Foundations Study Guide FINAL EXAM Unit 1 Chapter 1 Nurse Practice Act- defines legal scope of nursing practice,

and provides legal requirements and titles for Rns and LPNs, establishes education and licensure of nurses. Chapter 6 Values, Ethics, Advocacy Professionalism- Altruism ( concern for the welfare and well being of others) Autonomy ( the right to self determination) Human dignity ( respect for the inherent worth and uniqueness of individuals and populations) Integrity ( acting in accordance w/ an appropriate code of ethics and accepted standards of practice) Social Justice ( upholding moral, legal, and humanistic principles) Types of Ethics- Bioethics, Clinical, Nursing Utilitarian- acting based on consequences Deontologic- action is not based on consequences

Ethical Sensibility- The ability to recognize the ethical moment when an ethical challenge presents itself. Ethical Dilemma- two or more clear moral principles apply but support mutually inconsistent courses of action. Ethical distress- the nurse knows the right thing to do but factor make it difficult to follow correct course of action. Four Functions of Ethics committees- Education, policy making, case review, consultation. Standards- vouluntary standards, developed and implemented by the nursing profession itself, are not mandatory but are used as guidelines for peer review. I.E.- ANA- Standards of Practice Crime- wrong against a person or his or her property as well as the public. Tort- a wrong is committed by a person against another person or his or her property. Intentional- assault, battery, defamation, invasion of privacy, fraud, false imprisonment Unintentional- negligence, malpractice Legal Safegaurd for Nurses- Informed consent, contracts, collective bargaining, competent practice, pt. education, documentation (if you did not document, it wasnt done), staffing, professional liability insurance, risk mang. programs, incident reports, good Samaritan laws, and pt. bill of rights. SETINEL EVENTS- an unexpected occurance involving death or serious physical or psychological injury or the risk there of. reported to JACHO DRGs- Diagnosed Related Groups- A price which is paid for a certain DX whether stay 2 days or 2 weeks.

Medicare Never Events- things medicare wont pay for . Medicare part A- hospital insurance Medicare part B- out pt. care Part D- includes prescription Chapt. 27 Medical Asepsis- involves procedures and practices that reduce the # and transfer of pathogens Clean technique* Surgical Asepsis- practice used to render and keep objects and areas free from microbes. Sterile technique* Nosocomial Infections- Hospital Acquired Infections (JOINT REPLACEMENTS**) Stages- Incubation- grow and multiply, Prodromal- most infectious signs are vague and nonspecific Full stage- specific s/s Convalescent- recovery from infection. WBC count 4-11 PPEs personal protective equipment- gloves, gowns, masks, protective eye wear Chapter 29- Meds Generic Name- assigned by the manufacture what first develops drug. Trade Name- brand name copyrighted by the company that sells the drug. Elixir- clear liquid which contain water, alcohol, sweeteners and flavor Suspension- contains finely divided, undissolved particles in liquid medium Solution- a drug dissolved in another substance Syrup- med contained in water and sugar solun. 5 rights name, dose, route, drug, time new***reason*** Metric System 1kg= 1000g move 3 spaces to right b/c going bigger to smaller 1000g= 1 kg move 3 space to the left b/c going from smaller to bigger Check meds 3 times #1 when reaching for the med, #2 Right before opening med, #3 when putting the medication back. Preferred site for IM- ventrogluteal site Part c supplemental

Chapter 4 Health and Illness Stages of Illness Behavior- Experience symptoms (subjective) , Assuming sick role (seek validation from others) Assuming a dependent role ( follows the tx plan) Recovery and rehabilitation (gives up dependent role and resumes normal behavior) DUNN Theory- The High-Level Wellness Model Nurse cares for the total person, functioning to ones max potential, ROSENSTOCK Theory- The Health Belief ModelCognitive type theory concerned with what people perceive to be a true about themselves r/t their health. Pender (most predominant)- The Health Promotion Model Illustrates the multidimensional nature of persons interacting with their environment as they pursue health Personal, biologic, psychological, and sociocultural factors are predicative of a certain health related belief. Levels of Preventive CarePrimary prevention- diet, exercise, immunizations, safe sex. Secondary preventive- screenings, mammograms, family counseling Tertiary prevention- medications, surgical tx, rehabilitation Chapter 9- Continuity of Care Establishing a Nurse-Patient Relationship Discharge planning starts when pt. is admitted**** Use SBAR when giving report or calling the Doctor Return demonstration is the best way to know if someone has learned what youve taught them. Chapter 11 Critical Thinking and the Nursing Process ADPIE A- Assessment, collecting, validating and communicating pt. subjective and objective data D- Diagnosing, analyzing pt. data to identify pt. strengths and problems (nursing DX) P-Planning, specifying pt. outcomes and related nursing interventions I- Implementing, carrying out the plan of care E- Evaluating, measuring extent to which pt. achieved outcomes Problem solving-

Trial and error problem soving Scientific problem solving- using EVIDENCE BASED PRACTICE which is based on research Intuitive thinking- TRUST YOUR GUT Critical Thinking- linking all the data together to come to a good decision ALWAYS GIVE RATIONAL AS TO WHY YOU ARE DOING SOMETHING Chapter 12 Assessing types of assessments comprehensive (intial), focused, emergency, time-lapsed Phases of Nursing Interview Preparatory Phase- the nurse prepares the pt. and the environment for the interview Introduction- sets the tone for the remainder of the interview Working phase- pt. database is obtained Termination phase- the conclusion of the interview Chapter 13 Diagnosing Nursing Dx- describes the pt. problems nurses can treat independently ***always look for trends*** Nursing Diagnosis R/t (etiology( not medical DX) ) AEB: defining characteristics (subjective/objective data). Goal: Pt. will do what by when (must be measurable) Nursing Dx may be used to seek reimbursements for nursing services. Chapter 14 Outcome Identification and Planning Goals of outcomes and planning establish priorities, identify and write expected pt. outcomes, select evidence-based nursing interventions, and to communicate the care plan Comprehensive planning includes- initial, ongoing and discharge Maslows Hierarchy of Human Needs physiologic needs, safety needs, love and belonging, self esteem needs, self actualization needs Categories of Outcomes **** (study guide) cognitive- describes increases in pt. knowledge or intellectual behaviors. psychomotor- describes pt. achievement of new skills

Affective describes changes in pt. values, beliefs, and attitudes (mood,behavior,emotions) **always include an ACTION verb when writing a goal/outcome** Algorithm- set of steps used to make a decision procedure-set of how to action steps Standard of care- description of acceptable level of pt. care Clinical practice guidline- statement outlining appropriate practice for clinical condition or procedure (protocols) Chapter 15 Implementation Implementing Care Planorganize resources, anticipate unexpected outcomes/situations, promote self care, teaching, counseling, advocacy, assist pt. to meet heath outcomes. Common reasons for non-compliance lack of family support, lack of understanding about the benefits (rational), low value attached to outcomes, adverse physical or emotional effects of tx., inability to afford tx. Chapter 16 Evaluation Why evaluate??? allows achievement of outcomes, measures the effectiveness of tx, modifies plan as needed. Types of Evaluating outcomes Cognitive- ask the pt. to repeat information or apply new knowledge. Psychomotor- ask pt. to demonstrate new skill Affective- observe pt. behavior and conversation Physiologic- using physical assessment skill to collect and compare data Criteria vs. Standards Criteria- measurable qualities, attributes, or characteristics that specify skills, knowledge or health status. Standards- levels of performance accepted and expected by the nursing staff. ****If you do what youve always done, then youll always get what youve always got!**** Chapter 38 Skin Integrity and wound Healing Types of wounds Intention (surgical) and un-intentional (pressure ulcer) open or closed(soft tissue damage such as contusion)

Acute or chronic Partial thickness, full thickness, or complex Avulsion- crush injuries Wound Healing Primary (1st intention) surgical closure (approximated) Secondary (2nd intention) healing from inside out Phases of wound Healing Inflammatory, Proliferative, remodeling Inflammatory- begins at time of injury, prepares wound for healing, hemostasis occurs (blood clot) Proliferative- begins 2-3 days of injury and last 2-3 weeks, new tissue is built by fibroblasts, granulating Remodeling- final stage begins @ 3 weeks after injury , collagen is remodeled, new collagen is deposited Most at risk for complications obese, malnutrition, smoking, anticoagulation therapy, immunocompromised. Dehiscence- partial or total separation of wound layers as a result of excessive stress on wounds Evisceration- the most serious complication of dehiscence which is complete separation w/ protrusion of the viscera. Fistula- an abnormal tubelike passage in the body Stages of Pressure Ulcers Stage I- nonblanchable erythema of intact skin Stage II- partial-thickness skin loss Stage III- full-thickness skin loss; not involving underlying fascia Stage IV- full thickness skin loss with extensive destruction (involved muscle can see bone) Serous drainage- water like sanguineous- water like that is tinged with blood purulent- pus like drainage Drains----Penrose- abdominal surgery (open drainage system) Jackson Pratt- usually after breast removal or abd. surgery (closed drainage system) t tube- used for bile drainage, after gall bladder surgery

hemovac- abd. surgery or orthopedic surgery gauze, iodoform gauze or NuGauze- allows for healing from base of wound up. HEAT USAGE- dilates blood vessels, increase tissue metabolism, reduces blood viscosity and increases cap. permeability, reduces muscle tension, and relieves pain COLD USAGE- constricts blood vessels, reduces muscle spasm, promotes comfort. Also helps with hemostasis b/c it reduces permeability therefore reducing inflammation. Class Notes (personal note taking) Idiosyncratic reaction- an uncommon, unexpected or individual drug response thought to result from a genetic predisposition. Paradoxical reaction- causing an effect opposite of the intended effect. OS= left eye OU=both eyes, OD= right eye Eschar- slough produce by thermal burn, a corrosive application or gangrene Exudate- material such as fluid w/ a high content of protein and cellular debris that has escaped from blood vessels and has been deposited in a tissue or on tissue surfaces, usually as a result of inflammation. Maceration- softening or dissolution of tissue after lengthy exposure to fluid Corticosteroids---inhibit wound healing Un-stage able wounds- eschar or slough obscures the wound bed/edges Debridement Dressings hydrogel, hydrocolloid or biologic therapy ( larvae/maggots) Skin Cancer ABCD Types of Enemas Large Volume/ Return Flow- give in small incriments then lower until flatus is relieved Infants 50-150, Toddler 250-350, Child 300-500, Adolescent 500-700, Adult 7501000 Small Volume/ Oil Retention (most commom)- Retain as long as possible 30-60 minutes 150-200mls Oil retention enema lubricates the stool and intestinal mucosa making defecation easier. Cleansing- tap water, normal saline, soap suds Isotonic- Does not pull electorlytes CONTRA-INDICATIONS for ENEMA** ICP (intracranial pressure), glaucoma, rectal/prostate surgery Always warm enema solution to prevent cramping** A- asymmetry , B- Borders, C- Color, D- Diameter

Insertion- adult/adolescent 7.5-10cm ( 3-4 inches), Child 5-7.5cm C 2-3 inches Infant 2.5-3.75 cm ( 1-1 inches) DOCUMENTATION- Chapter 17

The primary purpose of a med. record is to provide a complete and accurate history of the pt. condition UNIT 2 Chapter 34 Sensory Stimulation gustatory (taste), stereognosis (perceived solidity of objects by touch) kinesthetic and visceral (internal orienting system) RAS Reticular Activating System- extends from hypothalamus to medulla, mediates arousal, optimal arousal state= sensoristasis ***monitors and regulates incoming sensory stimuli*** States of awareness conscious- delirium, dementia, confusion, normal consciousness, somnolence, chronic vegetative state. unconscious- asleep, stupor, coma Sensory Deprivation- decreased or monotonous stimuli, impaired ability to receive stimuli or the inability to process stimuli Sensory Overload- too much stimuli so cant ignore it or respond appropriate, pt. feels out of control and exhibits so manifestations of sensory deprivation. Nurse focuses on reducing stimuli and helping pt. to gain control of environment Preventing Sensory Alterations control pt. discomfort, offer care that promotes rest and comfort, Chapter 41 Comfort Categories of Pain nociceptive, neuropathic, psychogenic Somatic pain- is diffused or scattered and originates in tendons, ligaments, bones, blood vessels and nerves Cutaneous pain- usually involves the skin or sub q tissue Visceral pain- is poorly localized and originates in body organs Referred pain- is pain that originates in one part of the body and is perceived in another area of the body

Psychogenic pain usually cant be identified like physical pain can Pain Process----Transduction- activation of the pain receptors Transmission- conduction along the pathways (A delta and C delta) Modulation- initiation of the protective reflex response Perception of pain- awareness of the characteristics of pain Nociceptors (pain receptors) bradykinin, prostaglandins, substance P

Enkephalins- inhibit pain by release of substance P Endorphins/dynorphins- released when certain measures are used to relieve pain Nociceptors- are the peripheral nerve fibers that transmit pain. Gait Control Theory----small and large diameter nerve fibers conduct and inhibit pain stimuli Pain Assessment Tools Wong-Baker- faces scales WILDA words that describe, intensity of the pain, location of the pain, duration of pain aggravating/alleviating factors McCaggery MethodMc Gill-Melzack pain questionnaireNumeric Sedation Scale- # 1 awake and alert (no action necessary) #2 occasionally drowsy but easily awoke (no action necessary) #3 frequently drowsy, drifts to sleep during conversation (reduce dose) #4 somnolent with minimal or no response to stimuli (consider narcan) Chapter 43 Urinary Elimination Act of Micturition- urinating Anuria- no urination (less than 50 mls in 24 hrs), Oliguria- (less than 400 mls in 24 hours) Dysuriapainful or difficult urination, Glycosuria- sugar in the urine, Pyuria- pus in the urine, Nocturia- nighttime urinating, enuresis- nighttime bedwetting Meds affecting urine, Anticoagulants- red urine, Diuretics- pale yellow urine, Pyridium- orange to orange-red urine, Elavil- green or blue-green urine, Levodopa- brown to black urine Chapter 13 Bowel Elimination paralitic Illius- no peristalsis

hypotonic enema- does pull electrolytes

isotonic enema- does not pull electrolyest

Antielmintic enema- used for intestinal parasites Bowel SoundsResonance/tympany is a normal bowel sounds expected when percussing the abdominal Dullness- may be caused by fluid, a mass, or a tumor Hyperresonance- when excess fluid is trapped in the intestines Gurgling- can be heard upon auscultation of the abdomen for bowel sounds Inspect, Auscultate, Percuss, Palpation Chapter 40 Rest and Sleep UNIT 3

RAS- Reticular Activating System- facilitates reflex and voluntary movements Hypothalamus- control center for sleeping and waking Sarchadym Rhythm- 24 hour clock Stages of Sleep Non-Rapid Eye Movement (NREM) cosist of 4 stages Stage I and II sleep, light sleep Stage III and IV 10 % of sleep, delta waves, sleep state. Rapid Eye Movement- most difficult to arouse - dream Nursing Theories**** Chapter 5 Florence Nightengale- cleanliness, asepsis, ventilation system Gene Watson- health promotion Patricia Benner- The Novist Nurse--- Novice to Expert Theory: group of concepts that describe a pattern of reality that can be tested, changed or used to guide research. Types of Resoning Deductive Reasoning- general- specific Inductive Reasoning- Specific- General General Systems Theory- Theory for universal application ****Benefits of nursing theory #1 is that it provides rational and knowledgeable reasons for nursing actiions***** What is the central theme in theoretical frameworks? The Patient! Goals of theoretical Framework- holistic pt. care, individualized care, promotion of health, prevention

Goals of RESEARCH- Develop explanations (in theroies) Find solutions to problems, improve care, study people and the nursing process, develop greater autonomy and strength as a profession provide Edvidence-Based Nursing Practice Quantitative=numbers Qualitative=words

Holistic Assessment- family support, medicine availability (transportation, money), referrals ( services, for) Stage 1- the person is in transitional stage between wakefulness and sleep. Stage 2- the person falls into a stage of sleep but can be aroused with ease. Stage - the depth of sleep increases and arousal becomes increasing difficult Dyssomnias- characterized by insomnia or excessive sleepiness insomnia, hypersomnia, narcolepsy, sleep apnea, restless leg syndrome, sleep deprivation Parasomnias- patterns of waking behaviors that appear during sleep sleep walking (somnambulism), sleep talking, nocturnal erections, bruxism (gritting teeth) Promoting Sleep- prepare a good environment, promote bedtime rituals, offer appropriate snack (carbohydrates), promote relaxation and comfort, respect normal sleep wake patterns, schedule nursing care to avoid disturbances, Chapter 30 Perioperative Nursing Perioperative- begins with the decision to have surgery and last until transfer to OR IntraOperative- extends from admit to surgical dept. to Recovery Room Post Operative- last from recovery room until complete recovery from surgery Ablative Surgery= performed to remove a diseased part Informed Consent- explained by the surgon, nurse witnessed and consent is signed Risks per Developmental Levels Elderly most at risk for pneumonia, constipation Remember*** T/C/D turn, cough,deep breath ANTICHOLERGINIC= decrease secreations Times for Vitals Post Op Every 15 min until stable, then Every 1-2 hrs for the first 24 hours, then every 4 hrs there after Chapter 42 Nutrition

50-100 g of carbs a day are needed to prevent Ketosis Complete proteins= animals Incomplete proteins = plants RDA= 0.8g/kg Adults Fats- saturated(raises cholesterol) unsaturated ( lower cholesterol) animal fat=saturated vegetables= unsaturated digestion occurs in small intestine, RDA= less than 30% of caloric intake Vitamin A= affects visual acuity, skin and mucous membranes, immune function Vitamin D= provides calcium and phosphorous metabolism Vitamin E= an antioxidant that protects Vitamin A Vitamin K= help the synthesis of certain proteins necessary for blood clotting MacroMinerals- calcium, phosphorus, and magnesium MicroMinerals- Iron,Zinc, Manganese, and Iodine Factors affecting BMR (Basic Metabolic Rate) BMR for men 1 cal/kg BMR for Women is 0.9 cal/kg

Increase BMR- growth, infection, fever, emotional tension, extreme temps, elevated hormone level Decreased BMR- aging, prolonged fasting, and sleep Factors for poor nutrition- sex, state of health, alcohol abuse (affects Vit B absorption), meds, megadoses of nutrients Two most common measurments that assess nutritional assessment Ht/ Wt, Best way to assess diet data- 24 hr recall, or food diary ( most accurate) How to get how many calories you need---lbs x 10 = how many calories you need for women lbs x 11 = how many calories you need for men Modified Dietsclear liquid- clear juices, broth, jello, and popsicles full liquid- cream soups, milk, and ice cream. diet contains lactose and is often high in fat pureed- foods blended to baby food consistency mechanical soft ground meat with gravy, soft cooked vegetables, and canned selected soft- meat, fruit, and veg. chopped into bite-sized pieces soft- regular textured foods, omitting fresh fruits and vegetables.

fruit

thickened liquids -thin liquids- have the consistency of water, coffee and tea -nectar- thick liquids are the consistency of maple syrup or cream soups - honey thick as honey -spoon thick/pudding consistency of pudding NPO- enteral- directly to stomach Parental- IV therapy Short term Enteral nutrition- < 6 weeks nasogastric/nasointestinal Gatrostomy- PEG tube but need functional GI tract Jejunostomy- J tube tube inserted into stomach but then into jejunum Mickey buttons easier for kids Confirming placement X- ray, gastric PH, tube length, auscultation PH stomach=<5.5 Intestines= 7.0 or > Respiratory tract= 6.0 or > Aspirate- stomach grassy green, tan, off white, bloody or brown, intestines= medium to deep yellow, respiratory tract= off white tinged with mucous LABS: ELECTROLYTES: NA (sodium) 135-145 K+ (potassium) 3.5-5.0 Calcium Ca- 9-11 Magnesium (MG) 1.5-2.5 Choride (CL) 95-105 Phosporous 2.8-4.5 Co2 Carbon Dioxide 20-30 elevated Calcium- cancerous process, osteoporosis (decreased calcium), ace inhibitors make K+ go up, RENAL: BUN 10-20 if decreased dehydration Creatinine 0.8-1.2 Has to do with hydration if increased FBS: fasting blood sugar less than 110 HGB A1C= 6 or less if not diabetic 7-8 if diabetic

PROTIMES/ INR INR should be 2-3 if on anticoagulation therapy and 2.5-3.5 if mechanical heart valves HGB=12-18 HCT=40-50 if increased look for dehydration Albumin= 3.5-5.5 malnutrition if low

Chapter 45 Oxygenation Vesicular= low pitched soft sound heard during expiration over most of the lung Bronchial= high pitched and longer heard primarily over trachea Bronchialvesicular= medium pitched and sound during expiration heard over upper anterior chest and intercostal area

Crackles= intermittent sounds occurring when air moves through airways that contain fluid Wheezes=continuous sounds from swelling, secreations or turmors (sonorous/sibilant) atelecatasis- airlessness or collapse of lung bradypniea- < than 10 per min hypoxemia= excess co2 in blood hypoxia- a reduced supply of o2 to the tissues below levels adequate for perfusion non-rebreather mask- fits snuggly over the nose and mouth, delivers high flow of o2 at high rates and concentrations (one way valves) (no room air)_ Oxygen mask- fits over nose and mouth o2 is humidified Trach collar- small o2 fits over trach site Venturi Mask- holes in the sides to expel exhaled air (used for critically ill pts. who require specific amts. of O2 flow rates 4-12/lpm Early stages of hypoxia- restless, anxious, confused, elevated HR, RR, BP late stage of hypoxia- hypotension, bradycardia, metabolic acidosis, cyanosis flow rates of 4/lpm need sterile water for humidification PEAK FLOW RATES the point of flow during forced expiration, used in asthmatics, measures the severity of the disease and degree of control Pulse Oximetry-

UNIT 4 Chapter 32 Stress and Adaptation