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68WM6 Basic Nursing
phase 1 test 10 basic nursing
| Question | Answer |
|---|---|
| Describe the Patient Care Document | Primary Communication Tool,Don't Document, Didn't Happen,Illustrates what each member needs to know to continue care,Implementation Phase of Nursing Process,"Living Document",Relevevant to Patient |
| How can documentation can be used? | resources used, who saw patient, level of care, audit tool, may be basis for fraud claim |
| Hospital Policies and Procedures | illustrate hospital philosophy and standards, define mechanism for adherence, SOC, consistency |
| Components of Patient Care (Questions Answered) | Who?, What?, When?, Where?, Why? |
| Define Tampering | willful act to destroy record |
| Standards for Client Education | JACO sets standards, successful accomplishment requires collaboration |
| Purpose of Client Education | achieve optimal levels of health; includes maintenance and prevention, restoration, coping |
| Define Teaching | interactive process that promotes learning |
| Define Learning | purposeful acquisition of knowledge, skills, behaviors, attitudes |
| Domains of Learning | Cognitive: includes all intellectual behaviors and requires thinking Affective: deals with expression of feelings and acceptance of attitudes, opinions, or values Psychomotor: acquiring skills that require integration of mental and musclular activity |
| Role of Nurse in Patient Teaching | to client and family determines what client needs to know when client ready to learn parallels communication process part of effective interpersonal communication learning objective |
| Basic Learning Principles | Motivation: cleint's desire to learn Abilty: physical and cognitive abilities Environment: allows person to attend |
| Integrating Nursing and Teaching Process | relationship exists not the same nursing reuires assessment of all data teaching focuses on client's needs |
| ADPIE | Assessment Diagnosis Planning Implementing Evaluation |
| Stages of Lifecycle | Neonatal: birth-30 days Infancy: 30 days-1 year Toddler: 1-3 years Preschool: 3-5 years Schoolage: 6-12 Adolescence: 13-19 Early Adulthood: 20-40 Middle Adulthood: 40-65 Late Adulthood: 65+ |
| Growth | progressive anatomic and physiologic increase in size |
| Development | moves from simple to complex and is lifelong process |
| Personality | unique combination of characteristics that results in individual's reoccuring behavior |
| Developmental Theory | theory based on research that helps make obersvations meaningful |
| Life Expectancy | about 77 years old |
| Infant Mortality | number of deaths before age 1 |
| Cephalocaudal | growth and development that proceeds from head-feet |
| Proximodistal | growth and developtment that proceeds from center-outward |
| Principles of Growth and Developtment | highly individualized growth spurts and rest periods simple-complex in a predictable sequence varies for specific structures at specific times whole person; physically, socially, mentally, emotionally both continuous and interdependent |
| Sigmund Freud: Psychoanalytic Theory | Id: unconscious, present at birth, basic for survival Ego: reality factor, reason and good sense Super-ego: delays immediate gratification for socially appropriate reasons |
| Super-ego develops during what stage of the life cycle? | Adolescence |
| Erikson's: Psychosocial Theory Stages and Ages | Infancy birth-1 Toddler 1-3 Preschool 4-6 Schoolage 7-11 Adolescence 12-19 Young Adulthood 20-44 Middle Adulthood 45-65 Late Adulthood 65+ |
| Developmental Tasks in Erikson's Theory | Infancy: basic trust/mistrust Toddler: autonomy/shame,doubt Preschool: initiative/guilt Schoolage: industry/inferiority Adolescence: identity/role confusion Y. Adult: intimacy/isolation M. Adult: generativity/stagnation L. Adult: ego integrity/disp |
| Piager: Stages of Cognitive Development | Sensorimotor: birth-2, gain through senses and motor activity Preoperational: 2-7, egocentric, life to inanimate obj. Concrete Operational: elementary-early adolescence, 7 types of conversation, realistic Formal Operational: adolescence-adulthood, symb |
| Family Types | Nuclear: married, w/o children, indep. Extended: nuclear+additional family Single Parent Blended (Reconstituted): step-family Social Contract/Cohabitation: unmarried living together Adoptive Foster |
| Roles of Family | protection, nurture, education, sustenance, socialization, usually unconditional affection, first socialization agent |
| Patterns of Family | Autocratic: unequal, parents control children Patriarchal Matriarchal Democratic: equals |
| Characteristics of Infancy | rapid growth 4-6 months babbles 3 months 7 months- sitting up, crawling 9 months- creeping 8-15 months- stands and walks play important for learning |
| Characteristics of Toddler | speaks 1-2 word phrase vocab. 450 words by 2.5, 900 at 3 20 primary teeth by 2 walking steadily by 2 pincer grasp scribbling at 2, circles 3 potty training 18-24 months play alongside but not with |
| Characteristics of Preschoolar | growth slow and steady farsighted, 20/20 by 5 cooperative and dramatic play food jags |
| Characteristics of Schoolage | gradual and subtle growth "growing pains" adequate exercise to increase muscle dev. inadequate sleep |
| Characteristics of Adolescence | begins at puberty second major growth period sexual development often not very coordinate adult vitals increased sleep needs organized sports |
| Characteristics of Early Adulthood | optimal level of functioning physical appearance influences females max height 16-17, males 18-20 fewer calorie needs annual physical and dental exams |
| Characteristics of Middle Adulthood | bone mass decreases sight changes decreased muscle fibers basic neurological functioning remain high presbyopia, presbycusis, skin changes menopause/andropause fewer calories less sleep |
| Characteristics of Late Adulthood | individualized slow increase in weight loss of height after 50 kyphosis more rest needed but less sleep |
| Communication | use of verbal and behaviors to construct, send, and interpret messages |
| Sender | person who has a thought, idea, or emotion to convey to another |
| Message | thought, idea, emotion one person sends to another |
| Channel | how message transmitted may be auditory, visual, kinetic |
| Auditory | verbal, hearing and/or listening |
| Visual | nonverbal, sight, reading, observation, and/or perception |
| Kinesthetic | tactile/nonverbal, procedural touch and/or caring touch |
| Receive | person who receives message |
| Physiological | hearing, seeing, and reception of touch stimulus |
| Psychological | process may enhance or impede receiving of message |
| Unintended Receiver | one who overhears statement or conversation |
| Feedback | response from receiver that enables the sender to verify that the message sent was the message received |
| Influences Communication | both sender and receiver are influenced by their education, culture, emotions, and perceptions and by the situation in which they find themselves |
| One-Way Communication | highly structured, with the sender being in control and getting very little response from receiver |
| Two-Way Communication | requires both the sender and receiver participate equally |
| Verbal Communication | use of spoken or written words/symbols little room for misunderstanding |
| Connotative | word reflects individual's perception/interpretation of a given word |
| Denotative | refers to the commonly accepted definition of a particular word |
| Jargon | commonplace language/terminology unique to persons in a particular work setting or type of work |
| Nonverbal Communication | without use of words body language very powerful - cues not consistent with verbal, nonverbal received |
| Assertive | takes into account the feelings and needs of patient, yet honors nurse's rights as individual; most effective method |
| Aggressive | overpowering and forceful to meet one's own needs at others' expense |
| Unassertive | sacrifices nurse's legitimate personal rights to meet needs of patient at expense of feeling resentful |
| Therapeutic Communication | promotes formation of positive nurse-patient relationship and patient involved in all areas of nursing process |
| Listening | most effective, most difficult skill to acquire |
| Active Listening | full attention to patient, allows feedback |
| Passive Listening | nonverbally through eye contact and nodding, encouraging phrases |
| Silence | effective technique, underused allows time to organize thoughts and plan response |
| Minimal Encouragement | brief verbal comments, conveys interest and desire, nonverbal cues |
| Touch | can convey warmth, caring, comfort, support, understanding |
| Acceptance | what patient's communicating, non-judgmental,minimal verbal, interaction |
| Closed Questions | focused on particular answer, short responses, provides answer, doesn't foster open communication |
| Open-Ended Questions | doesn't seek answer, patient can elaborate, assess feelings, doesn't influence response |
| Restating | repeat main points, conveys what heard was what said, encourages additional information |
| Paraphrasing | restating what was said in own words to verify interpretation |
| Clarifying | more information/elaboration, verification of accuracy, useful if message difficult |
| Focusing | specific info. needed, message may be too vague, focus on specific data |
| Reflecting | assists "reflection" on inner thoughts/feelings, pt empowered-position of control, self-esteem |
| Stating Observation | makes observations at every interaction, validating accuracy, verbal doesn't equal non-verbal, validation |
| Offering Information | much of communication, feedback essential |
| Summarizing | review main points, useful pt teaching, sense of closure |
| Factors Affecting Communication | posturing and positioning space and territoriality environment level of trust language barrier culture age and gender pain altered cognition impaired hearing stress grieving |
| Comfort Zone | necessary distance to guard against threat or intimidation |
| Intimate Zone | 0-18 inches |
| Personal Zone | 18 inches-4 feet |
| Social Zone | 4-12 feet |
| Public Zone | 12+ feet |
| Communication Blocks | false reassurance giving advice false assumption value judgments cliche defensiveness asking for explanations changing subject |
| Special Circumstances of Communication | ventilator-dependent aphasia dysphasia dysarthria |
| Expressive Aphasia | can't send desired message |
| Receptive Aphasia | can't recognize/interpret message being sent |
| Dysphasia | impairment of speech |
| Dysarthria | dysfunction of muscles used for speech; speech difficult, slow, hard to understand |
| Components of Nursing Process | Assessment Diagnosis Planning Implementation Evaluation (ADPIE) |
| Types of Data | subjective (symptoms, verbal cues) objective (observable, measurable, signs) |
| Sources of Data | primary- patient secondary- family members, significant others, HCT, records, diagnostic procedures, nursing literature |
| Types of Assessments | comprehensive focused on-going |
| NANDA | North American Nursing Diagnosis Association approved official definition list of diagnoses |
| Types of Nursing Diagnosis | actual - condition currently present risk - more vulnerable to develop problem that others in same situation possible - problem feasible syndrome - cluster of actual/risk nursing diagnoses wellness - moving up from specific level of wellness to higher |
| 3 Phases of Planning | initial |
| Categories of Nursing Interventions | independent interdependent dependent |
| Common Hazards in Healthcare Environments | falls burns smoking fire poisoning biohazards choking electrocution |
| Fall Risks | age recent falls mental status visual acuity physical strength bowel/bladder control medications gait/balance |
| SRDs | Safety Reminder Devices "any of the numerous devices used to immobilize a patient/part of patient's body, such as arms/hands" |
| Who can apply restraints? | licensed personal |
| Nine Types of Patient Care Orders | nursing orders STAT orders telephone orders recurrent orders/standing orders PRN orders verbal orders single orders routine (prohibited) |
| Parts of DA Form 4256 | white - stays with record pink - to pharmacy yellow- unit use |
| Who can take verbal or telephone orders? | only RN |
Created by:
ealongo
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