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Chapter 7: Legal Issues

Vocab:
Law- governs how a person acts
Protect the patient and the nurse
Protected Health Information (PHI)- personal and health info specific to a pt, must be
kept confidential
Name, address, DOB, SSN, billing info
Negligence- failure of nurse to act as average nurse
Ordinary negligence
Professional negligence (malpractice)- failure of a person with professional
training to act in a reasonable and prudent manner
o Following physicians order is NOT a defense
o 5 components to occur
Duty: standard of care is in place
Breach of Duty: failure to meet standard of care
Predict ability of harm must exist
Causation: provable correlation between care and harm
Injury: actual patient injury must occur

Guidelines for Nursing Practice

ANA Standards America, whole country
o Protect and allow nurses to carry put professional roles
o Code of ethics
Standards of Nursing Practice
Nurse Practice Acts and Licensure- state only
o Legal scope of nursing practice
o State board of nursing in each state to make and reinforce rule
Move to a different state then license requires reciprocity
Nursing Process
o Guideline for nursing practice
o Enabling nurses to implement their role

Advance Directives
o Written statement of your wished regarding end of life health care decisions
o Need because your wished will be known
o Used if unable to express your decisions
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o Includes a:
Living Will
legal document with your wishes about medical treatment
Medical Power of Attorney (Health Care Proxy)
Legal form that states who you want to make decisions about medical
care.
Person only speaks for you when you are unable to make your own
medical decisions

o Advantages:
o You are in charge of making own decisions
o Documents can be changed anytime
o NO attorney needed
o Disadvantages
o May not be available when needed
o Not always available in pts chart

HIPPA
o Health Insurance Portability and Accountability Act
o Protects privacy of health information
o Improves portability and continuity of health insurance coverage
Breach
o Reviewing medical records of family/ friends
o Leaving papers around with pts name and info
o Failure to confirming fax number before faxing pt health info
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Chapter 16&20: Communication

Vocab:
Sympathy- feelings of concern one shows for another
Empathy- ability to perceive the meanings and feelings of the pt and to communicate the
understanding to the pt
Resistive behaviors- behaviors that inhibit involvement, cooperation or change
Difficulty in assuming a dependent role
The Communication Process
o Sender
o Message
o Receiver
o Response

Modes of Communication
o Verbal
spoken or written
o Nonverbal
Body language
o Electronic
Social media
Email
Factors influencing Communication Process
o Developmental
Keep in mind age of pt
o Gender
Males sometimes dont want to listen to women
o Roles and Responsibility
o Space and Territoriality
Intimate
Touching- 1.5 feet
Toileting, assessment
Personal
1.5- 4 feet
Social
4- 12 feet
Public
12- 15 feet
Nonassertive Communication
o Submissive Communication
Allows their rights to be violated by others
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Believe own feelings arent important

Insecure
o Aggressive Communication
Can be blaming and delivered in rushed manner

Stages of the Nurse- Patient Relationship

o Orientation
Introduce yourself
o Working
Pt will express feelings and concerns to nurse
Pt will actively participate in relationship
Taking pts vital signs
o Termination
Happens at change of shift, discharge
Pt will identify the goals accomplished or progress made toward goals
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Chapter 19: Violence

Types of abuse
o Physical
Signs and Symptoms
Incompatible injuries
Evidence of untreated injuries
Suspicious cuts/ bruises
Bone loss, weights loss
Depression, confusion
Loss of sleep

o Sexual- Nonconsensual sexual contact

o Emotional- Threats, intimidation

o Psychological
Signs and Symptoms
Pt states that they are verbally abuse
Unusually depressed
Fearful, agitated, confused

o Neglect- Caregiver doesnt meet physical, social or emotional needs

Signs and Symptoms
Sedated
Unusual weight loss, malnourished
Poor hygiene

o Abandonment

o Financial- Misuse of anothers property

Signs and Symptoms
Changes in finance
Suddenly written or changed will
Unmatched documents

Elder Assessment Instrument (EAI)

o Allows practicing nurses to screen for maltreatment in suspected causes
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Recognizing Older Adults at Risk

o Serious illness
o Dementia
o Social isolation
o Abusive toward self/ others
o Past or present domestic violence
o Substance abuse
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Chapter 31: Skin Integrity & Wound care

Vocab:
Desiccation- dehydration
Maceration- over hydration
Necrosis- death of tissue
Biofilm- thick grouping of micro organisms
Sections of skin
o Epidermis
Superficial layer
o Dermis
Layer below epidermis
o Subcutaneous
Underlying layer that anchors the skin layers to the underlying tissues of
the body

Causes of Skin Alterations

o Very thin and obese pts more likely to get skin injuries
Loose skin

Types of Wounds
o Intentional/ unintentional
o Open/ closed
o Acute/ chronic
o Partial/ full thickness, complex

Phases of Wound Healing

o Hemostasis
Immediately after injury
Blood vessels constrict, blood clotting begins
Exudate- fluid that accumulates in the wound- is formed
Heat and redness

o Inflammatory
Lasts 4- 6 days
WBC move to wound
Pt has generalized body response
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o Proliferation
Begins within 2- 3 days of injury
Lasts 2-3 weeks
New tissue is built

o Maturation
Final stage
3 weeks 6 months after injury
Scars form

Stages of Pressure Ulcer

o Stage 1
Nonblanchable erythema of intact skin
o Stage 2
Partial- thickness skin loss
o Stage 3
Full- thickness skin loss
Requires debridement- cleaning away devitalized tissue and foreign
matter from wound- through wet to dry dressing, surgical intervention, or
proteolytic enzymes
o Stage 4
Full- thickness skin loss w/ destruction
Can see the bone
o Unstageable
Base of ulcer covered by slough

When measuring, measure size and depth

Notice tunneling
When cleaning use normal saline 0.9%
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Report any drainage

Assessment of Wound Drainage

o Serous
Clear, serous portion of the blood and from serous membranes
o Sanguineous
Mixture of serum and RBC
o Serosanguineous
Mixture of serum and RBD
o Purulent
WBC, dead tissue debris, dead and live bacteria

Presence of Infection
o Swollen
o Deep red color
o Hot on palpation
o Increased drainage
o Odor

Dressings
o Telfa
o Gauze
o Transparent

Types of Binders
o Straight
Chest and abdomen
o T- Binder
Rectum, perineum, groin
o Sling
Arm

Drainage Systems
o Open Systems
Penrose
o Closed Systems
Jackson- Pratt
Hemovac drain

Classification open wounds

o Red
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Protect
o Yellow
Clean
o Black
Debride

Notes
o Heat
dilates peripheral blood vessels
helps relieve pain
Doctors Order
Never placed on direct skin
o Cold
constricts peripheral blood vessels
promotes comfort
reduces muscle spasms
Doctors Order
Never placed on direct skin
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Chapter 35: Metabolism (Nutrition)

Vocab:
Ketosis- anaerobic metabolism, burning fats, diabetes type 1
2 types
o Aerobic with oxygen
o Anaerobic w/o oxygen
Basal Metabolic Rate (BMR)
Body Mass Index (BMI)- height to weight

Energy Balance
o BMR
o Calories
Carbs, proteins, fats
o Caloric Requirements
Men: 1 cal/kg of body weight/ 24 hrs
Women: 0.9 cal/ kg of body weight/ 24 hrs
1 lb body fat= 3500 calories

Six Classes of Nutrient

o Supply Energy:
Carbs
90% of calorie intake
Converted to glucose
Primary source of energy
4 calories/ gm
Carbon hydrogen and oxygen
Simple: coffee, sugar
Complex: pastas
Proteins
required for formation of body structure
4 calories/ gm
Carbon hydrogen oxygen and nitrogen
Complete proteins- animals
Incomplete proteins- plants
Lipids (Fats)
Most concentrated source of energy
9 calories/ gm
Carbon hydrogen and oxygen
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95% of lipids in diet are triglycerides- major storage form of fat in

body
Cholesterol- fatlike substance only found in animal products
Saturated fats: animal fats
Unsaturated fats: vegetables
Trans fats: manufactures partially hydrogenate liquid oils, raises
cholesterol
Digestion occurs largely in small intestine
o Regulate Body Temperature:
Vitamins
Needed for metabolism of carbs, proteins and lipids
Water or fat solubles
Vitamin A: visual acuity, skin and mucous membranes, immune
function, protected by Vitamin E
Vitamin B: stress
Vitamin C: tissue
Vitamin D: calcium and phosphorus metabolism
Vitamin K: blood clotting
Minerals
Provide structure in body, regulate body processes
Macrominerals
o need more than 100mg/day
o Sodium, Potassium, Calcium, Phosphorus, Magnesium
Microminerals
o Need less than 100mg/ day
o Iron, zinc, iodine
Water
50%-60% of adults total weight
Aids digestion, absorption, circulation, excretion
More vital than food

Healthy Eating Plate

o plate of fruits and vegtables
o plate whole grains
o plate healthy protein

Risk Factors for Poor Nutritional Status

o Gender
o State of Health
o Alcohol abuse
o Medications
o Megadoses of nutrient supplements
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Developmental
o Growth
Infants, adolescence, pregnant increase nutritional needs
o Activity
Increases nutritional needs
o Fewer calories required in adulthood because of decrease in BMR

Clinical Data
o Anthropometric Data
Body Mass Index (BMI)
Height to weight
Ideal body weight
Usual body weight

Calculating Percent of Body Weight Loss

o % usual body wt. = current wt./usual body wt. x 100

Calculating Percent of Weight Loss

o % weight loss= usual wt. current wt./ usual wt. x 100

Biochemical Data
o Hemoglobin (Hgb) and Hematocrit (Hct)
Results found in Complete Blood Count (CBC)
o Hgb:
levels: anemia, recent hemorrhage, fluid retention (hemodilution)
levels: hemoconcentration (polycythemia, dehydration)

o Hct:
levels: anemia, fluid retention (hemodilution), massive blood loss
levels: polycythemia, hemoconcentration (dehydration, blood loss),
pathologic conditions (late-stage COPD, TIAs, burns)

o Serum Albumin
Results found on Complete Metabolic Panel (CMP)
levels = Hypoalbuminemia
Causes: Malnutrition, Burns, Acute liver failure, Cirrhosis,
Ulcerative colitis
levels = Hyperalbuminemia
Dehydration

o Serum glucose (Fasting: 60-100 mg/dL)

Diabetes?
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o Serum cholesterol levels

Total, TG, HDL, LDL

o Urinalysis
o Color: Clear, straw-colored to dark yellow
o Odor: slightly aromatic
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Chapter 36: Urinary Elimination

Vocab:
Dysuria- painful urinations
Glycosuria- sugar in urine
Pyuria- puss, cloudy
Anuria- less than 50ml in 24 hrs
Synonymous w/ kidney shutdown or renal failure
Nocturia- urinate in middle of night
Oliguria- abnormally small amount of urine output, less than 400 ml of urine output in a
day
Proteinuria- protein in kidneys
Polyuria- excessive amount of urine
Frequency- # of times
Urgency- right away
Enuresis- involuntary urination, especially by children at night

Effects of Medications on Urine Production and Elimination

o Diuretics: cause increased urine production, urge incontinence
o Cholinergic: produces urine
o Analgesics and Tranquilizers: suppress CNS

Medications Affecting Urine Color

o Anticoagulants: red urine
o Diuretics: pale yellow urine
o Pyridium: orange to orange- red urine
o Elavil: green or blue-green urine
o Levodopa: brown or black urine

Measuring Urine Output

o Ask pt to urinate in a urinal, bed pan in bed or a hat in the toilet
o If pt has catheter, empty in measuring container
o Measure urine and document

Urine Specimens
o Clean catch or midstream
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o Sterile specimens from indwelling catheter

o 24- hour urine specimen

Pts at Risk for UTI

o Sexually active women
o Postmenopausal women
o People with catheters
o People with diabetes
o Older adults

Reasons for Catheterization

o Relieving urinary retention
o Sterile urine specimen
o Emptying bladder before or after surgery
o Monitoring critically ill pts
o Comfort for terminally ill pts

Types of Urinary Incontinence

o Transient- appears suddenly, lasts 6 months or less
o Mixed- two or more types of incontinence
o Overflow- overflow of bladder
o Functional- caused by factors outside urinary tract
o Reflex- emptying bladder w/o sensation of need to void
o Total- continuous
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Chapter 37: Bowel Elimination

Foods Affecting Bowel Elimination
o Constipating Foods
Cheese, lean meat, eggs, pasta
o Laxative Effect
Fruits, vegetables, bran, chocolate, alcohol, coffee
o Gas Producing
Onions, cabbage, beans, cauliflower

Physical Assessment of Abdomen

o Inspect
o Auscultate
o Percuss
o Palpate

Physical Assessment of the Anus and Rectum

o Inspect
o Palpate

Patient Guidelines for Stool Collection

o Void first so urine isnt in stool sample
o Do not place tissue paper in bedpan or specimen container

Type of Direct Visualization Studies

o Esophagogastroduodenoscopy
Examines the esophagus, stomach, and upper duodenum through an optic
scope
o Colonoscopy
Visualizes the rectum, colon and bowel using a lighted scope
o Sigmoidoscopy
Examines the distal sigmoid colon, rectum, and anal canal through a
flexible or rigid sigmoidoscope
o Wireless capsule endoscopy

Individuals at High Risk for Constipation

o Pts on bedrest
o Reduced fluids or bulked diet
o Pts who are depressed

Types of Enemas
o Cleansing
Constipation, impaction
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o Retention
Oil
Lubricate the stool and intestinal mucosa, easing defecation
Carminative
Help expel flatus from the rectum
Medicated
Provide medications through the rectal mucosa
Anthelmintic
Destroy intestinal parasites
o Large Volumes
o Small Volume

Types of Ostomies
o Sigmoid colostomy
o Descending colostomy
o Transverse colostomy
o Ascending colostomy
o Ileostomy
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Chapter 38: Oxygenation

Upper airway
o Warms, filters, humidify inspired air
o Nose, pharynx, larynx, epiglottis

Lower Airway
o Conduction of air
o Trachea, right and left mainstem bronchi
o Segmental bronchi
o Terminal bronchioles

Lungs
o Right lung has 3 lobes
o Left lung has two lobes

Pulmonary Ventilation
o Inspiration
o Expiration
Movement of air out of lungs

Breath Sounds
o Bronchovesicular sounds- heard over upper anterior chest and intercostal area,
medium pitch sound during expiration
o Vesicular sounds- normal breath sounds heard over lungs, low pitched, soft
sound during expiration
o Adventitious breath sounds heard over lungs, abnormal
Crackles- pneumonia- air passes through fluid in airways
Wheezes- air flow trying to go through airway but its too narrow
o Bronchial high pitched and longer, heard over trachea

Promoting Proper Breathing

o Deep breathing
o Incentive spirometer
o Pursed lip breathing
o Diaphragmatic breathing

Administering Inhaled Medications

o Bronchodilators: open narrowed airways
o Nebulizers: disperse fine particles of liquid medication into the deeper passages
of the respiratory tract
o Meter-dose inhalers: deliver a controlled dose of medication with each
compression of the canister
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o Dry powder inhalers: breath-activated delivery of medications

Oxygen Delivery Systems

o Nasal cannula
Low flow
24-44%
o Nasopharyngeal catheter
o Transtracheal catheter
o Simple mask
Low flow
6-10 L
35%-60%
o Partial rebreather mask
Low flow
6-15 L
70%-90%
o Nonrebreather mask
Low flow
6-15 L
Only device that delivers 100%
o Venturi mask
High flow
4-10L
24%-55%
o Tent

Types of Artificial Airways

o Oropharyngeal and nasopharyngeal airway
o Endotracheal tube
o Tracheostomy tube
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Chapter 43: Sensory Functioning

Vocab:
Presbycosis- loss of high frequency
Conductive Hearing Loss- affects outer/inner ear, cerumen is packed
Sensorineural Hearing Loss- damage inner ear
Senses involved in Sensory Reception
o Visual
vision
o Auditory
hearing
o Olfactory
smell
o Gustatory
taste
o Tactile
touch
o Stereognosis
Solidity of objects
o Kinesthetic and Visceral

Conditions to Receive Data

o Stimulus
Trigger
Light, sound, taste
o Receptor
Sense organ
Takes stimulus, creates nerve impulse
o Nervous pathway to brain
o Functioning brain to receive and translate impulse into sensation

Disease Process in Older Adults

o Presbyopia
Difficulty seeing objects close up in lower light
o Macular degeneration
Central vision

State of Awareness
o Conscious
o Unconscious
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Sensory Overload
o Anxiety
o Pt feels out of control

Sensory Deprivation
o Perceptual Disturbances
o Cognitive Disturbances
o Emotional Disturbances

Caring for Visually Impaired Patients

o Speak in normal tone of voice
o Explain to the pt why touching before doing
o Orient the pt to sounds in the environment

Caring for Hearing- Impaired Patients

o Adequate lighting
o Check pts hearing aids
o Decrease background noises

Communicating with a pt who is confused

o Face to face contact
o Speak calmly, simply and directly to the pt
o Orient and reorient
o Orient the pt to time place and person

Communicating with an Unconscious pt

o Be careful what is being said, hearing is the last sense that is lost
o Assume that the pt can hear you and talk in normal voice
o Speak before touching the pt
o Low environmental noises
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