Nursing foundations notes Flashcards
Nursing process
a logical way to describe basic problem solving processes whereby knowledge is effectively used to guide nursing decisions
ADPIE
Assessment
Diagnosis
Plan
Implement
Evaluate
Assessment
Collect
Validate
cluster
record
data collection
OBJECTIVE = observation or measurements of a patients health statues
SUBJECTIVE = Patients verbal description of their health concerns
VALIDATION
After we have gather our data, we must validate we have collected to avoid incorrect inferences
DATA CLUSTERING
After collecting and verifying the data, analyze and interpret the data
Organize the information into meaningful
and usable clusters
* Look for patterns and trends
DOCUMENTING
The last step in the assessment is documenting
Diagnosis
Nursing diagnosis, the second step of the nursing process, determines health problems within the domain of nursing
Nursing Diagnosis
Determine the nursing care
● Nursing Diagnosis = Health Issue
● Clinical judgement within the
domain of nursin
Medical diagnosis
Identification of a disease condition
● Not in the scope of an LPN
example
MEdical diagnosis = myocardial infraction
Nursing diagnosis = for a client with myocardial infarction could include fear, altered health maintenance, knowledge deficit, pain, altered tissue perfusion, and more
NANDA 1
a global force for the development and use of nursing standardized terminology to ensure patient safety
Nursing diagnosis
Actual = responses to conditions that exist
Health promotion = judgement of motivation to change. do not reflect current levels of wellness
risk = response likely to occur
wellness = describes levels of wellness that can be enhanced
Planning
By failing to prepare,, you are preparing to fail
planning = goal setting
Person-centred, singular, and mutually agreed upon
* SMART (Specific, Measurable, Achievable, Relevant, and Time-Based)
* Measured using expected outcomes
Implement
The next step in the nursing process is to carry out our
planned interventions.
Interventions
“With a care plan based on clear and relevant nursing diagnoses, the nurse initiates interventions that are most likely to achieve the goals and expected outcomes needed to support or improve the patient’s health status.”
evaluation
The last step in the nursing process is to determine whether the interventions have worked or need adjusted.
● “the nurse reviews the expected outcomes for the patient and judges whether the planned goals have been successful.
Health promotion
Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health.”
Health promotion 2
● Addresses health issues in context
● Supports a holistic approach
● Requires long-term perspective
● Is multisectoral
● Draws on knowledge from social, economic, political,
environmental, medical, nursing sciences, as well as from first-hand experiences.
determinants of health
income and social
social support
education and literacy
employment and working conditions
physical environment
biological and genetic endownment
determinants of health
individual health practices coping skills
healthy child development
health services
gender
culture
social environment
levels of prevention
primary = measure taken before disease occurs
secondary = measure that promote early diagnosis treatment of a condition disease or condition
tertiary = measure taken after diagnosis has occure and symptoms are present
population health promotion model
integrates concepts of population health with health promotion
● Aims to develop actions that
improve health
● Answers 4 questions (who, what,
how, and why)
health promotion strategies
build healthy public policy
create supportive environments
develop personal skills
reorient health services
strengthen community action
documentation
Must be accurate/factual
● Comprehensive/complete
● Timely and organized
● Compliant with standards
● Remain confidential
● Can positively affect the quality of
life and health outcomes of patients
methods of documentation
narrative = Traditional method, story-like format to record assessment and care.
source records = The patient’s chart is separated by discipline and nurses typically
use narrative notes in their section
problem oriented medical = System to organize documentation in sections: Database, Problem List,
Care Plan, Progress Notes
charting by exception = Assumes the patient has no abnormalities in their
assessment/care, unless documented.
progress notes
narrative notes = nurses enter assessment findings, nursing care provided, and patients response
soap notes = subjective/objective/assessment/plan
Verbalizations of Patient followed by
Observations, the assessment, and then what the caregiver plans to do.
UNIT 2
what are microorganism
bacteria
protozoa
algae
fungi
not all microorganism cause disease. those that do are called pathogens
chain of infection
infections develop when this chain remains intact
all elements must be present
infectious agent
reservoir = place where a pathogen can survive but may or may not multiply
portal of exit = a path where pathogens leaves the reservoir
mode of transmission = through direct or indirect contact
portal of entry = can enter the body through the same routes they use to exit
host = depends on the individuals resistance to pathogens
normal body defences against infection
normal flora = micro organisms that normally reside in and on the body help maintain health
body system defences = many body systems have unique defences against infection
inflammation = protective vascular reaction in response to injury or infection
levels of infection
local = an infection present in one area of the body
systematic = an infection that has spread throughout the body
hospital infections
MRSA = positive bacteria that are genetically distinct from other strains of Staphylococcus aureus. MRSA is responsible for several difficult-to-treat infections in humans.
VRE = Enterococci are bacteria that are naturally present in the intestinal tract of all people. Vancomycin is an antibiotic to which some strains of enterococci have become resistant
C DIFF = a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon) and can be life-threatening. C. diff can affect anyone
asepsis is the process for keeping away disease producing microorganism
medical = commonly referred to as a clean technique. involves handwashing, using clean gloves and routing cleaning
surgical = commonly referred to as sterile technique. this is not included in our learning outcome
standard precaution
Routine Practices designed to care for all patients in any setting
Includes appropriate handwashing, cleaning of equipment, and disposal of contaminated linen and sharps
isolation precaution
contact = used for infections spread by direct, or indirect contact
droplet = used for infections spread by coughing, sneezing, or talking
airborne = used for infection transmitted by airborne droplets
personal protective equipment ppe
gowns = prevent contamination
gloves = prevent spread of pathogens by direct and indirect contact
mask = prevent transmission of infection through droplets and airborne particle - depending on type
eyewear = protect against transmission of droplets
nursing considerations for isolated patients
=Isolation can be psychologically harmful
=Patients may feel unclean, rejected, lonely, or guilty
=Education regarding the condition, reason for isolation and how they can help prevent the spread is key
=Keep the room tidy, curtains open (during the day) and don’t rush through care if possible
=Provide comfort measures, conversation, and puzzles/games/books if appropriate
Hand hygiene
“The most important and basic technique in preventing and controlling transmission of infection is hand hygiene.”
4 moments of hand hygiene
before - initial patient contact
before - aseptic procedure
after - body fluid exposure risk
after - patient contact
donning/doffing
putting on and putting off
donning step 1
isolation gown
Wash your hands
Apply gown, ensuring it covers all clothing
Tie at neck and waist
Pull sleeves down to wrists
step 2 mask
=Apply over mouth and nose
=Adjust nose piece to ensure snug fit
=If mask has ties, ensure to tie the top strings first.
step 3 eye protection
Apply over eyes and/or eyeglasses
Ensure eyewear/face shield is snug around your forehead and face.
step 4
Apply clean, disposable gloves
Bring cuffs over the edge of the gown sleeves
doffing gloves
Remove gloves by taking hold of the cuff and pulling off so that it comes off inside out. Put that glove into the other (still gloved) hand and remove the 2nd glove. Promptly place in the garbage.
Wash or sanitize hands
step 2 isolation gown
Carefully untie at neck and waist
Remove from the back of the gown at shoulders and pull gown down over the arms, turning it inside out
Place in hamper (if washable) or garbage (if disposable)
Try not to touch the outer front of the gown
Once again, wash/sanitize hands
step 3
Handle only headband or earpieces
Put reusable items in appropriate place for cleaning
Put disposable items into the garbage
step 4
Handle only by ties or elastic bands
Lean forward and remove away from face
If mask ties, undo bottom tie first
Put into the garbage
Once again, wash/sanitize your hands
cleaning
The process taken to remove foreign material from objects and surfaces
Once an object comes into contact with blood, secretions, excretions or microorganisms it is considered contaminated and must be cleaned or discarded.
The person cleaning the item must also protect themselves from becoming contaminated (use of PPE)
disinfection
Removes all pathogens with the exception of bacterial spores
Involves heat, chemicals or UV light
Objects must be cleaned BEFORE they are disinfected
What is the difference between a disinfectant and an antiseptic?
antiseptic kills germs onto the skin while disinfectant kills germ onto the surfaces. Both used to kill bacteria and viruses
What examples can you provide of chemical disinfectants?
alcohol
unit 3
sleep
a cyclical, physiological, and behavioural process that alternates with longer period of wakefulness
rest
when individuals are at rest, they are in a state of mental, physical, and spiritual activity that leaves them feeling refreshed, rejuvenated, and ready to resume the activities of the day.”
sleep wake cycles
ultradian process = occurs during state of sleep
homeostatic process = process S = dependent on sleep wake cycle
circadian process = function to maintain a state of wakefulness
circadian rhythms
biological functions of many living things are regulated by circadian rhythms
mechanism that regulate sleep
increased activity = The Hypothalamus secretes hypocretin that promote wakefulness and the reticular activating system (RAS)responds to stimuli to maintain wakefulness.
decreased activity = The Anterior Pituitary gland secretes hormones to promote sleep and the stimuli to the RAS declines when a person tries to fall asleep
pattern of sleep stages
pre sleep = person is aware of developing sleepiness
NREM stage 1 = easily interrupted
NREN stage 2 = deeper sleep
NREM stage 3 = deepest sleep
NREM stage 2 = adults return to stage 2 before progressing into REM sleep
REM sleep = usually begins 90 minutes after sleep begins
normal sleep requirements and patterns
newborn = sleep occurs equally across the day and night
infants = sleep wake periods begin to develop into a day/night cycle
toddles/preschoolers = generally sleep most of the night
school aged = school aged children average 9-10 hours per night
adolescents = excessive daytime sleeping is common in adolescence
young adults = most average 6-8.5 hours per night
middle aged adults = the amount of time in NREM stage 3 begins to fall
older person = aging associated with changes to sleep patterns and increased difficulty sleeping
factors affecting sleep
medication/substances = many medications disrupts sleep or causes sleepiness
lifestyle = daily routines influence sleep patters
usual sleep patterns = not following regular sleep patterns will affect sleepiness
emotional stress = stress causes difficulty falling asleep, frequent waking or even oversleeping
factors of affecting sleep
environment = ventilation, properties and position of bed ,lighting, noise, etc
exercise/fatigue = moderate fatigue promotes the highest sleep quality
food caloric intake = good eating habits are important for restful sleep
sleep deprivation
insufficient sleep during a specific time period
excessive daytime sleepiness
sleepiness becomes pathological when it occurs at times when individuals need to or want to be awake
physical illness
many illnesses cause sleep challenges.
sleep related breathing disorders
Include obstructive sleep disorders, apneas, hypoventilation syndromes and hypoxemia disorders.
insomnias
“problems falling asleep, staying asleep, and nonrestorative sleep with daytime consequences”
parasomnias
Include those associated with NREM and REM and those of other causes or unspecified causes.
central disorders of hypersomnolence
narcolepsy = type 1 and 2
insufficient sleep syndrome
kleine levin syndrome
hypersomnias
nursing actions
to promote comfort, rest, or sleep
community
Community Health Nurses use a Health Promotion approach to assist patients to develop good sleep habits at home.
Acute Care
Nurses in acute care settings should minimize disruptions to sleep, as normal routines are often affected by admission.
Continuing Care
Nurses in residential settings also need to reduce barriers to sleep, but also, focus more to promote comfort.
actions to promote sleep
Environmental Controls = Room temperature, ventilation, noise, lighting and comfortable bed help.
Promote BedtimeRoutines = Establishing bed time routines help patients relax and prepare to sleep.
Promote Safety = Removal offall hazards, as well as use of dim lighting at night can be helpful.
Promote Comfort = Encourage appropriate nightwear and bedding, as well as using the bathroom before bed.
Establish Rest/Sleep Periods = Encourage activity in the daytime to promote sleep at night.
Stress Reduction = If stress is keeping patients awake, they should not try to force sleep.
Bedtime Snacks = If patients find it helpful, offer warm milk or cocoa.
Pharmacological Approaches = Use of nonprescription sleep aids is not recommended.
positioning for comfort
supine = laying on flat
fowlers = laying on back with the head of bed raised
prone = laying face down
side = laying on one side or other
providing comfort
relaxation and guided imagery
massage
hot and cold therapies
distraction
unit 4
code blue = medical/cardiac
code red = fire
white = violence/aggression
purple = hostage
yellow = missing person
black = bomb threat/suspicious package
grey = shelter in place/exclusion
green = evacuation
code brown = chemical spill/hazardous
orange = mass casualty
harmful
an incident where there is harm to the patient
no
no harm
an incident that reached the patient but no harm was done
near miss
an incident that did not reach the patient and no harm was done
risks in care settings
“A nurse must be aware of common safety precautions and of the special risks to safety that are found in health care settings. A nurse must also be familiar with a patient’s developmental level, mobility, sensory and cognitive statuses, and lifestyle choices.”
risks in care settings
staff safety = Environmental risk: Workplace Hazardous Materials Information System (WHMIS)
Infection prevention and control
Violence
Patient safety = Falls (account for up to 90% of reported incidents)
Procedure-related accidents
Equipment-related accidents
developmental
infants and children
adolescents
adults
older person
individual
lifestyle
impaired mobility
sensory communication impairment
lack of safety awareness
Fall Prevention
Assessment and communication about risks
Proximity tonursing station
Signage
Improved patient hand off
Scheduledtoileting andsafetyrounds
Environmental modifications
fall prevention
environmental modification
exercise interventions
footwear
podiatry care
S A F E
safe environment
assist with mobility
fall risk reduction
engage client and family
“A restraint is a physical, chemical, or environmental means of controlling an individual’s behaviour or actions.”
“A least-restraint approach is recommended to ensure highest-quality care.”
types of restraints
physical = Used to immobilize a patient or one or more of their extremities.
chemical = sedatives/medications
environmental = locked units
legalities of restraint use
employer requirements, policies
CLPA guidelines
alternative to restraints
provide = companions and supervision
offer = physical activity/diversion
ensure = patients needs / toileting, hygiene
use = calm, simple language
injury prevention and intervention
fire/burns = can be caused by smoking, oxygen, bathing and use of heating pads
poisoning = chemical medications, cleaning products and disinfectants are ofter toxic
suffocation = check patients every 2 hours, posture, pillows, make sure they are comfortable
REACT
remove
ensure
activate
call
try
bedside safety checks
maintain appropriate bed height
ensure breaks are on at all times
call bell reach
use anti slips trips or footwear
bedside table stored on non exit side
commode on exit side, with breaks on
use a nightlight
use a height adjustable low beds to prevent injury from falls
classifications of health conceptualization
health as stability
health as actualization
health as actualization and stability
health as resource
health as unity
nursing process = intelectual process of reasoning
Assessment = which is collection of pertinent to the patients health status or situation
Diagnosis = analyzes the assessment data to determine key issues and make clinical judgements
Planning = creation of plan, requires strategies and alternatives
Implementation = providing health teaching/health promotion activities to the patient
Evaluation = patients response to selected interventions/whether the intervention works
medical diagnosis
identification of a disease condition on a basis of a specific evaluation of physical signs.
nursing diagnosis
2nd step of the nursing process/ determine the nursing problem within the domain of nursing
collaborative problem
actual or physiological complication that the nurses monitor or detect the onset changes of the patients. sc
screening assessment
data collection
data analysis
clustering information
potential diagnosis
consider all diagnoses that match information available
in depth assessment
focused data collection
data analysis
confirming or refuting potential diagnosis
nursing diagnosis
determining priority nursing diagnosis
diagnosis
the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs.
unit 2
microorganisms to cause diseases depends on the following factors
a sufficient number of organisms
virulence/ ability to produce disease
abilitiy to enter and survive
susceptibility of the host
Asepsis
process keeping away disease producing microorganisms
medical asepsis
clean or technique, includes procedure used to reduce and prevent the spread of microorganisms .
Hand hygiene
