Nursing foundations exam #4

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1

Patient interview

Orintation

working

termination

2

Standing order

Written by a physician and it lists specific actions to be taken by a nurse or other health care provider when access to a physician is not possible or when a care is common to a situation.

3

Five triage systems

Level 1- critical

level 2- emergent

level 3- urgent

level 4- nonurgent

level 5- fast tract

4

Focus assessment

Brief individualized physical exam conducted at the beginning of an acute care setting work shift

5

Comprehensive assessment

Includes thorough interview

health history

review of systems

extensive physical head to toe assessment

cranial nerves

6

Nurse educator

Ensures that patients receive sufficient info on which to base consent for care and related treatment

7

Change agent

Agent in a leadership role

8

Leader

Provides direction and purpose to others, builds a sense of commitment toward common goals. Communicates effectively, and assists with addressing challenges that arise

9

Manager

Manages all of the activities and treatments for patients

10

Professional identity in nursing

Sense of oneself that is influenced by characteristics, norms, and values of the nursing discipline and resulting in an individual thinking and feeling like a nurse

11

Delegator

The nurse delegates certain activities to other health care personal

12

Attributes and criteria

Doing

being

acting ethically

flourishing

changing identities

13

Being

Doing the right thing even when nobody is watching

14

Integrity

Following through with a pain meds

calling the MD when patient asks you to

checking the code cart by the prescribed time

giving meds within the 30 min window

15

Interrelated concepts

Clinical judgement

leadershio

ethics

communication

16

Deontology

Ethical theory that stresses the rightness or wrongness of an individual behaviors, duties and obligations

17

Beneficence

"Doing good"

18

Autonomy

Self determination

19

Utilitarianism

Maintains that behaviors are determined to be right or wrong solely on the basis of their consenquences

20

Reliability of POCT

Based on formal planning and systemic management to reduce errors and ensure the quality of patient testing

21

Recommend standards for POCT

Include routine assessment of the sampling practices, standarized evaluations of controls used in assessing the samples and review of the quality testing procesures

22

Scientific method

One approach to problem resolution. Is systemic, logical, and based on data collection and hypothesis testing

23

Nursing process

Requires critical thinking. Is based on assessments, diagnosis, planning, implementation and evaluation

24

Evaluation

Info including the reliability, credibility, and bias of the source is assessed

25

Analysis

Investigating plans of actions on the basis of examination of subjective and objective data

26

Inference

Making accurate conclusions that are based on sound reasoning

27

Critical decision making

Consistent use of the essential skills of critical thinking guides clinical decision making

28

Illogical thinking

Characterized by failure to follow rational, systematic processes when approaching an issue or problem

29

Bias

Inclination or tendency to favoritism or partiality

30

Leadership

Ability to influence and motivate others

31

SBAR

Charting technique

situation, background, assessment, and recommedation

nurse to physician interviews

32

Charting by exception

Documentation that records only abnormal or significant data

33

SOAPIE note

Subjective data, objective data, assessment, plan, intervention, evaluation

34

SOAP note

Subjective data, objective data, assessment, plan

35

Apie

Assessment, problem, intervention, evaluation

36

SOAPIER

Subjective data, objective data, assessment, plan, intervention, evaluation, revisions to plan

37

DAR note

Data, action, response

used to chart

38

Bureaucratic leader

Leader that assumes that followers are motivated by external forces

39

HIPPA

Federal standards for the protection of personal health information

40

Autocratic leader

Leader who exercises strong control over subordinates

41

Democratic leader

Leader that believes that employees are motivated by internal means and want to participate in decision making

42

Transformational leaders

Employ methods that inspire people to follow their lead

43

Laissez faire leader

Provides little or no direction to followers

44

Behavioral theories

Assume that leaders learn certain behaviors

45

Trait theories

Theories that assume that leaders are born with the personality traits necessary for leadership

46

Situational theories

Theory that leaders change their approach depending on the situation

47

Transactional leaders

Use reward and punishment to gain the cooperation of followers

48

Malpractice

Negligence committed by a person functioning in a professional role

49

negligence

Creating risk of harm to others by failing to do something

50

DNR-CC

Do not recuscitate, comfort care

51

Advanced directive

Living will- specifies treatment a person wants to receive when he or she is unconscious

durable power of attorney- legal document that allows a designated person to make legal decisions on behave of an individual

health care proxy- specifies the person who can make health care decisions for an individual

52

Euthanasia

Occurs when a person who willingly requests to die is injected with a lethal drug dosage by another individual

53

Assisted suicide

Occurs when a person causes his or her death with the assistance of medication or intravenous injection supplied by a physician or other health care provider

54

Clustering

Involves organizing patient assessment data into groupings with a similar underlying causes

55

Diagnosis label

Concise term or phrase that represents a pattern of related, clustered data. Taken from the official NANDA -I list

56

Components of nursing diagnoses

Diagnosis label

related factors

defining characteristics

57

Health promotions nursing diagnoses

Used in situations in which patients express interest in improving their health status. Through positive change in behavior

58

Veracity

Truthfulness

59

Nonmaleficence

First do no harm

60

Fidelity

Keeping promises or agreements made with others

61

Civility

Acting politely. Is essential in all intersections amoung faculty and nursing students

62

Code of ethics

Code of ethics- formalized statement that defines the values, morals, and standards guiding practice in a specific discipline or profession

63

Bioethics challenges in health care

Genetic testing

cloning and embryonic stem cell research

end of life care

64

Bioethics

Study of ethical and philosophical issues in biology and medicine

65

Sources of law impacting professional nursing

Constitutional, statutory, regulatory, and case law

66

Futile care

Care that is useless and prolongs the time until death rather than restoring life

67

Statutory law

Created legislative bodies such as the U.S congress and state legislature

68

Constitutional law

Derived from a formal written constitutional that defines the powers of government and that responsibilities of its elected or appointed officials

69

Case law

Historically referred to as common law because it originally was determined by customs or social mores that were common at that time

70

Regulatory law

Outlines how the requirements of statutory law will be met

71

Nurse practice act

Defines the nursing scope of practice in that state

72

Intentional torts

Wrong committed by individuals who deliberately seek to injure or hurt another person

73

Types of statutory law

Criminal, misdemeanor, felony, and civil law

74

Patient goals

All goals must be patient focused

realistic

measurement

75

Short term goals

Goals that are achievable within an immediate time frame of less than one week

76

Long term goals

Will take more time to achieve- weeks to months

77

Secondary data

Data obtained from reviewing a patients chart, medical records, results of labs, and diagnostic tests

78

Primary data

Data that comes directly from the patient

79

Researcher

Nurses concur research studies and apply research to practice

80

Referent

Event or thoughts initiating the communication

81

Sender

Person who initiates and encodes the communication

82

Receiver

Person who receives and decodes or interprets the communication

83

Message

Information that is being communicated

84

Channel

Method of communication

85

Feedback

Respons of the receiver

86

Encode

Translating their thoughts and feelings into communication with a receiver

87

Feedback

To avoid misinterpretation of a message, it is essential that the receiver provide feedback to the sender regarding conveyed meaning

88

Verbal communication

Spoke, written or electronic

most communication is nonverbal and provided in the form of body language such as gestures and eye contact

89

Nonverbal communication

Wordless transmission of information.

93% of communication is nonverbal. Body language constitutes 55% of all nonverbal communication and voice inflection accounts for 38%

90

Nonverbal communication

More accurate mode of conveying information

91

Proxemics

The study of the spatial requirements of humans and animals

92

Spaces

Intimate - 0-1.5 feet

personal -1.5 to 4 feet

social- 4-12 feet

public 12 feet or more

93

Personal space

Children demonstrate a need for greater personal space as they age.

english speaking people typically prefer at least 18 inches of distance between themselves and others when conversing

middle eastern people may be comfortable standing very close while communicating

94

Voice inflection

The second most significant form of nonverbal communication

95

Intrapersonal communication

Occurring internally

96

Positive self talks

Internal conversations that provides motivation and encoraugement. May be used to build self esteem and self confidence

97

Meditation

Mindful reflection or contemplation

98

Interpersonal communication

Takes place between two or more people

99

Interprofessional communication

Almost 70% of sentinel events were caused by communication breakdown and 50% of those cases occurred during patient handoff

100

professional role boundaries

limits and responsibilities of an individual in a given setting

101

4 phases of group development

forming

storming

norming

performance

102

5 areas of nurse -patient relationship

building trust

demonstrating empathy

establishing boundaries

recognizing and respecting culture influences

developing a comprehensive plan of care

103

helping relationship

the 5 steps of the nursing process are used in each phase of the helping relationships

nursing diagnoses for individual patients are identified during the orientation phase after assessment data are gathered and clustered

104

secondary date

with the patients permission relatives and friends may be considered secondary sources of subjective information

105

assertiveness

the ability to express ideas and concerns clearly while respecting the thoughts of others

106

therapeutic communication

the primary focus of therapeutic communication between a patient and nurse is the patient

107

social communication

most often occurs among individuals who know each other or who are getting to know each other informally.

108

SOLER

s- encourages the the listener to sit

o- reminds the nurse to maintain an open stance or posture

l- suggest the listener lean toward the speaker

e- to maintain eye contact without staring

r- reminds the nurse to relax

109

Uninterrupted sleep

Adults need 6-8 hours per night

110

Hospital sleep

Adults while in a hospital need at least 90 minutes of uninterrupted sleep

111

Ways to help your pt get their needed sleep

Cluster care

consult about medication regiment especially meds like diruretics- don't administer past 6 pm

112

Sleep disorders

20-30% of adults have some kind of sleep disorder

113

Stages of sleep

Stage 1- 3-10 minutes

stage 2- 10-20 minutes

stage 3 - 15-30 minutes

stage 4 - 15-30 minutes

REM sleep- memory is enhanced, cells regenerate, cerebral blood flow

cycle through about 6times/night

114

Sleep hygiene

Ritual to implement or promote sleep

drinking milk

brushing teeth

turning lights down

115

Not enough REM sleep

Increases agitation, and impulsiveness

116

Cortisol

Stress hormone

released early in the daytime

117

Melatonin

Hormone for sleep

induces sleep

118

Sleep study

Polysomnography

119

Multiple sleep latency test

During several 20 minute naps during the day

pt is suspected of having narcolepsy

120

Dyssomnia

Difficulty falling asleep

staying asleep

being excessively sleepy

121

Parasomnia

Disorders associated with abnormal sleep behaviors

122

Bruxism

Grinding teeth

123

Enuresis

Bed wetting

124

Somnambulism

Sleep walking

125

Other sleep disorders

Underlying medical or psychiatric problem

COPD-

pain

mentak health disorders

126

Insomnia

Difficulty with sleep

127

Hypersomia

Excessive day time sleeping

128

OSA

Obstructive sleep

apnea 10 seconds or greater without breathing

129

Sleep deprivation

Loss of good quality sleep

130

RLS

Restless leg syndrome

constantly needing to move legs

131

C-pap machine

Continuos positive airway pressure

132

Sodium

135-145 meq/l normal per textbook

133

Potassium

3.5-5.0 normal per textbook

134

Calcium

8.5-10.5

135

Magnesium

1.3-2.1

136

Phosphorus

1.76-2.6

137

Abnormal Na+ Levels

Behavior issues

138

Low sodium levels

Hyponatremia

Causes confusion, lethargy

139

High sodium levels

Hypernatremia

irritability, hallucinations

140

K+

Cardiac/ neuromuscular

141

Low Potassium

Weak, cardiac dysrhythmia

142

High potassium

Dysrhythmia

143

Hypervolemic

Too much volume

too much IV fluid

144

Hypovolemic

Too low volume

low BP, low heart rate

145

Fluid shifting

Good reason to keep electrolytes balanced

146

PH

7.35-7.45

147

Sa02

95-100

148

acid base balance

Respiratory- 1st thing to kick in with acid imbalance

renal - excretes hydrogen- doesn't kick in for 3 days

149

Kussmoulis

Deep shallow breathing

you exahule c02 when you breathe