Skills Exam 1 Flashcards
Definition of Health
State of complete physical, mental, and social wellbeing, not merely the absence of disease or infirmity.
What aspects of health are included when caring for a patient?
Physical aspects
Mental aspects
Emotional aspects
Social aspects
Define Health Promotion
Helps individuals maintain or enhance their present health
Define Health Education
Helps people develop a greater understanding of their health and how to better manage their health risks.
Define Illness Prevention
Protects people from actual or potential threats to health.
Between health promotion, health education, and illness prevention, which one is the one we really need to encourage?
Health Promotion. we can prevent the illness before it occurs.
What are the three levels of prevention?
Primary Prevention
Secondary Prevention
Tertiary Prevention
True prevention that lowers the chances that a disease will develop?
Ex. immunizations, health education, nutrition programs
Primary Prevention
Focuses on those who have health problems or illnesses and are at risk for developing complications or worsening conditions?
Ex. preventing the spread of diseases, performing diagnostic tests on patient and intervening appropriately
Secondary Prevention.
Occurs when a defect or disability is permanent or irreversible?
Ex. focus on the patients current status and prevent worsening complications, we want the patient to achieve the highest level of functioning possible
Tertiary Prevention
which of the three forms of prevention is the best one that we can utilize and is known as the most truest form?
Primary Prevention
what are variables that increase the vulnerability of an individual or a group to an illness or accident?
Genetics & physiology
Age
Lifestyle
Environment
Risk Factors include?
Nonmodifiable risk factors
Modifiable risk factors
Environmental risk factors
Age
gender
genetics/family history
are all known as?
Non modifiable risk factors
Behaviors
lifestyle
diet
are all known as?
Modifiable risk factors
risk factors that are due to where someone lives and the condition of the area are known as?
Environmental factors
A state in which a person’s physical, emotional, intellectual, social, developmental or spiritual functioning is diminished or impaired.
Illness
A type of illness that is
Usually reversible
has a short duration
happens abruptly and has severe symptoms.
Acute illness
A type of illness that is
Irreversible
persist longer than 6 months
goes through periods of normal functioning to exacerbations
can affect coping skills, family life, Jobs, finances, and mental status
Chronic illness
what is the nurses role with a patient that has a chronic illness?
To educate the patient so their illness improves and does not become worse.
At what age is an individual considered an older adult?
65 years old
Should you assume that all older adults are dependent?
NO, you should asses before determining how well they function.
Should you encourage independence in the older adult if possible?
Yes, you should learn their strengths and abilities to encourage independence
Discrimination against people because of increasing age.
Ageism
should you cal your older patients (or patients in general) pet names?
No, you should not call them pet names especially when you first meet them.
what are varying degrees of change and loss?
Health Significant others a sense of being useful socialization income independent living
Some older adults have to cope with…
Retirement
Residence Change
Death and spouse
Adult children
what are some things that should be done by the nurse to ensure that the older adult hears well and understands?
Take patient to a quite room, shut the door and turn off the TV
Speak clearly, don’t mumble and make eye contact
ask one question at a time and allow them time to respond
The moment that you first lay eyes on them and gather all of the information using all of the senses
General survey
changes in the skin of older adults
skin becomes less elastic and dry.
lesions may become more common( can be malignant or non malignant
changes in facial features in older adults
loss of fat and skin elasticity in face, becomes dry and facial features may be more pronounced.
visual and auditory changes in older adults
- visual acuity declines
- Hearing becomes more difficult (patient may deny they have issues hearing)
salivary and taste changes in older adults
- less saliva is secreted
- taste buds become smaller -diminished taste and smell.
changes in the thorax and lungs of older adults
- Respiratory muscle strength decreases
- Anterior-posterior diameter of thorax increases
Heart and vascular changes in older adults
- Decreased contractile strength of the myocardium results in decreased cardiac output (the patient is not pushing out as much blood as they once did)
- Weak pulses upon palpation
changes in the gastrointestinal system and abdomen in older adults
- increased fat storage in abdomen
- slower moving bowels, less frequent bowel movements( may often see patients on stool softners)
Urinary System changes in older adults
- Males experience an enlarged prostate
- Urinary incontinence is more frequent due to weakening muscles
- Urinary tract infections are more common
Musculoskeletal system changes in older adults
Decreased muscle mass and strength
Neurological system changes in older adults
- Slower response time( both physically and mentally)
- Sleep quality changes
- Non expected change (Disorientation, loss of language skills, loss of judgment, forgetfulness)
If the patient is limited in their ability to perform ADLs will they need Require help?
Yes, since they are not able to perform these activities on their own and it can affect their personal safety( especially when bathing)
What are ADLs?
Bathing Dressing toileting teeth brushing hair brushing feeding self
Does chronic illness or disease affect the ability to function in older adults?
It is possible that function may be affected, but it all depends on the degree of chronicity
A state of mental confusion? This can be an acute change or due to a chronic condition.
Disorientation.
You should always determine if it is expected or if it is a new change.
Acute confused sate that can worsen at night, also occurs suddenly usually due to an infection(commonly a UTI) or electrolyte balance?
Delirium.
If the adult has a new onset delirium, the nurse must asses the cause and intervene appropriately
Generalized impairment of intellectual functioning that interferes with social and occupational functioning
Dementia.
you will often see , gradual decline in mental status, which is irreversible, slowly begin to deteriorate and inability to perform ADLs in patients with dementia
When delirium occurs at night it is called….
Sundowning
It is vital for the nurse to educate older adults on the importance of…
-Regular exercise Maintaining independence -visiting a doctor and dentist regularly -eating a healthy diet -importance of receiving immunizations
Most common to Least common conditions leading to death in older adults?
- Heart disease
- Cancer
- Chronic lung disease
- Stroke
Is the patient eating enough? are they getting enough protein intake to keep their muscles strong? what is the patients diet like? these are all questions related to….
Nutrition concerns
infections caused by poor dental hygiene, decreased appetite due to decreased oral care are known as….
Dental problems
Health promotion and maintenance: physiological concerns include
- Nutrition
- Dental problems
- exercise
- falls
- sensory impairments
- pain
- medication use
Elder Mistreatment
- physical abuse
- psychosocial /emotional abuse
- Financial abuse
- sexual abuse
- Neglect
- self-neglect
- abandonment
Therapeutic communication skills
- Therapeutic communication
- Touch
- reality orientation
- validation therapy
- reminiscence
- body-image interventions
Can take place in the home or in a long term care facility, will address chronic conditions that affect daily functioning, and work on improving the ability of the patient to perform ADLs
Restorative care
If the family is considering restorative care what should the nurse do?
Provide as much information as possible, encourage the family to visit the center and make sure it is a good fit for the patient, answer questions but do not provide opinions.
what are the five steps to the nursing process?
- Assess
- Diagnose
- Plan
- Implement
- Evaluate
What part of the nursing process is when you determine if goals and expected outcomes were achieved
Evaluate
when in the nursing process do you gather information about the patients condition?
Assess
During what phase of the nursing process do you set the goals of care and desired outcomes and identify appropriate nursing actions
Plan
In which phase of the nursing process do you identify the patients problems?
Diagnose
In what phase of the nursing process do you perform the nursing actions identified in planning?
Implement
What are the three types of assessments?
- Patient-centered interview
- Periodic assessment
- physical examination (problem focused approach)
Types of Data
- Subjective(patients verbal descriptions of their health problems, patients feelings and perceptions.)
- Objective( Finding resulting from direct observation)
Assessment Data sources include:
- Patient
- Family caregivers and significant others
- health care team
- medical records
- other records and the scientific literature
- Nurse’s experience
Phases of the patient interview
- Orientation(setting agenda)
- working phase(collecting data)
- Termination phase
Assessment process
- Data Collection
- interpretation
- validation
The process of assigning part of your responsibility to another qualified person in a specific situation
Delegation
Five rights of delegation.
- Right Task/Place
- Right Circumstances
- Right person
- Right communication
- Right supervision/ Evaluation
Nurses are alowed to delegate these tasks to other trained nurses or assistive personnel
- showering
- Bed bath
- turning
- vital signs
- ambulation of patient with steady gait
Things that should not be delegated to other nurses or assistive personnel
- Nursing assessment
- clinical reasoning
- nursing judgement
- critical decision-making
- medication administration
- change in patient status;assesment is required.
- Unstable patients
What should be done by the nurse in charge before delegating?
- asses the knowledge and skills of the person
- match tasks to the person’s skills
- communicate clearly( task, outcome, time)
- listen attentively
- provide feedback
who is ultimately responsible for a task being done when delegating?
You, the Nurse
What if the assistive personnel reports they performed the task but it isn’t docummented?
Ask the assistive personnel that completed the task to document it asap
Communication is
- a lifelong process
- essential for establishing nurse-patient relationships and delivering patient centered care
- helps reduce the risk of errors
- maintains effective relationships
Therapeutic communication
- Promotes personal growth
- helps patients reach their health-related goals
Levels of communication
- intrapersonal
- interpersonal
- small group
- public
- electronic
One-to-one interaction between two people
Interpersonal
Occurs within an individual
Intrapersonal
Interaction with an audience
Public
Use of technology to create ongoing relationships with patients and health care team
Electronic
Interactions with a small number of people
small group
Verbal communication
- Vocabulary
- Denotative and connotative meaning
- Pacing
- Intonation
- Clarity and brevity
- Timing and relevance
Nonverbal
-Personal appearance
-Posture and gait
-Facial expressions
-Eye contact
-Gestures
-Sounds
-Territoriality and
personal space
Phases of the helping relationship
- Preinteraction phase
- Orientation phase
- Working phase
- Termination phase
Motivational interviewing
Encourages patients to share their thoughts, beliefs, fears, and concerns with the aim of changing their behavior
Caring relationships are the foundation of clinical nursing practice; they are created with skill and trust
Nurse-patient caring relationships
Use the same principles as one-on-one helping relationships
Nurse-family relationships
Affects patient safety and the work environment
Nurse-health care team relationships
Formed by participating in local organizations, volunteering, or becoming politically active
Nurse-community relationships
SBAR
- Situation
- Background
- Assessment
- Recommendation
Lateral violence
also known as workplace bullyingcan sometimes occur between colleagues
Professional Communication
- Courtesy
- Use of names
- Trustworthiness
- Autonomy and responsibility
- Assertiveness
Active listening
Being attentive to what a patient is saying both verbally and nonverbally
Therapeutic communication
- Sharing observations
- Sharing empathy
- Sharing hope
- Sharing humor
- Sharing feelings
- Using touch
- Using silence
Therapeutic communication continued
- Providing information
- Clarifying
- Focusing
- Paraphrasing
- Validation
- Asking relevant questions
- Summarizing
- Self-disclosure
- Confrontation
Nontherapeutic communication techniques
- Asking personal questions
- Giving personal opinions
- Changing the subject
- Automatic responses
- False reassurance
- Sympathy
- Asking for explanations
- Approval or disapproval
- Defensive responses
- Passive or aggressive responses
- Arguing
The Joint Commission (TJC)
sets standards for patient and family education
It is the nurse’s role to
document when any teaching/education occurs
Patient education includes
-Maintenance and promotion of health and illness prevention
-Restoration of health
Coping with impaired functioning
(If a patient doesn’t recover fully from an illness or injury, they must learn to cope with new functioning & they may have to learn new skills to care for themselves)
The concept of imparting knowledge through a series of directed activities.
Teaching
Acquiring new knowledge, skills, and/or attitudes that can be measured
Learning
steps of the teaching process
- Identify a need for information
- Establish learning objectives
- The nurse (the sender) conveys information
- The patient (the receiver) learns the information
- Provide feedback
- Evaluate the success of the teaching plan
Domains of Learning
- Cognitive learning
- Affective learning
- Psychomotor learning
Motivation to learn
- An internal state that helps arouse, direct, and sustain human behavior
- Influenced by the belief of the need to know something
- Cultural factors
- Active participation
Teaching process
- Assess what the patient knows, their readiness to learn, ability to learn, and motivation to learn
- Set goals and objectives for the learning
- Teach the patient
- Evaluation the learning outcomes, were the goals and objectives met?
Teaching approaches
- Telling
- Participating
- Entrusting
- Reinforcing
Instructional methods
for teaching
- Verbal one-on-one discussion
- Group instruction
- Preparatory instruction
- Demonstrations
- Use of analogies
- Role-playing
- Simulation
During a teaching session, the nurse tells a patient with a recent neck injury that damage to the nerves is comparable to a water hose that has been pinched off. During this teaching session, the nurse is using the process of:
analogy.
See through the patient’s eyes.
Have the patient’s learning needs been met?
-If not, revise the plan of care and offer additional instruction or reinforcement
Environmental safety
A safe environment protects the staff to function optimally
Basic human needs
Sufficient oxygen, nutrition, and optimum temperature, influence a person’s safety
Oxygen use
Supplemental poses fire risk
Falls
Rank as the second leading cause of accidental or unintentional injury deaths worldwide
Transmission of pathogens
A pathogen is any microorganism capable of producing an illness
Immunizations
Reduces, and in some cases prevents, the transmission of disease from person to person
Individual Risk Factors
- Lifestyle
- impaired mobility
- Sensory or communication impairment
- Economic resources
- Lack of safety awareness
Specific risks to a patient’s safety within the health care environment
- Falls
- Patient-inherent accidents
- Procedure-related accidents
- Equipment-related accidents
- Workplace safety
Type of restraints that can be used with precautions and justification?
-Distraction
-Bed alarm
-television
-reorientation
-sitter
Last option should be physical restraints, chemical restraints depending on the situation
When used correctly
side rails help to increase a patient’s mobility and/or stability when repositioning or moving in bed or moving from bed to chair
Infection occurs when
an individual becomes susceptible to the microorganism and the microorganism begins to invade and grow within the body
Risk factors for susceptibility to infection
chronic disease, smoker, immunocompromised, etc.
Factors influencing infection prevention and control
- Age
- Sex
- Nutritional status
- Stress
- Disease process
Health promotion
- Nutrition
- Hygiene
- Immunization
- Adequate rest and regular exercise
- Assist in eliminating the infectious organism
The technique that reduces the number of organisms present and prevent spread is known as
Medical asepsis
Standard precautions
Minimum infection prevention practices that apply to all patient care
Examples of standard precautions
-Hand hygiene
-Use of personal protective equipment (PPE) when necessary
(Gloves, masks, eyewear)
-Cough etiquette
Transmission based precautions
These precautions are used for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission
Contact
These precautions are used for patients with known or suspected infections that represent an increased risk for transmission through contact
Enhanced Contact
In addition to using standard precautions and contact precautions, enhanced contact precautions require the individual to wash hands with warm soap and water after contact with the patient or the patient’s environment.
Droplet
These precautions are used for patients with known or suspected infections that are transmitted by respiratory droplets (coughing, sneezing, talking)
Airborne
These rpecautions are used for patients with known or suspected infections that are transmitted via the airborne route. The patient must be in negative isolation room.
Sterile technique, also known as surgical asepsis
prevents contamination of an area
