generation to generation.
Acculturation - the process of acquiring new attitudes, roles, customs, or behaviors as a result of
contact with another culture. Both the host culture and the culture of origin are changed as a
result of reciprocal influences.
Assimilation is the process by which individuals from one cultural group merge with, or blend
into, a second group. Group merges with another culture.
Socialization is the process of being reared and nurtured within a culture and acquiring its
characteristics.
Community- A group of people that have a common interest or identity
Generalization-is a statement, idea, or principle that has a broad application.
Stereotypes-a set of fixed ideas, often unfavorable, about members of a group.
Prejudice-is the process of devaluing an entire group because of assumed behavior, values, or
attributes.
Discrimination -refers to policies and practices that harm a group and its
members,discrimination may be de facto (practiced, but not legally sanctioned) or de jure
(legally sanctioned).
Racism- is an unfounded belief that race determines a person's character or ability and that one
race is superior or inferior to another.
 Ethnocentrism is the belief that one's own culture is superior to that of another while
using one's own cultural values as the criteria by which to judge other cultures
Rule of descent- Arbitrarily assigning a race to a person on the basis of a societal dictate that
associates society identity with ancestry
Transcultural nursing focuses on human caring–associated differences and similarities among
the beliefs, values, and patterned life ways of cultures to provide culturally congruent,
meaningful, and beneficial health care
 Emic perspective focuses on the local, indigenous, and insider's culture;
 Etic perspective focuses on the outsider's world, and especially on professional views
Culturally congruent care uses culturally based knowledge in sensitive, creative, safe, and
meaningful ways to promote the health and well-being of individual people or groups and
improve their ability to face death, disability, or difficult human life conditions
Cultural competence refers to the complex integration of a person's knowledge, attitudes,
beliefs, skills, and encounters with those of people from different cultures
Time Orientation: Past, Present, Future
Australian, British, and Chinese/Asian cultures tend to be time-oriented in the past
 People of these cultures tend to believe that if certain solutions worked for their
ancestors, such solutions will work for them.
African American and Hispanic cultures orient to the present are less likely to embrace
preventive health care
 Focused on the “here and now”
 Think of time in a linear fashion
 Run on “island time”
Middle-class Americans, regardless of ethnic or cultural origin, tend to be future-oriented
Spirituality- Expression of meaning and purpose in life (with-in you, purpose)
Religion- Provides a structure for understanding spirituality and involves rites and rituals within
a faith community.
Nursing Dx
• Spiritual Distress related to chronic illness as evidenced by expressions of hopelessness and
statements indicating concern over the recent inability to pray
• Impaired Religiosity related to illness as evidenced by difficulty adhering to religious dietary
customs and expressions of emotional distress over special diet restrictions
• Readiness for Enhanced Religiosity as evidenced by rejecting harmful customs and seeking
reconciliation with previously estranged family members
• Moral Distress related to cultural conflict between medical treatment and religious beliefs as
evidenced by expressions of concern about rejection by religious community and hesitation in
accepting blood transfusion
• Decisional Conflict related to unclear personal beliefs as evidenced by questioning of personal
beliefs while making decisions and delayed decision making
 Readiness for enhanced spiritual well-being
Nurses Roles:
Teacher, Leader, Advocate, Caregiver
Sentinel Events:
1. Falls are #1
2. Error by personnel
3. Equipment malfunction
4. Self-harm
Write an incident report. ONLY facts go in the chart- do not record that an incident report was
done.
Culture/Spirituality:
1. Know dietary and medication restrictions
2. Review reading guide for cultures: Asian, Muslim, Hindu, African American, Latino,
Jewish
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Hindu (vegetarian): monitor iron levels after surgery
Muslim: may refuse Elixir (do not consume pork or alcohol); fast during Ramadan
Orthodox Jewish: Sabbath (won’t use call button because religion forbids use of
technology); do not eat meat and dairy together; only eat vegetarian animals, cloven hoof,
or ritually slaughtered, fish with scales or fins
Vietnamese: family may bring food from home (allowed but make sure it follows diet)