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Exam 1 Blueprint - Exam review
Fundamentals (NSG241)
Marian University
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NSG 241 Fundamentals Fall 2020 Exam One Blueprint
Lab Content
Hygiene and Personal Care
Main concepts of Hygiene Skills (p. 532-560) Always start with assessing the patient!
Bathing a Patient in Bed:
- Lay patient flat if tolerated for patient comfort during turning
- Proper positions of bed linens is important to provide warmth, privacy, and comfort while also protecting the linens and gowns from becoming dirty or wet.
- Wear Gloves
- For eyes, wipe from the inner to outer canthus, using a fresh surface of the cloth for each eye.
- Assess skin during bathing.
- Give patients the choice to have them take control of their care.
- For arms, wash distal to proximal, and apply deodorant.
- Always place a bath towel under the patient's body that is getting washed to prevent the bed from getting wet.
- For legs, wash from ankle to knee and then knee to thigh.
- Always dry the limb that was just washed.
Perineal Care (Male)
- Wear gloves
- If uncircumcised, retract foreskin by gently pushing it toward the body.
- Start at the urinary meatus, wash the tip of the penis with soap, using a circular motion; wash the shaft of the penis using downward strokes.
- Properly cleanse and dry.
Perineal Care (Female)
- Wear gloves
- Separate the labia, clean the pubic area by using downward strokes toward the anus.
- Use a different part of the washcloth for each stroke.
- Downward strokes prevent UTI’s
Foot and Hand Care
- Place a towel or waterproof pad under basin
- Soak the hand or foot for 10 minutes
- After soaking, wash with soap, rinse, and dry.
- Inspect nails, file or trim according to policies.
- Apply lotion if desired.
Therapeutic Massage
- Use lotion
- Massage from buttocks to shoulders and back to buttocks if possible.
- Effleurage Technique prevents ticking, promotes relaxation, trust, and imparts a sense of caring.
- Knead muscles using the Petrissage technique-promotes specific muscles relaxation.
- Tapoment technique- tap with the sides of the palm or ulnar surface of the hand up and down the patient’s back, avoiding the kidneys.
Hair Care
- Work at the top of the bed.
- Place towels and waterproof pads under the patient’s head and place a towel over the chest.
- Place a shampoo basin under the patient’s head, with the spout directly over the edge of the bed.
- Comb patient’s hair.
- Apply shampoo, lather, and rinse
- Dry and comb the patient's hair.
Oral Hygiene
- Apply water and toothpaste to toothbrush
- Brush teeth, gums, and tongue.
- Brush upper and then lower teeth, working on the outside surfaces and then the inside surfaces.
- Give water to the patient to be able to rinse and spit.
- Allow the patient to floss.
- Provide mouthwash after rinsing with water.
- Dry patient’s mouth and offer lubricant for the lips-since oral hygiene can promote drying and cracking of teeth.
With Dentures:
- Remove dentures w/ a 4x4 gauze pad.
- Clean gums and wash dentures with same teeth brushing technique
- Wash with warm water and washcloth laid in the sink to prevent breaking the dentures.
Shaving a Male Patient
- Apply warm water to the patient's face to lower the risk of nicks.
- Put shaving cream in hands, lather, and apply to their face. *ask patient if they prefer cream or soap
- Hold skin taut, shave one side of the face using long, firm strokes in the direction in which the hair grows.
- Use short strokes around the chin and lips.
- Rinse water with warm water after each stroke.
- Inflammation- New framework for blood vessel growth
- Proliferation or Granulation- pulls the wound closed
- Remodeling or Maturation- Final proper tissue
Factors Affecting Healing
- Vascular disease
- Diabetes
- Malnutrition
- Medications
- Excessive moisture
- External forces
- The aging process
Complications of Wound Healing
- Hemorrhage
- Hematoma
- Infection
- Dehiscence - separation or splitting open of layers of a surgical wound
- Evisceration - extrusion of viscera or intestines through a surgical wound
- Fistula Formation
- Pressure ulcers
Stages of Pressure Ulcers
Stage I: non-blanchable redness of intact skin Stage II: partial thickness skin loss or blister Stage III: full thickness skin loss (fat visible) Stage IV: full thickness tissue loss (muscle/bone visible)
Skin assessment tools and principles of skin assessment tools
Oxygenation/Airway (p. 935)
Nursing Care Guidelines- Incentive Spirometer
Used by pt’s to practice inhalation-->encourages deep breathing, maintains lung expansion, and helps to prevent atelectasis and pneumonia.
Steps:
1. Pt. should be in a Semi Fowler or Fowler’s position
2. Instruct the patient to inhale slowly with the mouth on the mouthpiece
**- Inhale as much as possible, and hold breath for 3-5 seconds
- Slowly exhale
- Repeat each inhalation and exhalation 5 to 12 times
- End with two controlled coughs
- Perform this exercise every 1 to 2 hrs per order.**
Evidence Based Practice: incentive spirometry breathing was found to decrease recovery time and improve lung functioning of obese patients if begun immediately after surgery in recovey and the PACU. Lung function was significantly improved for 24 hrs post-operatively.
Restorative Breathing Exercises
Pursed-lip breathing (from internet): To practice pursed lip breathing, breathe in slowly through your nose
for two counts, keeping your mouth closed. Take a normal breath. Pucker or "purse" your lips as if you
were going to whistle and breathe out.
Diaphragmatic breathing (from internet):
- Sit comfortably, with your knees bent and your shoulders, head and neck relaxed.
- Place one hand on your upper chest and the other just below your rib cage. This will allow you to feel your diaphragm move as you breathe.
- Breathe in slowly through your nose so that your stomach moves out against your hand. The hand on your chest should remain as still as possible.
- Tighten your stomach muscles, letting them fall inward as you exhale through pursed lips. The hand on your upper chest must remain as still as possible.
NG Tube Management/Enteral feedings (p)
Evidence-based practice
Confirming enteral tube placement:
- Use of a radiograph to confirm placement → most reliable - Using only pH and the appearance of aspirate from the newly inserted tube is not a safe method of verifying proper gastric tube - Auscultation of an air bolus to assess tube placement is no longer recognized as a reliable source.
Special Circumstances- NG insertion see p. 694-
- Assess: Was resistance encountered during the insertion of the tube?
Maslow’s Hierarchy of Needs - specifies the psychological and physiological factors that affect each person’s physical and mental health. A nurse’s understanding of these factors help w/nursing diagnoses that address a patient’s needs/values. Lower levels need to be met first.
Stage 1 - Physiological needs: O2, H2O, food, elimination, temperature control, sex, movement, rest, and comfort
Stage 2- Safety & security: from a physiological and psychological threat; and protection, stability and lack of danger
Stage 3 - Love and belonging: affection, intimacy, support, and reassurance
Stage 4 - Self-esteem: self-worth, self-respect, independence, privacy, status, dignity, and self-reliance
Stage 5- Self-actualization: recognition and realization of one’s potential, growth, health and autonomy
Erikson’s Psychosocial Theory - socialization is based on individual’s interacting and learning about their world. Nurses use concepts of developmental theory to care for their patients at various stages in life. B/c nurses strive to meet the holistic needs of the pt they need to address developmental issues
Age range psychosocial crisis virtue developed
Birth to 18 mo trust vs. mistrust hope (trust others will meet needs)
18 mo- 3 yrs Autonomy vs shame/doubt will (balance holding on/letting go)
3-6 yrs Initiative vs guilt purpose (initiate w/o fear reprimand)
6-12 yrs industry vs inferiority competency (self-worth not failure)
12-18 yrs identity vs role confusion fidelity (strong sense individuality)
18-35 yrs intimacy vs isolation love (fulfilling love/family relationship)
35-55 yrs generativity vs stagnation care (self-worth as kids leave home)
55+ integrity vs despair wisdom(fulfillment/accomplishments)
Lewin’s Change Theory - change is a 3-step process. (Nurses function as change agents and need to understand change theory). This theory recognizes the dynamic nature of change and the need to constantly evaluate nursing practice.
- Step 1 - unfreezing - overcoming inertia and changing the mind-set, which involves bypassing the defenses. During unfreezing the right environment is created for change
- Step 2- moving or changing - time of transition and confusion when change takes place. Change is supported by implementation
- Step 3 - refreezing - during which change is completed, reinforced and accepted.
Paul’s critical-thinking theory - critical thinking is an “intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by observation, experience, reflection, reasoning, or communication, as a guide to belief and action. (intellectual values
- clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth and fairness). Nurse application of Paul’s definition:
● Nurses analyze data ● Nurses develop a patient care plan ● Nurses implement a plan of action for the patient ● Nurses evaluate the plan of care
POWERPOINT INFO ON CRITICAL THINKING - NOT SPECIFIC TO PAUL’S THEORY
PPT synonyms for critical thinking - problem solving, decision making, reasoning, judgment
PPT definition of critical thinking - a complex process that is the “art of thinking about your thinking while you’re thinking so you can make your thinking more clear, precise, accurate, relevant, consistent and fair.
PPT critical thinking components
● Knowledge review ● Reasoning ● Inferences ● Validation ● Assessment
PPT critical thinking attitudes
● Confidence ● Thinking independently ● Fairness ● responsible/accountable ● Risk taking ● Discipline ● Perseverance ● Creativity ● Curiosity ● Integrity ● Humility
Rosenstock’s Health Belief Model - originally designed to predict pt response to treatment, but recently used to predict more general health behaviors. Model addresses possible reasons for noncompliance w/recommended health promotion behaviors. This model is important to nurses as they educate patients. 4 core beliefs of people’s perceptions by their own assessment:
● Perceived susceptibility of the risk of getting the condition ● Perceived severity of the seriousness of the condition and its potential consequences ● Perceived barriers of the influences that facilitate or discourage adoption of the promoted behavior ● Perceived benefits of the positive consequences of adopting the behavior
i. Practicing loving-kindness and equanimity within the context of caring consciousness. ii. Being authentically present and enabling and sustaining the deep belief system and subjective life world of self and one-being cared for. iii. Cultivating one's own spiritual practices and transpersonal self, going beyond ego self. iv. Developing and sustaining a helping-trusting, authentic caring relationship. v. Being present to and supportive of the expression of positive and negative feelings. vi. Creatively using self and all ways of knowing as part of the caring process; engaging in the artistry of caring-healing practices. vii. Engaging in genuine teaching-learning experience that attends to wholeness and meaning, attempting to stay within other's frame of reference. viii. Creating a healing environment at all levels, whereby wholeness, beauty, comfort, dignity, and peace are potentiated. ix. Assisting with basic needs, with an intentional caring consciousness, administering “human care essentials,” which potentiate alignment of mind-body-spirit, wholeness in all aspects of care. x. Opening and attending to mysterious dimensions of one's life-death; soul care for self and the one-being-cared for; “allowing and being open to miracles.” 3. Travelbee: Human-to-Human Relationship Model
From Internet: Travelbee’s theory defines health in 2 categories: subjective & objective.
Subjective health is an individually defined state of wellbeing in accord w/self-appraisal of the physical-emotional-spiritual status.
Objective health is an absence of discernible disease, disability of defect as measured by physical examination, lab tests and assessment by spiritual director psychological counselor.
Travelbee Human to Human Relationship Model has 7 basic Concepts:
a) Suffering, which is “an experience that varies in intensity, duration, and depth.. feeling of unease ranging from mild, transient mental, physical or mental discomfort to extreme pain...” b) Meaning , which is the reason attributed to a person c) Nursing, which helps a person find meaning in the experience of illness and suffering; has responsibility to help people and their families find meaning; and the nurse’s spiritual and ethical choices, and perception of illness and suffering, which are crucial to help patients find meaning d) Hope, which is a faith that can and will be a change that would bring something better with it. Six important characteristics of hope are: dependence on other people, future orientation, escape routes, the desire to complete a task or have an experience, confidence that others will be there when needed, and the acknowledgement of fears and moving forward towards its goal e) Communication, which is a “strict necessity for good nursing care”
f) Self-therapy , which is the ability to use one’s own personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions. This refers to the nurse’s presence physically and psychologically g) Targeted intellectual approach by the nurse toward the patient’s situation
4. Swanson: Middle Range Theory of Caring a. completion of three studies explored the experiences of women who suffered a miscarriage. b. Funded by the National Institute of Nursing Research: caring decreased negative emotions c. Five processes: i. Knowing ii. Being with iii. Doing for iv. Enabling v. Maintaining belief 5. Anne Boykin & Savina Schoenhofer: Theory of Nursing as Caring a. Six attributes of caring I. Compassion II. Competence III. Conscience IV. Confidence V. Commitment VI. Comportment (behavior) b. Theory defined as “the intentional and authentic process of the nurse w/another who is recognized as a person living caring and growing in caring” c. Major concept- the nursing situation in which the nurse and pt share the lived experience of caring. It is in the nursing situation that nursing is created and can best be understood.
Critical Thinking
Subjective vs Objective data
Subjective data - spoken information or symptoms that are typically difficult to validate. Usually gathered during the interview process if patients are well enough to describe their symptoms.
● Primary data comes from the alert/oriented pt ● Secondary data comes from family, friends or other health care workers that can contribute valid secondary data ● Subjective data should be documented as direct quotations (w/in quotation marks) ● PPT - patient’s feelings/perceptions
Objective data - referred to as signs, can be measured or observed. Nurses use sight, hearing, touch, and smell to collect objective data.
● Vital signs, labs, etc ● Conclusions about underlying cause of the pt’s actions cannot be assumed ● Validating data is making sure data is accurate
● Medical documentation should be based on fact, not opinions ● In the event of litigation, the medical record is often the only available evidence of the event in question ● STRIKE THROUGH ITEMS/CORRECTIONS ARE NOT ARE NOT ADMISSABLE ● Ethical practice dictates that nurses document only interventions that were/are performed ● Medical record entries cannot be altered or obliterated
Errors in Charting
PPT - errors in written documentation
● Lined through ● “Error” ● Nurse’s Initials
PPT - errors in written documentation
● Each state has different laws on how an EHR can be amended ● Remains as a part of the chart ● When correcting or making a change to an entry: ○ The original entry should be viewable ○ The current date and time should be entered ○ The person making the change should be identified ○ The reason should be noted
Hand-off reports
Hand-off : real-time process of passing patient specific info from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety
● Hand off reporting should provide accurate, timely, important information to the next caregiver to ensure patient safety ● Is vital because communication breakdown accounts for high number of medical errors ● When complete/accurate info is not shared during a hand-off report, patients may not get needed care, proper medications or recommended therapies ● Hand-off reports are enhanced by pt participation ○ Teach pt to actively participate w/staff during the bedside rounds ○ Ask pts to validate the info shared during the rounding process ○ Encourage pt to ask questions during rounding process
PPT - hand-off reports
● Face-to face, telephone, written, recorded ● Takes place: ○ Between shifts ○ At time of unit transfer ○ At time of discharge ● Functions of hand-off/change-of-shift reports ○ Provide accurate/timely info about:
■ Care ■ Treatment ■ Services rendered ○ Address: ■ Current condition ■ Anticipated change
PPT - SBAR - communication format specifically suggested for use in nurse-physician interactions
S- Situation
B- Background
A - Assessment
R- Recommendation
Nursing Process
Effective outcome (goal) statements
Goals are statements designed in collaboration w/patients to provide guidance and ultimately a measure of progress when addressing nursing diagnoses (patient problems). Need to be:
● Realistic - consider the pt’s physical, mental and spiritual condition in relation to the ability to attain the goals. ● Patient centered - written specifically for the pt. Goal should specify activity the pt is to exhibit or demonstrate to indicate goal attainment ● Measurable - specific w/numerical parameters or other concrete methods of judging whether goal was met ● Time limited goals - most goal statements need to include a time for evaluation
PPT - SMART goals
S- specific
M- measurable
A- attainable
R- realistic
T- time bound
Steps of the nursing process and what each entail
- Assessment - data collection (primary/secondary data, subjective/objective)
- Diagnosis - cluster related data, Nursing diagnosis, list supporting data
- Planning - prioritize nursing diagnoses, personalized care plan, long/short term goals, outcome identification (NOC)
● physician diagnosis based on the medical condition ● Nursing diagnosis is judgement based on a comprehensive nursing assessment. ● Medical diagnosis provides one important piece of data, but it doesn’t provide anywhere near the depth of info necessary for making an accurate nursing diagnosis
PPT - PES Format
● P - Problem (diagnostic label) ● E - Etiology (related/risk factors) ● S - Symptoms (defining characteristics)
Patient Safety/Fall precautions
Fall score tools
- Hendrich II Fall Risk Model - scored based on: confusion/disorientation/impulsivity, symptomatic depression, altered elimination, dizziness/vertigo, gender, any antiepileptics, any benzodiazepines, “rising from chair.”
- Johns Hopkins Hospital Fall Assessment Tool - divided in 2 categories - considers factors such as: age, fall hx, elimination (incontinence, frequency/urgency), medications, patient care equipment, mobility and cognition). Resulting in LOW, MODERATE, HIGH RISK
- Morse Fall Scale - scored based on 6 categories (hx of falls, secondary dx, ambulatory aid, IV/Heparin lock, gait/transferring, mental status)
Many others - Stopping Elderly Accidents, Deaths, and Injuries (STEADI) algorithm
Safety Interventions in the HealthCare Environment
Fire Safety
RACE
● R- Rescue all patients from danger and move to safe area ● A- Activate the manual pull station or fire alarm, and have someone call 911 ● C- Contain the fire by closing the doors, confining the fire, and preventing the spread of smoke ● E- Extinguish the fire if possible after all patients are removed from the area
Electrical
● Check for faulty wiring or anything unusual that needs maintenance/inspection ● Do not use machines on patients that are malfunctioning
Fall Prevention
● Call light w/in reach ● Pt items w/in reach to prevent reaching ● Making hourly rounds to make sure pt needs met reduces falls ● High fall risk pt should be near nurses’ station (pressure sensitive alarm can be used) ● Some may need a 24 hr sitter for observation ● Some facilities have virtual monitoring
● Apply brakes/locks on bed/wheelchairs ● Grab bars near toilets/showers ● Proper use of side rails
Other topics in Ch. 25
● Proper use of restraints ● Safe medication administration ● Reduction of pathogen transmission ● Reduction of procedure-related and equipment-related events ● bioterrorism
Legal/Ethical (p-146, 150-153)
Essential Principles of Ethics in Nursing LO 11.
Autonomy : a patient’s freedom to make decisions supported by knowledge and self-confidence.
● Nurses promote autonomy when they include patients in the process of developing care plans with realistic goals and interventions.
Accountability : the willingness to accept responsibility for one’s actions.
● A nurse who is accountable readily admits to actions without having to be questioned by others. They exhibit honesty, accept consequences for their actions, and initiate best nursing practices based on current evidence-based research.
Advocacy: supporting or promoting the interests of others or of a cause greater than ourselves.
● A nurse is ethically required to advocate for the rights for all patients, including those who are unable to express themselves and those with whom the nurse disagrees philosophically. This process requires nurses to focus on patients’ needs and benefits.
Beneficence: doing good.
● A nurse acts on behalf of others by placing priority on the needs of others rather than on personal thoughts and feelings even if the patient's needs differ significantly from those of the nurse.
Confidentiality: ethical concept that limits sharing of information
● Nurses should only disclose personal information to limited authorized individuals or agencies. (i. HIPAA)
Laws Impacting Professional Practice LO 11.
Constitutional Law: derived from a formal, written constitution that defines the power of governments and the responsibilities of its elected or appointed officials. It impacts nursing indirectly because the legislative bodies that enact statutory law are established and governed by the Constitution-Bill or Rights and other amendments to further the rights of individuals.
Principles of Delegation
Delegation : the process of entrusting or transferring the responsibility for certain tasks to other personnel ● Must know the scope of practice and skills of those receiving the tasks ● The RN maintains the ultimate responsibility that the delegated tasks are completed, accurate and supervised
First Principle of Delegation: ● Know your states RN scope of practice ● Know your job descriptions ○ Employers policy/procedure manual Second Principle of Delegation ● The RN cannot delegate assessment, planning, evaluation, or accountability for the assigned task ○ RN still has to follow up and verify the task has been completed ○ RN is responsible for assessment of pt even if certain tasks are delegated to others Third Principle of Delegation ● The person to whom the assignment was delegated cannot delegate the assignment to someone else
Exam 1 Blueprint - Exam review
Course: Fundamentals (NSG241)
University: Marian University
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