NUR 2349 / NUR2349 Exam 2 Concept Guide (Latest 2021 / 2022): Professional Nursing I / PN, Study Guides, Projects, Research of Nursing

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NUR 2349 Exam 2 Concept Guide:

Professional Nursing I / PN 1

Ethics: The study or examination of moralitythrough a variety of different approaches

HIPPA and nursing research in 2003

The law that protects the basic rights and privacy of the patient to control the disclosureof that patient’s personal health care information.

Information can only be shared with worksdirectly involved with the patient’s care.

Ethical responsibility shown by nurse

Intermediary: Nurses have more direct contactwith patients than any other health care member. They interact more and receive moreinformation.

Moral distress: Nurse is aware of the right and moral action to take in any given situation but they are unable to carry out the action becauseof external constraints (E.g. Heavy workload, lack of nurses, financial constraints in a facility,conflicts with co-workers/managers)

Patient advocacy: Speaking for the patient to the fullest extent. It’s up to nurses to plead theirsense in a legal manner.

Moral principles

Veracity: Truth (Obligated to tell the truth to the patient, even if the family doesn’twant you to)

Nonmaleficence: Do no harm Autonomy: Requires that the patient have autonomy of thought, intention, and action when making decisions regarding healthcare procedures. Therefore, the decision- making process must be free of coercion or coaxing. In order for a patient to make a fully informed decision, she/he must understand allrisks and benefits of the procedure and the likelihood of success.

Beneficence: Requires that the procedure be provided with the intent of doing good for the patient involved. Demand that health care providers develop and maintain skills and knowledge, continually update training, consider individual circumstances of allpatients, and strive for the net benefit.

Fidelity: Strict observance of promises,duties, etc.

Justice: Must be distributed equally among all groups in society. Requires that procedures uphold the spirit of existing laws and are fair toall players involved

Living will and DPAHC:

Living will: Allows a person to show specific documentation of what medical treatment theywant or do not want if they become terminally ill.

DPAHC: Allows a person to appoint an agent orproxy decision maker to make health care decisions in the case the patients capacity is lost.

**The living will goes into effect when a personhas a terminal illness and lacks capacity.

DPAHC is not constrained by a terminal state ofhealth.

Lack of decision capacity may be temporary.Palliative vs hospice

Palliative: The process that is focused on relieving pain and physical symptoms, enhancing psychosocial support, and enhancingthe families to feel meaningful to resolve the patient’s pain as they are passing. This is comfort care that is NOT federally funded.

Hospice: A program that is sponsored by Medicare to provide comfort care for the terminally ill and the families. An individual has to meet specific guidelines. These people have 6months or less to live.

Moral distress vs burnout

Moral distress: Inability to carry out a moraldecision.

Perceived constraints:

Physicians: nurse administrators; other nurses

The law; threat of lawsuit

Advanced directives and information to makeinformed consent

Advanced directives: Allows a person to makefuture decisions about his/her health care. These documents are typically written but canalso be verbal.

Informed consent: For a patient to give informed consent they must have the autonomyto do so. They must have: cognitive ability to understand, deliberate reasoning skills, be able to come to a conclusion, must not be coerced, information about what will happen if they do not give consent, and must be able to freely consent based on values an wishes.

Confusion with informed consent

Adults who do not have autonomy and need a decision maker or individuals under 18 cannot give consent. If someone does have the right toinformed consent but this becomes questionable, the ability is taken away. A nursecan question ability of an adult even if the health care provider doesn’t.

Right of terminally ill patient

Right to die: Formal advanced directives can assist in the making of end of life decisions evenif the patient does not have mental capacity (can be used when a patient is in a coma)

Active euthanasia: Someone other than the patient performs an action to end the patientslife. (E.g. lethal injection)

Passive euthanasia: Omission of an action to prevent death, allowing death to occur. (E.g. honoring a DNR)

Values vs. attitudes vs. beliefs

Values: Belief about the worth of something.Highly prized ideals, customs, conduct, and goals

Attitudes: Feelings toward a person, object, oridea. Includes thinking and feeling component

Beliefs: Something that one accepts as true. Notalways based on fact

GI

Diet for constipation

• Increase the intake of high-fiber foods ifintake is inadequate (25 to 38g, depending on age and sex)
• Increase fluid intake (eight to ten 8- ounce glasses/day)
• Eat a well-balanced diet that includesfive servings of whole grains, fresh fruits, and vegetables

Ways of the GI system with food

• Stomach, duodenum, pancreas, jejunum, ileum, colon, rectum, and anus
• Food enters the stomach and is mixed in by churning of the stomach, the food is moved along by peristaltic activity (slowgastric wave is occurring
• Cephalic stage: when there is anticipation of food entering your stomach, secretions of gastric acid iscompleted
• Gastric phase: once food enters the stomach
• Hydrogen chloride in the stomach startsto trigger the release of pepsin, pepsin begins the digestions of proteins in the food substrate (focuses in on digestion of proteins) . Pepsin allows for the intestinalabsorption of vitamin B
• Gastroferrin in the stomach binds iron so that it can later be absorbed in theduodenum
• Duodenum (first part of the small intestine) Major digestive and absorptive area that transports proteins, amino acids, and electrolytes.It selectively is able to absorb iron and calcium.
• Pancreas (origin of digestion) produces a large amount of digestive enzyme thathelps produce bicarbonate rich alkaline liquid (this liquid neutralizes acidity because bile and acids in the stomach are very acidic)
• Jejunum and ileum are the main areas for absorption of nutrients, vitamins, amino acids, and triglycerides. Vitaminb12 is removed and absorbed. Absorbsfat and bile salts are reabsorbed
• Colon (large intestine) reabsorbs liquid
• Rectum and anus (reservoirs and controls feces, increased pressurestimulates peristalsis)

Diverticulitis vs diverticulosis

• Diverticula: sac like pouches of mucosathrough the muscle layer of the bowel on the GI tract (mostly in the sigmoid colon)
• Diverticula (means more than one)
• Diverticulum (means one)

• Diverticulosis: means you havediverticula
• Diverticulitis: the diverticula is inflamed
• Diet plays an important role(prevention) o High fiber, low amounts of processed foods, lots of fluid
• S/S: LLQ pain, nausea/vomiting, bowelpattern changes, pain, bloating, constipation, diarrhea, abdominal cramping, fatigue

Side effects of diarrhea

• Diarrhea is the increase of liquid stateof stool and frequency of stool
• Acute: less than 3 weeks o Non-inflammatory ▪ No fever, no blood, andno fecal glucosides ▪ Cramps, bloating nausea, vomiting ▪ Occurs from small intestinal enteritis thatis produced by bacteriathat produces toxins (S.aureus or E. coli) o Inflammatory ▪ Fever, bloody diarrhea, infection irritation agent in the bowel, IBD,radiation diarrhea, tissue damage to colon
• Chronic: more than 3 weeks
• Patients are at risk for fluid and electrolytes imbalances, particularlypotassium.
• At risk for impaired skin integrity

CD and UC factors

• Both CD and UC o idiopathic, chronic, relapsing inflammatory disorders of theGI tract, characterized by mucosal inflammation that causes bleeding, ulcerations, edema, and fluid and electrolyte imbalances

o Fluid and electrolyte imbalances or loss occurs withsevere or high diarrhea incidences = dehydration

• Diet o could be influence for CD, itdoes not appear to have thesame effect with UC

• Smoking o has an effect on both but has adifferent effect. o CD: smoking is detrimental, current and former smokers have a higher risk of developing CD than nonsmokers. Smokers with CD have a higher number of relapses, repeat surgeries, and usually require more aggressive immunosuppressive

Surgical

rectum. Diarrhea, abdominal pain of the LLQ, rectal bleeding.Extensive sloughing of the mucosa, sloughing of the mucous and frequent necrosis of the muscle layers of the bowel and loss of motor tone with rapid development of colon dilation treatment o UC: appears to have a protective effect on the development of UC that means that possible due to the nicotine in the gut that UC develops, but it has a protectiveeffect so that it stays in one place, so it is not detrimental

• Pharmacology/Surgery o CD: amino salicylates (Cipro)ciproflaxin o UC: surgery – polypectomy withan ileostomy or total colectomyso the bowel is resection
• Crohn’s Disease o (all over) chronic inflammatory bowel disorder that has relapsing and remitting courses, usually begins with a small inflammatory lesion in the intestinal mucosa, eventually inflammation progresses and continues to all layers of tissue.Deep ulcerations, fissures, and lesions that persist into the deep layers of the bowel wall. Fistulas occur – causes the bowel wall to thicken o Abdominal pain, tenderness,diarrhea,
• Ulcerative Colitis o (colon and rectum) chronic inflammatory bowel disorder, itaffects both mucosa and submucosa of the colon and

Preoperative questions and information

• Have you had anesthesia before? (Some people have behavior issues-combative, delirious, not A&O, lethargic)
• Addictions/Psychiatric? (Those who are addicted will come out of anesthesia and experience more issues b/c the body is under more stress r/t withdraw)
• Developmental stage: (Elderly-special considerations-better immune system,etc.
• Weight-(underweight/overweight)
• Allergies? (Food, air-borne, and drugs)also: gloves(latex), tape, etc.
• Previous surgical events?
• 1. Prior cardiac disease-have you had a heart attack before?* (clotting factors) or 2. pulmonary issues (smoking history,chronic pulmonary disease like COPD oremphysema) – for oxygen/intubation purposes
• Medication usage? (Regimen remains unchanged prior to surgery- chronic disorder medications CAN NOT changeeven with surgery)
• Identify correct surgical site
• Chronic metabolic disorders? (Diabetes,hypertensives, arthritis)

Child considerations, concerns, andinterventions with surgery

• Tour the hospital prior to admission, explain things using basic terminology,

bring something into surgery (blanket orstuffed animal)

• Proper sized equipment (BP cuff, cannulas for IV-everything must besmaller)
• Myth: young children/kids do notexperience or remember pain
• Anesthesia consideration: smaller person, smaller body mass
• Pain: monitor s/s of pain using Wong baker faces and body language, monitors/s respiratory depression (fast metabolism, body works faster, heart istrying to compensate which leads to hypertension
• Top two interventions: o 1. Distraction techniques o Parental presence Malignant Hyperthermia s/s and treatment
• S/s: everything rises (temperature),muscles and skeletal system are effected
• Life-threatening, during general anesthesia, autosomal-dominantinherited disorder
• Treatment: Hyperventilate patient with 100% O
• Deepen anesthesia with opioids,benzodiazepines, barbiturates
• Prepare dantrolene perfusion
• Adjust ventilation according to bloodgas analysis and end expiratory
• CO2 Check immediately, after 30 minutes, 4 hours, 12 hours, 24 hours blood gases, electrolytes, creatininase,myoglobin, and lactate (arterial catheter)
• Stop surgery, if it is elective and if there are signs of masseter spasm orfulminant MH crisis
• Begin overall body cooling: e.g., icewater through a nasogastric tube
• Continue to do additional monitoring: arterial catheter, central venous

catheter, swan-Ganz catheter, or urinarycatheter

Possible post-op complication vs. normalfindings- system considerations involved

• Respiratory: Resting heart rate of lessthan 12 or more than 20, pulse ox of less than 95, cyanotic (lips, nails, or skin), air hunger, wheezing, using accessory muscles, pneumonia, hypoventilation (use splinting maneuver)
• Cardiac: dysrhythmias, ectopy (heart beat arising from a location other thanthe SA node), electrolyte imbalances, hypoxia, severe blood loss can lead to low blood pressure
• Compartment syndrome: causes swelling of an area to be confined (e.g.cast)
• Neurosensory: altered mental status due to increase intracranial pressure
• GI or urinary: UTI (catheters),temporary decrease in GI: o It is NORMAL to have no bowel sounds for up to 2 hours aftersurgery
• Skin: pressure points or allergic reactions
• Exocrine or endocrine glands: electrolyte or hormonal imbalances

Surgical and PACU pain management

• Pain (subjective-what the patient says itis) Also use faces or numbers to assess pain depending on orientation
• PACU normally uses pharmacological pain management (Most medicationsare delivered via IV until patient is stable)

Delays of wound healing

• Crush injuries

• Foreign bodies
• Necrosis
• Repeated injury to the same site
• “Tense” closure sites (obese patients;lengthy incisions; incisions over skin folds, joints)
• Wound infection
• Irradiation
• Poor nutrition
• Steroid use
• Low oxygen levels: locally orsystemically
• Persons who do not receive adequateoverall rest
• Persons who do not rest the area ofinjury
• Older patients
• Those with: atherosclerotic disease, diabetes mellitus, thromboembolic disorders, chronic stress, cirrhosis, renalfailure, or cancer

“time out”

Created to help with wrong-site surgeries

Surgical-team nurse calls the time-out to checkfor:

Right patient, right procedure, right site andside, right surgeon, and right position

Pharmacology- Pre-op

• Opioids: Are used to provide analgesiceffect, decrease anxiety, and provide sedation (Monitor for respiratory depression and lack of muscle coordination)
• Amnesic muscle relaxants: Potent medication. This medication might be

too strong for some individuals. (Monitor for respiratory depression andlack of muscle coordination)

• Anticholinergics: Given when the health care provider wants to reduce oral or respiratory tract secretions. (Dries up secretions) Also decreases post-surgicalvomiting or secretions.
• PPI’s: Reduce gastric acid in an individual. Reduce occurrence of stressinduced gastritis. Acids increase with stress which could lead to severe GERDor gastric a gastric ulcer (helps treat)
• Anticoagulants: Blood thinners that prolong clotting time. Used for increased risk for hemorrhaging orblood clot.
• Antihypertensives: Used to treat high blood pressure and also effectintraoperative blood pressure.
• Diuretics: Can have the same effect pre- operatively but also monitor forelectrolyte imbalance.

Sterile vs clean

• Sterile: what is used in the operatingsetting. Adhere to the principles of asepsis
• Clean: Asepsis (Absence of pathogens/organisms in the setting)Laminar airflow

Type of filtered air circulated on panels toreduce spread of microorganisms

Way to determine risk of patients undergoingsurgical procedures

Assessment is important to determine risks

Comorbidity, polypharmacy, if they have a poor baseline, impaired cognition, limited support at home

Cardiac: most serious post op problems, heartfailure, prior heart attacks, arrhythmias, dysrhythmias, valve disease, presbycardia (decreased function of heart muscle)

Diabetes: intermediate clinical predictor for death of cardiac tissues, myocardial infarction,neuropathy, delayed wound healing, ketoacidosis, renal failure, prevent hyperglycemia during perioperative care because it will help with prevention cerebral damage, promote wound healing,

2. Cardiovascular complications
3. Venous thromboembolism (clots inveins)
4. Post-operative ventilator associativepneumonia

Identify patients correctly. Use at least two ways to identify patients. It is especially important in blood transfusions that the correct patient gets the correct blood type.

Use medicine safely. Label all medicines that are not already labeled. Medicines insyringes, cups, and baring should be labeled prior to use.

Pulmonary disease: supine position, abdominalincision (not deep breaths), secretions, atelectasis, hypoxia, what medications we are using (watch for respiratory depression), impaired gas exchange, COPD, smoking, PE, emphysema, uncompensated right heart failure – focus on oxygen use and thrombosis prophylactic (preventing blood clots)

Parkinson’s disease: requires special attention.We cannot withhold a Parkinson's medication.They have tremors, twitching, and muscle tightness. The disease does not stop with anesthesia. The muscles are still contracting soif you do not give the medication they will have tremors, twitching, and muscle tightnessthat are way worse than they usually are. Will create stiffness of chest wall=not being able to breathe=hypoxia. Dysphagia=cannot swallow. MEDICATIONS DO NOT STOP!

Joint Commission’s four key components ofpatient safety

Surgical care improvement project

1. Surgical site infections

Improve staff communication. Quickly getimportant test results to the rights staff person.

Prevent infection. Use the hand cleaningguidelines from the Centers for Disease Control and Prevention or the World Health Organization.

Use safe practices to treat the part of thebody where surgery was done (Joint Commission, 2010).

Important areas of focus with PACU

• Allows a convenient area for surgicalteam to have access to
• Shorts the time of recovery
• Area with specific trained personnel andstate of the art equipment
• Patient usually spends 1 to 2 hours here - Monitor: respiratory status, cardio status, consciousness, and activity level - Rapid head to toe is conducted to focus on major body systems and surgical siteWound characteristics

Wound Review:

Serous drainage is composed primarily of theclear, serous portion of the blood and from serous mem- branes. Serous drainage is clearand watery.

Purulent drainage is thick, often has a musty orfoul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Thick, yellow, tan, green, or brown

Serosanguineous drainage is a mixture of serumand red blood cells. It is light pink to blood tinged. Pale, red, watery

Sanguineous drainage consists of large numbers of red blood cells and looks like blood.Bright-red sanguineous drainage is indicative offresh bleeding, whereas darker drainage indicates older bleeding.

Nursing Diagnoses for preop patient

• Risk for infection
• Risk for impaired skin integrity related to positioning, immobilization, pressure,or shearing forces
• Risk of injury r/t surgical environment, extraneous objects, and equipment(laser, electrical, and use of X- rays/radiation)
• Risk of hypothermia

Post-op teachings

• Wound care: demonstrate
• Activity and rest: when to be active andwhen to rest
• Medications: When to take, how to take, why they are taking (Copies forpatient and family)
• Possible complications (When to callMD)

Discharge planningStart at admission

Assess for two teaching/learning principles

1. Current patient and family knowledge
2. Readiness to learnTraffic control

Goal: to minimize microorganisms

Minimizing microorganisms by monitoring and restricting the number and type of people that come into, through, and out of the OR

Designated traffic patterns: distinct traffic areawhere you are allowed to walk

Different anesthesia/sedation

Medication for relief or elimination of pain. Painis still there but you can’t feel it.

• Local: Given temporarily to stop sensation to a particular part of the body. Conscious or minimal sedation. Better for patients and staff b/c requiresno respiratory support.
• Regional: Numbs only a specific region (portion of the body) so that nerves canbe operated on. Usually by injection
• Spinal: (Different than epidural) used for lower abdomen, rectal, pelvic, and lower extremity surgery. Medicationinjected in spinal cord fluid for thosespecific surgeries
• Epidural: Commonly used for surgery of lower limbs, also administered duringlabor for women. A thin catheter is placed in epidural space
• General: Loss of consciousness, relaxes all of the muscles, amnesia. Inhaled through mask or through IV. Can’t be aroused, can’t respond to pain, monitorfor respiratory assistance
• Minimum: drug induced state, cognitive function and coordination could beslightly impaired, pulmonary cardiovascular functions are not effective
• Deep:

Causes and high risks for hypothermia

• Age (very old or very young)
• Those who have heart disease or are atrisk for heart disease
• Anesthesia
• Having tourniquets on for longerperiods

Discharge teaching- pain and when to call MDCall MD if:

• Sudden numbness and tingling
• Sudden SOB
• Elevated temp
• Increased sudden pain
• Change in mental status Surgical team members’ responsibilities
• Perioperative Nurse: Have specialized knowledge base and physical skills. Practice principles of asepsis, sterilization, disinfection, and infectionprevention
• Surgeon: performs the surgery
• Certified Registered Nurse Anesthetist (CRNA): Takes care of the patient before, during, and after surgery. Constantly monitors vitals and modifiesanesthesia to ensure maximum safety and comfort
• Operating room nurse o Scrub nurse: works directly withthe surgeon directly in the sterile field. Passes sterile itemsin the procedure.
• Registered Nurse First Assistant (RNFA): Has additional extensive education andis trained to deliver surgical care. Assistthe surgeon in surgery: cutting tissues,using instruments, handling tissue, suturing, controls bleeding, known as “right hand man of surgeon”
• Education coordinator: Promotes education and competence of the team.

Assists patient and family members andgives information regarding surgical cares and treatments

• Director of surgical services/operating room: Handles the business aspect. How teams are scheduled, who is where, how and when tools are cleaned
• Surgical technologist: Ensures the operative procedure is done under optimal conditions. (Right spot, right equipment, conditions of the room areappropriate. “State with a clipboard”

Planning and implementation for surgery forfrail elderly, obese, and alcoholic patients

• Elderly: PACE them (slow steps and explain everything thoroughly), positionfor comfort, stretch before movement to avoid joint pain o Frail elderly couples: At risk due to being dependent on one another. If one is recovering from surgery, both individuals are at risk (Seek need for guardianship, home health care,or other family members that can help)
• Obesity: Surgical team must make adjustments (More anesthesia r/t longer to metabolize b/c there’s a greatcircumference to cover, takes longer to sedate) o Consider organs (failing or healthy?) o Consider blood flow (Cholesterol issues ordiabetes?) o Positioning (Unusual positions to access someone that isoverweight) o Heightened-risk: Atelectasis (gas exchange centers collapse),heart failure (have EKG machinein room), wound management

(higher risk or skin breaking open) o Supplies (bigger bed, bigger room, larger tubes)

• Alcohol or drug consumption: Will face withdraw which could lead to delirium, delayed wound healing, or unpredicted reactions with medications
• Smokers or COPD(Chronic respiratory issues) : Monitor closely for respiratory depression (These individuals have secretions sitting in their chest that will become thick and create breathing issues