Core Concepts Exam One Flashcards
ANA
is the largest professional nursing association in the US, and here to support and protect you (advance/protect the profession)
What is a profession?
Education, regulation, code of ethics, professional organization, commitment
Aspects of professional nursing behavior
appearance, demeanor, competence, integrity, compassion
Morals, Values, and Ethics
- These are often considered interchangeable terms and are closely related but do have slight differences
- Morals are personal beliefs of right or wrong for one’s own self
- Values are closely aligned with morals but can also be larger than self (professional, societal)
- Ethical principles are far-reaching and can be considered as “absolute” values
Autonomy
- the right to make one’s own decisions
- confidentiality and informed consent fall under autonomy
Beneficence
to do good
Fidelity
to keep one’s promise
Justice
fairness to all
Nonmaleficence
do no harm
Veracity
tell the truth
Ethical principles general
autonomy, beneficence, fidelity, justice, nonmaleficence, veracity
Ethical Dilemmas
- The interpretation and application of ethical principles is not an absolute – “it depends”!
- Ethical dilemmas occur when an ethical principle and the application of the ethical principle differ.
- Ethical decision-making often means striking a balance between science, ethics and personal moral values.
Self-awareness
- Self-awareness is a deep understanding, gained over time, of what is important to you personally.
- Self-reflection is the first step in developing true self-awareness.
- Self-awareness is crucial when faced with ethical dilemmas: knowing yourself, what is important to you, how you may react in certain situations and where the potential for conflict may occur.
A profession has certain elements in common
education requirements, regulation, code of ethics, professional organization, commitment of service
Professionalism
the overt action of a professional nurse engaged in the furtherance of his/her profession: appearance, demeanor, competence, integrity, and compassion
Behaviors that reflect professional decorum
be prompt, be organized, be prepared, be actively present, be respectful, acknowledge the value of time, be aware
Ethics
the study of conduct and character
Ethical principles definition
- the way one “ought to act”
- can be considered absolute values, but the interpretation of ethical principles is not absolute (how you apply ethical principles changes according to the situation presented)
-the nurse is obligated by the profession of nursing to understand and apply ethical principles and the profession’s moral norms, as well as his/her own moral values in the pursuit of integrity, accountability, responsibility, and professionalism
Morals
- values and beliefs that guide behavior and decision making
- not the same as ethical principles (they are more personal and aligned with one’s own personal beliefs)
Caring
- the BASIS of the nursing profession
- not an ethical principle, but it is one of the most important moral values that a nurse can posses
Kindness
- the overt expression of caring
- the most helpful virtue when in dealing with people, whether it is yourself, patients, families, or fellow healthcare providers
ANA Code of Ethics
- KNOW the difference between ethical (out to act) and moral values (own personal beliefs)
- accountability, advocate, autonomy, assault,battery, beneficence, fidelity, integrity, justice, non-maleficence, paternalism, patient, practice, respect, responsibility, values, veracity
Accountability
being answerable for one’s own choices, decisions, and actions
Advocate
to support (nurses are patient advocates)
Assault
the THREAT of coercive or punitive action by the nurse
Battery
the coercive or punitive ACTION by the nurse
Fidelity
- to be truthful and fulfill commitments
- to do what you say are going to do
Integrity
External consistency with one’s own internal values, beliefs, attitudes, and convictions
Justice
- access to and fair treatment for all
- bioethical justice usually refers to distributive justice- social resources and burdens are applied equally (including healthcare)
Paternalism
one person makes decisions for one another (may be voluntary or involuntary)
Patient
the recipient of nursing care
Practice
the professional actions of the nurse
Respect
Respecting the ethical values of others
Responsibility
- the duty to act in accordance to one’s education and professional standards.
- often used interchangeably with accountability, but it is slightly different. One may share responsibility, but not accountability, for one’s actions
Values
core beliefs that guide attitudes and actions
Veracity
- the duty to tell the truth and not withhold information
- needed in order for a patient to give truly informed consent
Therapeutic communication techniques
active listening, open-ended questions, clarifying, back channeling, probing, closed-ended questions, summarizing
Active listening
shows clients that you have their undivided attention
Open-ended questions
- use initially to encourage clients to tell their story in their own words. Use terminology that client can understand.
- best kind of questions to ask
Clarifying
questions clients about specific details in greater depth or direct them toward relevant parts of their history
Back Channeling
use active listening phrases such as “go on” and “tell me more” to convey interest and to prompt disclosure of the entire story
Probing
ask more open-ended questions such as “what else would you like to add to that?” to help obtain comprehensive information
Closed-ended questions
ask questions that require “yes” or no” answers to clarify information, such as “do you have any pain when you cannot sleep?”
Summarizing
validate the accuracy of the story
Board of Nursing
your regulatory board, there to protect public (safe/competent)-> get you in trouble, anything bad you do
AIDET
acknowledge, introduce, duration, explanation, thank you
Demographic/Health information
- name, address, contact information
- age, DOB
- gender
- race, ethnicity
- relationship status
- occupation, employment status
- insurance
- emergency contact information
- advance directives
Source of history
- client, family members or close friends, other medical records, other providers (SUBJECTIVE DATA)
- reliability of the historian
Chief concern
a brief statement in the client’s own words of why he/she is seeking healthcare
History of Present Illness
- a detailed, chronological description of why the client seeks care
- headaches, seizures, diabetes, kidney problems, high BP (SUBJECTIVE DATA)
Past Health History and Current Health Status
- past illnesses or surgery
- current immunization status
- allergies (SUBJECTIVE)
- medications
- habits and lifestyle patterns (alcohol, tobacco, caffeine, recreational drugs)
- headaches, seizures, diabetes, kidney problems, high BP (SUBJECTIVE DATA)
Family History
health information of family members
- Ex. do you live alone, have a good support system, employed?
- Ex. Family members with depression/anxiety, substance abuse, eating disorder, alcoholism, heart disease, cancer, stroke, TB
Psychological History
- alcohol use
- tobacco use
- recreational drugs
- exercise and diet
- life events
- cultural/spiritual/religion
- support system
-Ex. depression/anxiety, substance abuse, eating disorder, alcoholism, heart disease, cancer, stroke, TB
Health promotion behaviors
- exercise/diet, sun exposure, stress, sleep patterns
- awareness of risks for heart disease, cancer, diabetes, stroke
Information Technology
- if you didn’t document it, you didn’t do it
- if you didn’t do it, DO NOT DOCUMENT IT
System specific Assessments (cardiac)
- review vital signs
- look for signs of cardiovascular problems
- 5 auscultation points (5-10 seconds each, once with diaphragm and twice with the bell)
APETM (Ape to Man)
- A: Aortic= 2nd right intercostal space
- P: Pulmonic= 2nd left intercostal space
- E: Erb’s Point= 3rd intercostal space (left sternal border) (where S1 and S2 are equal)
- T: Tricuspid= 4th left intercostal space (left lower sternal border)
- M: Mitral (apex)= 5th left intercostal space (midclavicular line) (also called PMI (point of maximum intensity)
Pulse Deficit/Apical vs. Radial
Assess radial pulse and apical pulse simultaneously for 15-30 seconds (may need more than one nurse), and determine whether or not there is a deficit between the two
S1 and S2
- S1: the “lub,” beginning of systole (mitral and tricuspid valves closing)
- S2: “dub,” end of diastole (aortic and pulmonic valves closing)
General Survey
- a written summary or appraisal of overall health
- gather information during the first encounter with client and continue to make observations throughout the assessment process
- assess data about: physical appearance, body structure, mobility, behavior, vital signs
Pain
- the 5th vital sign
- pain is SUBJECTIVE
- when treating, always think of non-pharmacologic therapies first
PQRST
- P: provokes and palliates: what makes pain worse? what makes pain better?
- Q: quality: how does the pain feel? (sharp, dull, stabbing, throbbing, aching, burning, etc…)
- R: region/radiation: where is the pain? does the pain radiate (branch out)?
- S: Severity and setting: Methods to determine pain level (severity)
- scale of 0-10; used most often (0=no pain, 10=worse pain in life)
- face pain scale
- riley infant pain scale assessment tool (score from 0-3)
- FLACC behavioral pain assessment tool (score from 0-3) - pain setting: Where were you/what were you doing when the pain started?
-T: timing: when did the pain start? (acute or chronic)
Initial (Baseline) Assessment
- Time performed: within a specified time frame after admission to a healthcare facility
- Purpose: to establish a complete baseline for a problem
- Example: nursing admission assessment
Problem focused (system-specific) assessment
- Time performed: ongoing process integrated with nursing care
- Purpose: to determine the status of a specific problem identified in an earlier assessment
- example:
- hourly assessment of a patient’s fluid intake and urinary output in an ICU
- assessment of a client’s ability to perform self-care while assisting a patient to bathe
Emergency Assessment
- Time performed: during any physiological or psychological crisis
- Purpose: to identify any life-threatening problems; to identify new or overlooked problems
- Example:
- rapid assessment of open airway, breathing, and circulation during cardiac arrest
- assessment of suicidal tendencies or potential for violence
Ongoing Reassessment
- Time performed: minutes to months after initial assessment
- Purpose: to compare the patient’s current status to baseline data previously obtained
- Example: reassessment of a patient’s functional health patterns in a home care or outpatient setting, or shift assessments in an acute care setting
Techniques of physical assessment: Inspection
- begins with the first interaction and continues throughout the examination
- a penlight, otoscope, ophthalmoscope, or another lighted instrument can be used
- inspect for size, shape, color, symmetry, and position
Techniques of physical assessment: palpation
- the use of touch to determine the size, consistency, texture, temperature, location, and tenderness of the skin, underlying tissues, an organ, or a body part. palpate tender areas last!
- when assessing the abdomen palpate LAST
Techniques of physical assessment: percussion
-involves tapping body parts with fingers, fist, or small instruments to vibrate underlying tissues and evaluate size, location, tenderness, and presence or absence of fluid or air in the body organs, and to detect any abnormalities
Techniques of physical assessment: auscultation
- the process of listening to sounds the body produces to identify unexpected findings.
- use the diaphragm of the stethoscope to hear high pitched sounds (heart sounds, bowel sounds, lung sounds)
- use the bell of the stethoscope to hear low-pitched sounds (heart murmurs, bruits)
Techniques of physical assessment:
inspection, palpation, percussion, auscultation
Vital Signs
temperature, pulse, respirations, BP, Pulse oximetry
Temperature
- Normal Ranges: 36C-38C and (96.8F-100.4F)
- Can be taken: orally, rectal (core temp), axillary, tympanic (core temp), temporal (core temp)
Factors that can alter temperature
- newborns and elderly adults have a lower temperature
- hormonal changes can influence temp
- exercise, activity, and dehydration can contribute to hyperthermia
- illness and injury can raise temp
- recent food or fluid intake
- smoking
- stress and environmental conditions
Pulse
- Normal Range: 60-100 bpm
- Tachycardia: pulse above 100
- Bradycardia: pulse less than 60
- Factors that can alter pulse: medications, illness or injury and pain, etc…
Respirations
Normal Range: 12-20 breaths per minute
Blood Pressure
- Normal Range: Systolic 90-120 and Diastolic 60-80
- Prehypertension: Systolic 120-139 and Diastolic 80-89
Factors that can alter BP
- cuff too narrow= false HIGH
- cuff too wide= false LOW
- arm unsupported: false HIGH
- Insufficient rest before assessment: false HIGH
- Repeating assessment too quickly: False HIGH systolic or LOW diastolic
- cuff too loose/unevenly wrapped: False HIGH
- deflating cuff too quickly: false LOW systolic or HIGH diastolic
- deflating cuff too slowly: false HIGH
- arm above heart level: False LOW
- assessing immediately after smoking: False HIGH (smoking constricts blood vessels)
- failure to identify auscultatory gap: false LOW
Pulse Oximetry
Normal range: 95%-100%
Pulse points
- carotid (used in emergency situations)
- radial
- pedal
- post-tibial
- apical pulse
Strength/amplitude of Pulses
0= absent, unable to palpate 1+=diminished, weaker than expected 2+= brisk, expected 3+= increased, strong 4+= full volume, bounding
Blood pressure methods
- electronic
- manual
- 1step
- 2step: (sued when you don’t know what the patient’s normal BP is)
Bathing
- bathe clients to cleanse the body, stimulate circulation, provide relaxation, and enhance healing
- always promote independence
Changing bed linens
- always smooth out any wrinkles in bed linens to prevent skin breakdown
- follow standard precautions by wearing gloves if the linens are soiled and by keeping them away from your scrubs when throwing them in the linen hamper.
- do not shake linens or put them on the floor
- hospital corners=mitered corners
Nail, hand, and foot care
- when filing nails, file in one direction only
- be sure to dry feet and hands thoroughly (especially in between fingers and toes)
- NEVER apply lotion/moisturizer in between fingers and toes
- special considerations for diabetic patients
- NEVER use nail clippers (only file)
- NEVER soak feet
Oral Hygiene
- patients who are receiving oxygen therapy, have an NG tube, are NPO, or who are unconscious are at a higher risk for accumulating bacteria that could progress to pneumonia, so oral care is EXTREMELY IMPORTANT
- when performing oral care on an unconscious patient:
1. you must always have a suction set up at the bed side and ready to be used
2. position the patient on their side, to allow fluids to drain out - some facilities may provide oral care swabs for easy/safe/efficient oral care
Perineal Care
- one wipe per swipe
- “front to back, up the crack”
- always clean from dirtiest location to cleanest
- DO NOT CROSS CONTAMINATE
- dry thoroughly (prevents skin breakdown)
- When performing perineal care on an uncircumcised male:
1. retract the foreskin to wash the tip of the penis
2. clean from the meatus outward in a circular motion
3. DRY, then replace the foreskin
Hair
- caring for the hair and scalp is important for client’s appearance and sense of well-being
- take in to consideration the client’s cultural and personal preferences
Skin
always prevent skin breakdown!!!!
Accident/Error/Injury Prevention (Falls)
- perform fall risk assessment
- keep wheels on bed and wheelchair locked
- bed in lowest position
- call light within easy reach/patient knowns how to use it
- bedside table/personal belongings within easy reach
- appropriate number of side rails up on bed
Accident/Error/Injury Prevention: Six Core Competencies of Quality and Safety Education for Nurses (QSEN):
- patient centered care
- quality improvement
- evidence-based practice
- teamwork and collaboration
- safety
- informatics
Accident/Error/Injury Prevention: National Patient Safety Goals
- Identify patients correctly
- improved staff communication (i.e. getting critical lab values reported to the right person in a timely matter)
- use medicines safely (6 rights)
- use alarms safely
- prevent infection
- identify patient safety risks
- prevent mistakes in surgery (wrong site surgery)
- Major Topics related to client safety risks
Accident/Error/Injury Prevention: National Patient Safety Goals: Major Topics related to client safety risks
- falls
- restraints
- healthcare associated infections
- wrong-site surgery
- med errors
- patients at risk for suicide
Fire Emergency Response Plan: RACE Sequence
R-Rescue: and protect clients in close proximity to the fire by moving them to a safer location. Clients who are ambulatory may walk independently to a safe location
A-Alarm: activate the facility’s alarm system and then report the fire’s details and location
C-Contain/Confine: the fire by closing doors and windows and turning off any sources of oxygen and any electrical devices. Ventilate clients who are on life support with a bag-valve mask
E-Extinguish: the fire if possible using the appropriate fire extinguisher
How to use a fire extinguisher (PASS Sequence)
P-Pull: the pin
A-Aim: at the base
S-Squeeze: the handle
S-Sweep: the extinguisher from side to side, covering the areas of the fire
Fire Emergency Response Plan: All staff must:
- know the locations of exits, alarms, fire extinguishers, and oxygen shut-off valves
- make sure equipment does not block fire doors
- know the evacuation plan for the unit and facility
Home Safety: Major Safety Risks Across the Lifespan: Infants
- aspiration
- suffocation
- poisoning
- falls
- motor vehicle injury
- burns
Home Safety: Major Safety Risks Across the Lifespan: Preschoolers and School-Aged Children
- drowning
- motor vehicle injury
- firearms (accidental)
- play injury
- burns
- poison
Home Safety: Major Safety Risks Across the Lifespan: Adolescents
- motor vehicle injury
- burns
Home Safety: Major Safety Risks Across the Lifespan: Young/Middle Adulthood
-motor vehicle crashes are the most common cause of death and injury
Home Safety: Major Safety Risks Across the Lifespan: Older/elderly adults
falls
Standard Precautions
- apply to EVERY PT
- personal protective equipment (PPE)
Use of Restraints/safety devices: Restraints Should
- NEVER interfere with treatment
- NEVER be used for more than 4 hours per order
- Restrict movement as little as possible
- Fit properly and be as discreet as possible
- Be easy to remove or change
- Be a last-resort option
Use of Restraints/safety devices
-can ONLY be used with a physician’s oder AFTER the provider has a face-to-face assessment of the patient (except in emergency situations, when the provider may assess up to one hour after restraints are placed)
- Orders should include:
- reason for restraints
- type of restraints
- location of restraints
- duration of use
- type of behavior that warrants restraints
Comfort
-a relative, subjective feeling based on expectations and past experiences
Comfort: Alterations and Manifestations:
- End of life care: care that takes place when death is imminent
- Fatigue (acute or chronic): lack of energy or motivation with or without drowsiness
- Fibromyalgia
- Sleep and rest disorders
Non-Pharmacological comfort Measures List
- imagery
- breathwork
- humor
- meditation
- simple touch
- music/art therapy
- therapeutic communication
- cognitive behavioral measures
- cutaneous/skin stimulation
- distraction
- relaxation
- acupuncture and acupressure
Non-Pharmacological Comfort Measures: Imagery
- focusing on a pleasant thought to divert focus
- requires an ability to concentrate
Non-Pharmacological Comfort Measures: breathwork
reduces stress and increases relaxation through various breathing patterns
Non-Pharmacological Comfort Measures: Humor
reduces tension and improves mood to foster coping
Non-Pharmacological Comfort Measures: Meditation
uses rhythmic breathing to calm the mind and body
Non-Pharmacological Comfort Measures: Simple Touch
Communicates presence, appreciation, and acceptance
Non-Pharmacological Comfort Measures: Music/Art Therapy
- provides distraction from pain and allows the client to express emotions
- earphones improve concentration
Non-Pharmacological Comfort Measures: Therapeutic communication
allows clients to verbalize and become aware of emotions and fears in a safe, nonjudgmental environment
Non-Pharmacological Comfort Measures: Cognitive-Behavioral Measures
-changing the way a client perceives pain, and physically approaches to improve comfort
Non-Pharmacological Comfort Measures: Cutaneous/skin stimulation
- interruption of pain pathways
- cold for inflammation
- heat to increase blood flow and to reduce stiffness
Non-Pharmacological Comfort Measures: Distraction
decreased attention to the presence of pain can decrease the perceived pain level (turning on the TV)
Non-Pharmacological Comfort Measures: Relaxation
includes meditation, yoga, and progressive muscle relaxation
Non-Pharmacological Comfort Measures: Acupuncture and acupressure
stimulating subcutaneous tissues at specific points using needles (acupuncture) or the digits (acupressure)
Types of Pain List
Acute pain, chronic pain, breakthrough pain, central pain, phantom pain, psychogenic pain, nociceptive pain, neuropathic pain
Acute pain
less than 6 months, typically treated with opioids
Chronic pain
longer than 6 months, typically treated with NSAIDS or other non-opioid analgesics
Breakthrough pain
-a transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain
Central Pain
anything involving the CNS
Phantom Pain
- pain felt in an amputated limb or body part
- usually recurring rather than constant
Nociceptive pain
- arises from damage to or inflammation of tissues
- typically responds to opioids and non-opioid mediations
Nociceptive pain: Somatic
in bone, joints, muscles, skin, or connective tissue
Nociceptive pain: visceral
- in internal organs such as the stomach or intestines
- can cause referred pain in other body locations separate from the stimulus
Nociceptive pain: cutaneous
in the skin or subcutaneous tissue
Neuropathic pain
- arises from abnormal or damaged pain nerves
- includes phantom limb pain
- usually intense, shooting, burning, or described as “pins and needles”
- typically responds to adjuvant medications
Primary source
the patient (ONLY primary source), also called historian
Secondary source
Family, friends, previous health care providers, old records, a report (exams or labs typed up in a report), something that is indirect
Types of Data (two types)
subjective and objective
Types of Data: Subjective
- anything that the patient tells us (symptoms, their “chief” complaint or concern)
- PAIN is ALWAYS SUBJECTIVE
- Emotional feelings are subjective as well: something I CANNOT measure
Types of Data: Objective
-anything a nurse can measure, anything a nurse can see, tough, smell, hear, hopefully not tasting, a lab, vital signs, intake and output (I’s and O’s); what they are drinking, what goes in their IV, what comes out
- “Normal for ethnicity” is objective
- I can MEASURE; Vitals, what I witness, etc…
ADPIE
A: assess D: (Nursing) diagnosis P: PLAN I: intervention/implementation E: evaluate
-assessment is the first thing a nurse should do; when you do that, you are collecting data
Methods of Data Collection (and Interpretation)
- when interviewing, if you need an interpreter, USE THEM; NOT THE FAMILY
- observing, interviewing, examining
Methods of Data Collection (and Interpretation): Observing
getting a general survey, able to determine their facial expression, ability to hear you, during a bed bath or assisting them to the bathroom, etc.
Methods of Data Collection (and Interpretation): Interviewing
asking open-ended questions, name, DOB, family/full health history, our planned conversation to get as much information as we can
Methods of Data Collection (and Interpretation): Examining
physical assessment (pg. 130)
- inspect=look
- palpate= the use of touch
- percuss=tapping parts of the body directly and indirectly
Direct percussion
which involves striking the body to elicit
Indirect percussion
which involves placing your hand flatly on the body, as the striking surface, for sound protection
Fist Percussion
which helps identity tenderness over kidneys, liver, and gallbladder
Auscultate
listen
Methods of Data Collection (and Interpretation): Organize
- will organize and categorize how we are going to use it
- doing this by systems
- basic needs and everything after that is psychological
Methods of Data Collection (and Interpretation): Validate
- why is this important?
- for accuracy, continually assessing, updating health history, always doing this
- this is continuous
Methods of Data Collection (and Interpretation): Interpret
this is the nurses job
EHR
documents vital signs, health history, other assessment information
Joint commission
the joint commission began the national patient safety goals in 2002, to help accredited organizations deal with specific topics on patient safety
PSAG
- the goals for the national patient safety goals are developed and revised by the patient safety advisory groups PSAG
- PSAG: panel of nurses, physicians, pharmacists, risk managers, engineers, and other professionals
OSHA
occupational safety and health administration: enforce safety guidelines
NIOSH
National institute for occupational safety and health: research and generate new guidelines that OSHA enforces
Emergency Response Plan: Home (patient/ family education)
- keep emergency numbers near phone
- smoke alarms throughout the home
- change batteries in smoke alarms 2x per year
- family exit plan: “stop drop and roll,” stay close to floor when exiting building
