Test 1 Study Guide
Test 1 Study Guide NUR 231
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This 20 page Study Guide was uploaded by Issy Notetaker on Sunday September 20, 2015. The Study Guide belongs to NUR 231 at Ball State University taught by Marsann Shafer, Jane Edwards, Kathryn Humphrey in Summer 2015. Since its upload, it has received 75 views. For similar materials see Fundamental nursing skills in Nursing and Health Sciences at Ball State University.
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Date Created: 09/20/15
Chapter 26 Documentation 0 O O 0 Written or printed Proof of care IMPORTANT Accurate comprehensive exible Information is transferred verbally electronically or written Con dentiality O O O O O MUST OCCUR Pt has right to medical record w written permission release HIPPA What are the HIPPA rules What are medical records used for 3 things What are the rules for these uses Chart is LEGAL document and can be used in court Standards 0 O O O Govern information and documentation Determine frequency Admitted pt must have what assessments What institutions create standards of practice Interdisciplinary Communication 0 O O O 0 Record is continuous What percent of errors are made from bad communication 70 Types Change of shift telephone handoff incident reports Methods Verbal written audiotaped Difference between consultations and Referrals Purpose of a record 0 O O 0000 Source of data Communication Legal documentation When and How are medical records used in court Financial Billing What is a DRG Why are these important Educann Research Auditing and Monitoring Quality improvement Documentation Guidelines 0 Factual Avoid vague terms 0 Accurate Exact measurements clear concise spell correctly date and sngn 0 Complete needed information Care given and changes 0 Current timely Should you use a 12 hour time or military 0 Organized Logical order 0 Proofread Methods 0 Paper Disadvantages 0 Electronic Advantages Accessed and added to at each visit 0 o Narrative Traditional Storylike format Disadvantages 0 Problem Oriented Emphasizes pt problems All team member add on Sections Database All data for the pt Problem list Chronological order of all problems Care Plan Diagnosis Outcomes Intervention Progress Notes 0 Methods 3 0 Source Records New section for each discipline 0 Charting by Exception Only documents deviations from normal Advantages Easy to track changes reduces time 0 Case Management PlanCritical Pathway Problems interventions and expected outcomes Monitoring progress 0 Common Record Keeping Forms 0 Admission nursing History Form COMPLETE Baseline data 0 Flow Sheet Used commonly in critical care and acute care Quick and easy 0 Kardex Electronic Summary updates w newly added information Portable le 0 Standardized Care Plans Ef cient Preestablished guidelines Individualize for pt 0 Discharge Summary Save costs Important and must be timely Begins on admission What should you include o Acuity Record NOT part of medical record 1 is totally dependent needs assistance w everything 5 is totally independent an do all on own Home Care Documentation 0 O O 0 Info from family Must foIIow speci c guidelines Provide copies to all health care providers Document ALL services Long Term Health Care Documentation 0 Must be done carefully o What is RAI and MDS Why are they important Reporting 0 Hand off When does this happen Advantages What must this documentation include 0 Telephone 0 When are these used What needs to be documented Report vs Order Order Telephone or verbal When do these most often occur Frequent cause of errors Incidence Reporting When does this occur Helps to identify trends Important if improvements are to be made Don39t note in medical record but document objective description of accident Pt was on oor with puddle of water Health Informatics O 0 Computer and information science in biomedical sciences Use of EMR and EHR Nursing Informatics O O O O O 0 What is this Advantages what makes this helpful What is Information tech What is the Nursing Information System De ne Efficient and effective care Supports the exibility of nursing Helps to reduce errors What are the different designs What are the Advantages How do you dispose of information How do you keep the information con dential Clinical Information Systems 0 O 0 Monitoring system Automatically records and saves Advantages Common Malpractice mistakes 6 from lecture Chapter 27 0 Safety What is it o What does it do Reduces costs and injuries 0 Whose responsibility is it o What is QSEN Environment 0 Physical and Psychological 0 Physiological needs 3 main ones 0 Common Hazards Physical Vehicles Highest risk group is teens and after age 75 Poison What does it do Who should you call Falling High risk is 64 0 In uencing factors Fire Leading cause is smoking 0 How can they be prevented Disaster 0 Natural vs Bioterrorism Pathogen How are these transmitted What prevents transmission Pollution Types 0 Developmental Stage 0 InfantPreschooler Accidents are preventable o SchoolAge Environment is largerlncrease risk Teach Safety 0 Adolescent More independent Risk taking behaviors occur Driving and sexual activity increase risks 0 Adult Risks are associated with lifestyle habits 0 Older Adult What are the risk factors 0 Individual 0 Lifestyle Choices affect safety and risks 0 Mobility Is mobility impaired If so what does this increase 0 Impaired sensorycommunication Types of impaired senses Risks these lead to 0 Agency Risks Medical errors Know regulations Encourage pt to speak up Report incidents Why Know environmental risks What MSDS What assessments should be made to help prevent incidents Explain each 0 Falls Patientinherent Procedure Related 0 Equipment Related Critical Thinking is ongoing Assessment 0 Note pt view of safety and how it differs from yours 0 Consult about difference in perceptions and teach was to reduce hazards 0 Note risks 0 What history questions should you ask the pt 0 Health Care Environment Immediate hazards Collaborate When is a Fall risk assessment done and why is it important What factors increase the risk of medical errors What should be done in preparation for disasters Drills Proper communication Accurate and timely assessments Home Environment Hazard assessment is essential Diagnosis 0 Analyze and Cluster Data Planning 0 00000 Interventions prevent and minimize risks while addressing all pt needs Goals and Outcomes must be measureable and achievable Set Priorities Educate pt Teamwork and Collaboration is important What is SBAR and why is it important Be able to create a SBAR out of a situation Implementation 0 O 0 Use technology and practices Use pamphlet and iers to reduce need for memorization Promotion and prevention measures should be used What are some promotion activities for each developmental level InfantPreschooler School Age Adolescent Adult Elderly 0 Acute Care Standard Precautions What are they Make pt safe Falls 0 Protocol should be followed 0 Include family 0 Ways to prevent falls Restraints Temporary 0 What are the guidelines for their use 0 What documentation must be done 0 How often must they be monitored Is this different for children 0 What are alternatives Side Rails 0 Increase mobility and stability 0 Know policy 0 What position should the bed be in when nurse is not in room 0 Common causes 0 Have an evacuation plan 0 What do you do if one occurs Seizures Grand Mal is 25 minutes 0 What does a nurse do what a seizure occurs 0 Should you put anything in pt mouth 0 Evaluation 0 Were the outcomes met Chapter 28 0 Infection Prevention and Control 0 Nurses play primary role 0 What factors are increasing risks Antibiotic resistance and invasive procedures 0 What are sources of infection 0 Teach pt about prevention 0 De ne Infection Colonization Communicable Symptomatic Asymptomatic OOOOO o What is the Chain of Infection 0 Requires Pathogen Resident vs Transient Flora Virulence Reservoir Water food fomites animals hands equipment patients 0 Categories Symptomatic and Asymptomatic Factors affecting 0 Food 02 Water Temperature pH 0 Light Port of exit 0 Name some Transmission Mode 0 Each microbe is speci c 0 Name some Entry Port 0 Same routes as exit Host 0 Degree of resistance an individual has affects susceptibility What are some natural defenses What about risk factors 0 As long as chain is uninterrupted infection will continue 0 De ne o Localized infection Symptoms 0 Systemic Infection Symptoms Defenses 0 Normal Flora Resident bacteria needed to maintain health 0 Body System Each organ has on defense mechanisms 0 In ammation Vascular response Vasodilation redness warmth swelling pain fever WBC count normally Phagocytes Exudates Fluid discharge OOOO Serous Sanguineous Purulent Tissue Repair Damaged is replaced w healthy c When does scar tissue form What is an HAI O 0000 What happens to those who catch one Iatrogenic Infection Exogenous Infection Endogenous Infection Factors increasing risk of health care personal and type of invasive procedures length of stay 0 Increase Costs 0 High risk is elderly Explain in uences on infection control 0 Age 0 Nutrition 0 Stress 0 Disease Process Assessment 0 Note pt perception of illness 0 0 Assess susceptibility defenses and knowledge Assess if medical therapy will compromise naturaI defenses Why are broad spectrum antibiotics dangerous Destroy normaI ora in body Assess medication side effects Assess if infection Iooks LocaI Symptoms Systemic Symptoms Change in alertnessactivity How are the elderly different 0 Do WBCs increase or decrease with infection Diagnosis requires a quotrelated toquot factor Planning 0 Goals Prevention of further exposure Controlling infection Maintaining resistance Knowing prevention methods Implementation O 0000 Strengthen defenses Natural Minimize reservoirs ports organisms Use antiseptic and sterile techniques How can you reduce exposure chances What can be done in acute care to prevent infection Eliminate Prevent complications 0 Such as Encourage naturaI defenses De ne Asepsis Advantages of asepsis 0 When do you wash hands with soap and water 0 When should you alcohol 0 Explain differences bw Cleaning Disinfection and Sterilization and de ne them Cleaning 0 Process 7 steps Disinfection Sterilization What in uences efficiency 6 items 0 How can you increase pt safety Follow OSHA regulations Cough Etiquette Prevent skin break down Others 0 What is isolation Precautions Contact De ne and give PPE example 0 Direct or indirect 0 Hand hygiene Droplet Airborne Protective equipment 0 Other ways What are some psychological effects isolation can have on the pt Describe different environments 0 Negative Air ow Positive Air ow o PPE is used for Name different items What is the order for applying PPE What is the order for taking off PPE o What is surgical Asepsis When should this be used Difference bw bedside and OR What is included in pt prep 0 What are the 9 Principles of sterile technique Area where objects can be easily handled and protected from contamination Surface for proper placement Sterile kit sterile towel draped surface Only STERILE touching STERILE is still sterile Only STERILE objects should be placed on STERILE eld STERILE object outside of vision range or below waste is CONTAMINATED STERILE objects become CONTAMINATED if prolonged exposure to air When STERILE comes into contact w WET it is CONTAMINATED Fluid ows w gravity Edges of sterile FIELD are CONTAMINATED 1 inch border 0 What is require in prep and process of sterile technique Assembling PPE Opening a sterile package FIat Surface Preparing the Field Pouring solutions WASHING HANDS IS THE MOST EFFECTIVE WAY OF PREVENTING THE SPREAD OF INFECTION Evaluation 0 What are some exposure issues Chapter 39 Hygiene 0 Determine pt ability to perform selfcare 0 Allow pt to do as much as they can 0 Ensure comfort 0 Practices should be adapted to pt 0 Purpose What does the skin tell a HC provider 0 Layers and functions Epidermis prevent water loss Dermis Contains 0 What is sebum and its purpose Subcutaneous Contains 0 Heat insulator Feet hands Nails 0 Conditions impair selfcare ability 0 What do healthy nails look like What does disease do to nails 0 Oral Cavity 0 Normal appearance 0 What is Xerostomia o What does saIiva do Elaborate on the factors in uencing Hygiene 0 Social Products used Parent in uence Media and peer in uence 0 Personal When shower vs bath products used 0 Body image Subjective O Maintenance of hygiene Extra teaching and time may be needed for those who lack personal hygiene or w those who have had body image alterations SES Products and type Health Believes and Motivation Recognition of potential risks dental health not being seen as important Culture Practices are different Developmental Stage Skin 0 Infant 0 Toddler Adolescence Adult Elderly Feet and Nails 0 Chronic problems increase w age Dexterity and exibility are decreased 0 Foot pain is more common BUT NOT NORMAL Mouth Teething Permanent teeth 0 Lose vascular support and elasticity w age 0 What is Edentulous Hair 0 Distribution and amount change w age and gender Eyes Ears Nose Senses change w age Physical Condition Level of dexterity Rest periods needed ROM considerations Allow for as much independence as needed 0 Assessment O 0000 Ability of pt Perception of pt Don t make a routine every pt is an individual Ask what pt wants Assess pt Strength exibility balance acuity detection of temp and sensitivity Mental state Vitals performance Family assistance 0 Assess skin Color texture thickness turgor temperature hydration What does normal skin look like 0 Assess feet and nails Footwear and care practices Entire foot Circulation and sensation Frequency of foot care 0 Assess Oral Cavity Color moisture texture 0 Assess Hair Assess scalp What is pedicuosis capitis What is aopecia 0 Assess Ears Eyes Nose Condition and function What is normal what is abnormal 0 Assess use of sensory aids practices cultural in uences and pt risk for problems medication knowledge and side effects emotional of physical Planning 0 Work w NAP 0 Use family 0 Implementation 0 Assist and Teach 0 Health Promotion Education and counseling Tailor to individual 0 Bathing and Skin care Individualize routine for pt Base on pt preferences Differentiate from cleansing therapeutic and medicated baths 0 De ne Complete Bed Bath Partial Bed bath Bag Bath Perinea Care 0 Who is high risk What should be done for the Bath P vacy Safety Warmth Independence Needs should be anticipated Educate about skin health and care 0 When should a back rub occur Process Begin w oral hygiene use clean gloves 0 Move bed in high position 0 How often should you brush Floss lnspect all of mouth Then move on to arms chest abdomen legs feet pericare back rectal area Special needs Describe what is done differently for diabetics How should you care for dentures How do you provide oral care for someone who is unconscious What is stomatisis Hair and Scalp Care Frequently brushcomb hair Note cultural preferences Shampoo on the pt routine Shaving consult religious purposes 1st Groom mustache and bread daily Eyes Ears Nose Don39t use soap while cleaning eyes Go from inner to outer in order to reduce microorganism transmission Contacts should be removed nightly unless certain type and clean frequently w warm water Clean fake eyes w warm saline Clean ears w moistened end of wash cloth Temperature 2023 degrees C Ventilation Noise control Lighting should be as much natural as possible Check linens frequently for food and soiling Main concepts Infection control PrivacyConfidentially and Safety Chapter 44 0 Nutrition is an essential component to life and is needed for all aspects of life 0 What is food security 0 De ne O O O BMR REE Nutrients Nutrient Dense Carbohydrates What is it made of 1 gram 4kcal Monosaccharides Disaccharides Polysaccharides Soluble vs insoluble ber Proteins 1 gram 4 kcal Purpose Made of Amino Acids Made of HOCN Essential vs nonessential Complete protein vs incomplete protein Nitrogen balance 1 gram 9 kcal 2030 of diet Made of Water 6070 of body weight Infants have highest percentage lll person needs more Vitamins Organic Essential Catalysts Neutralize free radicals Fat soluble ADEK vs Water soluble C and B Complex Minerals Inorganic Catalysts Macro MicroTrace Digestion Mechanical Chemical Hormonal Trail MouthlesophagusljFundusljBodylentrumleyloric SphincterljDuodenum Enzymes Absorption Where does this mainly take place 8590 of water is absorbed in small intestine Where are electrolytes and minerals reabsorbed Metabolism Catabolic Example Glycogenolysis Anabolic Example Glycogenesis Catabolic Gluconeogenesis o Elimination Chyme o DRIs EAR RDA AI UL 0 Food Guidelines 0 Daily values are made from RDI and DRV but don39t replace DRI Based on of 2000 calorie diet In uenced 0 Environmental Lifestyle Work Meal Choices SES Lack of access and availability of fast food 0 Developmental Infant School Age 0 Rapid growth Breastfeed only for rst 6 months then add food to breast feeding for 612 months 0 Formula is about same as breastmilk 0 Babies should not be given straight cow39s milk for rst 1 o What foods should be introduced In what method should they be introduced Toddler More protein ess kcal bc slowed growth Preschoolers More nutrient dense foods Schoolage Limit high calorie Encourage exerciseactivity Adolescence Protein increases 0 Nutrient de ciencies are more common Hydration is important 0 Parents strongly in uence foods and habits Young and Middle Age Needless Pregnancy 0 Poor nutrition leads to bay complications 0 Quality rather than quantity 0 Protein and Ca2 increase 0 Folic Acid increase 0 Lactation 0 500 more calories a day o More protein Older Adult Decreased energy and lower metabolic rate 0 High risk for food drug interactions 0 Increased risk for dehydration Increased Ca2 is needed Alternative Food Patterns 0 Special due to ethnicity culture and religion 0 What are the Vegetarian Diets 0 Vegetarian 0 OvoLacto Vegetarian 0 Lactovegeta rian 0 Vegan 0 What is a child at risk for when on a vegetarian diet 0 Assessment 0 What is screening and its purpose Tools of screening Subjective Global Assessment MiniNutritionalAssessment Malnutrition Screening Tool 0 What is Anthropometry 0 Why are lab and biomedical tests needed What are common tests 0 Plasma proteins Nitrogen balance What do diet and Health histories focus on o What is Dysphagia and what does it lead to What can it be caused by What are associated complications 0 Planning 0 What is an RD Why they an important resource 0 Goals Physiological Therapeutic Individualized Education and CounseHng Implementation 0 Promotion Educate about healthy diets Identify risks and malnutrition early Consider income Plan meals early Educate about food safety 0 What does NPO mean Nothing by mouth 0 What are the types of advancing diets O Clear Full Liquid Pureed Mechanical Soft Low Residue High Fiber Low Sodium Low Cholesterol Diabetic o What are methods to promote appetite o What is Enteral Tube Feeding and when is it needed Explain the types ConUnuous Intermittent Bolus Open system Closed system Polymeric Modular Elemental Specialty What are the veri cation methods What is the only quotfor surequot con rmation method What level should the bed be elevated at at a MINIMUM What complication prevention measures should be put into place 7 o What is Parenteral Feeding and when is it needed 0 Diseases affecting GI function Peptic Ulcers In ammatory Bowel Malabsorption Diverticulitis Diabetes CVD Cancer H IVAIDS Chapter 46 Elimination Alterations are 55 of problems 0 Being regular is needed Elimination system 0 Hollow tubes lined w mucus membranes that absorb nutrients and provide storage 0 Electrolyte balance is a key function 0 Receives secretions from gallbladder and pancreas Mouth 0 Digestion begins 0 Mechanical and Chemical Breakdown Esophagus o Peristalsis Stomach 0 Storage Mixing Emptying HCI production and secretion 0 Small Intestine O O O SegmentationPeristalsisMixing of chime and digestive movements Digestion and Absorption Three sections Name them and name functions 0 Large Intesting O O O O O 0 Lower GI Cecum Colon Explain Rectum Explain Primary elimination organ How many major movements a day 0 What is defecation Where does it begin 0 What is the Valsalva Maneuver Explain bowel movement in uencing factors 0 O O O O 0 Age Diet Fluid Intake Activity Promotes Peristalsis Psychological Factors Prolonged Emotional Stress impairs function and can speed up process Personal Habits Position Squatting is preferred Pain Suppress need when in pain Pregnancy Constipation is common symptom Straining leads to hemorrhoids Surgery and Anesthesia Medications Opioids and others slow Laxatives and Cathartics How do diagnostic tests in uence 0 Explain De ne common bowel problems and their causes and implications O 0000 Constipation A symptom lmpaction Diarrhea lnconUnence Flatulence Trapped gas causing distension Pain and cramping occurs Hemorrhoids Dilated engorged veins Internal or external Painful Bowel Diversions 0 Why are these needed When normal passage is affected 0 What is an ostomy O O Types 0 Loop Colostomy End Colostomy Double Barrel Location determines consistency of stool Care is meticulous Irrigating regulates emptying never use enema What does pouching an ostomy do Protects Skin contains feces and odors Consider size type ad location TwoPiece vs One peice What nutritional considerations need to be made What are alternatives to an ostomy What are some psychological considerations that should be made 0 Assessment 0 000000000 Review bowel history and patterns Escribe normal color consistency shape Routine promote normal movements Use of arti cial aids Change in diet or uid intake Medication and emotional history Ability to chew state of mouth Bowel sounds masses or lumps on abdomen Lesion in ammation discoloration or hemorrhoids in rectum What can lab tests detect What is a fecal occult blood test 0 Planning 0 Keep pt patterns and routines as much as possible 0 Implementation 0 O 0 Educate about diet and activity effects on bowel movement Promotion measures Time urge will occur naturally privacy IMPORTANT Normal Sitting position Document feces characteristics Excessive use of cathartic and Laxatives leads to abnormal patterns Explain what an enema is and what it does Types Cleansing Complete Elimination Fleet o 120 mL 0 Common 0 How should this be rolled Tap Water Hypotonic Saline Safest o Stimulate peristalsis by V increase Hypertonic Pulls uid out of Large intestine walls Soap Suds Soap goes in after water and is gently shaken Oil Retention Lubricates Rectum Carminative For Gas Medicated How should an enema be administered 0 When is digital removal required 0 What is bowel training 0 How can skin integrity be protected
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