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68WM6 Basic Nursing

phase 1 test 10 basic nursing

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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