12 cranial nerves

Variations in vital signs

Normal vital infant

T - 98.7 -100.5

p- 80-150

rbm - 20-40

bp - 85/37

Pulse quality

droplet precautions

Standard precautions

contact precautions

Airborne precautions

Ppe

A man age 61 years is distraught because he has just learned that his most recent computed tomography (CT) scan shows that his colon cancer has metastasized to his lungs. Which of the following nursing aims should the nurse prioritize in the immediate care of this patient?

Facilitated Coping

A student nurse understands that the primary aim of the Healthy People 2020 initiatives is

health promotion

The nurse conducts a home safety assessment for a client. Which statement best explains the standard of care being implemented?

The nurse promotes a safe environment

The need for university-based nursing education programs was brought to light during which important historical time?

World War II

The registered nurse is teaching a community health class about illness prevention. Which of the following statements reflects understanding of this concept?

"It is important to enroll in a smoking cessation class."

A: Assessment
D: Diagnosis
P: Planning
I: Implementation
E: Evaluation

Nursing process

_______—collecting, validating, and communicating of patient data

Assessing

______________—analyzing patient data to identify patient strengths and problems

Diagnosing

________________—specifying patient outcomes and related nursing interventions

Planning

____________________—carrying out the plan of care

Implementing

______________—measuring extent to which patient achieved outcomes

Evaluating

Physiologic (Survival): food, fluids, oxygen, elimination, warmth, physical comfort
Safety and Security: physical safety and psychological security
Love and Belonging: family and significant other
Self-esteem: make people feel good about themselves and confident in their abilities
Self-actualization: need to grow, change, accomplish goals

Human Need Maslow

What is the nurse’s role in the Assessment phase of the Nursing Process?

What type of data is collected?

What are the different types of Nursing Assessments?

Assessment

What is the purpose of the Nursing Diagnosis?

How does the nurse develop the Nursing Diagnosis?

What is the difference between a Nursing Diagnosis and Medical Diagnosis?

What is the difference between an Actual Nursing Diagnosis, Risk Nursing Diagnosis, Possible Nursing Diagnosis, Wellness Diagnosis, and Syndrome Nursing Diagnosis?

Diagnosis

Problem --->> Etiology----->> Characteristics

OR
What is Wrong -------->>Why is Wrong Occurring------->>>

How do you Know What is Occurring

What are the parts of a nursing diagnosis?

What is the purpose of Planning?

How does the nurse prioritize the nursing diagnosis?

What is the difference between Short and Long term outcomes (goals)?

What is the difference between Cognitive, Psychomotor, and Affective outcomes/goals?

Planning/Outcome identification

S: Specific
M: Measurable
A: Achievable
R: Realistic
T: Timely

How are Outcomes/Goals written?

Assessment is done
Diagnosis is developed
Goal is identified
Now to develop the interventions that will meet the goals

Implementation

Determine the patient’s new or continuing need for assistance.
Promote self-care.
Assist the patient to achieve valued health outcomes.

Implementing the care plan

Developmental stage
Psychosocial background

Patient variables

Resources
Current standards of care
Research findings
Ethical and legal guides to practice

Nurse variables

Cognitive—increase in patient knowledge
Psychomotor—patient’s achievement of new skills
Affective—changes in patient values, beliefs, and attitudes
Physiologic—physical changes in the patient

4 Types of outcomes

Delete or modify the nursing diagnosis.
Make the outcome statement more realistic.
Increase the complexity of the outcome statement.
Adjust time criteria in outcome statement.
Change nursing interventions

Revisions in the Care Plan

How do you know the problem is occurring (Hint: objective and subjective data)?
Develop (1) SMART goal
Try an intervention

what is the cause (etiology) of the problem?

Mr. Smith is a 68 year old male who is post op day 4 from right hip replacement. Prior to surgery Mr. Smith was active and completed all ADLS independently. Mr. Smith’s physician ordered to resume is home medications; Lipitor (cholesterol med) and Lopressor (heart medication) and also added Percocet 4 times a day PRN pain and Protonix (anti ulcer medication).
Mr. Smith states that he has not moved his bowels since surgery.

You are developing the plan of care for Mr. Smith who was admitted 3 days ago after a stroke. Assessment findings include CN X deficit, hoarse voice, and left sided hemiplegia. Mr. Smith is married, with three adult daughters and is a retired school teacher. Vital signs: BP 128/78 HR 88 RR 16 equal and unlabored and Temp 98.7 F (oral)

You are revising the plan of care for Mr. Smith, who had a stroke 5 days ago. Assessment: lung sounds crackles in right lower base, “wet” voice. BP 136/80 RR 22 equal, unlabored, HR 92, T 99.8 F (axillary).

______________—a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity

Health

_________________—the unique response of a person to a disease; an abnormal process involving changed level of functioning

Illness

_____________—an active state of being healthy by living a lifestyle promoting good physical, mental, and emotional health

Wellness

Physical: genetic inheritance, age, developmental level, race, gender
Emotional: stress, emotional intelligence
Intellectual: cognitive abilities, educational background, past experiences
Environmental: housing, sanitation, food, water, air
Sociocultural: culture, economic level, family
Spiritual: beliefs, morals, values

Interdependent parts that make up the whole person, influences illness and illness behaviors

Physiological needs
Safety and security needs
Love and belonging needs
Self-esteem needs
Self-actualization needs

Basic human needs

Answer: C. Pneumonia
Rationale:
Pneumonia is an acute illness that has a rapid onset of symptoms and lasts only a relatively short time. Diabetes, rheumatoid arthritis, and osteoporosis are chronic illnesses that cause a permanent change, require special patient education for rehabilitation, and require a long period of care or support.

Which of the following is an example of an acute illness?
A. Diabetes
B. Rheumatoid arthritis
C. Pneumonia
D. Osteoporosis

Generally has a rapid onset of symptoms and lasts only a relatively short time
Examples: appendicitis, pneumonia, diarrhea, common cold

Acute illness

A broad term that encompasses many different physical and mental alterations in health
Examples: diabetes mellitus, lung disease, arthritis, lupus

Chronic Illness

It is a permanent change.
It causes, or is caused by, irreversible alterations in normal anatomy and physiology.
It requires special patient education for rehabilitation.
It requires a long period of care or support.

Characteristics of chronic illness

Experiencing symptoms
Assuming the sick role
Assuming a dependent role
Achieving recovery and rehabilitation

Stages of Illness behavior

Tell whether the following statement is true or false.
A person who is experiencing a productive cough and fever takes a sick day to recuperate and decide whether to make an appointment with the doctor. Which stage of illness behavior is the patient experiencing?
Experiencing symptoms
Assuming the sick role
Assuming a dependent role
Achieving recovery and rehabilitation

Answer: B. Assuming the sick role

A person who defines himself as sick and self-medicates or visits a doctor is said to be in stage 2 of illness behavior: assuming the sick role.

Factors that the client cannot change
Age
Gender
Race
Family History

non modifiable risk factors

Factors that the client can change
Health habits
Lifestyle
Environment
Physiologic

Modifiable risk factors

______________: the behavior of an individual that is motivated by a personal desire to increase well-being and health potential. Education is a health promotion activity.

Health Promotion

_________________: the behavior motivated by a desire to avoid or detect disease or to maintain functioning with the constraints of illness or disease. A diabetic patient looks at the soles of his feet with a mirror weekly

Illness Prevention

_______ directed to health promotion and the preventing the development of disease; interventions that prevent actual occurrence of a specific illness or disease; may focus on individuals or groups.

Primary

______________ focuses on screening for early detection of disease with prompt diagnosis and treatment

Secondary

_____________ directed towards recovery or rehabilitation of a disease or illness has developed

Tertiary

1.) A nurse is administrating immunizations at a back to school fair.

2.) The nurse is performing a skin assessment for a patient that works outside in the sun.

3.) A nurse is monitoring the progress of a patient participating in Cardiac Rehab.

Primary

Secondary

Teriary

1.) A nurse is teaching a class on Heart Healthy Nutrition to a group of middle aged adults

2.) The nurse is completing the health assessment on a patient that includes cholesterol screening and blood pressure measurements.

3.) The nurse is teaching the patient how to take the prescribed cholesterol medicine and dietary restrictions.

Primary

Secondary

Teriary

______
Weight loss, diet, exercise, smoking cessation
_________
Screenings, examinations, family counseling
_________
Medications, surgical treatment, occupational therapy

Primary

Secondary

Teriary

Which of the following is an example of a nursing activity that promotes secondary prevention as a level of preventive care?
A. Conducting a smoking cessation class
B. Performing a blood pressure screening at a local mall
C. Performing range-of-motion exercises on a bedridden patient
D. Promoting safer sex practices in school settings

Answer: B. Performing a blood pressure screening at a local mall
Rationale:
Secondary preventive care focuses on early detection of disease, such as the heart disease in this example.
Primary preventive care is directed toward promoting health and preventing diseases.
Tertiary care begins after an illness is diagnosed to reduce disability and rehabilitate patients.

Care must be sensitive to needs of individuals, families, or groups from diverse cultures.
The healthcare system is a culture with customs, rules, values, and a language of its own.
Nursing is the largest subculture of the healthcare system.

culturally competent nursing care

Cultural background of each participant
Expectations and beliefs of each person about healthcare
Cultural context of the encounter
Degree of agreement between the sets of beliefs and values of the two persons

Factors That Affect Culturally Diverse Interactions

Varying cultures
Racial and ethnic origin
Religion
Physical size, age, and gender
Sexual orientation
Disability
Socioeconomic and occupational status
Geographical location

Cultural Diversity

Shared system of beliefs, values, and behavioral expectations
Provides social structure for daily living
Defines roles and interactions with others and in families and communities
Apparent in the attitudes and institutions unique to the culture

Culture

Large group of people who are members of a larger cultural group
Have certain ethnic, occupational, or physical characteristics not common to the larger culture

Subculture

_________________ (usually largest group)
Group has the most authority to control values and sanctions of society
_________ (smaller group)
A physical or cultural characteristic identifies the people as different than dominant group

Dominant Group

Minority group

______________
Minorities living within a dominant group lose the characteristics that made them different
Values replaced by those of dominant culture

Cultural Assimilation (acculturation)

_____________
The feelings a person experiences when placed in a different culture
May result in psychological discomfort or disturbances

Culture shock

Belief that everyone should conform to the majority belief system

Cultural Imposition

Ignores differences and proceeds as if they did not exist

Cultural Blindness

Belief that one’s ideas, beliefs, and practice are the best or superior, or are most preferred to those of others

Ethnocentrism

Sense of identification with a collective cultural group
Largely based on group’s common heritage

Race
Typically based on specific characteristics
Skin pigmentation, body stature, facial features, hair texture

Ethnicity

One assumes that all members of a culture or ethnic group act alike
May be positive or negative
Negative includes racism, ageism, and sexism

Stereotyping

People become aware of differences and feel threatened
Response—ridiculing beliefs and traditions of others to make themselves feel more secure

Culture conflict

Physiologic variations
Reactions to pain
Mental health
Gender roles
Language and communication
Orientation to space and time
Food and nutrition
Family support
Socioeconomic factors

cultural influences in health care

Develop cultural self-awareness.
Develop cultural knowledge.
Accommodate cultural practices in healthcare.
Respect culturally based family roles.
Avoid mandating change.
Seek cultural assistance.

Guidelines for Providing Culturally Competent Nursing Care

Recognize each person holds various beliefs about pain.
Respect the patient’s right to respond to pain in his own fashion.
Never stereotype a patient’s responses to pain based on his culture

Culturally Sensitive Nursing Care—Patient in Pain

Infectious agent—bacteria, viruses, fungi
Reservoir—natural habitat of the organism
Portal of exit—point of escape for the organism
Means of transmission—direct contact, indirect contact, airborne route
Portal of entry—point at which organisms enter a new host
Susceptible host—must overcome resistance mounted by host’s defenses

Components of the Infection Cycle

Bacteria—most significant and most prevalent in hospital settings
Spherical (cocci), rod shaped (bacilli), corkscrew shaped (spirochetes)
Gram positive or gram negative—based on reaction to Gram stain
Aerobic or anaerobic—based on need for oxygen
Virus—smallest of all microorganisms
Fungi—plantlike organisms present in air, soil, and water
Parasites—live in or on a host

Infectious Agents

Number of organisms
Virulence
Competence of person’s immune system
Length and intimacy of contact between person and microorganism
Infection VS. Colonization

Factors Affecting Potential to Produce Disease

Other humans
Animals
Soil
Food, water, milk
Inanimate objects

Possible Reservoirs for Microorganisms

Respiratory
Gastrointestinal
Genitourinary tracts
Breaks in skin
Blood and tissue

Common portals of exit

Contact
Direct
Indirect

Vectors
Air

Means of transmission

Incubation period—organisms growing and multiplying
Prodromal stage—person is most infectious, vague and nonspecific signs of disease
Full stage of illness—presence of specific signs and symptoms of disease
Convalescent period—recovery from the infection

Stages of infection

Body’s normal flora
Inflammatory response
Immune response

Body’s Defense Against Infection

Intact skin and mucous membranes
Normal pH levels
Body’s white blood cells
Age, sex, race, hereditary factors
Immunization, natural or acquired
Fatigue, climate, nutritional and general health status
Stress
Use of invasive or indwelling medical devices

Factors Affecting Host Susceptibility

Elevated white blood cell count—normal is 5,000 to 10,000/mm3
Increase in specific types of white blood cells
Presence of pathogen in urine, blood, sputum, or draining cultures

Laboratory Data Indicating Infection

Includes all activities to prevent or break the chain of infection
Two categories
Medical asepsis—clean technique
Surgical asepsis—sterile technique

Aseptic Technique

Use of invasive medical devices
Antibiotic-resistant organisms developed in hospitals

Factors Predisposing Patients to Nosocomial Infections

HAND HYGIENE
Constant surveillance by infection-control committees and nurse epidemiologists
Written infection-prevention practices for all agency personnel
Infection control precaution techniques
Keeping patient in best possible physical condition

Measures to Reduce Incidence of Nosocomial Infections

what does the state's nurse practice act do?

establishes the criteria for the education & licensure of its nurses enforces rules for the profession legally determines what who can and cannot do.

what phenomena underlies the present and predicted nursing shortage in the US?

aging of the population increased prevalence of chronic illness
increased prevalence of disabilities

Florence Nightingale

is known as founder of modern nursing
created free standing nursing education

Clara Barton

is known for organizing hospitals and nurses
created the American Red Cross in 1882

Dorothea Dix

is known for she reformed treatment for the mentally ill.

Linda Richards

is known for the first trained nurse in the USA
began the process of record keeping and writing orders

Lillian Ward

is Known for the founder of public health nursing

Marya Elizabeth Mahoney

is known for the first African-American nurse

Nora Gertrude Livingston

is known for established the first 3 year nursing program in North America

Isabel Hampton Robb

is known for founder of the ANA -American Nurses Association

Mary Adelaide Nutting

is known for: published the History of Nursing

Mary Breckinridge

is known for: established the first midwifery school in the US - Frontier Nursing Service

Margaret Sanger

is known for: founded Planned Parenthood

name the 4 essential competencies nurses use:

cognitive
technical
interpersonal
ethical/legal skills

define cognitive competency:

offer a a scientific rationale for a patient's plan of care
select interventions that are most likely to yield the desired outcomes
use critical thinking to solve problems creatively.

define technical competency

the ability to use and creatively adapt technical equipment

define interpersonal competency

interact with patients
elicit their strengths and abilities
work collaboratively with other members of the healthcare team

In what culture is good health achieved by the proper balance of yin and yang

Asian

In what culture do granny women or folk healers provide care and may be consulted even if the patient is also receiving traditional care

Appalachian

In what culture is self- diagnosis and use of over the counter medication often used, also dieting and extensive use of exercise are common

White middle class

In what culture is the patient's illness viewed as part of the whole. emphasis is placed on preventive medicine

Hawaiian

In what culture may a patient refuse to allow the nurse to draw blood for a test- because he believes blood is the body's life force and cannot be regenerate

Asian

What is the most basic culturallly competent nursing care

Treating each person as an individual

What disorder might you screen for in an African American man

Keloid formations, hp, stroke and sickle cell anemia

Held the belief that illness was caused by sin and the gods' displeasure; theory of Animism

Pre civilized nursing

The roles of the physician and the nurse were separate and distinct.

Physician= Medicine man who treated dz with chanting , inspiring fear, opening the skull to release evil spirits.

Nurse= the mother who cared for her family during sickness by providing physical care and herbal remedies.

Theory of Animism

The belief that everything in nature was alive with invisible forces and endowed power. Good spirits brought health; evil spirits brought sickness and death.

Early Civilization Nursing

Temples became centers of medical care because of belief that illness was caused by sin and was the gods' punishment.

Religion played a major focus in healthcare

Physicians= highly regarded

Nurses= slaves; neither women nor human life was valued by society

During this time period, the Hebrews developed rules through the Ten Commandments and the Mosaic Health Code for ethical human relationships, mental health and disease control

Nurses cared for the sick in the community and in the home, as well as midwives.