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2431 Unit 4 Exam

2431 Unit Four Exam Blueprint

Clara Barton took volunteers into the field hospitals to care for soldiers of both armies.
Common Goals of nursing To promote wellness, To prevent illness, To facilitate coping, To restore health
Definition of nursing by theorists concept that integrates human relationships, environment and health.
Collaboration A role of the practical nurse, work with RN and health care team to provide continuity of care.
DRG (Diagnosis-Related Group) n a system of classifying hospital patients on the basis of diagnosis consisting of distinct groupings. A DRG assignment to a case is based on the patient's principal diagnosis, treatment procedures performed, age, gender, and discharge status.
Caregiver Role of the nurse to implement interventions to improve, maintain or restore health.
Educator Role of the nurse to teach health and counseling to promote wellness, and prevent illness.
Manager Role of the nurse to assign minor tasks to nurse assistant or other ancillary personnel.
Medicare Must be authorized within 72 hours.
Routine admissions are scheduled in advance, physician and patient have agreed to admission, and thept has had a short time in which to make arrangements.
Transferring patients physician should be notified, transfer requires documentation for reason and condition at time of transfer, Report is given between nurses, Business office notified, label all pts equipment with tape, check drawers!!!
Laboratory work and x-ray examinations are usually performed before admission
The admitting department is responsible for making sure that all admission criterias are met. Collect personal and insurance info. May be responsible for making payment info.
On the day of admission make a list of the medications and send them home. Notify the physician of any meds the pt is taking home that aren't on admission orders. List all OTCs and herbals.
Discharge begins at admission
When discharge orders are received: assist as needed in notifying fam or SO, collect Pt. belongings, Prepare for the ride home, if pt doesn't have transport you must arrange it.
Discharge to an extended care or rehabilitation facility pts may not be well enough to go home, RN completes a detailed pt info sheet, Any records to be transferred to the pt must be ready in an envelope prior to transport arrival.
Discharge home Verify travel arrangements, Prepare written discharge instructions and review with the pt and family member
Discharge AMA Make sure the pt understands the risk of leaving AMA, Offer to have the pt talk with the physician or supervising nurse, Have the pt sign AMA form. If thte pt refuses, it should be documented in nurses notes.
Pt must be pronounced dead by a physician
Document the following in the nurses notes: time that life signs ceased, time death was pronounced, and name of person making the official pronouncement.
Autopsies are required in most states for certain conditions or may be requested by the family. Next of kin is required to sign permission for autopsy.
Death of a pt, Providing support for significant others: Often the most important gift we can give is being there, People need to grieve it is an important step in healing, Offer to call spiritual advisor, Allow the fam and friends adequate time at bedside.
Autopsies are usually performed when the pt has died of unknown causes, has died at the hands of another, or has not been seen within a spefic period of time by a physician. May also be performed when it is felt that info valuable to medical research may be obtained.
Organ donation may be requested by the pt. Handled by physician or specially trained nurse. When handled sensitively, requests can be an opportunity for the fam to allow something good to come out of a personal tragedy. Health care workers must be culturally aware.
Routine admissions sched. in advance, phys. and pt have agreed to admission, pt has had short time to make arrangements
Emergency admissions no planning. sudden illness, injury or abrupt worsening of an existing condition requires immediate treatment. Stressful for the pt, family and friends.
Managed care considerable controversy about effectiveness of this approach, Nurses must constantly think about cost containment while trying to give optimal care to pts.
To prepare a teaching plan assess pt for: knowledge of the disease ("do you know anyone who...?"), Diet (if related), Activity regimen or limitations, Meds (Rx and OTC), Self-Care at home. <Prioritize learning needs so you can concentrate on teaching essential knowledge first.
Assess for factors that might interfere with the pts ability to learn: Poor vision or hearing, impaired motor function, illiteracy and impaired cognition. Age may interfere with the strength or dexterity for performing certain tasks.
Special considerations for teaching the elderly: provide good lighting, provide printed teaching materials with large type, Encourage glasses, Encourage hearing aide, Use short sentences with pauses, Keep med terms to a min, Ask questions at frequent intervals, have them demonstrate or repeat back
Evaluation of learning involves obtaining feedback from the pt regarding what was taught. Use this feedback to determine whether effective learning has in fact taken place.
Implementing of teaching, timing Teaching done when visitors, physician rounds, and treatments will not interrupt
Implementing teaching one on one or in group setting, pt should be comfortable, keep teaching sesh short, involve pt in the process, You may need to incorporate teaching into daily care.
Purposes of pt teaching: preventing illness or promoting wellness
Nurses teach pts about their: disease or disorder, diet and meds, treatment and self-care
Prior to discharge, the pt must be taught how to care for themselves at home
Pt Teaching begins at time of admission
Assessment of learning needs: prepare a plan, assess learning needs.
Factors affecting learning: cultural value, confidence and abilities, readiness to learn
Form a teaching plan: Collaborate with other health professionals (dietician, PT, etc.)
Visual learners learn through what they see
Auditory learners learn through what they hear
Kinesthetic learners learn through actually performing a task or handling itmes
Which mode is best to teach your pt with? A combination of all three!
ANA established what? scope of standards of practice
Level of consciousness, semicomatose: the client is unresponsive except to superficial, relatively mild painful stimuli to which the client makes some purposeful motor response to evade stimulation. Spontaneous motion is uncommon, but the client may moan or mutter.
Assessment of motor functions: pushing the palm or sole against the examiners palms, picking small and large objects between thumb and forefinger, grasping objects firmly, resisting removal of an object from the fists or forefingers, observe gait/balance. walk heel-toe.
To assess motor function, you may perform a Romberg test: client stands with feet close together and eyes closed. if client sways and tends to fall it is considered a positive romberg test, indicating a problem with equilibrium.
Evaluating motor/cerebral function: finger to nose test with eyes closed, writing words and identifying common objects.
Evaluating motor response in the comatoes or unconscious client: painful stimulus to determine if the client makes approp response (sternal chest rub), Check sensory response to all areas (rub bottoms of feet).
Glascow coma scale is a measure of the LOC it contains three parts: eye opening response, best verbal response, and best motor response.
Glascow Eye opening response determined by talking to the client andcalling his/her name. If no response is noted, a painful stimulus is introduced and the response is noted.
Glascow Verbal response Evaluated by a verbal response to questions
Glascow Motor response The ability of the client to follow commands such as "wiggle your toes" or "move your hand"
Glascow coma scale results normal response is 15, A score of 7 or less is considered coma.
Level of consciousness: somnolent or lethargic the client is drowsy or sleepy at inappropriate times but can be aroused, only to fall asleep again. Responses to questions are delayed or inappropriate. Speech is incoherent. Responds to painful stimulus.
Cranial nerve 1 Olfactory. Test ability to identify familiar odors one naris at a time with eyes closed.
Cranial nerve 2 Optic. Snellen chart. Rosenbaum near vision chart. Opthamoscopic exam of fundi. Visual fields by confrontation and extinction of vision.
Cranial nerve 3 Oculomotor. Drooping eyelids. Perrl.
Cranial Nerve 4 Trochlear. Same as CN 3.
Cranial Nerve 5 Trigeminal. Inspect face for muscle atrophy and tremors, palpate jaw muscles for tone and strength. Test superficial pain and touch. Test corneal reflex.
Cranial Nerve 6 Abducens. Same as CN3.
Cranial Nerve 7 Facial Nerve. Inspect symmetry of facial features with various expressions (puff, smile, squint eyes)
Cranial Nerve 8 Acoustic. Tests sense of hearing with whisper screening tests or by audiometry.
Cranial nerve 9 Glossopharyngeal. Test ability to identify sour and bitter tastes. Test gag reflex and ability to swallow.
Cranial nerve 10 Vagus. Inspect palate and uvual for symmetry with speech sounds and gag reflex. Observe for swallowing difficulty. Evaluate quality of guttural speech sounds.
Cranial nerve 11 Spinal accessory. Test trapezius muscle stregth (shrug shoulders). Test sternocleidomastoid muscle stregth (turn head to each side against resistance)
Cranial Nerve 12 Hypoglossal. Inspect tongue movement toward nose and chin. Test tongue strength with index finger when tongue is pressed against cheek. Evaluate lingual speech sounds.
Created by: christinego