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212 Final

Final study guide
Academic year: 2022/2023
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West Virginia University

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UNIT 1

Nursing Process, continuity of care 1. Apply the stages of the Nursing Process as it relates to a patient care scenario 1. Definition 1. A systematic, rational method of planning and providing individualized nursing care to patients. 2. The nursing process provides a framework for problem-solving, a means to define the nurse’s role in caregiving, and a method to communicate with other nurses and healthcare providers. 2. Assess: 1. Subjective and objective data 2. Interview/Health History (questions/ communication!) 3. Patient “ “ (subjective) -primary source 4. Family- second source 5. Observation (objective) 6. Information gathered from charts and records 7. Physical Exam/Head-to-Toe Assessment 8. Maslow’s Hierarchy of Needs 1. Prioritization! 3. Diagnose: 1. (NANDA NURSING DIAGNOSIS) 1. North American Nursing Diagnosis Association 2. Set of standardized terms for nurses to use in writing nursing diagnoses

  1. Examples: Risk for falls, Acute pain

  2. Problem, Etiology, and Signs/Symptoms

  3. Outcome Identification (GOALS) & Plan (INTERVENTIONS)

  4. (can be considered 2 steps):

  5. based on Dx & SX

  6. plan

  7. don’t fall

  8. healthy blood sugar

  9. Implement:

  10. Interventions based on etiology

  11. Meet the goal

  12. Ex:

  13. Independent

  14. Socks

  15. Dependent

  16. O

  17. Evaluate:

  18. Reassess to determine if goals met

  19. Apply concepts of AMA to a patient care scenario

  20. Against Medical Advice

  21. Patient is legally free to leave.

  22. Choice carries a risk for increased illness or complications.

  23. Patient must sign a release form.

  24. Polyuria (diuresis):

    1. abnormally large amounts

  25. Oliguria:

    1. scant amounts
    2. 1-29ml/day

  26. Abnormal Assessment

    1. Anuria:
      1. less than 100ml/day
      2. VERY Abnormal Assessment (MUST REPORT TO PROVIDER!)

  27. 30 ml hour! BASELINE! REPORT IF LESS, Especially in critically ill patients.

  28. Greater than 30= good

  29. Hourly assessment

    1. Ex: 30 times x

  30. Apply concepts r/t nursing interventions for alterations in urinary function

  31. Nursing process

  32. Nursing History:

  33. usual voiding pattern--change lately? Any symptoms? Recent catheterization? (strictures)

  34. Assessment:

  35. Costovertebral tenderness, distended bladder? (Can use bladder scanner)

  36. Check meatus area and skin

  37. Most output problems are either related to fluid status, kidney status, or structural problems – need to figure out which one!

  38. Assessment, continued

  39. Urine: output, characteristics (should be transparent, without strong odor, sediment, or blood; pale straw to amber in color;

  40. ph 4-

  41. Urine Specific Gravity 1-1.

  42. Decreased output and dark urine indicates fluid deficit or shift of fluids

  43. Most output problems are either related to fluid status, kidney status, or structural problems – need to figure out which one!

  44. Nursing interventions

  45. Promote normal voiding habits (schedule, privacy, position, hygiene)

  46. Promote adequate fluid intake (2000-2400 cc/day), may need to decrease fluids prior to bedtime

  47. Assist in strengthening pelvic floor (Kegel exercises)

  48. Assist in toileting

  49. Care for urinary devices

  50. is caused by conditions such as diabetes, hypertension, and glomerulonephritis. Progression of CKD will eventually lead to the final stage of CKD, known as end-stage renal disease (ESRD) or kidney (renal) failure.

  51. In ESRD,

  52. the kidneys are unable to adequately excrete metabolic waste and regulate fluid and electrolyte balance

  53. Measured by labs: (CUES)

  54. BUN (Blood Urea Nitrogen) .. B...U.... NOT BUN

  55. Urea final product of protein metabolism.

  56. BUN measures the nitrogen portion of urea

  57. Normal adult = 6-20 mg/dL

  58. Lab:

  59. Estimated Glomerular Filtration Rate (EGFR.. We may call this “GFR”)

  60. From few mL/min to 200 mL/min

  61. Normal ≥ 60mL/min

  62. (Slight difference for African-American, this population has higher levels of muscle mass so GFR may need to be multiplied by 1.2-1);

  63. May decrease with age

  64. EGFR

  65. Stages... Renal failure

  66. >60.. Normal

  67. 45-59.. Stage 1

  68. 30-44.. Stage 2

  69. 15-29.. Stage 3

  70. Less than 15.. Stage 4..

  71. Lab: Creatinine

  72. By-product of breakdown of muscle from energy metabolism, indicative of body’s ability to breakdown skeletal muscle waste

  73. Measures impaired renal function

  74. Excreted by kidneys

  75. Normal = 06 – 1 mg/dL

  76. *If both CR and BUN are elevated, this usually indicates true renal dysfunction

  77. Discriminate lab work related to alterations in urinary elimination.

  78. CR

  79. GFR

  80. Urine specific gravity

  81. Apply concepts of nursing interventions related to urinary catheterization,

  82. Place

  83. Take out

  84. Sterile specimen

  85. Indwelling vs external

  86. Identify nursing care for a patient with an A-V fistula for dialysis

  87. Do not want to mix stool and urine when collecting stool for testing.

  88. Defecate into new collection device (not toilet)

  89. Do not place tissue in container

  90. Transport immediately

  91. color

    1. coffee grounds (Upper GI bleed)
    2. bloody bright red (lower GI bleed)

  92. Testing for fecal occult blood

  93. “Occult” means hidden

  94. We may not always see the blood in patient’s stool.

  95. Educate about food and drug restrictions (and menstrual cycle)

  96. Avoid mixing specimen with urine or water

  97. Collect stool wearing clean gloves and place on slides with tongue depressor

  98. Follow developing policy on product

  99. Document date/time and initial specimen.

  100. Sent to lab ASAP

  101. Diagnostic testing

  102. Hemoccult.. Avoid for 7 days pretest—can cause false positive.

  103. Salicylate

  104. Iron

  105. Anticoagulants

  106. Steroids

  107. Vitamin C (orange juice). Can cause false negative.

  108. Postpone for current hemorrhoids, or recent nosebleed or throat bleed.

  109. Don’t test until 3 days after menses complete

  110. Esophagogastroduodenoscopy (EGD)

    1. visual examination of the esophagus, the stomach, and the duodenum

  111. Colonoscopy

    1. visual examination of the large intestine from the anus to the ileocecal valve

  112. Sigmoidoscopy

    1. visual examination of the sigmoid colon, the rectum, and the anal canal

  113. Upper Gastrointestinal (UGI) and Small-Bowel Series

  114. Barium Enema

  115. Most distal part of the bowel. The enema (contains contrast) is inserted into the rectum and then pictures are taken.

  116. MRI.. Uses magnets

  117. Abdominal CT.. With or without oral/IV contrast

  118. Specimen collection for pinworms

  119. Pinworms migrate to the anal area during the night to deposit eggs and retreat into the anal canal during the day.

drug infusion pumps, and cochlear implants, should not be exposed to MRI procedures. 5. Abdominal CT:

  1. An oral contrast is consumed before the study if the upper gastrointestinal tract is to be examined.

  2. Intravenous iodine contrast is usually administered.

  3. Assess for patient allergies to iodine, IV contrast, and/or shellfish. Pre-study preparation may be required if allergies are present.

  4. Assess for renal impairment

  5. Check laboratory values for elevated BUN and creatinine levels.

  6. Patient should be NPO for at least 4 hours before study.

  7. CT scan is contraindicated for pregnant patients.

  8. An informed consent is required.

  9. Metformin (TYPE 2 DIABETES MEDICATION) must be discontinued at the time of the study and held for 48 hours after the study to prevent renal insufficiency and lactic acidosis due to the interaction with the contrast dye. Consult with the ordering health care providers for patient medication modifications.

  10. Identify nursing interventions related to the prevention of vagus nerve stimulation 1. When a person bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in decreased blood flow to the atria and ventricles, thus temporarily lowering cardiac output. 2. Once bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart. 3. This act may cause the heart rate to slow and result in syncope in some patients 4. Therefore, this technique of bearing down, termed the VALSALVA MANEUVER, may be contraindicated in people with cardiovascular problems and other illnesses. 1. Use laxatives 1. Not trying to bear down 2. Heart rate can’t go back up if problem with bowel movement 2. Don’t want straining Infection Control

  11. Apply principles of Medical Asepsis to the care of the patient, including transmission based and standard precautions

  12. Clean technique

  13. It applies to administering oral medication, managing nasogastric tubes, providing personal hygiene, and performing many other common nursing tasks.

  14. Older adults have a reduced inflammatory and immune response and thus might have an advanced infection before it is identified. 1. Temp will not elevate like a younger person 2. WBC count may not elevate like a younger person 3. Atypical findings such as agitation, confusion, or incontinence can be the only manifestations.

  15. Identify risk factors for developing an infection including immunocompromised patients.

  16. Education

  17. Immunizations (esp. Immunocompromised)

  18. Good oral hygiene (teach and return demo; esp immunocompromised)

  19. Consume an adequate amount of fluids. (esp. Immunocompromised)

  20. Adequate fluid intake prevents the stasis of urine by flushing the urinary tract and decreasing the growth of micro-organisms.

  21. Adequate hydration also keeps the skin from breaking down. Health Promotion older adult

  22. Differentiate characteristics of acute vs. chronic illness

  23. Acute:

  24. Rapid onset

  25. Short duration

  26. Can be cured

  27. Acute illness goal: Cure or correct issue

  28. Chronic:

  29. Permanent or irreversible

  30. Lifelong duration

  31. Exacerbations/ Remissions

  32. Chronic illness/condition goal: manage, control, minimize impact of condition. Work toward high level wellness without “cure

  33. A broad term that encompasses many different physical and mental alterations in health.

  34. It is a permanent change.

  35. It causes, or is caused by, irreversible alterations in normal anatomy and physiology.

  36. It requires special patient education for rehabilitation.

  37. It requires a long period of care or support.

  38. Usually has a slow onset and may have periods of remission and exacerbation.

  39. Remissions (times of no symptoms)

  40. Exacerbations (return of symptoms/illness)

    1. Examples:
      1. Diabetes mellitus, lung disease (COPD) arthritis, lupus, Congestive Heart Failure, Hypertension, Coronary Artery Disease, HIV/ AIDS, Parkinson’s Disease

  41. Identify characteristics of Suchman’s Illness stages

  42. Suchman’s illness stages:

  43. Experiencing symptoms.

  44. focus on screening for early detection of disease with prompt diagnosis and treatment of any found

  45. Examples are assessing children for normal growth and development

  46. Encouraging regular medical, dental, and vision examinations

  47. Blood pressure screenings

  48. Mammograms

  49. Early detection/ screening

    1. DM
    2. Colon Cancer

  50. Tertiary:

  51. Have it, keep them from getting more sick

  52. begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning

  53. Examples include:

  54. Teaching a patient with diabetes how to recognize and prevent complications

  55. Using physical therapy to prevent contractures in a patient who has had a stroke or spinal cord injury.

  56. Referring a woman to a support group after removal of a breast because of cancer.

  57. Rehab services

  58. Apply concepts from the Models of Health Promotion to patient care.

  59. Pender

  60. Developed to illustrate how people interact with their environment as they pursue health

  61. Incorporates individual characteristics and experiences and behavior-specific knowledge and beliefs, to motivate health-promoting behavior

  62. Personal, biologic, psychological, and sociocultural factors are predictive of a certain health-related habit.

  63. Health-related behavior is the outcome of the model and is directed toward attaining positive health outcomes and experiences throughout the lifespan.

  64. Revised

    1. Three additional variables:
    2. Activity-related affect
    3. Commitment to a plan of action
    4. Immediate competing demands and preferences
    5. Behaviors may induce either a positive or negative subjective response or affect

  65. Apply concepts of Maslow’s hierarchy to the care of the patient

  66. Their lack of fulfillment results in illness.

  67. Their fulfillment helps prevent illness or signals health.

  68. Meeting basic needs restores health.

  69. Fulfillment of basic needs takes priority over other satisfactions when unmet.

  70. A person feels something is missing when a need is unmet.

  71. A person feels satisfaction when a need is met.

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212 Final

Course: Foundations of Nursing Practice (NSG 212)

University: West Virginia University

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UNIT 1
Nursing Process, continuity of care
1. Apply the stages of the Nursing Process as it relates to a patient care scenario
1. Definition
1. A systematic, rational method of planning and providing individualized
nursing care to patients.
2. The nursing process provides a framework for problem-solving, a means
to define the nurse’s role in caregiving, and a method to communicate
with other nurses and healthcare providers.
2. Assess:
1. Subjective and objective data
2. Interview/Health History (questions/ communication!)
3. Patient “ “ (subjective) -primary source
4. Family- second source
5. Observation (objective)
6. Information gathered from charts and records
7. Physical Exam/Head-to-Toe Assessment
8. Maslow’s Hierarchy of Needs
1. Prioritization!
3. Diagnose:
1. (NANDA NURSING DIAGNOSIS)
1. North American Nursing Diagnosis Association
2. Set of standardized terms for nurses to use in writing nursing
diagnoses

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