lOMoARcPSD|7074099

Nursing fundamentals: Final Study guide

Medical & Surgical Units (University of California Los Angeles)

StuDocu is not sponsored or endorsed by any college or university

Downloaded by Christina Graciani (chrissygraciani@gmail.com)
 lOMoARcPSD|7074099

1. Definition of Nursing:
-To promote better health, prevention of illness, collaborative care. Patient is the
central focus of all definitions. Includes: physical, emotional, social, and spiritual
dimensions. NURSING IS AN ART AND SCIENCE!!!

2. Aims of Nursing- {4 aims} promote health, prevent illness, restore health, and
facilitate coping with death and disability.

3. The 4 aims of nursing interrelate by the nurse using: cognitive, technical,

interpersonal, ethical/legal abilities or skills.

4. Nurse Role: [health and illness]: Nurses emphasize health promotion activities,
wellness-enhancing strategies, and illness prevention activities as important
forms of health care because they assist patients in maintaining and improving
health.

5. The Nursing Process:

-Assessment: collecting comprehensive data about the clients health
-Diagnosis: analyze the assessment data to determine the dx or issue
-Planning: develop a plan that prescribes strategies and alternatives to attain
expected outcomes
-Implementation: implements the identified plan
-Evaluation-evaluate progress

6. Benner’s stages of Nursing proficiency:

–Novice” has no prior experience”
–Advanced beginner” new graduation working at his or her first nursing
Job”
–Competent “develops within 2-3 years of experience on the same job”
–Proficient “ Holistic “This nurse has learned from experiences what to
expect in certain situations and how to modify plans”
–Expert “The Expert operates from a deep understanding of the total
situation” uses intuitive grasp of each situation.

7. Historical Perspective/ Pre- Civilization

•Belief that good and evil spirits bring health or illness
•Physician as medicine man: a member of an indigeneous society who is
knowledgeable about the magical and chemical protencies of various substances
and skilled in the rituals through which they are administered.
•Early Christian period: {nursing has formal and more clearly defined role;
deaconesses made visits to the sick during this period[ + leadership. women

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

made the first visits to sick people, male gave nursing care and buried the dead.
Nursing became a respected vocation
•Temple and church are used for patients’ care
•Characteristic of the 16th century: shift from a religious orientation to an
emphasis on warfare, exploration, and expansion of knowledge during this time
period. Nursing had a poor reputation; nurses received low pay and worked long
hours in unfavorable conditions during this time period.
•Historical Perspective/World War II: large numbers of women worked outside
the home and became more independent and assertive. Explosion in medicine
and technology broadened the role of nurses. Growth of nursing as a
professional discipline.
•Florence Nightingale: founder of modern nursing, Florence Nightingale
established the first nursing philosophy based on health maintenance and
restoration. Also wrote books about health care and nursing education.
Challenged prejudice against women and elevated the status of all nurses.

8. What are the Models of Health and Illness?

•Health Belief Model (Rosenstoch's 1974)
–Addresses the relationship between a person’s beliefs and
Behaviors
•Health Promotion Model (Pender)
–Directed at increasing a patient’s level of well-being

9. Healthy People 2020 Goals

Looking at the goals, How do you see your role as a nurse?
-Attain high-quality longer lives free of preventable disease, disability, injury, and
premature death
-Achieve health equity, eliminate disparities, and improve the health of all groups
-Create social and physical environments that promote good health for all
-Promote quality of life, healthy development, and healthy behaviors across all
stages

10. Health Promotion, Wellness, and Illness Prevention

a. Immunization Programs
b. Routine Exercise, Good Nutrition
c. Physical Awareness Stress management, Self-responsibility

11. Levels of Preventative Care

•Primary Prevention
–True prevention that lowers the chances that a disease will

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

Develop
•Secondary Prevention
–Focuses on those who have health problems or illnesses
and are at risk for developing complications or worsening
Conditions
•Tertiary Prevention
–Occurs when a defect or disability is permanent or
Irreversible

12. What is Illness:

•A state in which a person’s physical, emotional,
intellectual, social, developmental, or spiritual
functioning is diminished or impaired
•Acute Illness
–Short duration and severe
•Chronic Illness
–Persists longer than 6 months

13. Maslow’s Hierarchy of Needs

-step 1: Physiological Needs: Includes the need for air, water, food, and sex
-step 2: Safety Needs: Includes the need for safety, order, and freedom from fear
or threat
-step 3: Love & Belonging: love, affection, feelings of belonging, and human
contact
-step 4: Esteem Needs: self-respect, self-esteem, achievement, and respect from
others
-step 5: Self-Actualization Needs: need to grow, to feel fulfilled, to realize one’s
potential

14. Vital Signs (know all the CONTRAINDICATIONS for all vital signs)
- Temperature: [normal: 96.8-100.4] but average is 98.6
- Oral: 96.8-100.4 [average 98.6]
- Rectal: ⇡1 degree higher [99.6]
- Temporal: ⇡higher [99.6]
- Axillary: ⇣lower 0.9-1 [97.6]
- Tympanic: 98.6 [same as oral]
-------------------------------------------------------
*Pulse [average 60-100 bpm] in adults
-abnormalities:
bradycardia [pulse < 60 bpm]
tachycardia [pulse > 100 bpm]

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

Arrhythmia [irregular pulse rate]

--------------------------------------------------------
*Respiration: normal [12-20 in adults]
--------------------------------------------------------
*Blood Pressure
-normal 120/80
-abnormal: 220/40
-elevated: 120-129 sys/ 80 or less diastolic
↳stage 1 high BP: 130-139/80-89
↳stage 2 high BP: 140↑/90↑
----------------------------------------------------------

15. When do we assess vital signs?

- Admission
- Home visit
- Routine schedule
- Before & after surgical procedure
- Before and after medication administration
- When pt reports specific symptoms of physical distress

16. Maintenance of Body Temperature: {ch 30-funds}

↳Thermoregulation: controlled by hypothalamus / “set point” for comfortable temp
↳Anterior hypothalamus controls heat loss
-ex: sweating, vasodilation, inhibit heat production
↳ Posterior hypothalamus controls heat production
-ex: initiates heat conservation mechanism (vasoconstriction to reduce low to
extremities)

17. Heat Production in the Body:

↳ heat produced by the body is a by product of metabolism
-ex: food, more food = more heat production
↳ BMR= heat produced by the body at rest
-affected by thyroid hormone
-male testosterone increases BMR
-movement voluntary
-shivering

18. What are the Factors Affecting Body (influence normal body temp)
A. Individual metabolism differs. An increase in the emotional state of

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

the pt may increase the temperature

B. Body temperature is usually lowest in the morning and highest in
the late afternoon or evening.
C. Normal temperature for infants and children is usually higher than
the normal adult temperature. At birth, heat-regulating mechanisms
are not fully developed, so a marked fluctuation in body
temperature may occur during the infant’s first year of life.
D. In some women, ovulation may be signaled by a slight drop in body
temperature 12 to 24 hours before a post ovulation rise in
temperature of about 0.4 to 0.8 F.

19. Body Temperature Regulation

↳Neural and vascular control:

↳Heat production: thru metabolism of food (chemically). Food is used as energy

by muscle and glands to generate most of the heat in the body. Heat is also
gained (physically) from the environment.

↳Heat Loss : cold, shock, and certain drugs, which depress the NS, decreases
heat production

-radiation- body heat warms surrounding air which rises and is replaced by cooler
air

-conduction- direct physical contact with an object

-convection- when body heat warms surrounding air which rises and is replaced
by cooler air

-evaporation- perspiration that is removed from the body surface by change from
a liquid to vapor

↳ Skin Temperature regulation

↳Behavioral Control: when a person becomes angry or excited, the adrenal

glands become very active and the body warms as a result of the action of
certain body chemicals such as epinephrine.

20. Risk for Imbalanced Body Temperature:

↳Hyperthermia: overheating of the body, possibly due to extreme weather

conditions. Example: heat stroke, heat exhaustion, heat rash, cramps, fainting

↳Hypothermia: the condition of having an abnormally low body temperature,

typically one that is dangerously low.

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

↳Ineffective Thermoregulation: a state in which an individual’s temperature

fluctuates between hypothermia and hyperthermia. Damage to the hypothalamic
center / seen in pt with spinal cord injury, traumatic brain injury, stroke, and other
conditions that cause damage to the brain stem.

21. Types of Health Assessments

•Comprehensive
–Conducted upon admission to healthcare facility
•Ongoing partial
–Conducted at regular intervals
•Focused
–Conducted to assess a specific problem
•Emergency
–Conducted to determine fatal conditions

22.Cultural Sensitivity

•Culture influences a patient’s behavior

•Consider:
–Health beliefs
–Use of alternative therapies
–Nutritional habits
–Relationships with family
–Personal comfort zone
- Avoid stereotyping

23. Techniques of Physical Assessment: [define and give example]

-Inspection: critical observation *always first*

Ex: observe eyes, ears, nose, look at color, shape, symmetry, odors, skin, etc

-Palpation: light and deep touch

Ex: back of hand to assess skin temp, fingers to assess texture, moisture,
tenderness, sie shape, consistency of legions and organs (deep 5-8 cm/2-3’);
Light = 1 cm deep

-Percussion: sounds produced by striking body surface

ex : produces different notes depending on underlying mass (dull, resonant, flat,

tympanic)

Used to determine the size and shape of underlying structures by establishing

their borders and indicate if tissue is air-filled, fluid-filled or solid, action
performed in the wrist.

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

-Auscultation: listening to the sounds produced by the body

Ex: bell picks up low pitched sounds such as heart murmurs

24. CRANIAL NERVES

-12 pairs

-Originate in the brain

-Take impulses to and from the brain

-Some are sensory nerves, motor nerves or both

25. Testing of Cranial Nerves

•Can I – Olfactory (sensory) Smell and smell interpretation

•CN II- Optic Nerve (sensory) Vision, visual acuity, peripheral vision
•CN III- Oculomotor (motor) eye movement (EOM) Pupil constriction and eyelid raising
•CN IV-Trochlear ( Eye motor)
•CN VI – Abducens (motor)
–EOM: lateral
–Test
•6 cardinal fields of gaze
•CN VII – Facial (sensory and motor)
–Sensory: taste
–Motor: facial expression
–Test•Ask patient to smile, frown, show teeth, puff cheeks, raise eyebrows
CN VIII – Vestibulocochlear/Acoustic (sensory)
–Hearing and equilibrium
–Test
•Weber and rinne
•CN IX – Glossopharyngeal (sensory and motor)
–sensory: pain, touch, temp
–Motor: swallowing
–Test
•Open mouth and say “AHH”

25. Nursing Process

-Assess: Gather information about the client’s condition
-Diagnose: Identify the client’s problem
-Plan and Identify Outcomes: Set goals of care and desired outcomes and identify
appropriate nursing actions
-Implement: Perform nursing actions identified in planning
-Evaluate: Determine if goals and expected outcomes are achieved

26. Objective Data vs. Subjective Data

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

Objective data
–Observable and measurable data that can be seen, heard, or felt
by someone other than the person experiencing them
–For example, elevated temperature, skin moisture, vomiting
•Subjective data
–Information perceived only by the affected person
–For example, pain experience, feeling dizzy, feeling anxious

27. Types of Pain

-Acute/transient pain
↪protective, identifiable, short duration; limited emotional response
-Chronic/Persistent noncancer
↪Is not protective, has no purpose, may or may not have an identifiable cause
-Chronic episode
↪occurs sporadically over an extended duration
-Idiopathic
↪chronic pain without identifiable physical or psychological cause

What is the difference between Urinary retention, Urinary tract infection & Urinary
incontinence?
↳ Urinary retention ⇒ the ability to partially or completely empty the bladder
↳ Urinary Tract infection ⇒ an infection that characterized by burning or pain with
urination (dysuria), urgency, frequency, foul smelling urine, or hematuria.
↳ Urinary incontinence ⇒ the complaint of any involuntary loss of urine

What is the characteristic of urine?

↳ Color ⇒ pale straw color to amber
↳ Clarity ⇒ transparent
↳ Odor ⇒ ammonia odor

How does the nurse assess the patient for urinary retention?
↳ by palpating the bladder

What is the nurse role after testing?

↳ perineal care, follow up on the lab result

How do the nurse collect a sterile sample?

↳ Foley ⇒ clamp the tube below the port, come back in about 15-20mins, clean the port
of the foley catheter with antimicrobial swab, insert a syringe and draw about 3 to 5ml of
urine, and transfer to the specimen container.

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

↳ Clean catch urine ⇒ wipe from front to back, urinate and catch the urine midstream
into specimen container

How does the nurse teach the patient to reduce the risk of Urinary tract infection?
↳ educate to wipe from front to back
↳ if patient has a foley catheter, educate about foley care
↳ increase fluid intake
↳ do not hold pee
↳ urinate after sex

Components of Nutritional Assessment

↳ History taking
↳ Dietary, medical, socioeconomic data
↳ Physical assessments
↳ Anthropometric and clinical data
↳ Laboratory data
↳ Protein status, body vitamin, mineral, and trace element status

What is the calorie-dense nutrient for each of the nutrient's elements?

↳ Carbohydrates 4
↳ Protein 4
↳ Fat 9

What is the percentage of water in the body?

↳ 60%. Water 2/3 of the body content & more water in the vascular system.

What are the water soluble & fat-soluble vitamin?

↳ Water Soluble B, C
↳ Fat Soluble A, D, E, K

What organization published the Dietary Guidelines?

↳ USDA (United States Department of Agriculture)

What is the BMR?

↳ Basal Metabolic Rate ⇒ the energy needed at rest to maintain life sustaining activities

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

(breathing, circulation, heart rate and temperature)

Metabolism, Catabolism & Anabolism

↳ Metabolism ⇒ all biochemical reactions within the cells of the body
↳ Anabolism ⇒ building of more complex biochemical substances by synthesis of
nutrients
↳ Catabolism ⇒ breakdown of biochemical substances into simpler substances; occurs
during physiological states of negative

Why do the patients receive TPN?

↳ Patients unable to digest or absorb enteral nutrition or are in highly stressed
physiological states such as sepsis, head injury or burns.

What is the main nutrients in TPN?

↳ major electrolytes
↳ Vitamins
↳ mineral

How do we monitor TPN?

↳ Assess for initial placement (X-rays)
↳ Assess for nutritional needs using lab Value
↳ Pharmacy will deliver the TPN
↳ Verify patients equipment and tubes & labels
↳ Use aseptic technique to connect and dressing change for central lines or pick line
per facility protocol or PRN
↳ Monitor for complications
↳ TPN is adjusted according to lab values (weekly)

How is TPN administer?

↳ Peripheral or central line

Exercise and activity

↳ Friction ⇒ force that occurs in a direction to oppose movement

↳ Exercise and activity

↪ Activity tolerance
↪ Isotonic exercises

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

↪ Isometric exercises
↪ Resistive isometric exercises

Voluntary movement is a combination of isotonic and isometric contractions

Isotonic exercise
↳ Exercise when a contracting muscle shortens against a constant load, as when lifting
a weight. Isotonic exercise is one method of muscular exercise. Examples of isotonic
exercise include squats, stair climbing, bicep curls and push-ups.

Benefits
↳ Increased muscle strength and size
↳ Adding mass by using heavy weights and increasing resistance over time
↳ Improved range of motion in functional movements
↳ Training your body in movements required for daily activities

Isometric exercise
↳ are contractions of a particular muscle or group of muscles.

Benefits
⇒ Can be performed with little or no equipment
⇒ Can build muscle size when performed with weights
⇒ Builds strength in specific muscle groups
⇒ Aids in rehabilitation & Improves joint flexibility
⇒ May be performed seated, making exercises beneficial for the elderly
and others with mobility challenge

What are the factors influencing sleep?

↳ Drugs and substances (Rx meds, L-tryptophan in milk)
↳ lifestyles (rotating work shifts)
↳ usual sleep patterns (sleep deprivation, jet lag)
↳ emotional stress (Nursing school, exams, personal issues)
↳ environment (Noise, construction, alarms, equipments)
↳ exercise and fatigue (Exercising 2 hours or or more before bedtime)
↳ food and calorie intake (Eating a large, heavy, and/or spicy meal at night, caffeine,
alcohol, nicotine)

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

Stages of the Adult Sleep Cycle:

↳ NREM stage 1: few minutes, lightest level of sleep, easily awakes
↳ NREM stage 2: lasts 10 to 20 min, relaxation, body function continue to slow
↳ NREM stage 3: 15-30 min, initial stage of deep sleep. Vital sign declines, hard to
wake
↳ NREM stage 4: 15-30 min. Deepest stage of sleep
↳ REM sleep: 90 minutes after sleep has begun, duration increase w/each cycle and
average 20min. Dreaming occurs, rapid eye movement.

Sleep disorders:
↳ Insomnia (difficulty sleeping)
↳ sleep related breathing disorder (primary & obstructive sleep apnea) excessive
daytime sleepiness
↳ hypersomnolence (excessive sleepiness)
↳ narcolepsy (Cataplexy passing out asleep)
↳ parasomnias (sleep walking)

What is the nursing care of sleep disorders:

↳ sleep apnea - lifestyle changes, encourage to see Sleep Specialist for treatment
↳ insomnia - assess the patients sleeping pattern and help to develop a sleeping plan.
Provide a dark, quiet, and comfortable environment for the patient to sleep in.
↳ narcolepsy - scheduling daytime naps
↳ parasomnias - encourage to sleep downstairs

What are the factors affecting bowel elimination?

↳ Age (Infants w/ small intestine, older individuals have difficulty swallowing)
↳ diet (Fiber and veggies)
↳ fluid intake (Fluid intake affects characteristics of feces)
↳ physical activity (Promotes peristalsis)
↳ psychological factors (Depression affects peristalsis)
↳ personal habits
↳ position during defecation
↳ Pain
↳ pregnancy
↳ surgery & anesthesia
↳ medications

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

What are the common problems for bowel elimination? What is the management?
↳ constipation, impaction, diarrhea, incontinence, flatulence, hemorrhoids
problems because of physiological changes in the GI tract such as abdominal
surgery, inflammatory disease, medications, emotional stress, environmental
factors.
↳ management; bowel training, fluid and food intake, regular exercises

What are the safety guidelines for nursing skills in bowel elimination and ostomy
care?
↳ self administer enema to use side-lying position. CAN be delegated to NAP,
but nurse is responsible to assess pt for positioning, comfort, stable vital sign
procedures.
↳ if patient has cardiac disease or is taking cardiac or hypertensive meds, obtain
a pulse rate, because manipulation of rectal tissue stimulates the vagus nerve
and sometimes causes a sudden decline in pulse rate.
↳ ostomy care: empty @ ⅔ - ½ full, change 3-7 days, assess color (pink or red)

What is the nurse role in the process of inserting and maintaining a nasogastric
tube?
↳ Only the RN may insert and maintain the NG tube however, RN may delegate the
CNA or others to point out signs of discomfort or help with bed position.
↳ Check for residual
↳ Withhold feeding if GRV is 250-500

What is sensory deprivation?

↳ Sensory Deprivation - Reduced sensory input from the internal/external environment

What is the plan of care for a patient who suffers from Aphasia? Pg. 252 (ATI)
↳ Aphasia - Loss of ability to understand/express speech, caused by brain damage.
--------GOAL: pt communicate nonverbally-----IMPLEMENTATION: use pen/paper

Care for patient who has:

↳ Sensory deprivation or sensory overload
- Minimize overall stimuli & provide meaningful stimulation
↳ Hearing impairment
- Use flashing lights instead vs. a warning sound for alarms & doorbells

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

↳ Visual impairment
- Remove rugs
- Walking pathways clear
- Stairways well lit with secure handrails

What is the plan of care for a patient who has hearing and visual impairments?
↳ Amplify the sounds of telephones and TV for pts with hearing impairments and
make sure to check on hearing aids. For visual impairment, use incandescent
lighting and make sure environment is clear of hazards such as floor mats,
cables.

Describe the assessment of a wound?

↳ Appearance: note the color of open wounds:
↪ red: healthy regeneration of tissue
↪ yellow: presence of purulent drainage and slough
↪ black: presence of eschar that hinders healing and requires removal
↪ assess: length, width, and depth, any undermining

↳ Drainage (exudate)
↪ serous drainage: blood (serum) that is watery/clear, slightly yellow
↪ sanguineous drainage: red blood cells
↪ serosanguineous drainage: contains both serum + blood. It is watery and
appears blood streaked or blood-tinged
↪ Purulent drainage: Yellow. The result of infection. Thick and contains white
blood cells, tissue debris, bacteria
↪ Purusanguineous: A mixed drainage of pus and blood (new infection wound)

↳ Wound Closure: staples, sutures, wound closure strips

↳ Status: of any drains or tubes
↳ Pain: Note the location, Provoke, Quality, Radiating, Intensity, Timing, Setting,
associated manifestations, and aggravating/relieving factors.

Stages of wound healing (Partial Thickness)

↳ Inflammatory Stage
- Begins w/ the injury, lasts 3 to 6 days

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

↳ Proliferative Stage
- Lasts the next 3 to 24 days

↳ Maturation/Remodeling Stage
- Occurs after day 21
- Involves the strengthening of the collagen scar and the restoration of a
more normal appearance
- It can take more than 1 yr to complete, depending on the extent of the
original wound.

The stages of wound healing? (Full Thickness)

1) Hemostasis: Activates blood clotting and is the first line of defense for
blocking drainage
2) Inflammation: Phagocytosis to remove bacteria and debris, erythema and
edema, heat and pain, stage lasts 3 to 6 days
3) Proliferative: Fills the wound, contracts wound margins, and rise of
epithelialization. Stage last 3 to 24 days
4) Maturation: Collagen fibers strengthen and becomes scar tissue

Factors affecting wound healing

- Age
- Overall wellness
- Decreased leukocyte count
- Some medications
- Malnourished clients
- Tissue perfusion
- Low Hgb levels
- Obesity
- Chronic diseases
- Smoking
- Wound stress

What are the promote wound healing?

↳ avoid skin trauma: HOB below or at 30 degree, shift pt every 15 min
↳ provide supportive devices: use pressure-reducing surfaces and devices
↳ maintain skin hygiene: use braden scale, apply ointment
↳ encourage proper nutrition: hydrate 2000-3000 mL/day. Protein. Vitamin A, C,
zinc, copper, or enteral feed.

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

What are the principles of wound management?

↳wounds impair skin integrity. Inflammation is localized protective response to
injury or destruction of tissue. Wounds heal by various processes and in stages.
Wound infections result from the invasion of pathogenic micro-organism.
Principles of wound care include: assessment, cleansing, and protection
- Knowledge of the physiology of normal wound healing (stages of
hemostasis, inflammation, granulation, and maturation) and knowing the
advantages of primary, secondary, and tertiary wound healing

Stages of pressure ulcer:

↳ Stage 1: Nonblanchable redness ⇒ intact skin presents with nonblanchable
redness of a localized area, usually over a bony prominence.

↳ Stage 2: Partial thickness ⇒ partial thickness loss of dermis presents as a

shallow, open ulcer with red pink wound bed without slough. Can be an intact or
open/ruptured serum filled or serosanguineous filled blister.

↳ Stage 3: Full thickness skin loss ⇒ subcutaneous fat maybe visible, slough
present. It MAY include undermining or tunneling. Can be shallow.

↳ Stage 4: Full thickness tissue loss ⇒ bone, tendon, muscle are exposed.
Slough or eschar may be present. It OFTEN includes undermining and tunneling.

↳ Unstageable : full thickness tissue loss in which actual depth of an ulcer is

completely obscured by slough (yellow, tan, gray, green, brown) and/or
eschar (tan, brown or black) in wound bed. Until slough and/or eschar are
removed to expose the base of wound, true depth can be determined.

↳ DTI (Deep Tissue Injury) ⇒ purple or maroon localized area of discolored

intact skin or a blood filled blister cause by damage of underlying soft tissue from
pressure and/or eschar.

Nursing Knowledge Base

Prediction and prevention of pressure ulcers
↳Risk assessment ⇒ Braden scale

Prevention ⇒ Economic consequences of pressure ulcers

↳Medicare and Medicaid: no additional reimbursement for care

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

related to stage III and stage IV pressure ulcers that occur

during the hospitalization

What is the difference between ethics and moral?

↳ Ethics ⇒ study of conduct and character. a set of guiding principles that all
members of a profession accept
↳ Morals ⇒ personal belief of right and wrong

What is the principles of ethical decision making?

↳ Autonomy ⇒ commitment to include patients in decisions
↳ Beneficence ⇒ taking positive actions to help others
↳ Nonmaleficence ⇒ avoidance of harm or hurt
↳ Justice ⇒ being fair
↳ Fidelity ⇒ agreement to keep promise

What are ANA Code of Ethics?

↳American Nurse Association providing a baseline for professionalism in nursing

What is an ethical dilemma?

↳where two issues can be right. This poses for dilemma. Ethical dilemmas
cause distress and controversy for both patients and professional caregivers.

What is Moral Distress?

↳When policies or procedures prevents a nurse from doing what they think is right (Ex:
A nurse wants to treat/care for a patient but the patient does not have enough money
for the health care) or if person doesn’t get abortion they can die

What is the Professional Nursing Code of Ethics?

↳A set of guiding principles that all members of a profession accept
↳Helps professional groups settle questions about practice or behavior
↳Includes advocacy, responsibility, accountability, and confidentiality

Ethics and Philosophy

Deontology ⇒ defines actions as right or wrong
Utilitarianism ⇒ proposes that the value of something is determined by its usefulness
Feminist Ethics ⇒ focuses on the inequality between people

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

Ethics of Care ⇒ emphasizes the importance of understanding relationships, especially

as they are revealed in personal narratives

Issues in Health Care Ethics

↳ Quality of life: central to discussions about end-of-life care, cancer therapy,
physician-assisted suicide, and DNR
↳ Genetic screening: What are the risks and benefits to individuals and to
society of learning about the presence of a disease that
has not yet caused symptoms, or for which a cure is not
yet available?
↳ Care at the end of life: interventions unlikely to produce benefit for the patient
↳ Access to care: As a nurse, you will certainly deal with ethical issues related to
access to care

What are the legal limits of nursing?

↳ Legal guidelines that nurses follow originally were derived from constitutional law,
statutory law, regulatory law, and common law

What is the role of the American Nurses Association?

↳ Develops standards for nursing practice, policy statements, and similar resolutions

What are the Federal Statutory Issues in Nursing Practice?

- Patient Protection and Affordable Care Act: Consumer’s rights and protections,
affordable health care coverage, increased access to care, stronger Medicare to
improve care for the most vulnerable in the country
- Americans with Disabilities Act: Civil rights statute that protects the rights of
people with physical and mental disabilities
- Emergency Medical Treatment and Active Labor Act: Act that provides that when
a patient comes to the ER department or the hospital, appropriate medical
screening occurs within the capacity of the hospital
- Mental Health Parity Act as Enacted Under PPACA: Insurance companies to
offer the same level of coverage for mental health care that they provide for
medical and surgical care
- Advance Directives: Includes living wills, health care proxies, and power of
attorney

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

What is Good Samaritan Laws?

↳ to encourage health care professionals to assist in emergencies. These laws
limit liability and offer legal immunity if a nurse helps at the scene of an accident.
Ex: if you stop at a scene of an accident and apply pressure to stop hemorrhage,
you are acting within accepted standards
What is the statutory Guidelines for Legal Consent for Medical Treatment? Page
309
- Signed consent for any invasive procedure when admitted to a health care
agency or facility.
- A patient or representative needs to sign separate special consent or treatment
forms before the performance or procedure
- Informed consent is a patient's agreement to have medical procedure after
receiving full disclosure or risk, benefits, alternatives, and consequences of
refusal.
- Informed consent requires a health care provider to disclose information in terms
of a patient is able to understand to make informed choice. Failure to obtain
consent in situations other than emergencies can result in a claim of battery.
● Federal Statutory Issues in Nursing Practice (per maximus)
-Americans with disabilities Act: treat them like everyone else
-Emergency Medical Treatment and Active Labor Act: treating everyone
regardless of insurance
-Mental Health Parity Act: giving privilege for people with mental health
-Uniform Anatomical Gift Act: on a waiting list UNDER FEDERAL (organ donors)
-Living Wills, Durable power of attorney- self explanatory :)
-Advanced directives: They are based on values of informed consent, patient
autonomy over end-of life decisions, truth telling, and control over the dying
process.
-Health Insurance Portability and Accountability Act: patient privacy
-Restraints: needs doctors order. Can renew 24 hrs. Health care provide or nurse
must evaluate pt site or 4 hours after initial restraint.

The uniform determination of death act

↳ an individual who has sustained either:
1)irreversible cessation of circulatory and respiratory functions or
2) irreversible cessation of all functions of the entire brain, including brain stem, is
dead.
A determination of death must be made in accordance with accepted medical
standards.

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

Physician-assisted suicide: refers to the practice where a physician provides a

potentially lethal medication to a terminally ill, suffering patient at his request that he can
take (or not) at a time of his own choosing to end his life.

Civil and Common Law Issues in Nursing Practice

↳Quasi-intentional ⇒ invasion of privacy is the release of a patient’s medical information
to an unauthorized person such as a member of the press, the patient’s employer, the
patient’s family, or online.

↳Unintentional
↪Negligence ⇒ is conduct that falls below the generally accepted standard of
care of a reasonably prudent person.
↪Malpractice ⇒ criteria are necessary to establish nursing malpractice:
The nurse (defendant) owed a duty of care to the patient (plaintiff) & The nurse
did not carry out or breached that duty. The patient was injured and the nurse’s
failure to carry out the duty caused the injury.

Assault is an intentional threat toward another person that places the person in
reasonable fear of harmful, imminent, or unwelcome contact. No actual contact is
required for an assault to occur.

Battery is any intentional offensive touching without consent or lawful justification.

Battery also results if the health care provider performs a procedure that goes beyond
the scope of the patient’s consent.

False imprisonment, it’s a tort. Occurs with unjustified restraint of a person without a
legal reason. This occurs when nurses restrain a patient in a confined area to keep the
person from freedom. False imprisonment requires that the patient be aware of the
confinement.

Abandonment and Assignment Issues

↳ Short staffing ⇒ Legal problems occur if inadequate number of nurses will provide
care.
↳ Floating ⇒ Based on census load and patient acuities
↳ Physician’s orders ⇒ Nurses follow orders unless they believe an order is given in
error or is harmful

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

How can Patient Confidentiality be Breached?

↳ display information on public screen
↳ sending confidential email message via public networks
↳ sharing printers among unit with differing function
↳ discarding copies of patient information in trash cans
↳ holding conversations that can be overheard
↳ faxing confidential information to unauthorized persons
↳ sending confidential messages overheard on pagers

What are The Confidential Information?

↳ all information about patients written on the paper, spoken aloud, saved on computer.
↪ name, address, phone, fax, social security
↪ reason the person is sick
↪ treatment the patient receives
↪ information about past health conditions

What are the types of communication between the health care team?
↳ records or chart
↪ confidential permanent legal document
↳ reports
↪ oral, written, audiotaped exchange of information
↳ conferences
↪ team members communicating in group
↳ consultations
↪ a professional caregiver giving formal advice to another caregiver
↳ referrals
↪ arrangement for services by another care provider

What is the purpose of records?

↳ Communication
↳ Reimbursement
↳ Research
↳ Legal documentation
↳ Education

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

↳ Audit/monitoring

RELEVANT
↳ Document only facts relevant to event. Who, What, Where, When
↳ Do not offer explanation – not always immediately clear
↳ Do not use documentation to make excuses, blame others or complain about job
conditions – there are other avenues for this
What are the legal guidelines for recording?
- Correct all errors promptly, using the correct method
- Record all facts, do not enter personal opinions
- Do not leave blank spaces in nurse’s note
- Write legibly in permanent black ink
- If an order was questioned, record that clarification was sought
- Chart only for yourself, not for others
- Avoid generalizations
- Begin each entry with date/time and end with signature and title
- Keep your computer password secure

What are the methods of recording?

- Paper record
➾ Episode - oriented
➾ Key info may be lost from one episode of care to the next

- Electronic Health Record (EHR)

➾ a digital version of a patient’s medical record
➾ integrates all of a patient’s information in one record
➾ improves continuity of care

- Narrative
➾ traditional method

- Problem Oriented Medical Record (POMR)

➾ database
➾ problem list
➾ care plan
➾ progress note

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

What is specific about home care documentation? Why?

- Medicare has specific guidelines for establishing eligibility for home care
- Medicare guidelines for establishing a pt’s home care cost reimbursement serve
as the basis for documentation by home care nurses
- Documentation is the quality control and justification for reimbursement from
Medicare, Medicaid or private insurance
- Nurses need to document all their services for payment

What are the Methods of Recording in the Progress Notes?

- SOAP ⥤ Subjective, Objective, Assessment, Plan
- SOAPIE ⥤ Subjective, Objective, Assessment, Plan, Intervention, Evaluation
- PIE ⥤ Problem, Intervention, Evaluation
- Focus Charting (DAR) ⥤ Data, Action, Response

What is Hand-off report?

↳ Occurs with transfer of a patient care
↳ Provides continuity and individualized care
↳ Reports are quick and efficient

What is the policy for receiving a verbal orders in an Emergency?

↳ Read back and have a second nurse to confirm the order.

What is an incident or occurrence reports? How do we process it ?

↳ used to document any event that is not consistent with the routine operation of
a health care units or the routine care of patient
↳ follow agency policy

How do we process it?

↳ document an objective description of what happened, what you observed and
the follow up actions taken, including notification of patient’s health care provider
in the patient’s medical record. DO NOT INCLUDE ANY REFERENCE TO AN
INCIDENT IN THE PATIENT’S MEDICAL RECORD.

Why do we document an incident report?

↳ Analysis of incident reports help identify trends in an organization that provide
justification for changes in policies and procedures or for in service program.

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

What are the factors that contribute to spiritual distress and resulting
manifestations?
Spiritual distress: impaired ability to experience and integrate meaning and
purpose in life through connectedness with self, others, art, music, literature,
nature, and/or a power greater than oneself.
↳ acute illness
↳ chronic illness
↳ terminal illness
↳ near death experience

What is the nurse’s role when caring for patients who are experiencing
spiritual distress?
- Learning a person’s spiritual well being and implementing spiritual
interventions to maximize inner peace and healing, helping with gaining a
sense of control over their illness if pt is terminally ill, and giving patients a
chance to explore during near death experiences

What is the nursing process in caring of a spiritual or religion needs for

a patient?
- (FICA) Faith or belief, Importance and influence, Community, and Address
(Interventions to address)
1) Faith or Belief: Assess patient’s religious source of guidance and
conflicts within health care
2) Life and Self Responsibility: Assess the extent in which a pt
understands the limitations or threats posed by an illness
3) Connectedness: Assess whether the patient loses the ability to
express a sense of relatedness to something greater than self
4) Life Satisfaction: Assess pt’s well being such as how happy they
are with their life or how happy are they with their accomplishments
5) Culture: Assess a pt’s cultural background to see their values about
the health care problem and impending treatment
6) Fellowship and Community: Explore the extent and nature of a
person’s support networks and their relationship with the patient
7) Ritual and Practice: Assess use of rituals and practices (Prayer,
worship, sacraments, fasting, singing, meditations, scripture
reading)
8) Vocation: Determine if the illness or hospitalization alters the ability
to express some aspect of spirituality as it relates to the person’s
work or activities (google * a call to God’s service)

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

Review the specific needs of Catholic, Muslim, Jewish religion

1. Catholic: Does not use contraceptives, ask before the use of certain
birthing techniques and pain control, cannot eat meat during good
Fridays
2. Muslim: Uses faith healing, group prayer is generally practiced,
does not practice euthanasia, women prefer female health care
providers, fasting until sundown during month of Ramadan, usually
do not consider organ transplant or donation
3. Jewish: Euthanasia is forbidden, expects nurses to provide
competent health care, allows family to stay with dying patient, life
support is generally not encouraged, observance of Sabbath,
visiting sick is an obligation, does not eat pork, kosher food

Nurse-Patient Relationship
1. Pre-interaction phase: occurs before meeting the patient
2. Orientation phase: when the nurse and the patient meet and get to know each other
3. Working phase: when the nurse and the patient work together to solve problems and
accomplish goals
4. Termination phase: occurs at the end of a relationship

What are the Aspects of communication?

- Verbal communication which is the use of language such as voice, sounds,
gestures, or written signals which communicate thought and feeling.
- Nonverbal communication which is the use of language silently through gestures,
body language, signs, and symbols

What are the Methods of communication?

- Active listening such while giving eye contact, seeking information, avoid
attacking or being emotional, clarify the person’s statement, and keeping silent.
- Giving constructive feedback such as focusing specific behavior, offering
feedback once action is possible, direct any negative feedback so the person can
control, and ask questions to ensure understanding of feedback.

What influence the communication?

- Language barrier, unable to comprehend or understand the context, delivering
confusing or mixed messages, and any distractions

What are the types of communication?

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

↳Verbal communication uses spoken or written words.

↳Nonverbal communication includes five senses and everything that does not involve
the spoken or written word.
↳Metacommunication a broad term that refers to all factors that influence
communication.

What are the skills required for communication?

- Speaking, writing, understanding, listening, and reading

Nursing care of patient using O2 cannula & simple mask. Page 902.
↳ Verify setting on flowmeter and oxygen source for proper setup and prescribed flow
rate
↳ Check cannula/mask every 8 hours. Keep humidification container filled at times
↳ Post “oxygen in use” signs on the wall behind the bed and at the entrance to room
↳ Monitor patient’s response to changes in oxygen flow rate with pulse oximetry.
↳ Observe for decreased anxiety, improved level of consciousness and cognitive
abilities, decrease fatigue, absence of dizziness, decreased respiratory rate, improve
color, improved oxygen saturation.
↳ Observe patient’s external ear, bridge of nose, nares, and nasal mucous membranes
for evidence of skin breakdown

Provide O2 at the lowest liter flow ⇒ nasal cannula

What are the complications of oxygenation?

↳ Oxygen toxicity is a condition resulting from the harmful effects of breathing molecular
oxygen at increased partial pressures. Severe cases can result in cell damage and
death, with effects most often seen in the central nervous system, lungs, and eyes.

What is the purpose of humidification of oxygen?

↳ keep airways moist and loosens and mobilizes pulmonary secretions.

What is the role of nebulization medication?

↳ administer medication in the form of a mist inhaled into the lungs. It works in the
airways by opening breathing passages and relaxing muscles.

What are the Factors Affecting Medication Therapy? Page 630

↳ Patient’s knowledge and understanding of medication therapy influence the
willingness or ability to follow a medication regimen. Also determine if the patient

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

understands the purpose of medication, the importance of regular dosage schedules,

proper administration methods, and possible side effects.

Routes of Administration
↳ Oral routes ⇒ Sublingual administration
⇒ Buccal administration
↳ Parenteral routes ⇒ Four major sites of injection
↪ Intradermal
↪ Subcutaneous
↪ Intramuscular
↪ Intravenous
↳ Other routes ⇒ Epidural, intrathecal, intraosseous, intraperitoneal, intrapleural, and
intraarterial
↳ Routes usually limited to physicians ⇒ Intracardiac and intraarticular
↳ Topical administration ⇒ Skin, Mucous membranes
↳ Inhalation route
↳ Intraocular route

Types of Orders in Acute Care Agencies

Standing or routine: Administered until the dosage is changed or another medication is
prescribed
PRN: Given when the patient requires it
Single (one-time): Given one time only for a specific reason
STAT: Given immediately in an emergency
Now: When a medication is needed right away, but not STAT
Prescriptions: Medication to be taken outside of the hospital

Downloaded by Christina Graciani (chrissygraciani@gmail.com)

 lOMoARcPSD|7074099

Six Rights
↳ Right medication
↳ Right dose
↳ Right patient
↳ Right route
↳ Right time
↳ Right documentation

Medication Errors
↳ Report all medication errors.
↳ Patient safety is a top priority when an error occurs.
↳ Documentation is required.
↳ The nurse is responsible for preparing a written occurrence or incident report: an
accurate, factual description of what occurred and what was done.
↳ ANurses play an essential role in medication reconciliation

Downloaded by Christina Graciani (chrissygraciani@gmail.com)