phase 1 test 10 basic nursing
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| 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
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| How can documentation can be used? | resources used, who saw patient, level of care, audit tool, may be basis for fraud claim
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| Hospital Policies and Procedures | illustrate hospital philosophy and standards, define mechanism for adherence, SOC, consistency
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| Components of Patient Care (Questions Answered) | Who?, What?, When?, Where?, Why?
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| Define Tampering | willful act to destroy record
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| Standards for Client Education | JACO sets standards, successful accomplishment requires collaboration
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| Purpose of Client Education | achieve optimal levels of health; includes maintenance and prevention, restoration, coping
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| Define Teaching | interactive process that promotes learning
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| Define Learning | purposeful acquisition of knowledge, skills, behaviors, attitudes
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| 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
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| 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
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| Basic Learning Principles | Motivation: cleint's desire to learn Abilty: physical and cognitive abilities Environment: allows person to attend
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| Integrating Nursing and Teaching Process | relationship exists not the same nursing reuires assessment of all data teaching focuses on client's needs
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| ADPIE | Assessment Diagnosis Planning Implementing Evaluation
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| 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+
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| Growth | progressive anatomic and physiologic increase in size
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| Development | moves from simple to complex and is lifelong process
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| Personality | unique combination of characteristics that results in individual's reoccuring behavior
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| Developmental Theory | theory based on research that helps make obersvations meaningful
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| Life Expectancy | about 77 years old
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| Infant Mortality | number of deaths before age 1
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| Cephalocaudal | growth and development that proceeds from head-feet
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| Proximodistal | growth and developtment that proceeds from center-outward
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| 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
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| 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
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| Super-ego develops during what stage of the life cycle? | Adolescence
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| 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+
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| 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
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| 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
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| 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
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| Roles of Family | protection, nurture, education, sustenance, socialization, usually unconditional affection, first socialization agent
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| Patterns of Family | Autocratic: unequal, parents control children
Patriarchal
Matriarchal
Democratic: equals
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| 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
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| 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
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| Characteristics of Preschoolar | growth slow and steady
farsighted, 20/20 by 5
cooperative and dramatic play
food jags
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| Characteristics of Schoolage | gradual and subtle growth
"growing pains"
adequate exercise to increase muscle dev.
inadequate sleep
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| Characteristics of Adolescence | begins at puberty
second major growth period
sexual development
often not very coordinate
adult vitals
increased sleep needs
organized sports
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| 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
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| 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
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| Characteristics of Late Adulthood | individualized
slow increase in weight
loss of height after 50
kyphosis
more rest needed but less sleep
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| Communication | use of verbal and behaviors to construct, send, and interpret messages
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| Sender | person who has a thought, idea, or emotion to convey to another
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| Message | thought, idea, emotion one person sends to another
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| Channel | how message transmitted may be auditory, visual, kinetic
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| Auditory | verbal, hearing and/or listening
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| Visual | nonverbal, sight, reading, observation, and/or perception
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| Kinesthetic | tactile/nonverbal, procedural touch and/or caring touch
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| Receive | person who receives message
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| Physiological | hearing, seeing, and reception of touch stimulus
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| Psychological | process may enhance or impede receiving of message
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| Unintended Receiver | one who overhears statement or conversation
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| Feedback | response from receiver that enables the sender to verify that the message sent was the message received
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| Influences Communication | both sender and receiver are influenced by their education, culture, emotions, and perceptions and by the situation in which they find themselves
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| One-Way Communication | highly structured, with the sender being in control and getting very little response from receiver
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| Two-Way Communication | requires both the sender and receiver participate equally
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| Verbal Communication | use of spoken or written words/symbols
little room for misunderstanding
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| Connotative | word reflects individual's perception/interpretation of a given word
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| Denotative | refers to the commonly accepted definition of a particular word
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| Jargon | commonplace language/terminology unique to persons in a particular work setting or type of work
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| Nonverbal Communication | without use of words
body language
very powerful - cues not consistent with verbal, nonverbal received
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| Assertive | takes into account the feelings and needs of patient, yet honors nurse's rights as individual; most effective method
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| Aggressive | overpowering and forceful to meet one's own needs at others' expense
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| Unassertive | sacrifices nurse's legitimate personal rights to meet needs of patient at expense of feeling resentful
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| Therapeutic Communication | promotes formation of positive nurse-patient relationship and patient involved in all areas of nursing process
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| Listening | most effective, most difficult skill to acquire
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| Active Listening | full attention to patient, allows feedback
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| Passive Listening | nonverbally through eye contact and nodding, encouraging phrases
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| Silence | effective technique, underused
allows time to organize thoughts and plan response
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| Minimal Encouragement | brief verbal comments, conveys interest and desire, nonverbal cues
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| Touch | can convey warmth, caring, comfort, support, understanding
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| Acceptance | what patient's communicating, non-judgmental,minimal verbal, interaction
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| Closed Questions | focused on particular answer, short responses, provides answer, doesn't foster open communication
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| Open-Ended Questions | doesn't seek answer, patient can elaborate, assess feelings, doesn't influence response
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| Restating | repeat main points, conveys what heard was what said, encourages additional information
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| Paraphrasing | restating what was said in own words to verify interpretation
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| Clarifying | more information/elaboration, verification of accuracy, useful if message difficult
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| Focusing | specific info. needed, message may be too vague, focus on specific data
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| Reflecting | assists "reflection" on inner thoughts/feelings, pt empowered-position of control, self-esteem
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| Stating Observation | makes observations at every interaction, validating accuracy, verbal doesn't equal non-verbal, validation
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| Offering Information | much of communication, feedback essential
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| Summarizing | review main points, useful pt teaching, sense of closure
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| 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
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| Comfort Zone | necessary distance to guard against threat or intimidation
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| Intimate Zone | 0-18 inches
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| Personal Zone | 18 inches-4 feet
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| Social Zone | 4-12 feet
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| Public Zone | 12+ feet
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| Communication Blocks | false reassurance
giving advice
false assumption
value judgments
cliche
defensiveness
asking for explanations
changing subject
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| Special Circumstances of Communication | ventilator-dependent
aphasia
dysphasia
dysarthria
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| Expressive Aphasia | can't send desired message
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| Receptive Aphasia | can't recognize/interpret message being sent
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| Dysphasia | impairment of speech
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| Dysarthria | dysfunction of muscles used for speech; speech difficult, slow, hard to understand
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| Components of Nursing Process | Assessment
Diagnosis
Planning
Implementation
Evaluation
(ADPIE)
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| Types of Data | subjective (symptoms, verbal cues)
objective (observable, measurable, signs)
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| Sources of Data | primary- patient
secondary- family members, significant others, HCT, records, diagnostic procedures, nursing literature
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| Types of Assessments | comprehensive
focused
on-going
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| NANDA | North American Nursing Diagnosis Association
approved official definition
list of diagnoses
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| 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
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| 3 Phases of Planning | initial
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| Categories of Nursing Interventions | independent
interdependent
dependent
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| Common Hazards in Healthcare Environments | falls
burns
smoking
fire
poisoning
biohazards
choking
electrocution
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| Fall Risks | age
recent falls
mental status
visual acuity
physical strength
bowel/bladder control
medications
gait/balance
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| SRDs | Safety Reminder Devices
"any of the numerous devices used to immobilize a patient/part of patient's body, such as arms/hands"
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| Who can apply restraints? | licensed personal
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| Nine Types of Patient Care Orders | nursing orders
STAT orders
telephone orders
recurrent orders/standing orders
PRN orders
verbal orders
single orders
routine (prohibited)
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| Parts of DA Form 4256 | white - stays with record
pink - to pharmacy
yellow- unit use
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| Who can take verbal or telephone orders? | only RN
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